Specialty Payment Model Opportunities Assessment and Design

Transcription

1 Approved for Public Release. Distribution Unlimited CMS Alliance to Modernize Healthcare (CAMH) Specialty Model Opportunities Assessment and Design Cardiology Technical Expert Panel April 8, 2014 Washington, DC

2 Overview of the Day, Cardiology Delivery and Reform Framework 2

3 Agenda 3 Time Topic 8:30 9:00 Check-in 9:00 9:15 Welcome and Introductions 9:15 9:30 Overview of the Day, Cardiology Delivery and Reform Framework 9:30 10:30 DISCUSSION PERIOD: Management Category 1 (Population & Stable/Chronic Disease) Part 1 Primary Care-Focused Model(s) 10:30 10:45 BREAK 10:45 11:45 DISCUSSION PERIOD: Management Category 1 (Population & Stable/Chronic Disease) Part 2 Cardiology-Focused Model(s) 11:45 12:15 LUNCH 12:15 1:15 DISCUSSION PERIOD: Management Category 1 (Population & Stable/Chronic Disease) Part 3 Team-Focused Model(s) 1:15 2:15 DISCUSSION PERIOD: Management Category 2 (Acute Episode) 2:15 2:30 BREAK 2:30 3:30 DISCUSSION PERIOD: Management Category 3 (Complex Care) 3:30 4:00 RAND High Level Overview 4:00 4:25 TEP Review 4:25 4:30 Concluding Remarks 4:30 Adjourn

4 Project Overview 4 Comprehensive scan of the payment model environment. Inclusion of ideas and opinions from a broad range of interested stakeholders regarding opportunities for novel payment models in cardiology. Insightful analysis and assessment of the opportunities for novel payment models identified. Collaboratively designed payment models for CMS. Development of medical specialty payment model options that can be realistically executable in CMS s current business environment.

5 Project Overview 5 Project Timeline Environmental Scan Technical Expert Panel Model Design Model Simulation

6 6 Environmental Scan Methodology The project team conducted a comprehensive environmental scan: 1) literature review of the existing peer-reviewed and grey literature and popular media 2) 39 semi-structured strategic stakeholder interviews Stakeholders included academic researchers, providers in community and academic settings, payers, patient advocates, and heads of specialty organizations, among others. Following each recorded interview, comprehensive notes were then summarized by research team member.

7 7 TEP Goals Provide input on how to best design an alternative approach based on the following elements: Care delivery reform reform Requirements for providers Feasibility Potential barriers

8 Moving Towards Greater Coordination 8 Current Goal Other Specialists Radiologist Primary Care Physician Cardiac Surgeon Primary Care Physician Other Specialists Patient Cardiologist Cardiologists Patient Radiologist Cardiac Surgeon

9 9 Model Framework Population & Stable/Chronic Disease Management Primary Care-Focused Patient Centered Medical Home (PCMH) Accountable Care Organization (ACO) Medical Neighborhood ACO including Cardiologists Cardiology-Focused Add-on Shift to Person-Level (Case or Episode) Shared Savings Capitation Team focused Add-on Shift to Person-Level (Case or Episode) Shared Savings Capitation Acute Episode Management Major Procedures Partially-Bundled Bundled Major Disease Events Partially-Bundled Bundled Complex Care Management

10 10 Reforms in Cardiology Shifting Away from FFS Bundling/ Aggregation Across Providers Comprehensive Capitated ACO with Cardiology ACO Episode for Physician and Hospital Services (Acute Episode) Episode for Physician and Other Services (Stable/Chronic Disease) Add-on for a Team Traditional FFS Add-on for PCP or Individual Specialist Partial case-based physician payment Case-Based Physician

11 Model Framework 11 Current Model FFS s for Cardiology Care s for All Other Care Add-on FFS s for Cardiology Care Addon s for All Other Care If efficiency improves FFS s for Cardiology Care Addon s for All Other Care Shared Savings FFS s for Cardiology Care Shared Savings s for All Other Care Person- Level Physician (Case or Episode Based) FFS s for Cardiology Care Shift to Person- Level s for All Other Care Total Cost of Care

12 Questions for Alternative Model Discussions 12 What should the structure of the payment models be? Which patient populations should be included in the models? How do models improve care coordination between providers, particularly PCP and Cardiologists? How do the models improve appropriate use of diagnostics, procedures, and/or other treatments? How do the models promote efficiency in care delivery? How should site of service payment differentials be addressed? What data and infrastructure improvements are necessary for the models to succeed? What quality measures are needed with the models? What are the key barriers to implementing the various models, especially for smaller practices and those in underserved areas? How feasible are the models in the short term and longer term?

13 13 DISCUSSION PERIOD: Population & Stable/Chronic Disease PART 1 Primary Care-Focused

14 Primary Care-Focused Model(s) 14 Primary Care Only No direct incentives or financial support for coordination with cardiologists/specialists Savings through direct actions of PCPs Selective referral/engagement with specialists who reinforce the goals of the APM Models PCMH ACO Examples Iora Health MA Blue Cross Blue Shield (Alternative Quality Contracts) Primary Care + Cardiology Some segment of specialist payment is based on quality and possibly efficiency of care Cardiologists also share in overall savings with quality improvement Models Medical Neighborhood ACO with Cardiology Examples Blue Cross Blue Shield of Michigan Physician Group Incentive Program Blue Cross Blue Shield of Florida ACO Program

15 Primary Care-Focused Framework: PCMH 15 Current Model FFS s to Primary Care Physicians s for All Other Care (Including Cardiology) PCMH Models FFS s to Primary Care Physicians Case Mgmt. Fee s for All Other Care (Including Cardiology) FFS s to Primary Care Physicians Case Mgmt. Fee and Partial Person-Level s for All Other Care (Including Cardiology) Total Cost of Care

16 Primary Care-Focused Framework: ACO 16 Current Model FFS s to Primary Care Physicians s for All Other Care (Including Cardiology) Total Physician ACO Models FFS s to Primary Care Physicians Shared Savings Total Physician s for All Other Care (Including Cardiology) Global + Shared Savings to Primary Care Physicians s for All Other Care (Including Cardiology) Total Cost of Care

17 Primary Care-Focused Framework: Medical Neighborhood 17 Current Model FFS s to Primary Care Physicians FFS s to Cardiologists s for All Other Care Total Physician Medical Neighborhood Models FFS s to Primary Care Physicians Case Mgt Fee to PCP Total Physician FFS s to Cardiologists Case Mgt Fee to Cardio s for All Other Care FFS s to Primary Care Physicians Case Mgt Fee to PCP and Partial Person-Level FFS s to Cardiologists Case Mgt Fee to PCP and Partial Person-Level s for All Other Care Total Cost of Care

18 Primary Care-Focused Framework: ACO with Cardiology 18 Current Model FFS s to Primary Care Physicians FFS s to Cardiologists s for All Other Care Total Physician ACO Models FFS s to Primary Care Physicians Shared Savings Total Physician FFS s to Cardiologists Shared Savings s for All Other Care Global + Shared Savings to Primary Care Physicians Global + Shared Savings to Cardiologists s for All Other Care Total Cost of Care

19 DISCUSSION 19 What can we learn from the current PCMH/Medical neighborhood/aco experience? What are the potential advantages for stakeholders (e.g., clinicians, patients, others)?: What conditions within cardiology can be primarily managed by a PCP? How can the models support improved coordination between primary care and cardiology? How can models improve appropriate use of diagnostic testing and/or procedures? What data and infrastructure improvements are necessary for the model to succeed? How and when should quality metrics be integrated into this model?

20 20 DISCUSSION PERIOD: Population & Stable/Chronic Disease PART 2 Cardiology-Focused

21 Cardiology-Focused Model(s) 21 to cardiologists only Models Add-on payment for quality infrastructure such as team care, registry, decision support, data capabilities Shifting FFS payments to person-level payment tied to quality (episode or case payment) Shared Savings Capitation Examples Highmark Blue Cross Blue Shield of Delaware: for EHR infrastructure and guideline adherence SMARTCare: for provider decision support tools, patient engagement tools and EHR capabilities

22 Cardiology-Focused Model Framework 22 Current Model FFS s to Cardiology s for All Other Care Total Physician Add-on FFS s to Cardiology Add-on s for All Other Care Person- Level Physician (Case or Episode Based) Total Physician FFS s to Cardiology Shifting FFS Total Physician Add-on s for All Other Care Shared Savings FFS s to Cardiology Shifting FFS Shared Savings s for All Other Care Total Physician Capitation Full Capitation s for All Other Care Waste and Total Cost of Care

23 DISCUSSION 23 How broadly can these payment reforms apply in cardiology should some areas remain FFS? How much should payment reform depend on add-on fees, which types, and what is the evidence that such fees are sufficient to reduce costs? What diagnoses lend themselves to increased financial accountability through partial case-based or bundled payments? How should populations be identified for inclusion in cardiologist-led models? Should triggers be based on diagnosis (CHF, A Fib, CAD), and which ones, or should payments be population based? What are the biggest opportunities for improving appropriateness of care and efficiency? What data and infrastructure improvements are necessary for the model to succeed? What quality measures are necessary in conjunction with payment reforms? How can barriers to reform be addressed: lack of data and uncertainty about impact of care reforms, differences in patient mix that might be addressed through risk adjustment, etc.?

24 24 Population & Stable/Chronic Disease PART 3 Team-Focused

25 25 Team-Focused Model(s) Multi-disciplinary team of cardiac care providers for patient assessment and evidence-based care plan Models Add-on payment for care plan Shifting FFS payments to person-level payment tied to quality Shared Savings Capitation Examples STS Heart Team Others (IHS, Multispecialty groups)

26 Team-Focused Model Framework 26 Current Model FFS s to Team Members s for All Other Care Total Physician Add-on FFS s to Team Members Add-on s for All Other Care Person- Level Physician (Case or Episode Based) Total Physician FFS s to Team Members Shifting FFS Total Physician Add-on s for All Other Care Shared Savings FFS s to Team Members Shifting FFS Shared Savings s for All Other Care Total Physician Capitation Full Capitation for Team-based Cardiac Care s for All Other Care Waste and Total Cost of Care

27 DISCUSSION 27 What are the clinical opportunities where the team model would be most applicable? What would trigger referral to the team for each clinical condition? Who should be included in team payment for CAD, CHF, and A Fib? What payment structure is best to support the team model? Is an upfront payment needed? Can a portion of FFS payments be shifted to the team payment? How could shared savings be included? How would the payment be disbursed among the team members? What is the team required to do in order to receive the payment and how would this be documented? How does the team model apply to smaller practices? How could this model complement existing models, such as ACOs, PCMHs, and Bundled payments? What data would be necessary to design this model? What quality measures are necessary? Is there a role for this model in the care of complex cardiac patients with multiple co-morbidities?

28 Management Category 2: Acute Episode 28

29 Acute Episode 29 s for major cardiovascular events and procedures to include entire care team Most of the work in this area focuses on discrete cardiac procedures (PCI, CABG, etc) Limited application to major clinical events such as AMI or CHF exacerbation Include coordination with stable models to encourage prevention and volume control Model Bundled Examples Geisinger Health System [ProvenCare] Acute Care Episode (ACE) Demonstration Bundled s for Care Improvement (BPCI)

30 Acute Episode Framework: Bundled 30 Current Model FFS s to Physicians s for All Other Care Total Physician Partial Bundled FFS s to Physicians Bundled to Providers s for All Other Care Total Physician Bundled Bundled to Providers s for All Other Care Total Cost of Care

31 DISCUSSION 31 What opportunities are there to expand bundled payments beyond discrete procedures? How can the models support improved coordination between acute and post-acute care? How do the models ensure appropriateness of procedures? What data and infrastructure improvements are necessary for the model to succeed? What quality measures are necessary in conjunction with payment reforms? What are the barriers to implementing the various alternative payment models? What is the practicality of these reforms?

32 Management Category 3: Complex Care 32

33 Complex Care Model(s) 33 Model(s) Increase financial support for specialists working with other providers to improve care and reduce costs for beneficiaries with complex medical conditions Cover period of time corresponding to specialists long term involvement with management Clinical scenario(s) Higher intensity beneficiaries Transitions in care between settings Multiple clinician management Period of instability or complexity that requires more than a single specialty or primary care practitioner Examples The Coleman Care Transitions Intervention - Eric Coleman, MD, MPH Dual Eligible Integrated s

34 Complex Care Environment 34 Stable/Chronic Complex Diseases Pre- Diagnosis Hospitalizations and/or Procedures Transition Management Complex Care Management Acute Episodes/Events

35 35 Clinical Example Hypothetical Patient: Diabetic patient Stage 2b breast cancer survivor Recently evaluated for chest pain Newly diagnosed with ongoing renal insufficiency (in addition to continuing cardiac symptoms) E.g., focus on top 5% of Medicare beneficiaries Account for almost half of total health care spending Almost 1/3 have 3 or more chronic conditions

36 DISCUSSION 36 What are the clinical opportunities in the area of managing patients with multiple specialists and multiple care settings? What patient populations should be included, and how can they be identified to apply complex care payment reforms? What are the important considerations in assigning responsibility of care (e.g., co-managing specialists and/or PCP)? Are there models of care or potential pilots which could be implemented in community-based setting (e.g., non-integrated or capitated systems) How would accountability for drug utilization be factored into the payment model? What data and infrastructure improvements are necessary for the model to succeed? What quality measures should be assessed to ensure safe and effective care? Where are there the greatest opportunities for success and feasibility? What are the barriers to implementing this type of model?

37 37 The RAND Corporation High Level Overview

38 TEP Review 38