The Importance of Quality Measurement in a Bundled Payment Environment. Woody Eisenberg, MD Senior Vice President, PQA

Transcription

1 The Importance of Quality Measurement in a Bundled Payment Environment Woody Eisenberg, MD Senior Vice President, PQA

2 BUNDLED PAYMENTS FOR CARE IMPROVEMENT INITIATIVES Episode Services included in the bundle Model 1 Model 2 Model 3 Model 4 All acute patients, all DRGs All Part A services paid as part of the MS-DRG payment Selected DRGs, hospital plus postacute period All non-hospice Part A and B services during the initial inpatient stay, post-acute period and readmissions Selected DRGs, post-acute period only All non-hospice Part A and B services during the postacute period and readmissions Selected DRGs, hospital plus readmissions All Part nonhospice A and B services (including the hospital and physician) during initial inpatient stay and readmissions Payment Retrospective Retrospective Retrospective Prospective Quality Measures????

3 Implementing Quality Measurement The bundled care approaches to improving value do not currently work by providing payments based on assessed value using performance measurements. Bundled payment methods require robust quality measurement both to guard against potential adverse effects of bundled payment, such as stinting on care or avoiding sicker patients, and to provide tools for quality improvement and pay-for-performance. 7

4 Medicare s Payment Strategy For ESRD Embraces Bundled Payment and P4P To Cut Costs Date Payment Initiative Result 1972 Medicare institutes FFS coverage for dialysis, drugs, labs, ancillary services Composite rate services: nursing, dietary, clinical, equipment and supplies, social services, and certain laboratory tests and drugs Volume, intensity and cost of services spiral spectacularly over 2 decades Continued increases in costs 1991 FFS extended to erythropoietins Use increases dramatically $3.1B in FDA issues warning regarding health risks for use of erythropoietins 2011 Composite rate services Separately billable (Part B) injectables ESRD-related laboratory tests Selected ESRD Part D drugs(erythropoietins) Use declines bundled payment rate reduced by up to 2 percent for facilities that do not achieve or make progress toward specified

5 Performance Measures in the Final ESRD Pay-for-Performance rule Percentage of Medicare patients with: average hemoglobin levels of less than 10 grams per deciliter; average hemoglobin levels of greater than 12 grams per deciliter; and average post-dialysis urea reduction ratios of greater than 65 percent. Result: most dialysis units today meet these quality measures and the use of erythropoietin has declined

6 Challenges to the Successful Diffusion of the ACO Model and Approaches to Overcoming Them (Fisher, NEJM 2011) Challenge Providing timely and useful data Overcoming transition costs Gaining consumer support Learning what works; using that knowledge to inform policy and practice Clarifying the path forward Approach Payers provide ACOs with patient-level data to support care management. Quality measures used for accountability are also useful for care improvement. Use quality-related payments to support needed ACO investments. Provide up-front funding options for provider groups that need them. Adopt performance measures that are more meaningful to consumers. Support consumer choice and allow consumers to share savings as well. Develop and test multipayer or all-payer ACOs where possible. Track and evaluate both public and private ACO implementation. Create meaningful alternatives to FFS Measure effect on overall quality and cost in all payment reforms

7 How do you build quality measures? NQF Evaluation Criteria Importance High impact Opportunity for improvement / gap in care Evidence to support measure focus Scientific Acceptability Reliability Validity Usability Meaningful and understandable Public reporting/quality improvement Feasibility Data are available and retrievable without undue burden Unintended consequences Related or competing measures Harmonization

8 Measure Set for evolving models of care

9 Complimentary Medication Use Measures

10 Three condition-level framework questions for measure development 1. Is the condition chronic in nature, or is it an acute hospital-based condition? 2. Are there medical care quality measures relating to this condition that are likely to be impacted by pharmaceutical use, and are these quality measures being mandated by payers? 3. How large a role do pharmaceuticals play in the cost of treating the condition? What is their share of the overall costs, and to what extent are medical cost offsets possible from appropriate pharmaceutical use?

11 Two Chronic Condition Examples Condition Heart failure Rheumatoid Arthritis Conditi on Type Chronic, Hospital Rx Focus Outpatient Rx Impact on Quality? Receiving B-blocker Rx; % of patients requiring re-hosp Chronic Outpatient Receiving Rx; Functional Status Quality measure in CMS bundle? Yes; Rx written Rx Share of cost? Low Cost offset from Rxs? Impact rehospitaliz ation No High Unknown

12 Why Pharmacists Should be included in bundled care quality measurement Most bundled care products involve medications for chronic conditions Assessment of medication effectiveness and efficiency is key Pharmacists are the key professionals for: Performing comprehensive therapy reviews of prescribed and self-care medications Resolving medication-related problems optimizing complex regimens Monitoring adherence recommending cost-effective therapies Fulfilling medication use performance measures 1. Smith, et. al. HEALTH AFFAIRS 29, NO. 5 (2010):

13 PROMETHEUS*: a performance-based bundled payment programs Assigns evidence-based case reimbursement rates (ECRs) to common conditions A single ECR covers all inpatient and outpatient care associated with a given condition A quality score ties outcomes, treatment complications, and patient satisfaction to bundled reimbursement - ensures that providers are held financially accountable for inappropriate care and patient dissatisfaction - results may be reported back to providers for use in quality improvement and may be used to add performance-based bonuses or penalties to the bundled payment amounts. - incentives can account for as much as 10% to 20% of the total bundled payment - publicly reported provider rankings based on quality and patient satisfaction scores *Provider payment Reform for Outcomes Margins Evidence Transparency Hassle-reduction Excellence Understandability and Sustainability

14 Challenges Implementing the PROMETHEUS Bundle Model Implementation Challenge Defining Bundles Defining payment model Implementing Quality Measurement Determining Accountability Engaging Providers Delivery Redesign Pilot Site Experience ECR defined based on own experience Chicken (care re-engineer and quality measures) or egg (payment) first? EHR crucial, but implementation of electronic measures is time and resource intensive How to determine accountability and payment; leakage of patients beyond their system Frontline Physicians still skeptical Where do bundles fit in with FFS, ACOs, PCMH?

15 Geisinger s ProvenCare Physicians agree to follow 40 preoperative, perioperative, and postoperative treatment guidelines in exchange for a flat rate of reimbursement Quality Improvement Indicators (as opposed to Performance Measures) monitor guideline adherence - Process measures - Internal quality improvement indicators for rapid cycle improvement - Not publicly reported Performance Measure tied to reimbursement

16 ProvenCare Components Patient-centricity Appropriate care Evidence/consensus-based best practices Highly reliable care Optimized work flows Explicit accountabilities Packaged pricing Performance-based reimbursement "Warranty (patient satisfaction)

17 Proven Care Benchmarks (selected benchmarks for CV surgery) Preadmission documentation Operative documentation Post-Operative patient documentation Discharge documentation - Discharge medications (e.g., beta-blocker) - Discharge medication: aspirin - Discharge medication: statin Post-Discharge documentation - Patient correctly taking beta-blocker? - Patient correctly taking aspirin? - Patient correctly taking statin? - Patient correctly administering anticoagulant?

18 Conclusions With the rapidly changing health care environment, payers and policy makers are increasingly interested in payment models that reward quality and patient safety In order to achieve quality and cost goals, accountable systems of care need to consider medication management and might formally include Pharmacists on the care team Pharmacists will need to demonstrate the value they add to accountable care systems A core set of pharmacy quality measures can be built to compliment existing clinical quality measures, with an eye toward expanding this as gaps are identified

19 BUNDLED PAYMENTS FOR CARE IMPROVEMENT INITIATIVE Episode Services included in the bundle Model 1 Model 2 Model 3 Model 4 All acute patients, all DRGs All Part A services paid as part of the MS-DRG payment Selected DRGs, hospital plus postacute period All non-hospice Part A and B services during the initial inpatient stay, post-acute period and readmissions Selected DRGs, post-acute period only All non-hospice Part A and B services during the postacute period and readmissions Selected DRGs, hospital plus readmissions All Part nonhospice A and B services (including the hospital and physician) during initial inpatient stay and readmissions Payment Retrospective Retrospective Retrospective Prospective Quality Measures TBD TBD TBD TBD

20 Questions? Contact info: Woody Eisenberg