Dr. Woolseys Disclosure I have no industry or other financial
relationships to disclose.
Slide 3
Food & Beverages Courtesy of:
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Slide 5
Patient Centered Care care that is respectful of and responsive
to individual patient preferences, needs and values, ensuring that
patient values guide all clinical decisions IOM. (2001). Crossing
the Quality Chasm: A new health system for the 21 s century.
Washington, DC: National Academy Press.
Slide 6
Your community today Hospital Physician office Home Health
Agency Long term Care facilities Community Agency Government
Consumer
Slide 7
What would you like to . GIVE to the conversation today? TAKE
away from the conversation today?
Slide 8
Logistics/Workbook/Action Plan
Slide 9
Slide 10
Surviving and Thriving in the Age of Payment and Care Delivery
Reform Sarah Woolsey, MD Medical Director Patient Centered Care in
Action September 27th, 2012
Slide 11
Improved System Performance Relationships Better Outcomes &
Health, and Lower Costs Sharing Clinical Data Across Providers
& Care Settings Using HIT for Care Coordination Transparency
& Continuous Feedback Support Work Flow & Care Process
Redesign Consumer Engagement Payment Alignment Copyright
HealthInsight 2012 update Engaged Community
Slide 12
Overview Payment and care delivery system reform is upon us
Reformed systems will put providers at financial risk for excess:
Avoidable complications Adverse outcomes resulting from care
coordination failures Negative health outcomes associated with
patient health behavior and care plan execution choices Change is
not necessary. Survival is optional Deming
Slide 13
Medicare&Medicaid Largest Drivers of Future Federal
Spending
Slide 14
Healthcare Cost-Shifting Makes U.S. Businesses Uncompetitive
Source: Organisation for Economic Co-operation and Development
(2010), "OECD Health Data", OECD Health Statistics (database)
Notes: Data from Australia and Japan are 2007 data. Figures for
Canada, Norway and Switzerland, are OECD estimates. Numbers are PPP
adjusted.
Slide 15
Health Care Costs Have Wiped Out Real Income Gains $ 95 for
spending $ 945 for health care $ 870 for inflation $1910 more
income
Slide 16
Every system is perfectly designed to get the results it gets
Paul Batalden, M.D.
Slide 17
Current Payment Systems Reward Bad Outcomes, Not Better Health
Health Condition Continued Health Healthy Consumer No
Hospitalization Acute Care Episode Efficient Successful Outcome
Complications, Infections, Readmissions High-Cost Successful
Outcome $
Slide 18
REDUCING COSTS ( WITHOUT RATIONING ) What the Focus Should Be:
Reduce Costs By Improving Care Patients Lower Costs
Slide 19
Reducing Costs Without Rationing: Can It Be Done??
Slide 20
Reducing Costs Without Rationing: Prevention and Wellness
Health Condition Continued Health Healthy Consumer
Slide 21
Reducing Costs Without Rationing: Avoiding Hospitalizations
Health Condition Continued Health Healthy Consumer No
Hospitalization Acute Care Episode
Slide 22
Reducing Costs Without Rationing: Efficient, Successful
Treatment Health Condition Continued Health Healthy Consumer No
Hospitalization Acute Care Episode Efficient Successful Outcome
Complications, Infections, Readmissions High-Cost Successful
Outcome
Slide 23
Reducing Costs Without Rationing: = Better Quality Health
Condition Continued Health Healthy Consumer No Hospitalization
Acute Care Episode Efficient Successful Outcome Complications,
Infections, Readmissions High-Cost Successful Outcome Better
Outcomes/Higher Quality
Slide 24
How Big Are the Opportunities?
Slide 25
5-17% of Hospital Admissions Are Potentially Preventable
Source: AHRQ HCUP
Slide 26
Many Procedures Could Be Done for 80-90% Less Than Today
10-Fold Difference 5-Fold Difference
Slide 27
Many Other Savings Opportunities Better scheduling of scarce
resources (e.g., surgery suites) to reduce both underutilization
& overtime Coordination among multiple physicians and
departments to avoid duplication and conflicts in scheduling
Standardization of equipment and supplies to facilitate bulk
purchasing Less wastage of expensive supplies Reducing lengths of
stay Moving more procedures to outpatient settings (Your idea
here)
Slide 28
We Should Focus First on How to Improve Patient Care How Do We
Limit: New Technologies Higher-Cost Drugs Potentially Life-Saving
Treatment How Do We Help: Patients Stay Well Avoid Unnecessary
Surgery and Other Hospitalizations Eliminate Potentially
Life-Threatening Errors and Safety Problems Reduce Costs of
Procedures Contributors to Healthcare Costs
Slide 29
Every system is perfectly designed to get the results it gets
Paul Batalden, M.D.
Slide 30
Are There Better Ways to Pay for Health Care? Health Condition
Continued Health Healthy Consumer No Hospitalization Acute Care
Episode Efficient Successful Outcome Complications, Infections,
Readmissions High-Cost Successful Outcome $ ?
Slide 31
Episode Payments to Reward Value Within Episodes Health
Condition Continued Health Healthy Consumer No Hospitalization
Acute Care Episode Efficient Successful Outcome Complications,
Infections, Readmissions High-Cost Successful Outcome Episode
Payment $ A Single Payment For All Care Needed From All Providers
in the Episode, With a Warranty For Complications
Slide 32
Yes, a Health Care Provider Can Offer a Warranty Geisinger
Health System ProvenCare SM A single payment for an ENTIRE 90 day
period including: ALL related pre-admission care ALL inpatient
physician and hospital services ALL related post-acute care ALL
care for any related complications or readmissions Types of
conditions/treatments currently offered: Cardiac Bypass Surgery
Cardiac Stents Cataract Surgery Total Hip Replacement Bariatric
Surgery Perinatal Care Low Back Pain Treatment of Chronic Kidney
Disease
Slide 33
Payment + Process Improvement = Better Outcomes, Lower
Costs
Slide 34
It Can Be Done By Physicians, Not Just Health Systems In 1987,
an orthopedic surgeon in Lansing, MI and the local hospital, Ingham
Medical Center, offered: a fixed total price for surgical services
for shoulder and knee problems a warranty for any subsequent
services needed for a two-year period, including repeat visits,
imaging, rehospitalization and additional surgery Results: Health
insurer paid 40% less than otherwise Surgeon received over 80% more
in payment than otherwise Hospital received 13% more than
otherwise, despite fewer rehospitalizations Method: Reducing
unnecessary auxiliary services such as radiography and physical
therapy Reducing the length of stay in the hospital Reducing
complications and readmissions. Johnson LL, Becker RL. An
alternative health-care reimbursement systemapplication of
arthroscopy and financial warranty: results of a two-year pilot
study. Arthroscopy. 1994 Aug;10(4):46270
Slide 35
Caution: The Weakness of Episode Payment Health Condition
Continued Health Healthy Consumer No Hospitalization Acute Care
Episode Efficient Successful Outcome Complications, Infections,
Readmissions High-Cost Successful Outcome Episode Payment Still
paying only when care occurs Does not address upstream prevention
of the episode itself
Slide 36
Comprehensive Care Payments To Avoid Episodes Health Condition
Continued Health Healthy Consumer No Hospitalization Acute Care
Episode Efficient Successful Outcome Complications, Infections,
Readmissions High-Cost Successful Outcome A Single Payment For All
Care Needed For A Condition $ Comprehensive Care Payment or Global
Payment
Slide 37
Payment Levels Adjusted Based on Patient Conditions Providers
Lose Money On Unusually Expensive Cases Limits on Total Risk
Providers Accept for Unpredictable Events Providers Are Paid
Regardless of the Quality of Care Bonuses/Penalties Based on
Quality Measurement Provider Makes More Money If Patients Stay Well
Flexibility to Deliver Highest-Value Services No Additional Revenue
for Taking Sicker Patients CAPITATION (WORST VERSIONS)
COMPREHENSIVE CARE PAYMENT Isnt This Capitation? No Its
Different
Slide 38
Example: BCBS Massachusetts Alternative Quality Contract Single
payment for all costs of care for a population of patients Adjusted
up/down annually based on severity of patient conditions Initial
payment set based on past expenditures, not arbitrary estimates
Provides flexibility to pay for new/different services Bonus paid
for high quality care Five-year contract Savings for payer achieved
by controlling increases in costs Allows provider to reap returns
on investment in preventive care, infrastructure Broad
participation 14 physician groups/health systems participating with
over 400,000 patients, including one primary care IPA with 72
physicians Positive first-year results Higher ambulatory care
quality than non-AQC practices, better patient outcomes, lower
readmission rates and ER utilization
http://www.bluecrossma.com/visitor/about-us/making-quality-health-care-affordable.html
Slide 39
Not Just Better Acute Care, But Reducing the Need for It Health
Condition Continued Health Healthy Consumer No Hospitalization
Acute Care Episode Efficient Successful Outcome Complications,
Infections, Readmissions High-Cost Successful Outcome
Slide 40
Opportunity: Significant Reduction in Rate of Hospitalizations
Examples: 40% reduction in hospital admissions, 41% reduction in ER
visits for exacerbations of COPD using in-home & phone patient
education by nurses or respiratory therapists J. Bourbeau, M.
Julien, et al, Reduction of Hospital Utilization in Patients with
Chronic Obstructive Pulmonary Disease: A Disease-Specific
Self-Management Intervention, Archives of Internal Medicine 163(5),
2003 66% reduction in hospitalizations for CHF patients using
home-based telemonitoring M.E. Cordisco, A. Benjaminovitz, et al,
Use of Telemonitoring to Decrease the Rate of Hospitalization in
Patients With Severe Congestive Heart Failure, American Journal of
Cardiology 84(7), 1999 27% reduction in hospital admissions, 21%
reduction in ER visits through self-management education M.A.
Gadoury, K. Schwartzman, et al, Self-Management Reduces Both Short-
and Long-Term Hospitalisation in COPD, European Respiratory Journal
26(5), 2005
Slide 41
ER Visits Lab Work/ Imaging Hospital Stay Health Insurance Plan
Physician Practice/ ACO Global Payment Can Assist, ( But Its a Big
Jump from FFS ) FULL COMP. CARE/GLOBAL PAYMENT Avoidable $
Flexibility and accountability for a condition-adjusted budget
covering all services $ Condition- Adjusted Per Person Payment
Office Visits Nurse Care Mgr Phone Calls
Slide 42
Example: Washington State Medical Home Pilot Program Organized
by Puget Sound Health Alliance and Washington State Health Care
Authority 4-Part Payment Model Current FFS payments for PCP
services Additional PMPM payment for care management $2.50 per
patient per month in Year 1 (part of year) $2.00 per patient per
month in Years 2 & 3 No restrictions on how money is used
Targets for Reducing Preventable ER/Hospital Utilization Reduction
targets large enough to repay health plans for upfront payments
Penalty for failure: Repayment of up to 50% of PMPM payment Bonus
for success in reducing utilization beyond targets 50/50 split of
payers savings from reductions in ER visits and/or hospitalizations
net of PMPM payment Quality of care must be maintained based on
quality measures Implementation Began May 2011 7 health plans (5
commercial, 2 Medicaid) 12 primary care practice sites (8 provider
orgs), ~ 25,000 patients
Slide 43
CMS CMMI: The Federal $10 Billion Investment in Payment &
System Redesign Medicare Shared Savings Model ACO Initiative
Medicare Advanced Payment Model ACO Initiative Medicare Pioneer ACO
Initiative Bundled Payments for Care Improvement Initiative
Comprehensive Primary Care Initiative FQHC Primary Practice
Demonstration Independence at Home Demonstration Initiative to
Reduce Avoidable Hospitalizations Among Nursing Facility Residents
Medicaid Emergency Psychiatric Demonstration Medicaid Incentives
for the Prevention of Chronic Disease State Demonstrations to
Integrate Care for Dual Eligibles Community-based Care Transitions
Program Partnership for Patients Innovation Advisors Program
Innovation Awards Program
http://www.bluecrossma.com/visitor/about-us/making-quality-health-care-affordable.html
Slide 44
A Sampling of Utah Payment Reform Initiatives: Both Public and
Private Sector Approved Medicaid ACO Waiver Application Multiple
PCMH Initiatives with Private Payers and Providers Direct
contracting with Providers by Private and Public Employers Payer,
State, and Community-led efforts to measure and make visible
pricing and quality performance Onsite Work Clinics Developed by
providers Medical Home Infrastructure Development in Preparation
for ACO Other ACO Development Activities by Providers and Payers
(e.g., Central Utah Clinic) Limited Network Product Development by
multiple payers Aarches CO-OP insurance plan ($85M CMS loan)
http://www.bluecrossma.com/visitor/about-us/making-quality-health-care-affordable.html
Slide 45
Things Needed to Make Global Payment Work Well for Physicians
Trusted, Shared Data on Current Utilization, Cost Physician needs
to know current rates of admissions, complications, etc. to set
prices appropriately Purchaser/payer needs to know that theyre
getting a better deal than they are today Protections for
Physicians from Insurance Risk Severity adjustment of payment Risk
corridors in case costs were mis-estimated Outlier payments for
unusually expensive patients Risk exclusions for some patient
populations Good Measures of Outcomes Measures meaningful to
patients using high-quality data
Slide 46
Challenge: Gaining Support from a Critical Mass of Payers Payer
Provider Payer Patient Provider is only compensated for changed
practices for the subset of patients covered by participating
payers Better Payment System Current Payment System
Slide 47
Payers Need to Truly Align to Allow Focus on Better Care Payer
Provider Payer Patient Better Payment System A Better Payment
System B Better Payment System C Even if every payers system is
better than it was, if theyre all different, providers will spend
too much time and money on administration rather than care
improvement
Slide 48
Payer Coordination Is Beginning to Occur Around the Country
Examples of Multi-Payer Payment Reforms: Colorado, Maine, Michigan,
Minnesota, New York, North Carolina, Oregon, Pennsylvania, Rhode
Island,Vermont, and Washington all have multi-payer medical home
initiatives A Facilitator of Coordination is Needed State
Government (provides anti-trust exemption) Non-profit Regional
Health Improvement Collaboratives Medicare Needs to Participate in
Local Projects as Well as Define its Own Demonstrations Center for
Medicare and Medicaid Innovation (CMMI) created under PPACA
provides the opportunity for this Medicare is now participating in
eight of the state-led multi-payer medical home initiatives
Slide 49
Payment Reform Efforts Depend on Patient, Family & Consumer
Engagement
Slide 50
Slide 51
In the Clinic Outside the Clinic A ratio problem: 60 vs.
525,540 minutes How can individuals take control of their own
healthcare, and ultimately their own health? What can providers and
plans do to help?
Slide 52
Benefit Design Changes Are Critical to Success ProviderPatient
Payment System Benefit Design Ability and Incentives to: Keep
patients well Avoid unneeded services Deliver services efficiently
Coordinate services with other providers Ability and Incentives to:
Improve health Take prescribed medications Allow a provider to
coordinate care Choose the highest-value providers and
services
Slide 53
Current Lack of Incentives for Value-Based Patient Choice
Copays, Co-insurance, and High Deductibles can discourage patients
from getting preventive treatments or medications they need to stay
well and out of the hospital Copays, Co-insurance, and High
Deductibles do little to encourage patients to be cost- conscious
in choosing among high-cost providers and services
Slide 54
Pay the Difference in Price? Use the High-Value Provider
Consumer Share of Surgery Cost Price #1 $23,000 Price #2 $28,000
Price #3 $33,000 $1,000 Copayment:$1,000 10% Coinsurance w/$2,000
OOP Max: $2,000 $5,000 Deductible:$5,000 Highest-Value (Reference
Pricing): $0$5,000$10,000 Knee Joint Replacement
Slide 55
Blue Cross/Blue Shield of MA Hospital Choice Cost-Share Benefit
Low-Cost Hospitals High-Cost Hospitals PCP$20 SPC$35 Inpatient
Hospital$500$1500* Outpatient Hospital Day Surgery$250$1250 High
Tech Radiology$50$500 Laboratory$0$35 X-Rays/Other Imaging
Tests$0$100 PT/OT/ST$35$70 *LOWER INPATIENT COPAY APPLIES IF
EMERGENCY ADMISSION
Slide 56
Use Financial Incentives to Encourage Use of Medical Home?
CONSUMERS/ PATIENTS CAN CHANGE OR USE MULTIPLE PROVIDERS AT WILL
CONSUMERS/ PATIENTS ARE LOCKED IN TO A SINGLE GATEKEEPER PROVIDER
CONSUMERS/ PATIENTS ARE ENCOURAGED TO CHOOSE & USE AN ACO OR
MEDICAL HOME MIDDLE GROUND ROCKHARD PLACE OPTION 1:Charge patients
more for using providers outside the ACO or medical home (requires
changing benefits)
Slide 57
Or Offer a Better Product to Attract and Retain Patients?
CONSUMERS/ PATIENTS CAN CHANGE OR USE MULTIPLE PROVIDERS AT WILL
CONSUMERS/ PATIENTS ARE LOCKED IN TO A SINGLE GATEKEEPER PROVIDER
CONSUMERS/ PATIENTS ARE ENCOURAGED TO CHOOSE & USE AN ACO OR
MEDICAL HOME MIDDLE GROUND ROCKHARD PLACE OPTION 1:Charge patients
more for using providers outside the ACO or medical home (requires
changing benefits) OPTION 2: Give patients high quality,
coordinated care by using the providers inside the ACO or medical
home (requires payment change)
Slide 58
Today: Many Barriers to Patient Adherence & Care
Coordination PATIENT PCP OFFICE/ MEDICAL HOME SPECIALIST OFFICE LAB
FOR TESTING NON-MEDICAL SUPPORT (e.g., weight loss) Lack of
Transportation Multiple Days Off Work Services Unavailable or Not
Affordable
Slide 59
Flexible Payment Allows More Radical Care Redesign PATIENT
SNF/ASSISTED LIVING CLINIC URGENT CARE CENTER EMERGENCY ROOM
WORK-SITE CLINIC SPECIALIST SUPPORT LAB FOR TESTING PCP OFFICE
NON-MEDICAL SUPPORT Single, Flexible, Comprehensive Care
Payment
Slide 60
Where are we going? Care delivery system will need to
accommodate more patients and sicker patients New models of care
and innovation needed to address cost/capacity/quality issues.
Patient at the center and a new focus on care outside clinic walls.
Payment models will change; more accountability for outcomes, less
focus on activities.
Slide 61
Every system is perfectly designed to get the results it gets
Paul Batalden, M.D.
Slide 62
Rapid Cycle - Multiple Cycles Overall AIM Increase documented
eye exams for our diabetes population by 45% in the next 12 months
Time Expect Challenges and Barriers Cycle #1 Contact Eye Doctors
Cycle #2 Patient Fax Back Form Cycle #3 Front Office track down eye
results Cycle #4 Computer Network with eye doctors Cycle #5
Reminder letter from PCPs Implement Final Changes
Slide 63
Summary Payment and care delivery system reform is upon us
Reformed systems will put providers at financial risk for excess:
Avoidable complications Adverse outcomes resulting from care
coordination failures Negative health outcomes associated with
patient health behavior and care plan execution choices Change is
not necessary. Survival is optional Deming
Slide 64
Todays Engagement Agenda Can patient choices and behavior be
positively influenced by health care providers? Or are such patient
behaviors beyond the reach of providers (theres nothing we can do)?
can patient behaviors be influenced by providers, but not
systematically (instead luck dominates)? can patient behaviors be
influenced by providers, but those providers must be born with the
knack (it cannot be learned)? is there something else that makes
this impossible? What can we do to prepare for reform?
Slide 65
Self-assessment: Are you ready? Areas for improvement? Experts
and best practices.