TEXAS INSTITUTE OF HEALTH CARE QUALITY AND EFFICIENCY

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1 TEXAS INSTITUTE OF HEALTH CARE QUALITY AND EFFICIENCY Jimmy Blanton, Director Larissa Estes, Policy Analyst PRESENTATION OBJECTIVES To learn about statewide efforts to address health care quality and efficiency To learn how to actively engage in health care quality and efficiency dialogue in Texas through the Institute of Health Care Quality and Efficiency

2 TIHCQE: PURPOSE Improve health care quality, accountability, education, and cost containment in Texas Texas Health and Safety Code: Sec TIHCQE: CONTEXT Healthcare VALUE, how are we doing? VALUE = Outcomes + Satisfaction Cost

3 TIHCQE: CONTEXT The U.S. healthcare system has experienced rapid growth in the amount of resources it consumes to deliver care: Health care expenditures now account for 18% of GDP, compared to 5% in 1960 and 9% in 1980 Health care has become the largest industry in the United States In the State of Texas, since 1990, health care spending is growing more than twice as fast as the rest of the state budget TOTAL HEALTH EXPENDITURE GROWTH PER CAPITA

4 TIHCQE: CONTEXT More spending hasn t necessarily translated to similar increases in quality or outcomes: Prevailing evidence shows an inconsistent relationship between higher cost care and better patient outcomes; and both cost and quality vary widely across the U.S. According to reporting by the Agency for Healthcare Research and Quality (AHRQ), the overall quality of healthcare in the U.S. remains suboptimal and the pace of improvement has been slow The Institute of Medicine reports that: American health care is falling short on basic dimensions of quality, outcomes, costs, and equity. THE NEED FOR CHANGE

5 THE NEED FOR CHANGE THE NEED FOR CHANGE Mortality Rate (per 100,000) Cause of Death US Peer Countries U.S. Rates Above Average Cardiovascular Neuropsychiatric Respiratory Disease Infectious & Parasitic Diabetes Perinatal Conditions Unintentional Injuries Intentional Injuries U.S. Rates at or Below Average Malignant Neoplasm Digestive Diseases Respiratory Infections

6 THE NEED FOR CHANGE While the length of life has improved in the United States, other countries have gained life years even faster, and our relative standing in the world has fallen over the past half century. Harvey V. Fineberg President, Institute of Medicine Robert M. Hauser Executive Director, Division of Behavioral and Social Sciences and Education, National Research Council Potential Gains If TEXAS improved its performance to the level of the bestperforming state for this indicator, then: Adult Preventive Care 866,089 more adults (age 50 and older) would receive recommended preventive care, such as colon cancer screenings, mammograms, pap smears, and flu shots at appropriate ages. Diabetes Care 504,948 more adults (age 18 and older) with diabetes would receive three recommended services (eye exam, foot exam, and hemoglobin A1c test) to help prevent or delay disease complications. Childhood Vaccinations 84,364 more children (ages months) would be up-to-date on all recommended doses of five key vaccines. Adults with a Usual 3,012,775 more adults (age 18 and older) would have a usual source of care to help ensure that care is coordinated Source of Care and accessible when needed. Children with a Medical 1,255,030 more children (ages 0 17) would have a medical home to help ensure that care is coordinated and Home accessible when needed. Preventable Hospital 60,132 fewer hospitalizations for ambulatory care sensitive conditions would occur among Medicare beneficiaries Admissions (age 65 and older) and $408,595,206 dollars would be saved from the reduction in hospitalizations. Hospital Readmissions 17,306 fewer hospital readmissions would occur among Medicare beneficiaries (age 65 and older) and $243,610,186 dollars would be saved from the reduction in readmissions. Hospitalization of 10,714 fewer long-stay nursing home residents would be hospitalized and Nursing $88,207,043 dollars would be saved from the reduction in hospitalizations. Home Residents Mortality Amenable to 5,028 fewer premature deaths (before age 75) would occur from causes that are potentially treatable or Health Care preventable with timely and appropriate health care. Source: Aiming Higher Results from a State Scorecard on Health System Performance, 2009, The Commonwealth Fund, October 2009 Page 12

7 Key Challenges Delivery or Payment Systems? You need both Integration of Data Systems Timely collection, analysis and dissemination Creating a learning environment Information quality improvement and measuring progress Sharing best practices in data collection and analytics Page 13 TIHCQE: HISTORY The Texas Institute of Healthcare Quality and Efficiency: Established by Article 3 of S.B. 7 (82nd Regular Legislature, First Called Session, 2011) Now known as Chapter 1002 of the Texas Health and Safety Code Governed by a board of 15 directors appointed by the Governor Membership on the Board includes healthcare providers, payers, administrators, attorneys, experts, and others Makes recommendations to improve the value of health care in this state

8 TIHCQE: VOTING MEMBERS Steven M. Berkowitz (Chair) Joel Allison, MS Patrick M. Carter, MD Thomas Feeley, MD Alexia Green, RN, PhD Robyn Jacobson John Joe, MD, MPH, FAAP Ronald Luke, JD, PhD Elena Marin, MD Beverly Nuckols, MD, FAAFP Steve Nguyen, OD Thomas Quirk Shannon Stansbury, MBA, FACHE Alan Stevens, PhD Susan Strate, MD, FCAP TIHCQE: EX OFFICIO REPRESENTATION

9 TIHCQE: STAKEHOLDER INVOLVEMENT Stakeholder groups providing testimony: Texas Medical Association Texas Hospital Association Texas Association of Health Plans TMF Health Quality Institute Society of Professional Benefit Administrators Advocacy groups Castlight Health Representatives from public and private national, state, and local health data programs Health researchers from academic and other institutions TIHCQE: RESPONSIBILITIES General Responsibilities of the Institute: Institute is charged with issuing recommendations in three general areas: Improving the quality and efficiency of healthcare delivery Improving the reporting, organization, and transparency of healthcare information Supporting the implementation of innovative healthcare collaborative payment delivery systems

10 IHCQE: FIRST 24 MONTHS A Committed Board 11 Full Board Meetings Over 30 Work Group Meetings Active Support from Ex Officio Agencies Active Stakeholders - Robust Forum for Discussion Organizational Infrastructure Institute Vision, Mission, and Values Work Group Structure Website Launch Subject Matter Expert Resources Staff synergy within across HHSC and HHS Enterprise TIHCQE: INITIAL LEGISLATIVE CHARGE Assess health related data collected by the state and develop a plan for enhancing the transparency and benefit of this data Study the feasibility and desirability of establishing an all payer claims database (APCD) Recommend actions to promote consumer driven health care Study methods for improving the availability of information on amounts accepted as payment in full, including by requiring providers to post the amounts publicly and adhere to the posted amounts Identify key measures for reporting health care quality and efficiency and make recommendations for recognizing health care facilities for exemplary performance

11 TIHCQE: INAUGURAL RECOMMENDATIONS FRAMEWORK Business Intelligence: Leverage resources, technology, and data to support improved decision and policy making in the health care system Collaboration: Foster increased collaboration between state health data programs, major academic centers, and other public and private researchers Patient Activation: Increase consumer engagement in health care decision making and improve transparency in the health care system TIHCQE: INAUGURAL RECOMMENDATIONS Expand public reporting of health outcomes measures at the facility level That which is measured, tends to improve. That which is measured publicly, tends to improve faster Improve collaboration in the analysis and use of health data between state and local health programs, academic institutions, community groups, foundations, public and private healthcare providers, and other stakeholders involved in quality improvement research Possible activities include: data collection and sharing, research design, outcomes analysis, and support for the spread of evidence based practices

12 TIHCQE: INAUGURAL RECOMMENDATIONS Build on current state health data collection efforts Begin with the collection of data from hospital emergency departments to allow for better reporting and analysis of potentially preventable events Integrate and maximize the use of existing state health data resources By supporting development of an integrated warehouse of key health care data, improving the THCIC master patient index (MPI), facilitating data sharing, accommodating the collection of clinical data elements, and speeding the release of information into the public domain Support a voluntary public/private collaboration for obtaining additional data on the commercially insured population As a collaborative public/private partnership alternative to an all payer claims database (APCD) with mandatory reporting requirements TIHCQE: INAUGURAL RECOMMENDATIONS Authorize ERS to develop and offer a consumer directed health plan (CDHP) as an option in the state employee benefit package A CDHP is a health plan with a high deductible and a tax preferred health savings account In theory, CDHPs incentivize consumers to become more engaged in choosing cost effective treatments and providers A CDHP should be implemented as an additional health plan option for state employees and should not replace current offerings The CDHP should be combined with tools that increase transparency of the quality and cost of health care services available to employees Authorize ERS and TRS to implement cost effective incentives for employees to participate in disease management / wellness programs

13 TIHCQE: PRICE TRANSPARENCY Options to improve price transparency (amounts accepted as payment in full) : All-payer claims database Public reporting by hospitals and other health providers and adherence to the posted amount Public reporting by providers of an average price for select, standardized bundles of services Prohibiting the practice of balanced billing Making additional information available upon request through health insurers Prohibiting certain kinds of contract clauses Promoting private transparency vendors and tools TIHCQE: INAUGURAL RECOMMENDATIONS Promote Smart Transparency rather than require providers to publicly post the amounts they accept as payment in full by: Ensuring that consumers understand their rights to request information on expected out of pocket costs, treatment outcomes, and lower cost provider alternatives Shortening the time allowed for facilities, physicians, and health plans to provide estimates of charges and expected out-of-pocket costs Encouraging that estimates are provided by secure electronic communications when possible upon a consumer s request Generally promoting efforts in the private sector to increase transparency on health care quality, costs to the consumer, outcomes of care, and patient safety Develop a consumer-friendly website to engage consumers and help them navigate available information on the quality and efficiency of health care

14 TIHCQE: STRATEGIC PLAN Vision: Optimal health and well being for all Texans Mission: To serve as a catalyst for improved and sustained health care quality, accountability, education, and cost containment in Texas Values: Collaboration Diversity Equity Evidence-based Innovation Integrity Transparency Trust TIHCQE: HIGH LEVEL PRIORITIES Do no harm. Efforts to promote efficiency in the health care system should not impede the medical innovation that has been a wellspring for raising the quality and length of life Reduce unnecessary and low value health care spending. Efforts to bend the health care cost curve should begin by increasing transparency about low-value care and administrative processes Improve the prevention and management of chronic disease, with particular focus on people whose conditions are medically complex. Medical treatments for chronic diseases that often can be prevented, delayed, or better managed, have become the primary driver of health expenditure in Texas and the rest of the U.S.

15 TIHCQE: STRATEGIES THAT WORK Activating Patients Choosing Wisely, health literacy Engaging Providers Best practices Promoting Collaborative Care Focusing on complex cases Measuring Performance Counting what counts Rewarding Outcomes Promoting value over volume Reducing Administrative Complexity A leading cause of waste Continuously Improving Quality Every process at all times Reducing Preventable Events Not just an issue for hospitals Investing in Population Health Health care alone is not enough A TIHCQE: WORK GROUPS Measurement and Analytics B Provide recommendations to improve data collection, analysis, sharing, and reporting Developing shared analytical resources with stakeholders Determining the outcome measures that are the most effective measures of quality and efficiency* Meaningful use of electronic health records* * Statutory obligations; statute available upon request Best Practices and Patient/Stakeholder Engagement Provide recommendations on the research, development, support, and promotion of strategies to improve the use of best practices and engagement of patients and stakeholders Reduce the incidence of PPEs Identify evidence-based, best / promising practices and cost-benefit assessments Informing stakeholders and patients about health care quality and efficiency Promoting patient activation strategies

16 C TIHCQE: WORK GROUPS Delivery System Innovation and D Productivity and Process Improvement Improvement Provide recommendations based on research of innovative delivery and reimbursement systems Implementing and supporting collaborative payment and delivery systems under Chapter 848 Insurance code Quality-based payment systems* Alternative health care delivery and payment* Evaluate HCC effectiveness* Provide recommendations to promote productivity through workforce development, better use of technology, and process improvement Enhance health professions training and education in Texas Reduce administrative burdens Promote innovations in the organization of health care practice Leverage electronic communications, telemedicine, and other technologies * Statutory obligations; statute available upon request TIHCQE: 2014 RECOMMENDATION TOPICS Serious and persistent mental illness (SPMI) Health Literacy Administrative Simplification Promoting Value-Based Care Expanded Access to Care

17 SPMI SPMI is responsible for large expenditures by the Texas Medicaid Program FY12 Medicaid spent approximately $400 million on the treatment of organic and other psychotic conditions Does not include pharmaceutical costs Need for better data and analysis to guide managed care organizations in the integration of behavioral health services into Medicaid IHCQE is partnering with the Meadows Mental Health Policy and Research Institute to Create a comprehensive data base to describe the service utilization patterns for the SPMI population in Texas Determine current and best practices for serving the SPMI population Develop recommendations regarding policies and practices for improving care in the SPMI population HEALTH LITERACY Nearly 9 out of 10 adults have difficulty using the everyday health information that is routinely available in our health care facilities, retail outlets, media, and communities Health literacy is estimated to cost the nation $106-$236 billion annually Uninformed and misinformed consumers are unlikely to meet the shared responsibility expectations placed on them by providers and payers IHCQE is looking to support recommendations related to the Integrate health literacy through continuing education, provider/payer initiatives, Texas education system Implementation of the 10 attributes of a health literate organization

18 ADMINISTRATIVE SIMPLIFICATION How do we direct a greater percentage of the health care dollar to direct care and away from complex, redundant, low value administrative processes? Senate Bill 1150 Provider Protection Plan Streamline payment and reimbursement; prompt and adequate adjudication of claims Prompt credentialing Uniform efficiency standards and requirements for preauthorization IHCQE is looking to support recommendations that Support state s efforts to implement Provider Protection Plan Determine applicability of administrative simplification in Medicaid to commercial payers PROMOTING VALUE BASED CARE Medicaid is moving from fee-for-service to Managed Care While Managed Care Organizations (MCOs) are paid on a continuum of value-based care, providers are still being reimbursed using a fee-forservice model Variability in payment for MCOs makes it difficult to implement payment innovations IHCQE is looking to support recommendations that Encourage MCOs to extend value-based payment to Medicaid providers Change process for setting capitation payments to MCOs to reduce or eliminate unexpected reductions in capitation payments to MCOs Reward MCOs for achieving lower total medical costs rather than penalize MCOs by reducing future payments

19 EXPANDED ACCESS TO CARE According to the most recent BRFSS, 36% of Texans ages are uninsured State needs to better understand who lacks insurance, why they lack insurance and how the uninsured currently access health care services IHCQE is looking to support recommendations that Establish health homes for the care coordination of high risk, high cost patients Expand health insurance options Reform reimbursement for quality not quantity Implement best practices from the 1115 Medicaid Transformation Waiver that increase access to quality and timely care and reduce costs TIHCQE: TIMELINE FOR RECOMMENDATIONS Current Draft recommendation language August 14, 2014 Board review and consider proposed recommendations August October 2014 Draft recommendations report and legislative/stakeholder engagement November 12, 2014 Board review and consider final recommendations to the 84 th Legislature Stakeholder Engagement Opportunities Public comment at meetings Written feedback Invited presentations

20 TIHCQE: NEXT MEETING August 14, :00 am 3:00 pm University of Texas at Austin Thompson Conference Center, Room Featured Speakers Dr. Clay Johnston, Dean UT Dell Medical School Dr. Richard Migliori, Chief Medical Officer UnitedHealth Group Meeting materials available at Thank You! Jimmy Blanton Director Phone: Larissa Estes Policy Analyst Phone: Website