Hello, and welcome to today's ACC Intelligence webinar, Value-Based Care, New Revenue Opportunities for Home-Based Care Practices. Before we start today, I want to go over a few housekeeping items. All participants will be muted during this event. However, you can submit comments and questions in the Q&A box located at the bottom of your screen, any questions that you may have submitted at the time you registered or that you submit in that box, we will address those during the Q&A session of this discussion at the end. A recording of this webinar, the presentation, and supplemental slides will be available on our HCCI Learning Hub in the coming days. Today's discussion will be moderated by Amanda Tufano, Chief Executive Officer of Genevieve, and she'll be joined by Panelist Dr. Tom Cornwell, Executive Chairman of Home-Centered Care Institute, and Senior Medical Officer, Village Medical at Home. Jeremy Phillips, Chief Executive Officer of Geriatrics Care of Nevada, and Brianna Plintzner, Senior Consultant Manager, Practice Development at Home-Centered Care Institute. I know I personally work with these individuals, and I can tell you, you are going to have a phenomenal call today full of valuable information and a lot of engagement. So with that, I'm going to pass it over to Amanda. Thank you very much. So excited for our conversation today. I'm having a little bit of trouble advancing the slide. I know I have control, but if you could get me kind of set up. I think this is a great time to talk about value-based care and what is in store for the future today. So just a couple of invitations for our panelists and our participants here. Start throwing questions right into that chat. So we're going to have an opportunity to do a Q&A at the end of this after a moderated discussion. What I really like about this work for home-based medical practices is it's not really a massive shift in what you're doing. It's really our discussion today is how do you get paid for the work that you are already doing? And maybe there's some things that need to shift, but if you're doing home-based care, you want to get into home-based care, value-based care is a perfect contracting partner to that space, that clinical space. So I'm really looking forward to talking with our panel. They are experts in their field. They're going to tell us the good, the bad, the ugly. We're going to have a really fun discussion around their experiences and what they see on the future or in the future for Medicare. So first, if we could go, let's see. I'm going to go to the next slide. Slide. And Dana, I see your lips moving, but we're not hearing you. Yeah, so Amanda, well, let me take back control here. Let me give me a second. You still don't have control on your end? I no longer have control, yeah. Okay. Let's just start here with this slide, and I'll go along with you. Does that work? Which slide? Oh, it's still the cover slide. And this was working just before we got on, everybody. I'm so sorry. Well, luckily, we've had the last 18 months. Just like house calls. You know, you kind of have to, okay. So that's, if in doubt, just restart. There you go. There we go. You got it. There you go. Great. So this is just a slide to kind of set us up. And one thing that I like to talk about a lot, and we talk about it at HCCI and our panelists may talk about too, is how we use data. And one of the easiest data points to talk about as we think about value-driven care is the driving statistic for us is the top 1% of the population is accounting for more than a fifth of all spending. So again, you have a clear set of patients that you're targeting, and you have payers, you have partners, you have individual entities and individual groups that are interested in controlling that extreme cost. Slide. So I'm just going to briefly introduce this slide and get into it. So here's just an evolution of fee-for-service-to-value-based care. Now, the Medicare Modernization Act of 2003 definitely brings in Part D. The Balanced Budget Act starts Medicare Advantage, which used to be Medicare Choice and TEFRA. You know, we see the rise around 2010 of ACOs and CMMI, which has come forward with a number of other opportunities. And now we've seen the last 11 years pass and Pioneer ACO, Next Gen ACO, and now Primary Care First, the Seriously Ill Population, Direct Contracting, High Needs. This is the perfect time to invite our panelists for the conversation. So, panelists, thanks for joining us today. It's one of my favorite topics. We're thriving in financial and clinical arrangements to help support our provider teams. Can you talk more about your practice and what value-based contracts you're in today or have experienced within the past? Tom, we'll start with you. Okay, great. Yeah, and so I joined about a year and a quarter ago Village MD, and their whole goal is to have as many of their patients in the value-based contract as they can. They had been a large part of their population had been in MA plans, but now they actually have heavily invested in the new direct contracting program. We actually have 60,000 lives, and you'll probably hear during the discussion there's different ways you can take risks. Sometimes you can take just primary care risk. We are actually taking global risk, where you actually are at risk for hospital cost, home health, hospice, just everything on your patients. And that risk can be a little scary and something that is difficult for smaller home-based primary care organizations to take on. But with that risk also comes reward in terms of when you really do a good job taking care of those most expensive patients that you were describing, Amanda. There's just really great rewards and it gives you, and we're going to discuss this in a slide to come, just amazing ability to transform healthcare by using money that you would use on these patients in the hospital, and instead just give them incredible care in the home. Yeah, the reallocation of where the dollars can go upfront, preventative, and in right resource to keep people in their homes. Is that kind of what you're saying, Tom? Exactly, exactly. And that's what I keep, that's what I'm talking about. This is what the fun part is, is we get to do what we want to do or how we're already practicing. We're just moving money around to put it in the right spots. Jeremy, do you want to talk to us a little bit about GSC and what the work you're doing? Yeah, definitely. So geriatric specialty care, we've been on this journey for quite a while. Started fee-for-service, got into the ACO world really around 2014 was probably the first time we went there. So that was our first foray into more value-based contracts, if you will, right? But we've always been a upside-only sort of corporation. And with our partners, we partnered locally with Renown Health Systems for our ACO, and we actually left them in 2016 to try the next gen. That's some of the bad, if you will, right? We found out that if you don't have the right partnerships, it doesn't quite pan out the way you think it can. And then we came back to Renown and helped them achieve shared savings for the past three years now. And this year as well, we're really excited because we're going into that direct contracting arena as well. And I think the one thing, just talking about value-based, that we definitely don't want to lose sight of, I mean, this slide's really definitely heavily focused on Medicare and the fee-for-service world, but it's your advantage plans as well, and really taking advantage of that. That's where you can really dip your toe into the waters, right, and just focus on working on their quality measures, right? It's usually a little simpler, right? They give you the cheat sheets. He just measures work and star ratings, capture the risk and the HCCs. So it kind of gives you that little bit of that roadmap, and you can benefit from it financially as well as give a better product to the end users. That's great. Thanks so much. And Brianna, I want to make sure I introduce you. You're not with the practice today, but you have a lot of experience in consulting with groups that have tried some of these options. And so do you see a pickup with organizations in the last couple of years trying direct contracting, primary care, MA, MSSP, ACL work, and any early thoughts as we get into the discussion? Yeah, thanks, Amanda. I think what's exciting is just the recognition that home-based programs are starting to receive and be sought out after for these different partnerships. I've heard from a variety of groups that just contact directly with Medicare Advantage plans, like we were mentioning. I've also heard from a handful of practices that are being approached by the larger direct contracting entities to either be what's called a preferred or a participant provider, and that kind of window in those final partnership opportunities is going on now, as well as if you got in the primary care first cohorts that were, which is now closed, but there was some opportunity there for advanced primary care practices to get in the primary care first model as well. So I think it's just an exciting time, and the value of home-based programs is getting recognized. That's great. That's great. I'll take a slide. I want to just kind of ground all of us in some common language here, and I really like this slide because it kind of sets up an X and Y axis here of degree of risk managed by provider, and that was where you heard Tom talk about that global payment, and we're going to keep talking about that with Tom, and then the level of provider sophistication and transformation from that fee-for-service to this global payment or capitation. These don't have to go as single steps. You can jump steps. You can enter in different places. You can have different types of contracts in different places here. You can go back. You can have mixed components, right? You can have some pay-for-performance or quality measures in some shared savings or risk programs, but just, again, a grounding. The blue really talks about how do you have a service or activity, this kind of widget-based, it's fee-for-service, or even a CCM type or TCM type of structure where you're doing some activity and you're getting paid a set amount for it, and then we move really into you're hitting these quality goals, or you're hitting this performance level, and these are targets that we agree on, and again, it's you and your partner, you and your payer, and now we start to manage events or conditions and bundle payments, and a lot of these really have risen up and live on CMMI when you can have kind of a singular DRG or a singular controlled moment of, and we hear a lot of hips and knees and joint replacements kind of living here, cardiology events, and as specialty care continues to have value-based opportunities, it lives a lot in that bundled payment structure, and then we start to talk about how do you manage a whole population, and shared savings really is no downside. If we perform well, we get some upside on this deal. Now we start to talk about what Jeremy's talking about of some shared risk and downside components, and those can come with ceilings and floors, and then finally, how do we have a global payment connection and partnership around just capitation, and we just put a little box here. These are the ACOs, direct contracting, MA, some Medicare Advantage and special needs plans. So for our panelists, what contracting arrangements have worked well for your practices? Tom, do you wanna start us off? Right, and I'm more the setting up home-based primary care programs. I'm not as involved, and so I'm gonna be quick, and Jeremy is much more experienced at that, but again, basically, we are taking global risk as much as we can because we have great faith in both our primary care practices as well as our at-home. The Village MDM with is actually 3,000 providers in 14 states right now. Only 30 of us are at-home providers. It's a very small program, but has a significant impact, again, because of the cost that we save, but basically, we're just trying to get as much global contracts as we can. Again, we just take full risk, but it's very complex because you actually have to be able to pay hospital bills and pay home health agencies, set up contracts with home health agencies that you can do with the direct contracting as a direct contracting program, but Jeremy, you have had much more experience, and one of the things I'm gonna ask you, Jeremy, when you talked about your success with the MA plan, not every program has Dr. Phillips in it that you have who's been doing this and setting up relationships with insurance and is just such an admired person in this space. A lot of smaller programs, really, I can just tell you from working nationally in this, they really have a difficult time breaking into the MA space just because, again, they're so small that they have not been able to get the attention of MA plans. If you have any advice for them, I think that would be helpful. I appreciate that, and I agree. I mean, my bad, I'm not even mentioning Dr. Phillips in my intro. I'm very fortunate to have a Dr. Phillips. I mean, I think every home-based practice should have one, quite honestly, because it would definitely proliferate what home-based would actually be, right? And so to your point of the relationships, I mean, it's been years, right? I mean, a lot of what came to fruition during COVID was eight years in the making, right? So we've been on and off again with every health plan in Northern Nevada for years trying to prove our value, and they always saw it, and they're like, yep, we appreciate what you do, but we don't know what to really do with you. But what COVID allowed was it allowed us to get into a more value-based contract with our transitional care program. So that opened the door with one of our health plans with a value-based contract just around transitional care with the focus not only solely being on reducing your return to acutes, but really focusing on the capture rate, right? So it goes back to, you know, and I know Amanda was laying some groundwork here with the ACOs and the different levels of fee-for-service, but really it all revolves around risk adjustment and coding appropriately, right? And a big gaping hole are those members that are on home health, but never seen by an appropriate clinician that can drop a claim so that you can risk adjust them, right? And that's where we are now with our health plans, which has helped tremendously. I think, I mean, yeah, I don't know how you actually create that. I mean, I think the easiest way is thankfully a lot more health plans nowadays. I mean, the four that we really work with closely up in Northern Nevada, they all have a similar sort of structure, right? And they all use a different program though, right? One is Matrix, one's Pulse 8, one's, right? But they have their forms that you fill out, and that's a way, again, to kind of dip your toe in the water, and then you just expand on it, right? And I think that's what all of us who are on this call and the panelists and everyone who put this together, being in home-based puts you in a very unique situation because there are so many of those members that can't leave their house. They can't get seen by a provider, and therefore if they can't get seen, they can't get coded, right? And that's where you can have this huge value, not just to the health systems, but to that member, because at the end of the day, if they're not being served, maybe they can flip them to you because that's the right thing to do. All right, got it. So we're getting some questions in the chat, and then we're getting some questions. Also, people submitted some questions, so I'm going to kind of throw one at you, and again, just as grounding for our conversation. So when a practice has full capitation payment, what does that mean? What is that global cap you're talking about, Tom? Does it include hospitalizations, pharmacy costs, or only outpatient primary care specialty visits? And so how do you set up those contracts and what does that look like for you, Tom? Yeah, it's really everything except for medicine. The medicine is covered under the Medicare Part D, but everything else, can you actually go to that slide on the revenue? Because I really think it kind of brings this to light in terms of... And so what I did in order to help my colleagues kind of understand this whole thing about fee-for-service versus value-based, you guys that are out there doing home-based primary care, what I did was in order to be a direct contracting entity, you have to have 5,000 lives, but there's this high needs part where you only need 250 in the first year. You do have to work up to 1,440 by I think year four, but you only have to start with 250 in those that are in high needs. And even though this is closed, people that have already started a high needs or a DCE can add as much as they want. And so the program's not completely closed, but the new programs it is. But so here you have in my program, and these are actual determined numbers. If you have 10,000 lives at 5%, I think this is a common number, we say about 5% probably would benefit from home-based primary care, that's 500 patients. If we have Breanna, I usually say, to do all of our billing and get us to do 10 visits a year, which is a pretty common average, that we do chronic care management on 90% of our patients once per month, that is doing a very, very good job. We do advanced care planning, let's say twice a year. You can see all the things here. This is, I think, very difficult to do. Well, if you are a physician practice, you would get 1.2 million Medicare allowable. If you're mostly APPs, you would get about 1 million, and that's under fee for service. So let's flip to direct contracting. What Medicare does, and this is hugely important, what they do is they predict based on this methodology how much your patients are gonna cost for their primary care, for their specialty care, for home health, hospice, hospitalization. And they do it based on these five things I'm not gonna go into. They look at the history of their costs. They look at regional parameters. But this number four is hugely important, which is what Jeremy was talking about, is risk adjustment. And the way they risk adjust is, and you're gonna hear this from Breanna, is by us doing an excellent job showing them how sick our patients are. We talk about being value-based because of keeping our patients out of the hospital and saving money. From a revenue standpoint, coding correctly gets you much more revenue than we can ever save in reduced costs generally, okay? But so on these same 500 patients, what do we predict we are gonna get for these 500 patients where we would get a million, 1.2 million. Next, can you press the next? And you'll see what we would get for these patients is $16.3 million, $16.3 million for these same patients. Now realize, again, we have to pay for all those things, but think of the transformative care that we can do. And with this money, you also have things that Medicare allows you to do that you cannot do under regular Medicare. So we can directly admit a patient from the home to a skilled nursing facility without a hospitalization and pay for it. We can have a patient that's in the hospital only one or two nights instead of the three go to a SNF. We can actually pay for things like home health aids in order to help them go home after a hospitalization if that's where they wanna be. And we can send them our at-home program and save the money of not going to a SNF. We can pay for over-the-counter medicines, transportation, dental care. It is amazing what we can do, but the only way we can do that is if we give these patients great care, keep them out of the hospital, and then all those dollars saved from not going to the hospital. Amanda, you use the term like diversion of dollars or altering where the money goes, but it's basically giving these patients amazingly better care because of the flexibility as well as the dollars you have to just do amazing work. And the last thing I will say because Brianna has people calling saying, now, wait a minute, these organizations are calling us saying they're gonna give us like $75 for every patient, every visit we make, 75 in addition to Medicare, it sounds too good to be true. And it's because they are getting these dollars that they can, in a win-win relationship, help give home-based primary care programs extra money for doing these visits to help them be able to do their businesses better. But they also win because when you keep these people out of the hospital, when you code correctly, when you improve quality metrics, which is what we do, they end up saving money that would otherwise be used in the hospital as well as the better coding. So I hope that kind of, I think answers a lot of the questions that I have seen in terms of why this sounds too good to be true, but this is what is behind it. I think it really does. And you guys keep throwing them in the chat if there's something we can answer later or now and we'll fit it in for sure as we're going here. And just to clarify, primary care first, if we'd go back one slide and then we'll come back to the slide. Primary care first, direct contracting, these are all through CMMI and these are direct contracts with Medicare. So I'm not trying to direct contract capital letters, DCE, direct contracting entity. But these are, this is where, there are ACOs and MSSP, NextGen, Pioneer, and these are coming out of legislation for MACRA. But that again is a direct contract, lowercase with Medicare. That's you contracting with Medicare. Medicare Advantage, special needs plans. These are often you contracting with payers who are already in these programs. And so just to clarify one thing, Tom, where we take quite a bit of risk in our practice and a lot of it is through SNPs. And we have some that we take PharmD for risk because it's all wrapped together. With a Medicare Advantage plan, you have part A, B, and D wrapped together. And so you can negotiate those pieces when you're contracting directly with Medicare because PharmD, part D is always a separate program. It's not included. And so it's, you know, just from a global payment structure, is there all of these tracks? And that way, that's why we kind of opened with that first slide of just the history of it is the history is us continuing and with Medicare and with a number of advisory boards and support is trying to find what are multiple routes to value. And there are, and you can set up multiple value routes and maybe Jeremy, you can talk a little bit about some of your experience as well, because I think you're joining, you're in MA contracts today, you're in an ACO and you're talking about direct contracting is, am I right? Are there kind of three different tracks you're working in right now? Yep, that is correct, yeah. And we're doing a global DCE as well. So we're at the same, yeah. And why do you like one or the other and how do you pick when you're looking at your population? Like, how do you move through that thinking for us? You know, again, thankfully we have some history that we can rely on, right? And so we've seen that, you know, we've achieved shared savings the past three years with the same health system. And so it just makes sense to move to a model to where you can actually gain more of the savings, right? And I think, you know, at the same time, I think we also got to the same point, us in the health system, thankfully at the same time of saying, well, we've been saying this for years, if at some point we don't just like put up and actually go for it and actually go at risk, then, you know, we're just continuing to just talk and say, hey, we think we can do this, right? Even though we've seen it, right? And you've seen the shared savings, but I think to your point of how do you know what's right at what point in time? That's a more loaded question, right? It's everyone's own personal ability to take on risk, where they want to be, where they see themselves as a corporation, right? And again, I think that's where, you know, I would play it safe, quite honestly, and start with the MA plans, right? And promote, I think that's one thing that we don't necessarily do a wonderful job at, or at least GSC doesn't, maybe every other practice is amazing at this, but, you know, we've been in the market since 2001, and people are still just realizing, oh my gosh, we have a home-based primary care practice in Reno, Nevada, right? So I think if you actually just knock on the door and say, hey, this is what we can do, right? And kind of have that roadmap of, hey, this is what we do, this is what we offer. To Dr. Cornwell's points on that, the slide that we were just on, if you can say, hey, we can knock these five things out for you, that's a great starting point of any conversation for value-based. Absolutely, absolutely, because a partner's, this is, I always say, follow the money. Whoever, when you, someone, when you do the right thing and you lower costs and improve quality, someone's making money. The question is who, and how do you share in that partnership or how do you work that arrangement? Brianna, thoughts on what you're seeing in the community and some of the global or risk-based, value-based care? Yeah, I'll just kind of offer a comment of what we were talking about first, because we've talked a lot about taking risk and global risk too. So I think an important consideration too is gonna be when you're ready to take risk, like you're gonna need, if you're a small practice that doesn't have a lot of lives, going right into a global risk arrangement is probably not possible and not feasible, right? So just, I just wanted to make that point because we talked a lot about global risk is you need to know when you're ready for that point and that you have enough lives to be successful. So to Jeremy's point and Amanda's point, you can start small. You could start with partnering with a Medicare Advantage plan or the primary care first model that Amanda mentioned is less risk. It's more about giving you a PMPM and that is determined based on the HCC risk score of your population. So I think it really depends. Like I said, there's a lot of paths that you can go. But when you're having these negotiations and these partnership conversations, you really need to understand what the target population is gonna be, how is success gonna be measured? Is there opportunity for shared savings? Or if you are taking on some risk, what that looks like for your practice? Anna, you're setting me up perfectly. I'm really interested. We talk a lot about what works well today and what has worked well for your practices. Any kind of horror stories? What has not worked well? What did you not like being part of? What did you have to pivot because of X, Y, Z? Was it a partnership didn't quite work out, something happened, you were just ready to move on, but anything that didn't work out that you guys wanna share as panelists? You can start anywhere. Jeremy, you've had a lot more experience. I can make one comment, but I'd like to hear from you. I appreciate that. I think it just comes down to the partnerships, right to Brianna's point, right? And I agree with you, Amanda, she set us up perfect for that, because I mean, it really is. I mean, like I said, GSC, for quite a while, we were kind of the Lone Ranger out West and we were a hired gun, if you were, right? And that's part of the reason why we jumped around some, right? We felt like the relationships we had thought we had and cultivated weren't what they actually were, right? And that's what led us to the next-gen ACO. And that one just didn't work out, right? We found out that, hey, the grass isn't always greener on the other side, right? And so then it allowed us to then realize, well, this is who we actually are, right? And then go back to the table and renegotiate with our old partner and say, okay, well, we both maybe made the wrong decision, but we both grew quite a bit, honestly, because us leaving who we were with before, they achieved shared savings the year before we left. We left and they ended up losing $3 million. So it kind of opened their eyes up as well of, oh my gosh, this is what it meant to have a home-based primary care practice. And then we came back and then we achieved shared savings the last three years. So I do, I think it's, you have to be in it for the long haul. I think that's the biggest part of, right? Anyone who's gonna be doing value-based, I would not suggest you go down and do value-based if your desire is to not be in this space within 12 to 24 months. That's great advice. Can I add one thing to your partner comments? You know, the other, and Tom, we're going right to you after this to ask you the same question here, but one of the things I learned when we had not a great partner a few years ago is, you know, these partnerships are set up with payer entities or ACOs and they're run by people. And those people sometimes get new jobs and they, or they have short memories on stuff. And these, when you form these relationships, it's so key to stay up on how you're demonstrating value and who everybody is and how you're continuing to be the solution to their problem. That's why they continue to keep you in the space. And so it's, for me, I have found too, that I continue to push, you know, hey, we got this award or hey, we got this, even if it's not applicable to them, to show them that we're still in it and what that looks like, so. But Tom, anything that hasn't worked well in your experience that you want to share with everyone? Yeah, and actually you touched on it because you talked about like people change at these insurance companies, where there's these also things, administration changes, right? And so you have these Medicare programs and there was talk when, with the administration changes that, you know, do they want to continue direct contracting and realize when you are planning on taking on millions of dollars of bills from hospitals and stuff, you have to create infrastructure, which costs a lot of money. And then all of a sudden there's talk of, well, do we really want to continue this? Right now there's not great concern, but even, you know, the fact that they are not taking new people next year, you know, what does that, you know, what does that mean? And what we've heard from that CMMI, Liz Fowler, is actually just kind of wanting to take a pause is what we have heard and just kind of review things. But again, there is that risk that with innovation programs that they might decide, you know, we don't want to do it. And to Jeremy's point too, you know, the great thing about getting involved in value-based contracts is you can get information from the insurance company, how you are doing. In general, they want to share. So Jeremy, and Jeremy is much more experienced than this, and I see him shaking his head, but they want you to do well, and you need to know how to do well. And if you can't measure, you can't manage it, right? And so all of a sudden you start getting information about how you are with your, you know, A1Cs and your blood pressure control. And because of these codes that go in with that and how you're doing, because all of a sudden you can get all your admission information that you didn't realize, oh, these patients were going to the hospital. And so I would really caution about taking on any significant risk. Like you even heard, Jeremy started this in 2014, and I know from knowing them that they had actually been involved in this many years before that, and still they did not take significant risks for the past three years, I heard, and only now are really starting to do that. And so they kind of, even on this slide that we see right here, they've kind of moved up these steps. And again, they're not in order as Amanda said, but really as you get towards the top one, shared savings and then shared risk and then global risk, those really are kind of in order. And so I would just advise, you know, first, you know, get your toes in the water by, you know, kind of partnering with an organization where they're kind of taking on most of the risk and then, you know, over time as you get your data and you see how well you're doing, then as Jeremy's practice did, you can consider taking on more and more risks. That's well said. I want to make sure that we touch again on the direct contracting and your expertise in that. Tom, can we do one more slide? So, and you walked us through direct contracting here. We have a question and so I'm going to come back to that, I know that some of the questions that came in from, you know, the registration were specifically around like, how do you, so direct contracting is not taking new applicants. How do you find a direct contracting entity to partner with and how do you evaluate if they're any good and how do you get connected today? Because Brianna's timeline is saying we really need to find who that is now and explore that. So how do you do that? Yeah, September 10th is the deadline of signing on the line. And so you will, and so really, you know, CMMI, you know, the innovation website, if you just do direct contracting entity participants or direct contracting participants, I think it's 51 participants come up, it lists, you know, what states they are in and it's just kind of finding out, is there a DC around you? You know, also they're actually kind of advertising, looking for home-based, you know, a couple of them are actually looking for home-based primary care providers in certain parts of the country. You know, Brianna, you might have, I know Clover is one of them, but yeah, you, you know, it's just kind of, you know, doing, it's not that difficult. And the same thing with on the same site, you can, there's a list of ACO participants. If you want to see, you know, who is involved, there's another organization called Allidade, which is, you know, works on with home-based primary care companies. And so it's just kind of finding them. And Brianna can be a source for that. That's perfect. Dana, could you advance the slide one more here? And then one of the questions came in of how much, so Tom, Jeremy popped in the chat here, but Tom, how much was your savings per beneficiary average in this direct contracting example? Right. And so the direct contracting started April 1. And so they're really, in terms of data lag, we really don't have, you know, information yet, but you know, what is, again, really important is to make sure that you get the 16.3 million. And that is through making sure that you're coding correctly. There's quality indicators, there's CAHPS surveys that go out, you know, to patients. The biggest quality indicator is reduced admissions and readmissions, which we all know we are good at preventing. A big part of, I think, this care is also excellent palliative care and end-of-life care, which consumes, you know, the last year of life consumes 25% of costs. And just doing a great job at, again, palliative care and end-of-life care is also hugely important in terms of this patient population. Fantastic. I wanna touch on what Jeremy was talking about with HCC risk adjustment. And so we, you know, HCCI has so many resources dedicated to both the revenue, you know, attack and your expense attack. Today is really about value-driven contracting and how we think about revenue. And that key component is getting paid what you are doing and playing the rules of the Medicare game with HCCs. So could I get a slide? Let's talk about the HCC risk adjustment here. Oh, let's bring in the graph. There we go, perfect. And so this really talks about hierarchical condition categories and the payment per beneficiary per month of what you're getting paid if you have sicker patients. And the idea behind Medicare is if you have more diagnoses that roll up to these HCCs, you are providing more care and thus should be paid more money to take care of that patient from a global payment. Whether you're at risk or not, if you have a Medicare patient, these things are still being attached to them from the Medicare level. And so the question is when you're at risk and you have these global capitation, risk-based, shared savings, how do you maximize this? And so Jeremy, how do you set up your infrastructure to appropriately capture these HCCs and make sure you get that money in the revenue bucket? Yeah, so we have, it's been years and thankfully Dr. Phillips is an expert on coding as well as everything else he does. But what we do right now is we're focusing, especially with the health plan, we're focusing on just four categories. It's morbid obesity, hypercoagulable state with AFib. I'm gonna miss the other two, Dr. Phillips. Oh, peripheral arterial disease, we use Quantaflow. I forget the last one. Well, he does it more than I do, so he focuses on it apparently. But with that said, sorry for that. I'm sure he'll type in the chat. So I think that the key is, and to Carla's point, I'm reading the questions over here, right? And I get it, like a lot of folks feel the same way I think you do, where HCC looks like it might be manipulation of data, right? And I think that the GSC approach, me not being a clinician and more on the business side, I should potentially want that, right? But my goal has always been, it's about the patient care, right? So if you code appropriately, you're gonna provide the appropriate level of care. GSC does not work with health plans that are telling us, hey, we expect you to code this. We only wanna work with good partners. And so a good partner is not one that's gonna dictate to us, hey, we expect you to code all these things, right? If it's not there, it's not there. And then we go and we actually go and educate the health plan and say, well, everything you wanted us to code, we actually couldn't code. Maybe that patient has all that information because they had an acute exacerbation. They ended up in the hospital and then they go to the hospital. Who knows what they're gonna come out with, right? They come out with everything under the sun because that's just how hospitals kind of work every now and then. So I think it's coding appropriately so you can work with that patient. I think a great plug here is the quantum flow and the peripheral arterial disease. So that's something GSC just integrated into our practice and it can help identify early onset folks who may have PAD. And our entire education on that is educating the patient about why that's important. So we can start making life changes to that member as well as it definitely benefits the health plans. Brianna, would you, oh, sorry, Tom, go ahead. No, and actually, we're gonna go to Brianna because she's the expert here. She is just the expert in this work. And really, and again, everybody who's sitting out there watching this from a practice standpoint, HCCI has a ton of resources on how to think about HCCs. Brianna, any thoughts? Yeah, so I'm gonna put a few HCC resources in the chat, but kind of to Carla and Jeremy's point about manipulating data. I mean, the true goal of risk adjustment coding is to make sure that the sicker patients are getting more resources. So they really do have good intentions, right? And you also are held accountable because there's yearly risk adjustment audits. They are very on the, you know, there was two MA plans that had big audit cases this year. So they are holding people accountable and making sure that the progress notes are supporting these HCC diagnoses. But in a nutshell, this is your ICD-10 diagnosis coding. That's what they're looking at. Every year, you know, you have to code every chronic condition that your patient has. Certain diagnoses, you know, CMS feels carry higher disease burden, which means higher cost. And so this graph is actually just an example of a PMPM, you know, that I believe this was the primary care first model of, you know, based on your HCC score. So how good you are at your diagnosis coding within a 12 month, within a calendar year, because every patient is reborn at the start of the year. You have to code all of those chronic conditions. You got to stop using those unspecified diagnosis codes to really accurately reflect risk. And that's, the goal is to make sure that those sicker patients, you're paid more to give them the resources that they need. And I just want to so echo that, you know, one of the things, one of our values at Village MD, is we say that compliance is in our DNA. And, you know, this is really about appropriately showing, you know, I don't know if, you know, we had at the, at a former talk, you know, Sarah Zanton with Capable. You know, I get to send out a handy worker with a $1,600 budget to do grab bars and ramps in my patients' homes, but it's only because, you know, we accurately show how sick they are. And there is a knowledge base to this. And again, Brianna is going to show you some things, but just some examples. You know, we see the COPDers that are on oxygen. Well, when you're on oxygen, by definition, you know, you have to have a pulse ox less than 88% or lower. That is considered respiratory failure under Medicare. That's an additional $2,800. If you just put obesity, when their BMI is over 40, where it's morbid obesity, morbid obesity gets you $2,500. If you have a MS patient who is quadriplegic and you put down that they are functionally quadriplegic, which is what they are, and you know how much at risk they are for pressure sores, pneumonia, all those other things that add costs, well, you literally get an extra $12,000 for functional quadriplegia. And I'll stop there. But this is just a knowledge base that really helps to identify our patients that are so sick so that Medicare under a value-based system gives us the appropriate revenue to take care of these horribly sick people. I think that's great. We have a few minutes for questions. I would say this, I've been trying to kind of work in some of the questions, and I know some of you have tried to answer some of the chats as we go here. We are overflowing with questions and probably won't get to them all, but I wanted to pull out a couple of them. Before we break, I want to ask this question, and I love it. How confident are you that value-based payments will replace fee-for-service? What's, and I think that goes with my favorite question, is what's your Medicare, CMMI, local national trend prediction? You know, where is this going? I don't think it will replace it in part because it's more difficult to do, well, actually, look at Jeremy. He's in Reno in more rural areas, and please correct me, but I do think that as we are seeing, you're going to see more and more value-based care. I think over time, as our whole country is wising up, that it is in our country's interest for the healthcare system to make more from keeping people healthy than make more when they get sick. And so the just aligning incentives is so wonderful, and it's wonderful, especially for value-based services like home-based primary care. And so my prediction is that, yes, we are just, and even Medicare Advantage, where we saw an increase, it really has kind of gotten stuck at about, I think, 35%, but I do think you're going to see more value-based care over time, but it is not going to replace fee-for-service. Others? Yeah, I have called it the same capitation of the 90s, but instead I call it ethical capitation. It's this quality component. Oh, I like that. But it's the same, yeah, it's the same work. We've been talking about this for decades upon decades. How do we build that road? Jeremy, thoughts? I echo, I echo. I mean, I don't see it going anywhere. I think it will, I think it will get larger. I mean, right now we're getting a little more of a shift, right, where you're seeing some lives revert back to traditional fee-for-service, right, from Medicare Advantage plans in certain areas. And I think that, you know, Medicare's realizing that. I also think it depends on the success of it, right? As long as it's successful, they'll continue to feed it. Right, and I think the success is there. I mean, you know, we've only kind of briefly touched on CMMI, but right, a lot of this really started from Independence at Home, right, and that whole endeavor, right? I mean, and unfortunately that's, you know, I know there's some people on here from, you know, VPA and, you know, they're huge partners in that whole thing, right? And so, you know, I don't see it going away. I think that if anything, the dartboard might get a little bit larger, right? We may get a few more options out there, but I love what you call it, Amanda, because that's exactly what it is, right? Ethical capitation, I like that. Thanks, guys. Brianna, thoughts on future of Medicare CMMI trends? Yeah, you know, I shared a blog post that CMMI, for a health affairs blog post about an interview with Liz Fowler and some of the CMMI heads about where they see the vision for value-based care going. I think, you know, financially, you know, it's kind of an imperative, you know, that we're trying to provide better quality care at a lower cost to save the kind of Medicare program in a way, so I think we're gonna continue to see this push towards value. But if you think about it, I mean, even organizations that have heavy value-based contracts, there's generally some population of fee-for-service, right? So I don't see that fully going away. And so you need to understand, you know, fee-for-service kind of components to be successful and then understand, you know, what your target populations are. So I think, you know, I would just encourage practices to not get left behind. You don't wanna be the only one still stuck on the fee-for-service train until there's maybe not a choice at some point, but you wanna, you know, you're still gonna have that population, so you need to understand both, but also just don't miss out on the opportunity to get into what you want for a value-based arrangement and not be forced into something. And I may not be popular in this, because I've done contracts a couple different ways, but I also think fee-for-service serves as a necessary cashflow component at times. And just depending on how you do your contracts and how much you're getting in your care coordination rates and some of those pieces, you know, however you set it up, whether it's a fixed care coordination or it's fee-for-service, there will always be a cashflow component that you need to kind of think about. And so, again, groups set it up different ways, but I don't think it's a replacement either, if anyone is asking me. I have one fantastic question to end on. Brianna, can you talk to us about the opportunity of telehealth and what you see in the future of telehealth? I think what we've seen, well, obviously during the public health emergency, it's really just been a necessity in order to provide care still, right? So it's been a huge asset to programs. We've seen a lot of innovative ways that programs are also using virtual services to just promote efficiency, right? Maybe they're doing a virtual visit to address that acute same-day concern rather than routing their providers out of the schedule. Or maybe they're starting to do annual wellness visits and collecting really that kind of preventative visits over telehealth and then following up with in-person. So I think there's a lot of opportunity, a lot of what is dependent on what we're able to do from a regulatory and legislative perspective, at least in the fee-for-service world, but that's the benefit of a value-based care arrangement. You're gonna have a lot more waivers and benefits generally where you will have more flexibility to do things like telehealth and things that otherwise, and I know someone was talking about RN visits earlier that under a traditional fee-for-service model, you're just not gonna get paid for, obviously, with the exception of right now, because we have a ton of flexibility, but we have to see where that goes in the future. Do you know what the latest is in terms of dates, in terms of, I know the public health emergency has been extended, I think, till sometime in September. I've heard that Medicare is gonna be looking this over and they plan on continuing this through the end of 22. Have you heard any recent dates in terms of Medicare continuing to pay equal amounts for telehealth as face-to-face visits? Yeah, so I know we're coming up on time here, but real quick, the public health emergency has to be extended each 90 days. So it was extended in July. So we'll have all of the current telehealth waivers at least till October. We suspect that'll be at least through the end of 2021 that we'll have these flexibilities, and then who knows from there. But just keep an eye on that, just for everyone on the call, those public health emergencies, that declaration is what gives us the fee-for-service telehealth flexibility that we have right now, and then has to be extended every 90 days. Thank you. Thank you very much for a spirited discussion. We have a lot of questions. I'll continue to reach out to HCCI, and I'll turn it over to Dana to talk more about the work they do here. Great. So thank you all for joining what I knew was gonna be a very fruitful conversation. With that said, I would like to take a moment to share with you that HCCI will be hosting a joint virtual workshop with our partner, a key partner of ours, the Center to Advance Palliative Care on Thursday, September 23rd from 1030 to 430 Central Time. We are very fortunate to have with us today, Allison Silvers, the Vice President of Payment and Policy for CAHPSI, and we would love to take some time for her to share with us some valuable information about that upcoming event. Thank you. Thank you, Dana. And I'll say this was such a rich discussion, and one of the selling points of the accelerator is that it's many more hours. So this is a rich topic. There's so much opportunity. And on September 23rd, we'll be spending a lot more time on it. But in addition, we'll also be going through a lot of things that I heard today. We'll be diving a lot deeper in building those relationships. How do you actually pick up the phone and say, hey, I wanna join your network, and I want a capitated rate? How do you find where folks are? Those are just a couple of examples. So we set up the accelerator that it's some basic how-tos and information. And then the second half, we switch gears. And I also heard a lot of this today, really impressive people on this panel. But we spend a lot of time diving into, okay, great, you got what you wished for, you got your capitated arrangement, or it's free for service with a quality bonus. How do you then operate? If you have a partner who's gonna send you patients, how do you make sure that you don't have a waiting list and you're giving the service that your partner is expecting? So that's the way the accelerator is structured. We have four, what we call voices of experience. I call them the people that have the battle scars, who went through this, learned all their tough lessons. Again, I think this panel shared some great tidbits, but you'll get to spend more time with those folks, really asking questions, almost like office hours. Tell me this, tell me that. They'll share their, I'm expecting a lot of cautionary tales, and you'll be able to interact. We also go into a little bit of the financial calculations and management. How do you actually figure out what you need and where you would go? So the idea is that some of the topics today in more depth, but giving you really the tools and the information to really hit the ground running. And speaking of tools, CAHPSI has put together over the years, a real rich trove of downloadable tools and resources and guides and spreadsheets. And if you come to the accelerator, those are all for your use as well. Great, thank you for that information, Alison. I do wanna mention that if you bring three or more individuals from your practice, there will be a promotion code that you can obtain for a discount. You can reach out to education at HCCI or hccintelligence.org, or you could go here to our HCC Intelligence Resource Center. So on this resource, I know there was quite a few questions maybe that we didn't get to today. If you could please direct those questions to this hotline, you can either call, send an email, and we will happy to address it here. And as a reminder, this webinar is recorded and the presentation will be on our HCCI Learning Hub, which will also be where you can register for the CAHPSI Joint Workshop. And then we will also be following up with some specific information to kind of wrap up all of these resources for you all. So that does conclude today's event. Thank you for joining, and we hope to see you again, hopefully on the CAHPSI HCCI Joint Workshop. Thank you all, bye-bye. Thanks. Thank you.

value-based care

revenue opportunities

home-based care practices

value-based contracts

fee-for-service

complementary approach

partnerships

contracting arrangements

HCC risk adjustment