Transformational Payment Reform: How will FQHC s survive?

Transcription

1 Transformational Payment Reform: How will FQHC s survive? Arthur Chen, MD Senior Fellow/Family Practice Asian Health Services Oakland, CA artc@ahschc.org

2 Learning Objectives Familiarity with major Payment Reforms Traditional Value-based/outcomes Alternative Payment Models Impact/Survival Approaches that will support our transition Leadership Challenge Capturing the best of what we do Beefing it up if you can (high performance culture and Redesign) Risk Adjustment Issues Data-to-Action Capacity (EMR??? HIT?) Key Documentation Elements Back to our Roots of Community Engagement

3 Triple Aim Don Berwick Patient Centered --better care for individuals Cost-Effective reduced per capita costs better health for populations

4 Population Health the health outcomes of a group of individuals, including the DISTRIBUTION of such outcomes WITHIN the group (Kindig and Stoddart 2003). Includes TOTAL Population Health defined by geographic areas Recognizes HEALTH DISPARITIES/INEQUITIES

5 Population Health Population health improvement is conditional on a health-promoting societal context. Characterized by a culture in which healthy behaviors are the norm and in which the institutional, social and physical environment support this mindset. Achievement of this ambition will require a positive, holistic, eclectic and collaborative effort, involving a broad range of stakeholders Davies SC, Lancet 4/2/14; 384:

6 Traditional Physician Payment Models FFS Fixed Payment Capitation Bundling Other Salary Medicare FFS SGR Incentives for Performance (P4P)

7 HYBRID Payment Models Accountable Care Organizations (ACO s) CMS Programs Medicare Shared Savings Program Pioneer Accountable Care Program Physician Group Practice Transition Demonstration Program Commercial Health Insurance ACO s Patient Centered Medical Home (PCMH)

8 Acowatch.wordpress.com

9 Healthaffairs.org

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11 PCMH at of Medical Neighborhood Community Centers Health IT $ Home Health Hospital Public Health Employers Schools Faith-Based Organizations Community Organizations 11 Patient-Centered Medical Home Health IT $ Skilled Nursing Facility Pharmacy Specialty & Subspecialty Diagnostics Mental Health Health Care Delivery Organizations

12 Base Payment w/ Flexibility PPS to Capitation (PMPM PPS Equivalent)

13 Game Changer Announcement! Tie Medicare FFS payments to quality or value 2016: 85% of payments 2018: 90% Shift above new Medicare FFS to Alternative Payment Models 2016: 30% of payments 2018: 50% Burwell SM, NEJM 1/26/15: Setting Value-based payment goals

14 What is an FQHC to do? LEADERSHIP CHALLENGE Transformational Change Revisit our History and our Mission Reaffirm values of staff & community (Re)Commit to Excellence & Innovation Redesign/Update policies & practices of care Build data-to-action capacity Firmly establish learning processes (CQI) Get ready for a bumpy ride!!!

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16 Act on High Performance Culture Define Discuss Insert Track Report Review Regularly Quality of Care (HEDIS, PQRS, PCPI,AMA, etc) Patient Experience (CAHPS) Cost Containment (Hosp, ERV, Drugs, Imaging, Referrals) Population Health

17 Central vs. Peripheral Management of Care Managed care is central management by policies controlled by an insurance plan or managed care organization Continuous Quality Improvement (CQI) is peripheral management controlled by care providers at the local level

18 Play to our Strengths In Primary Care!! First Contact Care Continuity of Care Comprehensive Care Coordination of Care Barbara Starfield s four pillars of primary care practice; UCSF Center for Excellence in Primary Care: Facilitating care integration in CHC s: A conceptual framework and literature review on best practices for integration into the medical neighborhood, March 2014.

19 BlueCross BlueShield of Michigan PCMH Project Michigan 3 million patients PCMH Strategies Two-part program: (1) Physician Group Incentive Program and (2) PCMH designation of practices Develop patient registries to track and monitor patients care Offer 24-hour patient access to a clinical decision-maker through extended office hours telephone access a linkage to urgent care Provide online patient resources that allow for electronic communication and greater patient access to medical information 19 Results 27.5% lower rate hospital stays 11.8% lower rate of adult primary care-sensitive ER visits 9.9% lower rate adult ER visits 14.9% lower rate pediatric ER visits 21.3% lower rate pediatric ER visits due to appropriate and timely inoffice care $26.37 PMPM cost savings ( ) $155 million cost savings ( ) Source: Blue Cross Blue Shield Blue Care Network of Michigan. Press Release. (July 2014). BCBS of Michigan designates more than 1400 physician practices to PCMH program for 2014 program year.

20 Best Practice Medical Group Redesign Clinical practice: improved workflows Care Coordination and Care Plans Physician and Staff Communication/Team Development Health and Information Technology Linkage Clinical and Community Integration REF: Care Redesign 2020 at Sharp Rees-Stealy Medical Group. Group Practice Journal, Feb 2015,

21 Veterans Health Administration Patient Aligned Care Team PCMH Strategies Optimize workflow and coordinate care through use of an interprofessional teamlet model Enact advanced scheduling, such as same-day appointments Add phone consults and group appointments Nelson, K., et al. (2014). Implementation of the PCMH in the Veterans Health Administration. Associations with Patient Satisfaction, Quality of Care, Staff Burnout, and Hospital and ED Use. JAMA Intern Med. 174(8): Hebert, P., et al. (2014). PCMH Initiative Produced Modest Economic Results for Veterans Health Administration, (6): Results National program 5 million patients Lower ED use Lower hospitalizations for ambulatory care-sensitive conditions Lower staff burnout Higher scores of patient satisfaction Increased primary care visits Higher performance on 41 of 48 measures of clinical quality 21

22 Priority: Identify and Manage High Risk Patients High Cost Over-Utilizers 20 50% of costs Multiple Chronic Disease Patients 5-20% At Risk Patients Everyone Else Prevention & Well-being Collaborate with Payers for Data/Information Ref: McClellean M, Mostashari F, Adopting Accountable Care An Implementation Guide for Physicians, Nov

23 Enabling Services Capture Case Management Assessment Case Management Treatment & Facilitation Case Management Referral Services Financial Counseling/Eligibility Assistance Health Education/Supportive Counseling Interpretation Services Outreach Services Transportation Other Enabling Services

24 Summary of Weighted Risk Calculation Methodology

25 RISK ADJUSTMENT TRADITIONAL Age Gender Claims history (diagnoses/behaviors, utilization) ADDITIONAL (SDOH+) Race/Ethnicity SES: income, education Marital status/children/dependents Housing Occupation MUA/Neighborhood/Zipcode LEP Well-Being Health literacy Many Others???

26 Risk Assessment Questionnaire PRAPARE Protocol for Responding to and Assessing Patients Assets, Risks and Experiences Develop and Pilot a national SDOH Risk Assessment Tool in the EMR Collaboration with NACHC, OPCA, IAF, AAPCHO

27 Political Interests as Cost Drivers RELIANCE ON TECHNOLOGY & EXPENSIVE CARE Pharmaceutical Industry Biomedical Devices Hi-Tech Solutions Sick Care Delivery System Workforce bias towards Specialists Commercial Health Insurance Industry WHAT ABOUT COMMUNITY INTERESTS???

28 "Every system is perfectly designed to get the results it gets." Don Berwick Former CMS Administrator

29 Our Challenge High Performance in our current system Document risks and corresponding services Redesign for efficiency and effectiveness Welcome the highly complex patients Push for innovation and change towards a model within a true health system (Population Health) Well-Being and Prevention Early Intervention Health Equity SDOH Community engagement in Policy