MAH Grand Rounds July Healthcare Policy: Novel Models for Healthcare Delivery

Transcription

1 MAH Grand Rounds July 2016 Healthcare Policy: Novel Models for Healthcare Delivery David Shein, MD Mount Auburn Hospital Reservoir Medical Associates Assistant Professor, HMS Medical Director, MACIPA

2 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: Individual Role Commercial Interest Nature of Financial Relationship David Shein, MD Speaker MACIPA Medical Director No others in a position to control the content of the CME activity have any relevant financial relationships to disclose.

3 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

4 Payment Models Outline Focus: - AQC - ACO Quality Risk Adjustment

5 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

6 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)

7 Outcomes and Quality

8 What is Healthcare Quality? Teach to the test? How does measurement improve patient outcomes? Quality Measures Environment of Quality Toyota lean Does environment improve patient outcomes? Process Outcomes Patient experience Patient-reported outcomes: PROM What Are We Measuring? How Do We Measure? Claims data Clinical data Questionnaires and surveys

9 Categories of Quality Measures Listed in the National Quality Measures Clearinghouse (NQMC). Porter ME et al. N Engl J Med 2016;374:

10 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

11 Example of A Measure: Breast Cancer Screening Numerator: Women with mammogram at least once in 24 months Denominator: Women ages Exclusions: Medical reason for not having mammogram: Bilateral mastectomy or 2 unilateral mastectomy procedures

12 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

13 Patient Surveys Clinical PHQ-9 Fall Risk Satisfaction MHQP CAHPS Consumer Assessment of Healthcare Providers & Systems

14 Efficiency and Cost

15 Risk Adjustment How can we balance risk and cost across diverse populations? Critical when looking at efficiency Utilization Cost Case Mix

16 DxCG: Predictive Risk Perspective Relative Risk Scores Derived from Hierarchical Condition Category (HCC) Predictive Models Age: 50 Gender: Male Hypertension Type I diabetes Congestive heart failure Drug/alcohol dependence Prospective Risk Score 4.90 Age/Gender 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 Verisk Health

17 Mt. Auburn Examples Risk score impact Why appropriate risk coding is so important Utilization Quality management

18 Payment Models Impact of coding on risk adjustment Impact of quality measures Surplus Budget Quality Impact of cost and utilization: efficiency - Avoidable ED/admits - Unnecessary tests and procedures - High vs low cost providers - Leakage - Pharmacy formulary

19 Risk Coding Drives budgets (reimbursement) Enables identification of high-risk patients to manage utilization risk and improve care Risk identification Intervention Early outreach

20 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)

21 COMPASS Results: Identification and Intervention Improved Outcomes PHQ9 score % Baseline PHQ-9 > 9 % Final PHQ-9 < (48%) 30% (28%) 21% (25%) 16% Depression Remission Baseline HbA1c % Baseline Poor Control Final HbA1c < 8% < (21%) 38% < (15%) 33% < Diabetes Control 241 (14%) 20% 815 (49%) 14% Baseline BP category Stage 1 HTN: SBP or DBP Stage 2 HTN: SBP 160+ or DBP 100+ % Baseline HTN Final BP < 140 / < (72%) 60% 131 (28%) 53% BP control

22 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

23 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

24 2015 QI Project Success Stories: Chlamydia Screening (16-24) 2 Pediatric PCP s: QI Project Chlamydia Screening Actions: Routine ecw Reports Component of PE Outreach to parents about requirement Patient Education STD Sheets AQC Screening Rate improved

25 Leakage Prevention (Keepage) Patient Satisfaction

26 Urology Patient Experience Leakage Rate decreased Patient Experience Survey Patient/PCP Interaction Patient/Staff Interaction Communication Dermatology Patient Access Leakage Rate decreased Actions: MACIPA Urgent Access Slots One Touch Appointment Cancellation

27 Utilization

28 Variation in Average 2009 Medicare Spending among Selected Hospitals for a 90-Day Episode of Congestive Heart Failure. Mechanic R, Tompkins C. N Engl J Med 2012;367:

29 Impact on SNF ALOS ACO MA SNF #

30 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

31 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

32 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 welldefined 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.

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