South Carolina Public Health Institute southcarolinahealthcarevoices Quality-related Initiatives in the ACA Presented by Joyce Dubow AARP Office of Policy and Strategy March 28, 2011
Impetus behind HCR The problems that need to be addressed The Patient Protection and Affordable Care Act of 2010 (ACA) provisions for quality and delivery reform Quality infrastructure Hospitals/Physicians/Health Plans New models of care/strengthening the workforce ACOs Medical Homes Primary care Implications for states A consumer advocacy agenda
Impetus behind HCR The problems that need to be addressed
NHE in trillions $6 Current projection (6.7% annual growth) $5.2 $5 Constant (2009) proportion of GDP (4.7% annual growth) $4 $3 We are here $4.2 $2 $1 $2.6 Estimated savings achieved by Health Care Reform 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Total National Health Expenditures, 2009 2020, Current Projection and Alternative Scenario
Percent of adults ages 19 64 who are very confident that they will be: 75 Total Insured all year, not underinsured Insured all year, underinsured Insured now, uninsured during the year Uninsured now 50 25 47 46 47 39 38 40 40 36 37 29 25 26 19 19 24 0 Able to get high quality and safe health care when needed Able to receive the most effective drugs when needed Able to receive the best medical technology when needed Source: The Commonwealth Fund Biennial Health Insurance Survey (2007).
Percent of adults reporting a time they experienced each event in the past two years Ordered a test that had already been done Medical, surgical, medication, or lab test error Failed to provide important medical history or test results to other doctors or nurses 17 17 19 Recommended unnecessary care or treatment 25 Any of the above 42 0 25 50 Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006.
100% RAND Study: Only 55% of recommended care preventive, acute, chronic) was received 80% 60% 40% 20% 0% Adequate Care Elizabeth McGlynn, et al, "The Quality of Health Care Delivered to Adults in the United States, The New England Journal of Medicine, Vol 348(26):2635-2645, June 26, 2003.
Blacks and American Indians and Alaska Natives received worse care than Whites for about 40 percent of core measures. Asians received worse care than Whites for about 20 percent of core measures. Hispanics received worse care than non-hispanic Whites for about 60 percent of core measures. Poor people received worse care than high-income people for about 80 percent of core measures
SC Medicaid National mean/ppos/2009 Commercial: 67.1 Medicare: 65.5 Source: Health Services Research Team, University of South Carolina, December 2009
SC Medicaid National mean/ppos/2009 Commercial: 47.0 Medicare: 40.1 Source: Health Services Research Team, University of South Carolina, December 2009
SC Medicaid National Mean/PPOs/2009 Commercial: 74.6 Medicare: NA Source: Health Services Research Team, University of South Carolina, December 2009
SC Medicaid National Mean/PPOs/2009 Commercial: 83.3 89.3 Medicare: Source: Health Services Research Team, University of South Carolina, December 2009
Source: Health Services Research Team, University of South Carolina, December 2009
Defining Quality
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Desired health outcomes are those sought by the recipients of the services Current professional knowledge refers to a changing technical standard of care
Safe Avoiding harm to patients from care intended to help them Effective Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit Patient-centered Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patients values guide all clinical decisions Timely Reducing waits and sometime harmful delays for both those who receive and those who give care Efficient Avoiding waste, including waste of equipment, supplies, ideas and energy Equitable Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status
Structure + Process Outcomes Structure Organizational characteristics and structure, personnel, equipment and resources Process Diagnosis, prevention, interventions, patient education Outcomes Lab values, mortality rates, functional status, satisfaction with care
The Patient Protection and Affordable Care Act of 2010 (ACA) provisions for quality and delivery reform Quality infrastructure Hospitals/Physicians/Health Plans New models of care/strengthening the workforce ACOs Medical Homes Primary care
Strengthen quality infrastructure Offer financial incentives Address delivery reform Address wellness and health promotion Address workforce reform HITECH provisions in ARRA meaningful use of HIT also address quality
Patient-Centered Outcomes Research Institute, a private, not-for-profit entity to: identify research priorities and a research agenda conduct research, with priority to AHRQ, NIH release and disseminate findings (which many not be used in making Medicare coverage determinations, or for reimbursement or incentive programs.)
Performance measurement to improve quality, safety and efficiency, promote accountability, payment, and delivery reform HHS will develop and implement a national strategy (3-21-11) identify and fund gaps in measures oversee a process for collecting and aggregating data develop a framework for public reporting engage in a consultative process with stakeholders on selection of national priorities and quality measures
Making care safer by reducing harm caused in the delivery of care. Ensuring that each person and family is engaged as partners in their care. Promoting effective communication and coordination of care. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. Working with communities to promote wide use of best practices to enable healthy living. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.
Hospital readmission reduction program Reduced payment for excess readmissions for 3 high cost/high volume procedures (acute MI, HF, Pneu) Public reports of readmission rates on Hospital Compare Assistance for hospitals with high rates of readmission Reduced payment for health care acquired conditions (e.g., bedsores, complications from extended use of catheters, injuries caused by falls) in the 25 percent of hospitals with highest rates)
Physicians rewarded for P4R through 2014, then those who fail to report lose $ Physicians participating in MOC eligible for bonuses HHS to provide physicians with information on their resource use In 2013, public reporting on Physician Compare Value-modifier to reward physicians who deliver better care, lower costs
New payment approach ties eligibility for quality bonuses to performance (star ratings) Eligibility for rebates tied to performance
The Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models that enhance quality of care provided to Medicare and Medicaid beneficiaries First set of innovations will test health home and medical home concepts 8 states to evaluate effectiveness of health professionals working in more integrated fashion and receiving coordinated payment from public/private payers. (ME, VT, RI, NY, PA, NC, MI, MN) FHQC Advanced Primary Care Practice Demonstration New state plan option to all Medicaid beneficiaries w. 2+ chronic conditions to designate a health home to coordinate their care. States would receive enhanced financial resources to support these.
Better healthcare: Improve individual patient experiences of care along the Institute of Medicine s six domains of quality: Safety, Effectiveness, Patient-centeredness, Timeliness, Efficiency, and Equity. Better health: Encourage better health for entire populations by addressing underlying causes of poor health, such as physical inactivity, behavioral risk factors, lack of preventive care and poor nutrition. Reduced costs: Lower the total cost of care resulting in reduced monthly expenditures for each Medicare, Medicaid or CHIP beneficiary by improving care.
Shared Savings Program (ACOs) Payment models to include global payments, partial capitation, other methods Bundled payments to encourage accountability for entire episodes of care (including acute and postacute care) Medical Homes pilot (Health Homes in Medicaid) Shared decision making program Medicare Community-based Care Transitions program Independence-at-home demonstration
Patient Tracking and Registry Functions: Can easily generate a list of patients by diagnosis with the current patient medical records system Test Tracking: Provider usually receives an alert or prompt to provide patients with test results; or laboratory test ordered are usually tracked until results reach clinicians Referral Tracking: When clinic patients are referred to specialists or subspecialists outside largest site, center usually or often tracks referrals until the consultation report returns to the referring provider Enhanced Access and Communication: Patients usually are able to receive same- or next-day appointments, can get telephone advice on clinical issues during office hours or on weekends/after hours Performance Reporting and Improvement: Performance data are collected on clinical outcomes or patient satisfaction surveys and reported at the provider or practice level
Establishing community health teams to support PCMH (grants, contracts) Support for training clinicians in primary care Community-based collaborative care networks (with FHQCs) to serve low-income individuals ACOs, PCMH pilots
U.S. medical school seniors filled 1,301 family medicine positions, up from 1,169 in 2010. In 2011, 48% of available family medicine slots were filled by U.S. seniors, up from 44.8% in 2010. Internal medicine matches for U.S. seniors increased 8%, and also grew for a second straight year. In 2011, 57.4% of available internal medicine residency slots were filled by U.S. seniors, up from 54.5% in 2010. In both internal and family medicine, a greater percentage of slots were filled even as the overall number of available positions increased.
Implications for states
Insurance marketplaces where individuals and small businesses can compare and purchase health plans and receive premium subsidies for which they are eligible. States have the option to develop and host own exchanges, or let the federal government establish and run exchanges. States that choose to implement exchanges will tailor the exchanges to their own circumstances and determine governance, design, marketing, administration, technology, and other factors.
Certification, recertification and decertification of plans Operation of a toll-free hotline Maintenance of a website for providing information on plans to current and prospective enrollees Assignment of a price and quality rating to plans Presentation of plan benefit options in a standardized format Provision of information and determination of eligibility for Medicaid and CHIP Provision of an electronic calculator to determine the actual cost of coverage taking into account eligibility for premium tax credits and cost sharing reductions Certification of individuals exempt from the individual responsibility requirement Establishment of a Navigator program that provides grants to entities assisting consumers
Presentation of enrollee satisfaction survey results Provision for open enrollment periods Consultation with stakeholders, including tribes Publication of data on the Exchange s administrative costs
Marketing Network adequacy Accreditation for performance measures Quality improvement and reporting Uniform enrollment procedures Information on the availability of in-network and out-of-network providers including provider directories and availability of essential community providers Consideration of plan patterns and practices with respect to past premium increases and submission of plan justifications for current premium increases Public disclosure of plan data, including claims handling policies, financial disclosures, enrollment and disenrollment data, claims denials, rating practices, cost sharing for out of network coverage, and other information identified by the Secretary Timely information for consumers requesting their amount of cost sharing for specific services from specified providers Information on plan quality improvement activities
Accreditation, public reporting of clinical quality and patient experience Implementation of quality improvement strategies Market-based incentives for improved health outcomes, care coordination, chronic disease management, medication compliance initiatives, prevention of hospital readmissions, improved safety and reduced errors, and implementation of wellness and health promotion activities
Summary
Meaningful Use Use of technology to achieve significant improvement in care Financial incentives ties payment specifically to the achievement of advances in health care processes and outcomes Stage 1 identifies core objectives basic functions to enable an EHR to support care improvement (vital signs, demographics, medications, allergies, problem list, smoking status) Provide patients with electronic versions of their health information
Accountable entities (e.g., physician practices, hospitals, health plans should: be accountable for the care and service they deliver have the infrastructure necessary to deliver high quality care and service increase the likelihood of desired health outcomes consistent with current professional knowledge Strategies: Measurement (we can t improve what we don t measure) Transparency (quality data must be translated into understandable, actionable reports for consumers and purchasers) Accountability (once we can measure we can hold everyone accountable for improvement
Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe. Healthy People & Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care. Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government
Build the evidence base: comparative effectiveness research Incent HIT and data exchange Promote accountability through transparency/public reporting Align payment with performance Bundled, episode-based payments Penalties for preventable re-hospitalizations MA bonuses for attainment/improvement in quality Improve health service delivery Primary care; Medical homes; ACOs Care coordination Promote wellness and prevention Adopt enhanced role for patients through shared decision making and greater engagement through selfefficacy