As the types and structures of Accountable Care Organizations (ACOs) and Clinically Integrated Networks (CINs) continue to evolve, organizations moving into value-based care face an ever-changing landscape. Alternative payment model arrangements have driven provider organizations to hone in on specific tactics to meet their contractual and strategic objectives. Please join Health Catalyst Senior Vice President Dr. Amy Flaster and Population Health Management Consultant Jonas Varnum as they discuss the evolution of the ACO and CIN models, what new tools ACOs employ today to promote success, and lessons learned from organizations that have succeeded in alternative payment models. They will dive deep into lessons learned in addition to providing a primer on what has always been and continues to be vitally important to success in value based care. Specifics they will cover include: - Approaches to simplify quality metric reporting - Enhanced methodology that zeroes in on identifying high-value opportunities to improve patient populations - Key tips to expand your business with new contracts Dr. Flaster and Mr. Varnum’s combined experience make them uniquely qualified to guide you in your ACO or CIN journey. Dr. Flaster comes from a clinical background where she worked as Associate Medical Director at Partners HealthCare - one of the largest ACOs in the country. Mr. Varnum is a professional services strategy leader with demonstrated expertise delivering payment model transformation and helping providers and payers to strategically adjust their operations.

1. ACOs and CINs – Where Did They Start, How Have
They Evolved, and Where Are They Going Next?
Amy Flaster, MD, MBA
SVP, Population Health and
Management, Health
Jonas Varnum
Population Health Management
Consultant, Health Catalyst

2. • Context: Historical and Today
• ACOs and CINs: The Basics
• Evolution of ACOs and CINs
• Key Components of Success: What
Has Not Changed
• Coming Next: What Has Changed
Agenda

3. Background & Context
Understanding the Landscape for
Population Health Management

4. © 2018
Health
Catalyst
The Challenge: Rising Health Spend….
Healthcare spending growth outpaces the growth of the U.S. economy
and healthcare prices
grow faster than prices
in the general economy
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Health
Catalyst
…Has Led To
The Wave of Clinical Integration
Today
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6. • Context: Historical and Today
• ACOs and CINs: The Basics
• Evolution of ACOs and CINs
• Key Components of Success: What
Has Not Changed
• Coming Next: What Has Changed
Agenda

7. © 2018
Health
Catalyst
ACO = Accountable Care Organization
• An ACO is a defined by CMS as “a Legal entity recognized and authorized under
applicable Federal or State laws comprised of eligible groups of providers that
work together to manage and coordinate care for a payer-specific population.”
• Defined by CMS in common terms: “ACOs are groups of doctors, hospitals, and other
health care providers, who come together voluntarily to give coordinated high-quality
care to their Medicare patients.”
• Defined by AAFP: “An accountable care organization (ACO) is a group of health care
providers who agree to share responsibility for the quality, cost, and coordination of care
with aligned incentives for a defined population of patients. ”
• Defined by ACP: “ACO refers to a legal entity composed of a group of providers that
assume responsibility (are accountable) to manage and coordinate care for a defined
group of patients in an effective (high quality) and efficient (low cost) manner.”
• Unlike the traditional fee-for-service reimbursement model, which pays providers
for each care service delivered, an ACO directly ties payment to outcomes and
the providers’ abilities to deliver care in an efficient manner.
What is an ACO?
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Health
Catalyst
ACO Commonalities
• Standardize clinical protocols and
reduce clinical variation
• Meet quality targets
• Coordinate care amongst providers
• Organize and optimize a broad
spectrum of care management
• Ensure appropriate site of care and
coordinate efforts
• Develop patient engagement
strategy
• Create and monitor governance,
partnership operations
• Identify solutions for core clinical,
analytic, IT, and resource functions
• Monitor quality and payment targets
• Negotiate and manage contracts
• Establish procedures to distribute
financial payments to participants
Clinical Administrative
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Health
Catalyst
Contract Goal: Population-specific reduction of the Total Cost of Care
Contract Components:
• Benchmarks
• Minimum / Maximum Savings Rate
• Quality Score
• Attribution – Retrospective vs. Prospective
• Performance period and ramp up schedule
• Data access
• Contract review provisions
ACOs: What are the Contract Goalposts?
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Health
Catalyst
CIN = Clinically Integrated Network
• A CIN is “is a structured collaboration between community and employed
physicians and hospitals to develop active and ongoing clinical initiatives
designed to improve the quality and efficiency of healthcare services.
Participation in such clinical integration creates a high degree of interdependence
and cooperation among participants. Clinically integrated systems are recognized
by the FTC and allow joint managed care contracting in order to accelerate
improvements in healthcare delivery.”
• A CIN grants the group the ability to negotiate better rates with payers and
provides protection against anti-trust laws
• A CIN has systems in place to enable their participants to share information about
their patient populations.
• A CIN allows participating physicians and practices to collectively track a
shared patient population in order to optimize quality and cost reduction goals
What is a CIN?
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Health
Catalyst
The 4 Key Principles of Every CIN
• Active participation, engagement, and time committed to
enhancing clinical quality (care pathways) and reducing costs.
1. Provider
responsibilities
• CIN standards of participation create recourse for providers
noncompliant in quality and cost reduction policies.
2. Provider
accountability
• Must demonstrate the CIN improves quality and efficiency over
time.
3. Clinical quality
standardization
• Efforts to meet quality standardization and cost efficiencies include infrastructure
investment (IT), efficient network participants (monitored through IT), and clinical
improvement tactics (care management and care pathways).
4. Resource Use
Clinically Integrated
Entity
IPA Entity
Ind. MDs Hospital(s) /
Health System
Post-Acute Care
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Health
Catalyst
A Level Deeper – the Components of a CIN
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Health
Catalyst
Which value-based contracts does your organization currently participate in?
(Select all that apply)
1. Upside risk Medicare ACO/product – 40%
2. Downside risk Medicare ACO/product – 18%
3. Medicaid ACO/risk product – 22%
4. Commercial ACO/risk product – 34%
5. Payer/provider partnership – 53%
Poll Question
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14. • Context: Historical and Today
• ACOs and CINs: The Basics
• Evolution of ACOs and CINs
• Key Components of Success: What
Has Not Changed
• Coming Next: What Has Changed
Agenda

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Health
Catalyst
Clinically Integrated Infrastructure
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Clinical Quality
Committee
Legal Requirement and
Operating Agreement
Stipulations:
• Executive Committee
• Compliance
• Audit
• Management Authority
Finance
Committee
IT Committee
Network Management
Committee
Tasks:
• Oversee protocol
implementation
• Care Management
Program
• Patient engagement
Opt-In and
Other
Initiatives
OperationalPlanning:
HowtomakeaneffectiveCIN
Example Operational Structure
Staff:
• 2 FTEs @ 10 hours /
month
Charter Responsibilities:
• Provide PMPM target
Staff:
• Utilization
management
Clinically Integrated
Entity
IPA Entity
Ind. MDs Hospital(s) /
Health System
Post-Acute Care

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Health
Catalyst
Multi-Payer Effort
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IPA EntityInd. MDs Hospital Post-Acute Care
CMS Programs
Contract
Timeline
Self-Insured Product
Private Payer Program
Intervention
Timeline
1. Specialist financial incentives and engagement
increase substantially
2. PMPM cost reductions increase
3. Network keepage tightens
1. Utilization management
2. Care Management Pilot begins
3. Other tactics
1. Clinical variation reduction
2. Clinical documentation initiative
1. Develop protocol standards
2. PMPM reductions
3. Post-acute network develops, delivers better
quality
Year 1
Other Contracts
1. Prevention Tactics
Network
Value
1. Physician solution to MACRA
concerns
2. Physician engagement
3. Clear KPI improvement
Clinically Integrated
Entity

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Health
Catalyst
Scaled Long-Term Efforts
Contract-Specific
Participants
CIN Participants
Narrow
Network
Super CIN
Scaled
Infrastructure
Contract-specific
Services,
Participant
Agreement
Contract-specific
Agreement
Providers join together with additional
networks to expand their opportunities.
Providers seek contracting and services
support in contracting through interconnected,
CI companies
CIN / ACO Contract CIN Services Super-CIN
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Catalyst
Evolution of ACO Model
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• 5,000+ Medicare
beneficiaries
• One-sided risk
(share in up to
50% of savings,
not losses, not to
exceed 10% of
benchmark)
• Retrospective
attribution
• Reduce costs by
2.0 – 3.9% to
share in savings
2018 CMS ACOs
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Level of Risk, Financial Reward
MSSP Track 1
• 5,000+ Medicare
beneficiaries
• Two-sided risk:
-30% - +50%
• Prospective
attribution
• Reduce costs by
0.5 – 2.0% to
share in savings
MSSP Track 1+
• 10,000+ Medicare
beneficiaries
• Two sided risk
(choice of +-80% or
+-100%)
• Prospective
attribution
• First-dollar
savings (receive
what you save)
above/below
benchmark
• 4 payment options
from FFS to
capitation
Next Generation
ACO
Providers meet MIPS / MACRA requirements
669,000
3,200,000
4,900,000
7,300,000
7,700,000
477,197
9,000,000
10,500,000
~1,500,000
0
2000000
4000000
6000000
8000000
10000000
12000000
Pioneer
MSSP
MSSP
MSSP
MSSP
NextGen
MSSP
NextGen
MSSP
NextGen
2012 2013 2014 2015 2016 2017 2018
CMS Beneficiaries Per Year

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Health
Catalyst
Innovation and Transformation in Payment
“Secretary Azar and I are working for
competition and better value by moving away
from a fee-for-service approach, to a system
that is value-based – and that rewards value
over volume….
We also want to think about models that
create a true competitive market, where
providers compete for patients on the
basis of price and quality, and move the
government out of the business of setting
prices. And in all of our models we will also
make sure that our beneficiaries have
incentives to seek value when they obtain
care.”
Government officials are continuing a push for transformation
Seema Verma, CMS Administrator:
Speech at AHA Annual Membership Meeting; May 7, 2018
https://www.cms.gov/newsroom/fact-sheets/speech-remarks-cms-
administrator-seema-verma-american-hospital-association-annual-
membership-meeting
“It's also (the Centers for Medicare and
Medicaid Innovation’s) job to say to folks, 'If
you're not cutting it, get out of the way,'
because there are others that will come that will
cut it ... People will come in and take that risk
and do something with it…"
Adam Boehler, CMMI Director
Speech at the National Associations of ACOs (NAACOS); October 5, 2018
https://www.medpagetoday.com/publichealthpolicy/medicare/75542
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Catalyst
Pathways for Success – New Proposed Rule
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Source: Health Affairs, 2018

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Health
Catalyst
Are ACOs Successful?
Current Government Analysis Advocacy and External Analysis
2013-2015:
-$358 Million in Net
Shared Savings
Payments
(CMS saved money)
2013-2015:
-$541.7 in net Shared
Savings Payments
(CMS saved money)
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23. • Context: Historical and Today
• ACOs and CINs: The Basics
• Evolution of ACOs and CINs
• Key Components of Success:
What Has Not Changed
• Coming Next: What Has Changed
Agenda

24. © 2018
Health
Catalyst
Know Your End Goal
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….To A Contract-Based Focus…
“Meeting contractual requirements from commercial insurers, Medicaid and the
Centers for Medicare and Medicaid (CMS) related to dollars saved and quality
metrics upheld in the context of small but growing at-risk contracts, while remaining
successful in FFS contracts.” – Partners Healthcare
…To An Aspirational Long-Term Goal
“The science and art of preventing disease, prolonging life, and promoting
health through the organized efforts and informed choices of society,
organizations, public and private communities, and individuals.”
– C.-E.A. Winslow, Founder, Yale Department of Public Health
From The Pragmatic…
“The proactive management of the health of a given population by a defined
network of financially linked providers in partnership with community
stakeholders” -Chilmark Research

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Catalyst
Educate and Engage Physicians and Stakeholders
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Catalyst
Let The Patient Be Your Guide
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Health
Catalyst
A Framework for Transformation
PHM leadership lays groundwork for a
high-functioning analytic platform
Analytics leadership builds a structure
to identify and evaluate opportunities
Financial leadership balances risks and
helps set a sustainable course forward
Clinical leadership identifies and implements
appropriate changes in care delivery
KEY ACTIVITIES
1. Ensure baseline understanding of
current requirements, goals
2. Interview stakeholders for context
3. Assess available data to identify
quick wins, long-term focus areas
4. Synthesize and prioritize
opportunities
5. Plan for ongoing evaluation,
analysis
KEY ACTIVITIES
1. Align PHM with financial plans
2. Look to benchmarks to set expectations
3. Ensure you’re paid for value you provide
4. Pace utilization efforts carefully
5. Increase ability to understand true cost of care
KEY ACTIVITIES
1. Streamline your approach to quality
measures
2. Optimize care management
3. Shore up primary care infrastructure
4. Seek opportunities for inpatient
transformation
5. Ensure appropriate site of care
6. Develop patient engagement strategy
Near term
 Meet contractual requirements
in FFV contracts
 Remain successful
in FFS business
Long term
 Better quality of care
 Lower costs
 Stronger organization
 Healthier community
Create a Framework for Formulaic Success
1 2
3a
3b
KEY ACTIVITIES
1. Prioritize data sources, starting
with claims data
2. Educate stakeholders on the
available data
3. Define supporting logic—like
attribution
4. Invest in staffing
Transformative activities and investments that grow your ability to deliver the highest quality, most cost-effective, and most care for patients across the continuum
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28. • Context: Historical and Today
• ACOs and CINs: The Basics
• Evolution of ACOs and CINs
• Key Components of Success: What
Hasn’t Changed
• Coming Next: What Has Changed
Agenda

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Health
Catalyst
• Mix various types of contracts for overall strategic impact
o Shared Savings, PMPM bonus, Care Management PMPM, Bonus Fee Structure
• Depth in contracting operations, benchmarks, attribution
o Base benchmark upon clean, transparent historical data
o One source of claims data is one source. Understand or define attribution and
assignment across multiple payers.
• Define upfront expectations on quality measures
o Create simple slate of quality metrics across payers
o Be purposeful of definitions for trending and maintenance
A Shift to Purposeful, Aggressive Contracting
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• CINs and provider systems are starting health plans
• Compete and/or join with payers to support new clinic structures
• Mutual alignment between end goals allows partners to determine
who is most efficient at what operations
o Network Utilization
o Care Management Continuum
o Network Design, Products, and Services
o Member Services
• The Next Frontier: Renewed emphasis of employer-space with a lot
of innovation (Amazon, Berkshire, JP Morgan)
Increasing Payer-Provider Integration
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Enhanced Speed In Defining Impact Populations
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Catalyst
Ongoing Expansion of Medicaid Value Based Care
Source: Center for Healthcare Strategies
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Increasingly Sophisticated Data Components
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SDoH Data
Geomapping Data
Genomic Data
Wearable Data
PROMs Data

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Health
Catalyst
Evolving Care Management Models
• Care Management ‘team leads’ tailored to the types of patients they serve
• From RNs, to CHWs, to SWs, to MAs
• CM Management outsourcing solutions:
• AWVs to full-suite of services
• Digitization of Care Management:
o Patient Stratification with Machine Learning
o Risk Identification for targeted interventions
o Telemedicine
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35. Q&A

36. Thank You!