PA Optometric Association Annual Congress

Transcription

1 May 18, 2012 PA Optometric Association Annual Congress Andrew Bloschichak MD, MBA Senior Medical Director, Highmark

2 Emerging Health Care Reform Delivery and Reimbursement Systems

3 Introduction Key Drivers for Health Care Reform: Access 50 million uninsured Quality 100,000 die annually from medical errors / HAI Poorly coordinated care Cost Per capita spend far exceeds other developed countries Employers are highly dissatisfied with value received from premiums and care cost payments Spending on healthcare in the United States is growing at an unsustainable rate of ~6-8%/year; Approximately 3 x Inflation Rate 2

4 PENNSYLVANIA PATIENT SAFETY AUTHORITY 225,624 Serious Events and Incidents 2010 Report 7,508 (3.3%) with patient harm

5 Pennsylvania HealthCare Cost Containment Council IMPACT of HAIs in PA Of 1.9 Million patients admitted to PA hospitals in 2009, 23,287 (1.2 percent) contracted at least one HAI during their stay Mortality rate for patients with HAI was 9.4% compared to 1.8% for those patients without a HAI LOS for patients with HAI was 21.6 days, compared to 4.9 days for those patients without a HAI 29.8% of patients with HAI were readmitted within 30 days compared to 6.2% for those without a HAI; Surgical infections had a 53% readmission rate. Hospital costs for patients with HAI were 3 X those for patients without HAI 4

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7 CMS Roadmap on Quality 6

8 Health Reform: Policy Concepts Improve Quality of Care and Reduce Cost Trends Reduce Unwarranted Variation (Dartmouth Atlas) Facilitate Use of Health Information Technology; Health care data transparency Advance New Care Delivery Models Accountable Care Organizations Patient Centered Medical Home Develop new reimbursement models to align incentives Bundled payments Episode based payments Shared savings Emphasis on personal responsibility Wellness and prevention Member incentives

9 So What Are Health Plans Doing? Facilitate improved quality of care Pilot new care delivery models Assist with adoption of EHR and HIE Move from FFS to more aligned reimbursement models: bundled payments, episode payments, shared savings Increase value of care management activities, transitioning accountability to physicians/providers Develop new products Tiering and steerage to higher value providers Shared savings models Member incentives for wellness

10 Shared Minimal Potential for Care Cost Savings Substantial

11 Patient Centered Medical Home 1967 American Academy Pediatrics coined the phrase Medical Home 2007 AAP, AOA, AAFP, ACP agreed to Joint Principles of Medical Home : Personal physician Physician directed care Whole person orientation Coordinated/integrated care Quality and safety Access Alignment of incentives 10

12 High Risk Patients Age Gender Genetic disposition Child birth history Hormone replacement therapy Lobular carcinoma insitu (LCIS) Observation Tamoxifen for 5 years Follow-up with yearly exam medical, physical, breast, pelvic Pelvic exam annually for women on hormone therapy Patients with Breast Cancer Symptoms Abnormal growth in breast tissue Altered appearance of breast Nipple discharge Screening Exam Diagnosis based on mammogram and palpation Stage 0 (non-invasive, cancer not spread to lymph nodes, no distant cancer spread) Mastectomy Comorbidity Check Ductal carcinoma in situ Pathology review Measurement of hormone receptors Widespread disease in 2 or more areas Total mastectomy No lymph node removal Breast reconstruction Consider tamoxifen for ER positive treated with lumpectomy Additional Tests Diagnosis based on mammogram and palpation Ultrasound MRI Biopsy Surgical Needle Surgical excision Margin positive Exam biannually for 5 years Blood count Chemical tests MRI with breast coil ER/PR and HER-2 test Bone scan Pain Stages I and II Cancer spread to and IIIa with bones tumors >5cm Abdominal CT, US or MRI Stage IIIa Blood chemistry Comorbidity abnormal Check Stage II (tumor 5 cm, spread to 0-3 lymph nodes under the arm) Lumpectomy and sentinel node biopsy or Removal of under arm lymph nodes No cancer spread to lymph nodes Radiation to whole breast Added boost to former tumor site Margin negative Radiation Total mastectomy (patient choice) Follow-up Margin negative low grade tumor Possible radiation Total mastectomy (patient choice) Yearly mammogram Cancer spread to 1/2/3 nodes Radiation to whole breast Added boost to tumor site Possible radiation to supraclavicular area and nodes near breast bone Stage 1 (no cancer spread, <2cm) Stage IIIa (tumor 5cm, spread to 0-9 lymph nodes under arm) Cancer spread to >4 lymph nodes Radiation to whole breast Added boost to tumor site and supraclavicular area Possible radiation to nodes near breast bone Common Co-morbidities Cirrhosis Poor renal functions CAD Peripheral vascular disease Stroke/embolism Asthma Peptic ulcer Diabetes Rheumatoid arthritis Diarrhea Leukemia Cancer noninvasive >2cm, diagnosed by needle biopsy Mastectomy and sentinel node biopsy Removal of under arm lymph nodes Preserve breast Don t preserve No cancer in Tumor <5 cm nodes No cancer spread Tumor >5 to nodes cm/positive margins No radiation therapy unless margins are close then radiation to chest wall ER/PR + HER-2 + Herceptin Hormone therapy Chemotherapy Pelvic exam annually for women on hormone therapy Chemotherapy Hormone therapy Herceptin Mastectomy Sentinel node biopsy Underarm node removal Chemotherapy Radiation to chest wall, supraclavicular area Possible radiation to lymph nodes next to breast bone Adjuvant therapy Tumor receptor classification ER/PR HER-2 + Herceptin Chemotherapy Tumor shrinks enough for lumpectomy Lumpectomy Removal of Tumor underarm lymph doesn t nodes if shrink/ necessary grows Tumor shrinks but still too large for lumpectomy Cancer spread to Cancer spread to >4 nodes 1-3 nodes ER/PR HER-2 + Follow-up Exam biannually for 5 years Hormone therapy Chemotherapy Chemotherapy Possible radiation to chest wall, supra claviscular area Possible radiation to lymph nodes near breast bone ER/PR HER-2 + Chemotherapy Yearly mammogram PCMH Six Common Fundamental Elements 1 Continuous Care 6 Appropriate Reimbursement 2 First Contact Access Patient-Centered Medical Home 5 Coordination of Care Comprehensive Evidence-Based Care 4 3 Performance Measurement 11

13 PCMH The Patient-Centered Medical Home model will serve as a Care Coordination Hub for patients, with the PCP and the PCP team serving as the Quarterback for care Care Team Roles Diagnostics/Drugs Manage drugs Avoid duplicate tests Allied Health Facilities Care Coordination Team- Based Care Convenient care partnership Highmark Care Management PCP Care Team Specialists Discharge follow-up Coordinate with outpatient and inpatient procedures Plan treatment with specialists Coordinate care 12

14 Highmark Essentials for Care Delivery Models Physician-directed medical practice Quality and safety as foundation Patient with established relationship with a personal physician trained to provide continuous and comprehensive care, with enhanced access to care Care is coordinated and integrated across all aspects of care delivery system, utilizing IT tools to facilitate care and coordination; Significantly improved communications between physicians and providers Appropriately aligned payment and incentives which reward quality and cost savings Enhanced patient experience

15 PCMH Pilot: Participating Practices Region Western PA Central PA West Virginia Participating systems and practices # of sites Current PCP Count Member attribution count Preferred Primary Care Physicians 3 8 5,459 Premier Medical Associates ,615 St Vincent Family Medicine ,485 Washington Family Practice ,037 Annville Family Medicine PC 1 9 2,865 Wellspan ,461 Lancaster ,434 Hershey ,227 Holy Spirit 2 8 1,639 Pinnacle Health 1 5 1,940 Family Care Wheeling Hospital Inc Total ,805 Total by region 20,596 18,

16 Clinical Outcomes Reduction in hospital admissions and avoidable readmissions Improved select preventive service utilization Reduced ER utilization Improved patient satisfaction Improved physician satisfaction Improved coordination of care; Communication agreements Reduction in care cost trends

17 Highmark PCMH Pilot Diabetic Eye Exam: Percentage of patients aged with diabetes (type 1 or type 2) who had a retinal or dilated eye exam or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the last 24 months; NCQAC PCMH Benchmark: 56%

18 GOHCR Learning Collaborative PCMH results

19 Reimbursement Moving from fee-for-service to fee-for-quality outcomes Current State PCMH Pilot 2011 PCMH Future State Fee-for-service Today s standard: provide a service, get a payment Pay-for-performance An opportunity for additional reimbursement, based on quality Fee-for-service Pay-for-performance An opportunity for additional reimbursement, based on quality Prospective payment Fee-for-service Retrospective payment Based on outcomes Shared Savings Bundled Payments Upfront financial support Helps practices make changes Retrospective bonus Back-end bonus to properly encourage quality outcomes 18

20 Seeking To Change Physician/Provider Incentives Three Levers for Increasing Physician/Provider Accountability Enhanced P4P 1 Bundled Payments Shared Savings Description Financial bonuses, penalties, or withholds assessed based on outcome or process performance Payer disburses single payment to cover hospital, physician, or other services performed during an inpatient stay or episode of care Total expense (to payer) for a given patient population compared to riskadjusted benchmark; portion of any savings below benchmark returned to provider Reform Law Elements Hospital VBP 2 Readmissions Penalties HAC 3 penalties Integrated Care Demonstration National Episodic Bundling Pilot Shared Savings Voluntary Program Accountable Care Organization Underlying Assumption Adherence to best demonstrated practice can improve outcomes and reduce longterm utilization Better care coordination can reduce expenses associated with care episodes Better care coordination can minimize inappropriate or duplicative utilization 1- Pay for Performance 2-Value-Based Purchasing 3-Hospital-Acquired Condition Source: Centers for Medicare and Medicaid Services; Health Care Advisory Board interviews and analysis.

21 ACOs have a set of key elements that are centered around the concept of shared accountability for cost and quality.. Legal organization and local accountability May involve an enhanced service agreement with payers and providers or may involve a new formal, accountable legal entity Include PCPs and a core group of specialists to cover care continuum Shared savings ACO-specific expenditure benchmarks established based on historical trends and adjustments for patient mix Bonus payments based on risk-adjusted, per beneficiary spending levels below benchmark Payment incentives Development of payment models to align incentives across participants De-coupling of clinical and financial risk to better allocate risk to enhance accountability Health information exchange Sharing of data / information to equip providers to manage clinical risk Risk-adjusted performance reports for providers, payers, and consumers Health management infrastructure and capabilities Use of infrastructure to provide better population and treatment management

22 As providers reduce waste and bend overall cost trend to drive actual spending even lower, residual savings remain to be shared among participants Launch Current trend trend Spending Spending Benchmark Shared Savings Actual Costcost Spending Time

23 Eye Care and the Emerging Health Care Reform Delivery and Reimbursement Systems Access: Extended services; Urgent Care; Coordination of Care; Improved communications Quality: Cost: Quality performance measures; Population management; Evidence-Based Medicine Bundled Payment; Shared-savings; Cost-Efficient Care 22

24 The Future Ain t What It Used To Be Yogi

25 Thank You Andrew Bloschichak MD, MBA Sr. Medical Director, Central PA Highmark