Thriving in the New Health Care Landscape: Payment Reform, Data and Engagement Sarah Woolsey, Medical Director, HealthInsight Utah
HealthInsight’s Annual Quality Conference October 18, 2016
What You’ll Learn Today
By attending this session, participants will be able to: • Discover how new and ongoing health care
initiatives across the nation impact health care providers and patients
• Identify opportunities for change and a plan for action
• Identify resources for learning more along with colleagues and the HealthInsight team
Key Topics for Today
• Payment reform and the alternative payment movement
• The data imperative • Patient engagement
– a must
PAYMENT REFORM AND THE ALTERNATIVE PAYMENT MOVEMENT
What is the Problem?
• Our health care costs keep going up and are a much greater percentage of gross domestic product (GDP) than other countries
• Wage increases are being eaten up by insurance cost
• Even spending all that money, our quality outcomes are mediocre at best
• This decreases our global competitiveness
Average Annual Worker and Employer Contributions to
Premiums and Total Premiums for Family Coverage, 1999-2016
Cumulative Increases in Health Insurance Premiums, Workers’ Contributions to Premiums, Inflation and Workers’ Earnings,
1999-2016
“Value” Reform: The Vision
Value-Based Purchasing
• Federal – Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
• Medicare Incentive Payment System (MIPS) • Advanced Payment Models (APMs)
– Comprehensive Care for Joint Replacement (CCJR) – Centers for Medicare and Medicaid Innovation (CMMI)
• Employers – Private Accountable Care Organizations (ACOs) – Bundled or Tiered Payments – Direct Primary Care
• States – State Innovation Models – Public Employer Retirement Systems – Medicaid Managed Care
Who it Really Impacts
Payers Providers
Patients Purchasers
Federal Program: MACRA
• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
• Focuses on Part B Medicare • Intent is three-fold:
– Sustainable growth rate repeal – Improve care for Medicare beneficiaries – Change our payment system from focus on
volume to value
CMS Framework
CMS Target Percentage of Payments in Fee for Service Linked to Quality and Alternative Payment Models
A Step: Medicare Incentive Payment System (MIPS)
Clinicians will be scored under MIPS using a single composite score that will factor in performance in four weighted categories for Year 1:
Advanced APMs
Based on the proposed criteria, which current APMs will be Advanced APMs in 2017? • Shared Savings Program: Tracks 2 and 3 • Next Generation ACO Model • Comprehensive End Stage Renal Disease Care
(CEC): Large dialysis organization arrangement • Comprehensive Primary Care Plus (CPC+) • Oncology Care Model (OCM): Two-sided risk
track available in 2018
Where Does MACRA Fit in the Big Picture?
• Where CMS goes others will follow • Track/report quality on care and understand
and act on information about the cost of care • Use technology to support internal
improvement efforts as well as to coordinate across the continuum of care
• Very likely leading to changes in patient engagement and experience
The Systems Vision: Transforming the Care of Complex Patients
Acr
oss
Car
e Se
tting
s
Essential Services System Requirements
Care Mgt
Clinical Pharmacy
Health IT
QI Training
Performance Incentives
Collaboration and
Integration Medication
Reconciliation
Informed, Activated, Discerning
Consumers, esp. End-of-
Life
Data to Treat,
Measure, Evaluate
Perfect Patient Care
Rewards for
Collaboration
Hospice/Palliative Long-Term Care
Rehab Hospital
Emergency Services Specialty Care
Primary Care
Screening and Tx
Behavioral Health
Engaged Patient
U.S. ACO Participation: Contract Growth
U.S. ACO-Covered Lives to Date
Source: Leavitt Partners Center for Accountable Care Intelligence
Utah Alternative Payment Model Participation
• Utah State Innovation Model review of 7/12 large health plans reported (spring 2016) – All have patients in shared savings arrangements, (4-
26%) of their panels – 5/7 only bonus for hitting targets, no penalty – 2/7 have up and downside targets – 1/7 has bundled payment arrangements
• Medicaid ACOs (capitated payment, aligned quality) spread to all major population centers
• Significant Medicare Advantage participation • Many direct care employer opportunities
Utah Participation in Alternative CMS Payment
• Medicare Shared Savings Program ACOs – Granger Medical, Revere Health,
Aledade Mountain West , and Utah Physicians' Quality Care
• Medicare Care Choices Model – Intermountain Homecare and
Hospice • Oncology Care Model
– Utah Cancer Specialists • Cardiovascular Disease Risk
Reduction Model – University of Utah Department
of Family and Preventive Medicine
• Bundled Payments for Care Improvement – Encompass Home Health and
Hospice – Sandy Health and Rehab – Copper Ridge Health Care – St. Joseph Villa – HealthSouth Rehabilitation
Hospital – University of Utah Health Care – Salt Lake Regional Medical
Center
So, Where Are You?
THE DATA IMPERATIVE
Data Reports
• Audiences • Purposes • See your organization • See other organizations • Target areas for
improvement • Determine additional data
needs • Public/private data
collection • Availability/transparency • Sources
Sources • CMS
– Medicare Compare – Value-Based Purchasing Reports – Material Data Safety Reports (MDS) – OASIS OBQI/Outcome-Based Quality Improvement Reports – Quality and Resource Utilization Reports (QRUR) – Program for Evaluating Payment Patterns Electronic Report
(PEPPER) – HealthInsight prepared reports on CMS data
• CDC – National Healthcare Safety Network (NHSN)
• Agency for Healthcare Research and Quality (AHRQ) – Quality and safety indicators – Healthcare Cost and Utilization Project (HCUP) – Consumer Assessment of Healthcare Providers and Systems
(CAHPS®)
Sources (continued)
• State/County – Office of Healthcare Statistics
• All Payer Claims Database • Health Care Facilities Data • Health Plan Quality and Satisfaction Data
– IBIS Public Health Indicator System – My HealthCare in Utah – County Health Rankings Report
• HealthInsight – National rankings by setting – UtahHealthScape
Home Health Agencies
• CMS – Home Health Compare and Star Ratings – Outcome and Assessment Information Set (OASIS) – Medicare provider utilization and payment data – Home Health Quality Improvement (HHQI) data
access reports • HealthInsight
– National rankings – Performance feedback reports – UtahHealthScape
Skilled Nursing Facilities
• CMS – Nursing Home Compare and Star Ratings – Certification and Survey Provider Enhanced Reporting
system (CASPER) – Cost Report Data
• HealthInsight – National rankings – HealthInsight website – Composite scores provided to participating facilities – UtahHealthScape
Hospitals
• CMS – Hospital Compare – Utilization and payment data reports
• State-based reports – Inpatient – Ambulatory surgical – Emergency department
• HealthInsight – National rankings – Performance feedback reports – UtahHealthScape
Clinical Practices
• State-based reports – Clinic Quality Comparisons on Open Data – Total Cost of Care reports (primary care) – UtahHealthScape
• CMS
– Physician Compare – Physician Quality Reporting System (PQRS) feedback
reports – Medicare provider utilization and payment data – Quality and Resource Use Report (QRUR)
Quality and Resource Use Report (QRUR)
• Shows how a group or solo practice performed on quality and cost measures used to calculate the Value Modifier
• Based on care provided to Medicare fee-for-service (FFS) beneficiaries attributed to the practice
• Composite scores: Compares practice’s average score to national mean on – Quality across six domains of care – Cost attributed to care of key conditions
QRUR Scatter Plot
QRUR Utility
The QRUR provides information to PCP regarding: • Care coordination efforts • Areas where care is more costly than peers (DM,
CAD, COPD, CHF) • Referral patterns • Worklist of high-risk patients that need more
attention • Post-acute care partners
Clinical Health Information Exchange (cHIE)
• A resource to enhance individual patient and organizational decision making
• Real time clinical data • View a patient’s history and encounters with
the health care system • Alerts can be set up to notify on your patient’s
access of health care
Health Information Exchange
• May reduce (costly) duplication of lab and radiology tests
• Improves – Decision-making – Timeliness, effectiveness and quality of care
• Meets reporting requirements – meaningful use
Utah Statewide Immunization Information System (USIIS)
• Information exchange for vaccinations • Reduces duplication • Improves workflow • Useful to assess gaps in population health
Data to Ensure Success
PATIENT ENGAGEMENT – A MUST
Source: Health Affairs 32, no.2 (2013):223-231 Patient And Family Engagement: A Framework For Understanding The Elements Adams, Christine Bechtel and Jennifer Sweeney Kristin L. Carman, Pam Dardess, Maureen Maurer, Shoshanna Sofaer, Karen doi: 10.1377/hlthaff.2012.1133
The Continuum of Engagement
Effectiveness of Patient Engagement: What Do We Know?
• Systematic review to assess strategies for informing, educating and involving patients – 129 systematic reviews, 2007
• Key findings – Health literacy – Acute and chronic health problems
• Clinical benefit at home and clinical settings • Better use of resources
– Shared decision-making and self-management • Mutually supportive approaches, use together
– Health information materials, decision aids, self-management action plans, technologies supplement or augment not replace, personal interactions
– Develop health professionals skills, provide resources for them to assist patients
Source: Coulter A and J Ellins. Effectiveness of strategies for informing, educating, and involving patients. BMJ. July 2007. 335: 24-27
Evidence for Patient and Family Centered Care
Patient and Family Centered Care Pediatric Literature • Study outcomes included patient experience, patient knowledge, attitudes to
care, provider behavior and health status – Assessed
• Education from provider to family • Information sharing from family to provider • Social-emotional support • Adapting care to match family background • Shared decision-making
• Results – Addition of social emotional support was single factor impacting knowledge, attitudes to
care, and experience of care – Best outcomes when targeting patient and family, provider and patient/family
• Not provider-only interventions
– Impact on health status hard to show (less than 50% showed benefit) but impact on improving patient experience of care may be precursor of eventual health-related outcomes
Source: A Narrative Synthesis of the Components of and Evidence for Patient- and Family-Centered Care. Clin Pediatr. April 2016 55: 333-346, first published on June 26, 2015 doi:10.1177/0009922815591883
NATIONAL CMS TRENDS
MACRA Proposal and Patient Engagement
• Care coordination and communication among health team members, including patients and families
• Managing transitions of care in partnership with community-based entities and services
• Developing and updating individual care plans with patients
• Fostering linkages with neighborhood/community-based resources to support patient health goals
• Use of evidence-based decision aids to support shared decision-making
• Support for patient self-management using techniques such as teach back, action planning or motivational interviewing
• Expanded access to care • Beneficiary engagement activity
(assessment, surveys, advisory councils)
• PCMH elements of – Collecting and reporting patient
experience of care – Meaningful engagement of
patients and families – Shared decision-making
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) as a priority not mandate
Comprehensive Primary Care Plus (CPC+)
• CMS Alternative Payment Program • One of five key components of CPC+ is
convening and engaging a Patient and Family Advisory Committee
• Requires supporting patients’ self management of high-risk conditions
• Requires psychosocial needs assessment and inventory resources and supports
Survey of ACOs and Patient Activation and Engagement Practices
Process % of ACOs Surveyed Using this Practice
Patient Reminders (EHR, phone, mail) 100
Patients may access EHR (Portal) 71
Patients may access own EHR notes (i.e. Open Notes) 24
Health Coaching 45
PCP with training in Pt Activation and Engagement 48
Decision Aids for Patients 45
Formal Health Literacy Assessment 23
Patients may participate in ACO governing Board 63 (low pt. participation)
Patients may participate in ACO QI 50
Provide Patient experience data provided to PCPs 87
Source: Shortell, SM et.al An Early Assessment of Accountable Care Organizations’ Efforts to Engage Patients and Their Families. Medical Care Research and Review 2015, Vol. 72(5) : 580–604.
ACO Continued
• Of ACOs calculating ROI of patient activation and engagement – Report 2:1 to 4:1 – Emergency department and hospital use reductions
• Commonly reported strategies – Heavy use of coordinators and care managers – Developing patient communication and IT
infrastructure – Training staff in Motivational Interviewing Source: Shortell, SM et.al An Early Assessment of Accountable Care
Organizations’ Efforts to Engage Patients and Their Families. Medical Care Research and Review 2015, Vol. 72(5) : 580–604.
EXPANDING ENGAGEMENT
Key Themes
• Assess and move patient along a continuum of engagement or activation
• Use decision aids for shared decision-making • Advocate for patient held records • Add patients to leadership and QI teams,
meaningfully • Imbed self-management opportunities for
patients
Train and support your workforce
Patient Activation Measure
• Commercial tool (owned by Insignia Health) – Assesses an individual’s knowledge, skill, and
confidence for managing one’s health and care – Measures patients on a 0-100 scale – Predictive of success with most health behaviors – Extensive evidence that it is possible to increase
activation levels in patients
Source: Hibbard, Judith; Stockard, J; Mahoney, ER; Tusler, M (August 2004). "Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers". Health Services Research. 39 (4): 1005–10026. doi:10.1111/j.1475-6773.2004.00269.
Strategies Used by Clinicians with High and Low Change on Patient Activation Scores
The Ottawa Hospital Patient Decision Aid Site
Source: The Ottawa Hospital
Shared Decision-Making Support From Payer
• United Healthcare • Shared Decision-Making Support for members
with preference sensitive conditions – Targeted RN counseling on individual options for
care – 2009 analysis of 4225 “engaged members” from
151 employers – $11,000 savings/procedure as patients chose
evidence based conservative treatment options
Source: G. Sandy, Reed V. Tuckson and Simon L. Stevens. UnitedHealthcare Experience Illustrates How Payers Can Enable Patient Engagement. Health Affairs 32, no.8 (2013):1440-1445. doi: 10.1377/hlthaff.2012.1082
Patient Held Records
• Patient held records can enhance patients’ knowledge and sense of control
• Self monitoring of blood pressure, blood glucose, and oral anticoagulation
• Remote tele-monitoring, can be both effective and cost effective
• Open Notes
Open Notes Movement
• Initiative to give patients access to their medical providers’ notes via secure patient portals – Not a specific vendor product or software – Epic, Cerner, Allscripts, Meditech can support
implementation at this time – Currently implemented in 50+ organizations reaching
more than 10 million patients in 35 states – Same model in place at VA since 2010
Source: Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting Patients to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead. Ann Intern Med. 2012;157:461-470. doi:10.7326/0003-4819-157-7-201210020-00002
Open Notes Movement (Continued)
Study in 2010, trial of PCPs and patient volunteers over one year Patient results:
– 80% read a note initially, 50-60% long term – 75% reported benefits (replicated multiple times) in Engagement,
Adherence, Planning, Control, Understanding – 99% wanted to continue (replicated multiple times) – 85% would use OpenNotes as criterion for selecting providers
PCP results:
– Little impact on workflow, email volume unchanged – Worries about negative patient effects didn’t materialize – After study, no provider stopped – Providers do need to improve notes
Source: Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting Patients to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead. Ann Intern Med. 2012;157:461-470. doi:10.7326/0003-4819-157-7-201210020-00002
Benefits of Patient and Family Advisory Councils
For Health Care Organizations • Provide an effective mechanism for
receiving and responding to consumer input
• Result in more efficient planning to ensure that services really meet consumer needs and priorities
• Transform the culture toward patient-centered care
• Strengthen community relations • Recognize that collaboration leads
to better self-management of chronic conditions and improved adherence to medication regimens
For Patients and Families • Gain a better understanding of the
health care system • Appreciate being listened to and
having their opinions valued • Become advocates for the patient
and family-centered healthcare in their community
• Understand how to become an active participant in their own health care
• Provide an opportunity to learn new skills (facilitating groups, listening skills, telling their story)
Laurie West et. al Patient and Family Advisory Council Getting Started Tool Kit accessed at http://c.ymcdn.com/sites/www.theberylinstitute.org/resource/resmgr/webinar_pdf/pfac_toolkit_shared_version.pdf
HealthInsight Initiative: Development of Patient and Family Advisor Councils
• Patient and Family Advisory Council Development – St. Mark’s Hospital – Uintah Basin Medical Center/Hospital – Exodus Healthcare – Eastern Utah Women’s Health Clinic – Provo Care Center (nursing home) – University of Utah PA Program Satellite in St. George – Socorro General Hospital – Albuquerque – Gerald Champion Regional Medical Center – Alamogordo
• Five training modules over the next six months • Technical assistance from HealthInsight facilitators • Councils live by March 2017
Process Mapping Quality Improvement Initiative with Patients and Staff
Impact go-zone diagram: The green quadrant contains statements rated as having high impact by both patients and providers.
Lanoue M, Mills G, Cunningham A, Sharbaugh A. Concept mapping as a method to engage patients in clinical quality improvement. Ann Fam Med. 2016;14(4):370-376.
Patient Engagement with Chronic Disease
• Educational and self-help programs that are actively supported by clinicians improve health outcomes for patients chronic disease
• Chronic Disease Self-Management Program – Stanford Model, evidence-based – Self management focused – Six weeks of workshops, 2 ½ hours, led by trained
peer leaders who have chronic disease or diabetes
Outcomes
• 2009 randomized, controlled, trial, at six and 12 months after workshop completion – 345 participants with DM2 had significant
improvements in depression symptoms – Fewer symptoms of hypoglycemia – Better communication with physicians – Reported increased healthy eating, and reading food
labels – Increased patient activation and self-efficacy
Source: Lorig K, Ritter PL, Villa FJ, Armas J, Community-based peer-led diabetes self-management , a randomized trial. Diabetes Educator, 35(4):641-651, 2009.
Diabetes Prevention Plan (DPP) Prevention of Diabetes
• Diabetes Prevention Plan (DPP) will add to Medicare plan as of January 2017
• Core curriculum consisting of 16 sessions delivered by lifestyle coaches weekly – Sixteen sessions delivered approximately monthly that
promote healthy lifestyle changes and weight loss – Maintenance sessions following one year – Payment based on attendance and percent weight lost
• Extensive evidence to show better results than placebo, particularly in > 61 years old, reducing risk of DM 2 by (71%) across diverse patient groups
Source: https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp/Pages/default.aspx
Access to Classes in Utah
• Livingwell.utah.gov – Links to state classes available
• Contact HealthInsight if you want to train your staff to deliver chronic disease sessions on your setting – Uptake is higher with on site classes and provider
support of patient attendance throughout
Action!
• Re-look at the Inventory • What are you going to focus on today? • Listen for opportunities in all these areas to
augment of expand your capacity to thrive • Share with the person next to you one thing
you will focus on today
Questions
Thank You
Sarah Woolsey, M.D. HealthInsight Utah Medical Director
[email protected] 801-892-6622
This material was prepared by HealthInsight, the Medicare Quality Innovation Network -Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.11SOW-CORP-16-118-UT