National Readmission Prevention Collaborative Dallas, TX October 22, 2015 Healthcare Transformation and the Affordable Care Act David Nilasena, MD, MSPH, MS Chief Medical Officer, CMS Region VI
Disclaimers The presenter is a full time US Government employee and will represent the positions of the Centers for Medicare and Medicaid Services (CMS), US Dept. of Health and Human Services (DHHS). The presenter reports no activities or conflicts of interest. This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.
Health Care Delivery Reform Historical state Public and Private sectors Evolving future state 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
Clinical Practice Leaders Have Already Charted the Pathway to Practice Transformation Traditional Approach Patient s chief complaints or reasons for visit determines care. Care is determined by today s problem and time available today. Care varies by scheduled time and memory/skill of the doctor. Patients are responsible for coordinating their own care. Clinicians know they deliver high quality care because they are well trained. It is up to the patient to tell us what happened to them. Transformed Practice We systematically assess all our patients health needs to plan care. Care is determined by a proactive plan to meet patient needs. Care is standardized according to evidence-based guidelines. A prepared team of professionals coordinates and engages patients in care. Clinicians know they deliver high quality care because they measure it and make rapid changes to improve. You can track tests, consults, and followup after the ED and hospital. Adapted from Duffy, D. (2014). School of Community Medicine, Tulsa, OK. 4
Delivery System Reform requires focusing on the way we pay providers, deliver care, and distribute information { Improving the way providers are incentivized, the } way care is delivered, and the way information is distributed will help provide better care at lower cost across the health care system. FOCUS AREAS Pay Providers Deliver Care Distribute Information Source: Burwell SM. Setting Value-Based Payment Goals HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.
Better. Smarter. Healthier. So we will continue to work across sectors and across the aisle for the goals we share: better care, smarter spending, and healthier people.
During January 2015, HHS announced goals for value-based payments within the Medicare FFS system
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: 1967-8.
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) 2011 2014 2016 2018 0% ~20% 30% 50% ~70% >80% 85% 90% Historical Performance Goals
Value-Based Purchasing 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. Hospital value-based purchasing program shifts approximately $1 billion based on performance Five Principles: - Define the end goal, not just the process for achieving it - All providers incentives must be aligned (includes hospital & physicians) - Right measures 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, 2012 12
Hospital Value-Based Purchasing The first federally implemented pay-for-performance program impacting the acute inpatient care setting. Inpatient hospital care represents substantial Medicare spending $139 billion in Fiscal Year (FY) 2013 50.5% of FY 2013 Part A spending 23.8% of FY 2013 total Medicare benefits The Hospital VBP Program statute dedicates an increasing percentage of Medicare hospital payments to value-based incentive payments FY 2013: 1.00%, $963 million (est.) FY 2014: 1.25%, $1.1 billion (est.) FY 2015: 1.50%, $1.4 billion (est.) FY 2016: 1.75% ($ TBD) FY 2017: 2.00% ($ TBD)
Program Evolution: FY 2017 Domain Weights & Measures Patient and Caregiver Centered Experience of Care/Care Coordination 25% Domain Weights Safety 20% 25% Outcomes Clinical Care 5% 25% Process Efficiency and Cost Reduction Patient and Caregiver Centered Experience of Care/Care Coordination Outcome Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Outcomes MORT-30-AMI MORT-30-HF MORT-30-PN An asterisk (*) indicates a newly adopted measure for the Hospital VBP Program. Clinical Care Process AMI-7a IMM-2 PC-01* Efficiency and Cost Reduction MSPB-1 Safety CLABSI CAUTI SSI: Colon & Abdominal Hysterectomy MRSA Infections* C-difficile Infections* AHRQ PSI-90 16
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What s the re-admission problem? High re-admission rates could indicate breakdowns in care delivery systems. Payment systems incentivized fragmentation. More complicated cases = more hands in the pot. Expectation of patients to self-manage is great. Medicare patients said they were more dissatisfied with their preparation for discharge than any other patient satisfaction measure. 80% received discharge information. 59% received medication information. 16
What s all of this costing us? Re-admissions cost Medicare $17.4 billion in 2004. 1 30-day re-admission rate: 19.6%. Of them, 50.2% didn t see a doctor before re-hospitalization. Re-hospitalized patients stayed 0.6 days longer on average. We could have saved $12 billion if we prevented 30-day potentially preventable readmissions in 2005. 2 Potentially preventable per MedPAC estimates. 13.3% of all hospitalizations or 3 out of 4 re-admissions! First NEJM article published November 1984. 3 Rate was 22% after 60 days. Re-admissions comprised 25 of every inpatient claim dollar. 1 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360:1418-1428. 2 Anderson GF, Steinberg EP. Hospital readmissions in the Medicare population. N Engl J Med 1984;311:1349-1353. 3 Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Promoting greater efficiency in Medicare. Washington, DC: June 2007. 17
30-Day Readmission Rates, 2010 (Fee-for-service Medicare Beneficiaries) Source: http://www.dartmouthatlas.org/data/map.aspx?ind=192&loct=3&ch=201 18
Hospital Readmissions Reduction Program Required by Section 3025 of the 2010 Affordable Care Act Requires Secretary to establish a Hospital Readmissions Reduction Program which Reduces Inpatient Prospective Payment System (IPPS) payments to hospitals for excess readmissions For discharges on or after October 1, 2012 (Fiscal Year [FY] 2013) Required initial adoption of the National Quality Forumendorsed 30-day Risk-Standardized Readmission measures: acute myocardial infarction (AMI), heart failure (HF), pneumonia 19
Payment Adjustment FY 2014, Based on readmissions for AMI, HF and Pneumonia Algorithm introduced to account for planned readmissions In FY2015, adding 3 conditions Acute exacerbation of chronic obstructive pulmonary disease Elective total hip arthroplasty Total knee arthroplasty Applies to hospital s base DRG payments for Medicare discharges started October 1, 2012 FY 2014 no more than 2% reduction FY 2015 no more than 3% reduction Calculation methodology finalized in rule-making 20
Aims for Readmission Measures Promote broadest possible efforts to lower readmission rates: Assume all patients are at risk of readmission and their risk can be lowered Opportunity to focus efforts on patients most at risk of readmission CMS is targeting funding support to hospitals and communities with greatest need for improvement Goal is not zero readmissions, but to lower readmission rates overall 21
Public Reporting Measures reported yearly based on 3 years of data Reported on Hospital Compare as: Better than the U.S. national rate; Worse than the U.S. national rate; No different than the U.S. national rate; or Difference is uncertain Will not classify performance for hospitals with <25 cases in 3 year period 22
Partnership for Patients GOALS: 40% 20% Reduction in Preventable Hospital- Acquired Conditions 1.8 Million Fewer Injuries 60,000 Lives Saved Reduction in 30-Day Readmissions 1.6 Million Patients Recover without Readmission partnershipforpatients.cms.gov 23
Partnership for Patient contributes to quality improvements Data shows 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% 24
Medicare all-cause, 30-day hospital readmission rate is declining Readmission Rate Legend: CL: control limit; UCL: upper control limit; LCL: lower control limit 25
Source: CMS OMH Analysis 30-Day, All-Cause FFS Readmission Rates National and by Race - 2007 through 2013
Continuous Improvement and Innovation 27
The CMS Innovation Center was created by the Affordable Care Act to develop, test, and implement new payment and delivery models The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care furnished to individuals under such titles Section 3021 of Affordable Care Act Three scenarios for success 1. Quality improves; cost neutral 2. Quality neutral; cost reduced 3. Quality improves; cost reduced (best case) If a model meets one of these three criteria and other statutory prerequisites, the statute allows the Secretary to expand the duration and scope of a model through rulemaking 28
The Innovation Center portfolio aligns with delivery system reform focus areas Focus Areas Pay Providers Deliver Care CMS Innovation Center Portfolio* Test and expand alternative payment models Accountable Care Pioneer ACO Model Next Generation ACO Medicare Shared Savings Program (housed in Center for Medicare) Advance Payment ACO Model Comprehensive ERSD Care Initiative Primary Care Transformation Comprehensive Primary Care Initiative (CPC) Multi-Payer Advanced Primary Care Practice Demo Home Health Value Based Purchasing Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Independence at Home Demonstration Graduate Nurse Education Demonstration Medicare Care Choices Model Support providers and states to improve the delivery of care Learning and Diffusion Partnership for Patients Transforming Clinical Practice Community-Based Care Transitions Health Care Innovation Awards Episode-Based Payment Initiatives Bundled Payment for Care Improvement Model 1: Retrospective Acute Care Model 2: Retrospective Acute Care Episode & Post Acute Model 3: Retrospective Post Acute Care Model 4: Prospective Acute Care Oncology Care Model Comprehensive Care for Joint Replacement Model Initiatives Focused on the Medicaid Medicaid Emergency Psychiatric Demonstration Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicaid Innovation Accelerator Program Dual Eligible (Medicare-Medicaid Enrollees) Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents State Innovation Models Initiative SIM Round 1 SIM Round 2 Maryland All-Payer Model Million Hearts Initiative Increase information available for effective informed decision-making by consumers and providers Distribute Information Information to providers in CMMI models Shared decision-making required by many models * Many CMMI programs test innovations across multiple focus areas 29
CMS has engaged the health care delivery system and invested in innovation across the country, every state and most territories Sites where innovation models are being tested Models run at the state level Source: CMS Innovation Center website, January 2015 30
The Health Care Payment Learning and Action Network will accelerate the transition to APMs Medicare alone cannot drive sustained progress towards alternative payment models (APM) Success depends upon a critical mass of partners adopting new models The network will Convene payers, purchasers, consumers, states and federal partners to establish a common pathway for success Identify areas of agreement around movement to APMs Collaborate to generate evidence, shared approaches, and remove barriers Develop common approaches to core issues such as beneficiary attribution Create implementation guides for payers and purchasers Network Objectives Match or exceed Medicare alternative payment model goals across the US health system -30% in APM by 2016-50% in APM by 2018 Shift momentum from CMS to private payer/purchaser and state communities Align on core aspects of alternative payment design 31
Health Care Payment Learning and Action Network http://innovation.cms.gov/initiatives/health-care-payment- Learning-and-Action-Network/ Strong emphasis on businesses in this network. A number of very large employers and associations are already part of this network. Share their ideas with CMS but also all the major insurance companies in the country. Learn about efforts by business to run their own models. Boeing has their own ACO. Caesar s Entertainment is running a bundles experiment. Walmart participates in a center of excellence program. 32
Practice Transformation in Action Transforming Clinical Practice (TCP) would employ a three-pronged approach to national technical assistance. This technical assistance would enable large scale transformation of more than 150,000 clinicians practices to deliver better care and result in better health outcomes at lower costs. Aligned Federal and State programs with support contractor resources Communities Practice Transformation Networks (PTNs) to provide on the ground support to practices Primary and Specialty Care Clinicians and Practices Ambulatory and Post Acute Care Support and Alignment Networks (SANs) to achieve alignment with medical education, maintenance of certification, more Hospitals and Healthcare Systems Public Health Services 33
Transforming Clinical Practice Initiative (TCPI) Goals 34
What can you do? Eliminate patient harm Focus on better health, better care, and lower costs for the patient population you serve Engage in accountable care and other alternative contracts that move away from fee-for-service to model based on achieving better outcomes at lower cost Invest in the quality infrastructure necessary to improve Test innovative models to better coordinate care for people with multiple chronic conditions Test new innovations and scale successes rapidly Relentless pursuit of improving health outcomes 35
Thank you for joining with us on the journey towards coordinated, seamless, reliable, and patient-centered care. Collaboration
Thank You Questions? 37