Edifecs value based reimbursement 2017 01 27

Pathways to PartnershipsValue Based Reimbursement – paying for health outcomes

Erasmus MC, 27 januari 2017

Remko Manders, AchmeaMichiel Walsteijn, Edifecs

Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare

Some Definitions

Quality (in medicine):

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990)

Value:

Outcomes Achieved divided by Resources Expended

Health

Cost


Value Based ReimbursementA Continuum of Provider Risk

Fee for Service

Fee for Service Plus P4P or

Shared Savings

Episode ofCare / Payment

Bundling

Partial Capitation

Global Capitation

Provider Sophistication

Pro

vide

r R

isk


VBR: Prostate

VBR Models Examples of Performance Measures

• P4P• Bundled

Payments• Full Risk

1. Mortality rate2. Impotency3. Incontinence4. Anesthesiology and Critical Care: Prevention of Catheter-Related Bloodstream Infections (CRBSI) –

Central Venous Catheter (CVC) Insertion Protocol5. Febrile Neutropenia Risk Assessment Prior to Chemotherapy6. Gains in Patient Activation (PAM) Scores at 12 Months7. Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections8. Prostate Cancer - Cancer Surveillance9. Prostate Cancer: Adjuvant Hormonal Therapy for High or Very High Risk Prostate Cancer Patients10.Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients11. Prostate Cancer: Three-Dimensional Radiotherapy12.American Medical Association - Physician Consortium for Performance Improvement (AMA-13.Radical Prostatectomy Pathology Reporting14.Shared Decision Making Process15.Assesses whether men 70 years of age and older were screened unnecessarily for prostate cancer

using prostate-specific antigen (PSA)-based screening.

Market Participant Examples

Comments • Prostate programs are directed primarily at over-screening that leads to needless follow and false positives, and steering patients to identified centers of excellence (COE)

• Treatment decisions and outcomes vary significantly but a standard set of best practices is emerging


VBR: In Vitro FertilizationVBR Model Examples of Performance Measures

• VBID/ Steerage to COE

• Bundled payment per cycle

Primarily facility success/failure measures related to two factors:1. Live birth event or a take home baby2. Success/Failure ratio of IVF cycles per cumulative live births Measures are Milestone Measures of success or failure3. Cycle Started4. Patient achieving trigger5. Oocyte retrieval6. Patient w/sufficient embryos7. Transfer procedure8. Embryo transferred9. Course of treatment started10.Time to pregnancy resulting in birth

Market Participant Examples

Comments • Adherence to best practices and track record of success establish an IVF Center as a COE• The leverage held by payers to negotiate for bundled payments per cycle and unit cost discounts

varies dramatically from region to region• Lack of precise data makes it difficult at this time to apply true value based outcome measures to

IVF services. Patient experience reporting and process measures are the current state of the art• In US, full coverage of a limited number of IVF cycles is mandated in eight states, seven more have

a more limited but mandated infertility treatment benefit


Creating a win for the patient New Contract for OBs

Pay for Performance:

Physicians who follow guidelines earn a bonus

payment for following criteria consistently

New Contract for OBs

Shared Savings:

Physicians who follow guidelines earn 50% of savings, if other quality measures remain high

1) Information Only

2) Pay for Performance

3) Shared Savings

Pathways to Partnerships | Bridging Connections For Valueedifecs confidential

Implementing Value-Based Care

Payers and providers are evolving end-to-end capabilities to scale Value-Based Care

Target Populations

Design Contracts

Assemble Integrated Patient Records

Coordinate Care

Measure Outcomes

Pay for Value

Pre - Contracting Post - Contracting

Target Interventions

100 Fastest Growing Companies in WA

Washington’s 100 Best Places to Work For

4 consecutive years

Inc. 5000 Fastest- Growing Private Companies in the US

6th consecutive year

Deloitte Technology Fast 500, North America

5th Consecutive year

Puget Sound Business Journal, Washington Best Workplaces

3rd consecutive year

Seattle Business Magazine’s, Tech Impact Award

Fierce innovation award

Top 3 FinalistBest In BizBest Place to work:

Silver

HCI 100 Healthcare Informatics

Ranking #78

Pathways to Partnerships | Bridging Connections For Value


Appendix: Value-Based Care Solution




How are PMPM Costs

changing?

What is your budget to

date performance?

What savings might you anticipate?

How is your attribution changing?

What is your leakage?

How is your quality

performance so far?

What is your performance

against KPIs?

What is driving your

costs?