Distribution Shared Losses/Savings Among Providers

  • Distribution is also available in Portable Document Format (PDF, KB)

An Introduction

Guiding Principles
NYS Road Map

  • Funds are to be distributed according to provider effort, provider performance, and utilization patterns in realizing the overall efficiencies, outcomes, and savings.
  • Required investments and losses of the involved providers can be taken into consideration in calculating and distributing overall savings.

Integrated Primary Care Models
Key Features

  • Integration will (usually) be virtual
  • Getting the right balance is critical
    • Incentives and Protections
    • Risks and Rewards
    • Investments and Returns

Core Services of Primary Care
A Taxonomy

  • Preventive Services
  • Diagnosis and Treatment of Illness
  • Management of Chronic Disease
  • Birthing/Maternity Care
  • End of Life Care

The Trajectory of Advanced Primary Care
New Capabilities

  • Information Management
  • Adoption of Evidence-Based Standards
  • Team Orientation
  • Continuous Improvement

Advanced Primary Care
Added Services

  • Assured Access
  • Care Coordination
  • Care Management
  • BHS Integration/Collaborative Care
  • Specialty Integration/Care Compacts

Getting to Advanced Primary Care
Initial Investments

  • EMR
  • Training
  • Lost Productivity
  • Additional facility requirement
  • Data Management Technology

Providing Advanced Primary Care
Operating Costs

EMR $1.91
APC Administrative Operations $1.31
APC Clinical Operations $2.42
Care Management $2.91
Total $8.55

Costs of Care
Medicaid -2013 ADK Medical Home Pilot
Matched Cohort/Non-ADK, Non-PCMH

  ADK Non-ADK Difference %
Primary Care 3,861,179 2,695,703 1,165,477 ↑ 43%
Other Outpatient 34,950,365 43,350,048 (8,399,683) ↓ 19%
Inpatient 6,195,511 12,568,293 (6,372,782) ↓ 50%
Pharmacy 6,012,280 8,552,919 (2,540,638) ↓ 30%
All costs 51,019,335 67,166,964 (16,147,628) ↓ 24%

Distribution of Shared Savings/Losses
Guiding Principles

  • The relative budgets of the providers involved should not be the default mechanism for making the distribution of savings/losses
  • The distribution of shared savings should follow the same principles as the distribution of shared losses.
  • For shared losses, smaller providers, financially vulnerable providers, or providers with a regulatory limitation on accepting certain losses (e.g. FQHCs) may be treated differently by the VBP contractor to protect these individual providers from financial harm. It is legitimate that this 'special treatment' would weigh in as an additional factor in determining the amount of shared savings that these providers would receive.