Volume to Value Transition in the USA

Transcription

1 Volume to Value Transition in the USA Lee A. Fleisher, M.D. Robert D. Dripps Professor and Chair of Anesthesiology Perelman School of Medicine at the University of Pennsylvania Acknowledgement: Patrick Conway, MD (former Acting Administrator of CMS) for some of his slides 1

2 Unexplained Variation Dartmouth Atlas of Healthcare 3 3 Value The core issue in health care is the value of health care delivered Value = Patient health outcomes per dollar spent Value is the only goal that can unite the interests of all system participants Michael Porter NEJM

3 Triple Aim better care for individuals better health for populations lower costs 5 The Six Goals of the National Quality Strategy 1 Make care safer by reducing harm caused in the delivery of care 2 Strengthen person and family engagement as partners in their care 4 3 Promote effective communication and coordination of care Promote effective prevention and treatment of chronic disease 5 Work with communities to promote healthy living 6 Make care affordable 6 3

4 CMS support of health care Delivery System Reform will result in better care, smarter spending, and healthier people Historical state Evolving future state Public and Private sectors Key characteristics Producer-centered Incentives for volume Unsustainable Fragmented Care Systems and Policies Fee-For-Service Payment Systems Key characteristics Patient-centered Incentives for outcomes Sustainable Coordinated care Systems and Policies Value-based purchasing Accountable Care Organizations Episode-based payments Medical Homes Quality/cost transparency 7 Value-Based Programs Goal is to reward providers and health systems that deliver better outcomes in health and health care at lower cost to the beneficiaries and communities they serve. Five Principles - Define the end goal, not the process for achieving it - All providers incentives must be aligned - Right measure must be developed and implemented in rapid cycle - CMS must actively support quality improvement - Clinical community and patients must be actively engaged VanLare JM, Conway PH. Value-Based Purchasing National Programs to Move from Volume to Value. NEJM July 26,

5 CMS has adopted a framework that categorizes payments to providers Category 1: Fee for Service No Link to Value Category 2: Fee for Service Link to Quality Category 3: Alternative Payment Models Built on Fee-for-Service Architecture Category 4: Population-Based Payment Description Payments are based on volume of services and not linked to quality or efficiency At least a portion of payments vary based on the quality or efficiency of health care delivery Some payment is linked to the effective management of a population or an episode of care Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk Payment is not directly triggered by service delivery so volume is not linked to payment Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., 1 year) Medicare Fee-for- Service examples Limited in Medicare feefor-service Majority of Medicare payments now are linked to quality Hospital valuebased purchasing Physician Value Modifier Readmissions / Hospital Acquired Condition Reduction Program Accountable Care Organizations Medical homes Bundled payments Comprehensive Primary Care initiative Comprehensive ESRD Medicare-Medicaid Financial Alignment Initiative Fee-For- Service Model Eligible Pioneer Accountable Care Organizations in years 3-5 Maryland hospitals Source: Rajkumar R, Conway PH, Tavenner M. CMS engaging multiple payers in payment reform. JAMA 2014; 311: Ten-Year Medicare Spending Projections, January 2010 through March Blumenthal D et al. N Engl J Med 2015;372:

6 During January 2015, HHS announced goals for value-based payments within the Medicare FFS system On March 3, 2016, President Obama and HHS announced that 30 percent of Medicare payments are tied to quality payments through APMs. This goal was achieved one year ahead of schedule! 11 Target percentage of payments in FFS linked to quality and alternative payment models by 2016 and 2018 Alternative payment models (Categories 3-4) FFS linked to quality (Categories 2-4) All Medicare FFS (Categories 1-4) % ~20% 30% 50% ~70% >80% 85% 90% Historical Performance Goals 12 6

7 Partnership for Patients contributes to quality improvements Data shows from 2010 to , million PATIENT HARM EVENTS AVOIDED $20 billion IN SAVINGS Leading Indicators, change from 2010 to 2013 Ventilator- Associated Pneumonia Early Elective Delivery Central Line- Associated Blood Stream Infections Venous thromboembolic complications Readmissions 62.4% 70.4% 12.3% 14.2% 7.3% 14 7

8 Readmission Rate Legend: CL: control limit; UCL: upper control limit; LCL: lower control limit 15 'Jaw-dropping': Medicare deaths, hospitalizations AND costs reduced Sample consisted of 68,374,904 unique Medicare beneficiaries (FFS and Medicare Advantage) Difference All-cause mortality 5.30% 4.45% -0.85% Total Hospitalizations/ 100,000 beneficiaries In-patient Expenditures/ Medicare fee-forservice beneficiary End of Life Hospitalization (last 6 months)/100 deaths 35,274 26,930-8,344 $3,290 $2,801 -$ Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or Older, ; Harlan M. Krumholz, MD, SM; Sudhakar V. Nuti, BA; Nicholas S. Downing, MD; Sharon-Lise T. Normand, PhD; Yun Wang, PhD; JAMA. 2015;314(4): ; doi: /jama

9 Payment reform Traditional fee-forservice Reduced reimbursement Bundled payments Accountable Care Organizations 17 Bundled Payments for Care Improvement is also growing rapidly The bundled payment model targets 48 conditions with a single payment for an episode of care Ø Incentivizes providers to take accountability for both cost and quality of care Ø Four Models - Model 1: Retrospective acute care hospital stay only - Model 2: Retrospective acute care hospital stay plus post-acute care - Model 3: Retrospective post-acute care only - Model 4: Prospective acute care hospital stay only 337 Awardees and over 1500 Episode Initiators as of January 2016 Duration of model is scheduled for 5 years: Model 1: Awardees began Period of Performance in April 2013 Models 2, 3, 4: Awardees began Period of Performance in October

10 Medicare Payment Prior to MACRA Fee-for-service (FFS) payment system, where clinicians are paid based on volume of services, not value. The Sustainable Growth Rate (SGR) Established in 1997 to control the cost of Medicare payments to physicians I F Overall physician costs > Target Medicare expenditures Physician payments cut across the board Each year, Congress passed temporary doc fixes to avert cuts (no fix in 2015 would have meant a 21% cut in Medicare payments to clinicians) Implications of MACRA The new MACRA law significantly impacts a number of key areas across health care provider organizations Financial Affects future Medicare reimbursement for all clinicians paid under the Medicare PFS Operational Requires organization-wide collaboration and coordination of eligibility, multiple moving parts and regulatory requirements Clinical Requires clinicians to change/ add incremental workflow and assess and improve clinical quality outcomes Technological Requires robust clinical data capabilities (data governance, capture, collection, validation and reporting) Strategic/Competitive Prioritizes strategic Physician Acquisition/Growth decisions related to who (Primary Care Physicians (PCPs)/Specialties, etc.), where, when, how (types of arrangements) Key Impact Areas Reputational MIPS Composite Performance Score (CPS) results will be made public and transparency will expose the good and the bad Clinician Involvement Relationships/Partnerships/Arrangements will need to evolve in order to attract, retain, evaluate and optimize Patient Engagement Greater coordination of care and two-sided risk for health care providers will raise the stakes for health care providers to foster closer ties with patients and help them actively manage their health 20 10

11 MIPS: First Step to a Fresh Start ü ü MIPS is a new program Streamlines 3 currently independent programs to work as one and to ease clinician burden. Adds a fourth component to promote ongoing improvement and innovation to clinical activities. Quality Resource use 2a Clinical practice improvement activities MIPS provides clinicians the flexibility to choose the activities and measures that are most meaningful to their practice to demonstrate performance. :Advancing care information Porter s Integrated Practice Unit Traditional Model: Organize by Specialty and Discrete Service Primary Care Physician Radiologist Emerging Model: Organize into Integrated Practice Units Around Conditions Shared Ancillary Services Smoking Cessation Patient Education Substance Abuse Head & Neck Center Dentist Speech & Swallow Outpatient Oncologist Radiation Oncologist Anesthesiologist Primary Care Physicians Medical Oncologists Surgical Oncologists Radiation Oncologists Dental Oncologists Radiologist Pathologist Facilities Outpatient Clinic Swallowing Lab Hearing Lab Prosthodontic Lab Nurse Social Worker Patient Access Nutritionist Patient Advocate Shared Specialties Anesthesiologist Cardiologist, Endocrinologist & Other Specialties Pathologist Surgical Oncologist Source: Porter, Michael E., Jain, Sachin, The University of Texas MD Anderson Cancer Center: Interdisciplinary Cancer Care. February 26, Shared Facilities Operating Rooms Chemotherapy Radiation Therapy Diagnostic Imaging Pathology Lab 22 11

12 Why do we need to define value? Bundled care- How do we divvy up the pie? Traditional FFS Fixed payment Lower fixed payment and share in any profit margin Should the anesthesiologist be allowed to share in potential reward? Does the anesthesiologist want to assume any risk? 23 Healthcare Consumerism 24 12

13 HCAHPS Patient Experience Domains Summary Measures Communication with nurses (3 items) Communication with doctors (3 items) Responsiveness of hospital staff (2 items) Pain management (2 items) Communication about medicines (2 items) Discharge information (2 items) Individual Measures Cleanliness of hospital environment Quietness of hospital environment Global Measures Overall rating of hospital 25 13

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15 RACI CHART 29 My vision When we transition from volume to value, we will need to be more engaged in patient care Perioperative Care- SURGEON IS ACCOUNTABLE BUT MAY DELEGATE eg. Urology, Ortho at UCI, Kaiser Decision making with regard to surgery- ANESTHESIOLOGIST AS CONSULTANT Intraoperative Management- ANESTHESIOLOGIST RESPONSIBLE Postoperative Care- ICU- ANESTHESIOLOGIST RESPONSIBLE Ward- NURSES RESPONSIBLE, ANESTHESIOLOGIST OR SURGEON OR INTERNIST/HOSPITALIST INFORMED ABOUT PAIN WHO IS ACCOUNTABLE- EG. CARDIAC SURGEONS DELEGATE TO ANESTHESIOLOGIST AT PENN Post-discharge- SURGEON ACCOUNTABLE BUT MAY DELEGATE TO INTERNIST 30 15

16 Future of Health System Ø Alternative payment models greater than 50% of payments - ACOs - Bundled Payments - Comprehensive Primary Care - Other APMs Ø Private payer and CMS collaboration critical Ø States and communities driving Innovation and delivery system reform Ø Increasing integration of public health and population health with health care delivery system Ø Patient-centered, coordinated care is the norm Ø Focus on quality and outcomes 31 16