MAH Grand Rounds July 2016 Healthcare Policy: Novel Models · PDF fileMedical Director, MACIPA...
Transcript of MAH Grand Rounds July 2016 Healthcare Policy: Novel Models · PDF fileMedical Director, MACIPA...
MAH Grand Rounds July 2016
David Shein, MD Mount Auburn Hospital Reservoir Medical Associates
Assistant Professor, HMS Medical Director, MACIPA
Healthcare Policy: Novel Models for Healthcare Delivery
Disclosure Mount Auburn Hospital is accredited by The Massachusetts Medical Society
(MMS) to provide AMA PRA Category 1 CME Credits™ to hospital activities
developed to enhance and improve the practice of medicine. We endorse the
ACCME Standards for Commercial Support™ and hereby state that the
following individuals have disclosed relevant financial relationship(s) with
commercial interests:
No others in a position to control the content of the CME activity have any
relevant financial relationships to disclose.
Individual Role Commercial Interest Nature of Financial Relationship
David Shein, MD Speaker MACIPA Medical Director
Objectives
Participants will understand:
• Newer payment models and their impact on the delivery of healthcare
• Impact of federal healthcare legislation on models of care
• Measuring quality in modern healthcare
• Role of risk adjustment in clinical care
Payment
Models
Focus:
- AQC
- ACO
Quality
Risk
Adjustment
Outline
How Would You Reimburse for Healthcare Delivery?
• Fee For Service – Drives individual, short-term volume-based performance – No incentives for efficiency or quality at a system level – > Choosing Wisely
• Capitation 1.0 – Favors efficiency – Short timeline (contract year) – > “Drive-thru deliveries”
• Value-Based Purchasing – Considers efficiency/cost + outcomes/quality – Process can be intrusive; may be costly; not always accurate – > Outcomes that matter – > Physician burn out
Major Payers With Novel Models
• BCBS MA
– Alternative Quality Contract
• CMS / Medicare
– Affordable Care Act
• MIPS / MACRA / SGR
• Alternative payment models – ACO (Pioneer/NextGen) / Shared Savings
– Bundled payments
– Medicare Advantage (Part C)
Outcomes and Quality
•Process
•Outcomes
•Patient experience
•Patient-reported outcomes: PROM
• Toyota “lean”
• Does environment improve patient outcomes?
• “Teach to the test?”
• How does measurement improve patient outcomes?
What is Healthcare Quality?
• Claims data
• Clinical data
• Questionnaires and surveys
Quality Measures
Environment of
Quality
How Do We
Measure?
What Are We
Measuring?
Porter ME et al. N Engl J Med 2016;374:504-506.
Categories of Quality Measures Listed in the National Quality Measures Clearinghouse (NQMC).
Anatomy of A Measure
• Numerator = subpopulation with intervention/measure/outcome in question
• Denominator = entire population under consideration
• Exclusions = reasons a member would be excluded from the denominator
• Analysis period = time frame under consideration
• Result – %-age measure performance
– Absolute # of compliant / non-compliant members
Example of A Measure: Breast Cancer Screening
Numerator:
• Women with mammogram at least once in 24 months
Denominator:
• Women ages 50-75
Exclusions:
• Medical reason for not having mammogram: Bilateral mastectomy or 2 unilateral mastectomy procedures
Data Sources
Claims: See the world, limited detail
EMR / Chart: Detailed picture of local care, no reference to the outside world
(e.g. care with another institution)
Lab: Great detail, little context
Patient Surveys
• Clinical
– PHQ-9
– Fall Risk
• Satisfaction
– MHQP
– CAHPS Consumer Assessment of Healthcare Providers & Systems
Efficiency and Cost
Risk Adjustment
• How can we balance risk and cost across diverse populations?
– Critical when looking at efficiency
• Utilization
• Cost
• Case Mix
Verisk Health
DxCG: Predictive Risk Perspective
Prospective Risk Score 4.90
Age/Gender
45 - 54 Male 0.50
Condition Categories
Type I Diabetes 0.75
Hypertension -----
Congestive Heart Failure 2.13
Depression 0.92
Interaction
Type I Diabetes & CHF 0.60
John contributes additional risk to the group’s illness burden and is predicted to spend 4.9 times the plan average Individual average spending for medical services factors into aggregate medical costs for a defined fiscal period Provider contracts are based on the relative risk of their affiliated members
• Hypertension • Type I diabetes • Congestive heart failure • Drug/alcohol dependence
Age: 50 Gender: Male
Relative Risk Scores Derived from Hierarchical Condition Category (HCC) Predictive Models
Mt. Auburn Examples
• Risk score impact
– Why appropriate risk coding is so important
• Utilization
• Quality management
Payment Models
Budget
Surplus
Quality
Impact of coding on risk adjustment
Impact of cost and utilization: efficiency
Impact of quality measures
- Avoidable ED/admits - Unnecessary tests and procedures - High vs low cost providers - Leakage - Pharmacy formulary
Risk Coding
• Drives budgets (reimbursement)
• Enables identification of high-risk patients to manage utilization risk and improve care
– Risk identification
– Intervention
• Early outreach
COMPASS Program
• Criteria for identification and intervention
– Depression (PHQ-9 score > 9)
+
– Poorly controlled diabetes (HbA1c > 8%)
or
– Poorly controlled CVD risk (BP > 140 / > 90)
COMPASS Results: Identification and Intervention Improved Outcomes
PHQ9 score
% Baseline
PHQ-9 > 9
% Final PHQ-9 <5
10-14 1605 (48%) 30%
15-19 927 (28%) 21%
20-27 834 (25%) 16%
Baseline HbA1c % Baseline Poor Control
Final HbA1c < 8%
8.0 - <8.5 357 (21%) 38%
8.5 - <9.0 253 (15%) 33%
9.0 - <9.5 241 (14%) 20%
9.5+ 815 (49%) 14%
Baseline BP category % Baseline HTN
Final BP < 140 / < 90
Stage 1 HTN: SBP140-159 or DBP 90-99
331 (72%) 60%
Stage 2 HTN: SBP 160+ or DBP 100+
131 (28%) 53%
Diabetes Control
Depression Remission
BP control
Impact of Quality:
… On the bottom line
Members under quality contracts
• AQC
• Harvard Pilgrim
• Tufts
• TMP
• Medicare
… On the front line
– Tiered copayments
• Cost and Quality – TME, HEDIS, MHQP
– Medicare.gov
• Physician Compare
• Hospital Compare
– Consumer Reports
– Google yourself… • Healthgrades, etc
MACIPA Prelim BCBS AQC Performance
Antidepressant Med. Mgt. (84-Day) Antidepressant Med. Mgt. (180-Day)
Well Child Visits (15 Months) Well Child Visits (3-6)
Well Child Visits (12-21) Chlamydia Screening (16-20) Chlamydia Screening (21-24)
Testing for Pharyngitis Treatment for Acute Bronchitis (no Abx)
Appropriate Treatment for URI Colorectal CA Screening
Cervical CA Screening Breast CA Screening
Diabetes Mgt: Eye Exam Diabetes Mgt: Hba1c Test
Diabetes Mgt: Nephropathy Diabetes Mgt: Hba1c Out of Control Diabetes Mgt: BP Control
Hypertension Mgt: BP Control
Performance improved in most categories
Opportunities: - Cancer
screening - Engaging
specialists in their areas
2015
2015 QI Project Success Stories: Chlamydia Screening (16-24)
• 2 Pediatric PCP’s: QI Project Chlamydia Screening
AQC Screening Rate improved
Actions: Routine eCW Reports Component of PE Outreach to parents about requirement Patient Education STD Sheets
Leakage Prevention (Keepage) Patient Satisfaction
Urology • Patient Experience
Leakage Rate decreased
Dermatology • Patient Access
Leakage Rate decreased
Patient Experience Survey Patient/PCP Interaction Patient/Staff Interaction Communication
Actions: MACIPA Urgent Access Slots One Touch Appointment Cancellation
Utilization
Mechanic R, Tompkins C. N Engl J Med 2012;367:1873-1875.
Variation in Average 2009 Medicare Spending among Selected Hospitals for a 90-Day Episode of Congestive Heart Failure.
Impact on SNF ALOS
0
5
10
15
20
25
30
2011 2012 2013
ACO
MA
SNF #1
Population Management
• Manage utilization / cost risk – High risk scores
– High utilization
– Gaps in care (quality measures)
– Leakage
• Maximize quality performance – Manage the measures
• High-quality and efficient healthcare for our patients
Conclusion
• Healthcare reimbursement is evolving • Optimal models align patient outcomes and
reimbursement • Providers should understand the models and drivers of
payment • We are all responsible for and capable of delivering
high quality care • Continuous quality improvement remains critical
– Clinical quality – Patient experience – Patient access
NEJM Michael E. Porter, Ph.D., M.B.A., Stefan Larsson, M.D., Ph.D., and Thomas H. Lee, M.D.
“If we’re to unlock the potential of value-based health care for driving improvement, outcomes measurement must accelerate. That means committing to measuring a minimum sufficient set of outcomes for every major medical condition — with well-defined methods for their collection and risk adjustment — and then standardizing those sets nationally and globally”
JAMA Robert A. Berenson, MD
“The requirement for measurement as essential to management and improvement is a fallacy, not a self-evident truth and not supported by… management experts or common sense. There are many routes to improvement, such as doing things better based on experience, example, as well as evidence from research studies.”