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Healthcare Reform: Improving the Healthcare World in Cleveland

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Healthcare Reform: Improving the Healthcare World in Cleveland & Beyond Barry M. Straube, M.D. Director, The Marwood Group Former Chief Medical Officer, – PowerPoint PPT presentation

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Title: Healthcare Reform: Improving the Healthcare World in Cleveland


1
Healthcare ReformImproving the Healthcare World
in Cleveland Beyond
  • Barry M. Straube, M.D.
  • Director, The Marwood Group
  • Former Chief Medical Officer,
  • Centers for Medicare Medicaid Services
  • October 27, 2012
  • University Hospitals Case Medical Center
  • Medical Quality Summit Moving Forward

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Life Expectancy at Birth vs.Spending by Country
Source OECD Health Data 2010
9
U.S. Healthcare Quality/Value Challenges
  • In the U.S. we spend more per capita on
    healthcare than any other country in the world
  • In spite of those expenditures, U.S. Healthcare
    quality is often inferior to that of other
    nations and often doesnt meet expected
    evidence-based guidelines
  • There are significant variations in quality and
    costs across the nation with increasing evidence
    that there may be an inverse relationship between
    the two
  • Healthcare expenditures account for a larger
    section of the U.S. economy over the years and
    funding those expenditures is increasingly more
    difficult
  • Heretofore we have not addressed the problem of
    45 million uninsured Americans
  • Cost Effectiveness Analysis is resisted as a tool

10
U.S. Healthcare Quality/Value Challenges
  • Care is uncoordinated
  • Care is not patient-centered, it is more provider
    centered
  • Care is inefficient
  • There continues to be considerable waste
    (overuse) in the delivery of healthcare, as well
    as overt fraud abuse
  • Insufficient emphasis is placed on major problems
    of
  • Patient safety
  • Healthcare Acquired Conditions
  • Prevention
  • Unnecessary admissions and readmissions
  • Palliative End-of-life Care
  • Health disparities
  • Health Information Technology has a critical
    unfulfilled role in this

11
U.S. Healthcare Quality/Value Challenges
  • The private and public sectors collectively have
    failed to reform healthcare using conventional
    healthcare delivery and payment models
  • Traditional Fee-for-Service is a major reason
    Pays for quantity, not quality
  • Managed care has intermittently controlled costs
    gt quality
  • Regardless of payment system we havent publicly
    measured compared cost or quality, and
    payers/providers are not held sufficiently
    accountable
  • All healthcare is local means integrated health
    systems have a significant role to play, Academic
    Centers special
  • The Affordable Care Act of 2010 has great
    potential to address the healthcare quality/value
    challenges

12
Ensuring Quality ValueTools/Drivers/Enablers
  • Contemporary Quality Improvement
  • Transparency Public Reporting Data Sharing
  • Incentives Payment reform by All Payers
  • Regulatory vehicles State Federal
  • Payer Benefit Design and Coverage Decision Making
  • Demonstrations, pilots, research, innovation

13
Contemporary Quality Improvement
  • Need to set priorities, goals and objectives,
    strategic framework first
  • Evidence-Based goals, metrics, interventions,
    evaluations
  • Includes conformance with evidence-based
    guidelines, balanced with patient-centered
    considerations
  • Cost-effectiveness, let alone comparative
    effectiveness, has not yet been addressed
    adequately
  • Rapid-cycle development, implementation and
    change methodology
  • Leveraging of resources and efforts Current and
    future models-collaboration, alignment, synergy,
    priorities
  • Many examples Hospital Quality Initiative, Organ
    Donation Campaign, QIOs, ESRD Networks, IHI,
    Bridges to Excellence, NCQA, Nursing Home
    Health Campaigns, many health plan
    collaboratives, local collaboratives, Partnership
    for Patients, etc.

14
Transparency Public Reporting Data
Availability
  • CMS Compare Websites
  • Hospital Compare
  • Nursing Home Compare
  • Home Health Compare
  • Dialysis Facility Compare
  • MA Health Plan and Medi-Gap Compare
  • Prescription Drug Plan Compare
  • New under ACA
  • Physician Compare
  • VBP Programs Above plus ASCs, LTCHs, IRHs,
    Hospices, others
  • Other comparative websites
  • www.WhyNotTheBest.org
  • MyMedicare.gov
  • HHS/CMS Data Dissemination Efforts www.data.gov,
    www.healthcare.gov
  • Potential explosion of federal govt. private
    sector data availability for private sector to
    drive data use innovation in previously
    unimaginable ways

15
Incentives
  • Pay for Reporting and Adoption Programs
  • P4R Hospital Inpatient/Outpatient , PQRI,
    e-Prescribing, Home Health
  • ARRA /HITECH EHR adoption and meaningful use
  • Value-based Purchasing (VBP)
  • ESRD Bundled Payment System January 1, 2011
  • ESRD Quality Incentive Program (QIP) January 1,
    2012
  • Hospital VBP (ACA Section 3001) October 1, 2012
  • VBP in many additional settings in pipeline
  • Competitive bidding, gain sharing, shared
    savings, bundled payment, ACOs, medical homes,
    salaries, integrated delivery, etc.
  • Will any of these be effective ?

16
VBP Issues for Future
  • Alignment of multiple programs in existence or in
    pipeline
  • Goals and objectives, priorities
  • What do we want to accomplish other than plain
    measurement?
  • Public-Private alignment
  • Measures
  • Many not actionable or likely to lead to
    improvement
  • Process to develop and gain consensus too long,
    too contentious, too academic looking for the
    perfect
  • Financial Incentives
  • Balance of penalties, bonus/rewards, shared
    savings, etc.
  • How much?
  • Phase out P4R and adoption of outcomes-based VBP

17
Regulation
  • Conditions of Participation or Conditions for
    Coverage
  • COPs are minimum health and safety standards set
    by CMS for facilities that may receive Medicare
    payments
  • 17 separate provider/supplier settings have COPs
  • Survey Certification
  • U.S. healthcare facilities certified must be in
    compliance with current Medicare regulations
    applicable state laws
  • SC process uses interpretive guidelines to
    assess compliance with regulations
  • In combination, a powerful tool for quality/value

18
Affordable Care Act (ACA) of 2010
  • Title I Quality, Affordable Health Care for all
    Americans
  • Title II Role of Public Programs
  • Title III Improving the Quality Efficiency of
    Health Care
  • Title IV Prevention of Chronic Disease
    Improving Public Health
  • Title V Health Care Work Force

19
Affordable Care Act (ACA) of 2010
  • Title VI Transparency and Public Reporting
  • Title VII Improving Access to Innovative Medical
    Therapies
  • Title VIII Community Living Assistance Services
    Support (CLASS) Act
  • Title IX Revenue Provisions
  • Title X Strengthening Quality, Affordable Health
    Care for All Americans (Amendments)

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High Profile ACA Topics
  • Greater Access to healthcare coverage
  • National Quality Priorities Strategic Plan
  • National Prevention Priorities Strategic Plan
  • Attention to not only Medicare Commercial
    healthcare, but Medicaid and Dual-Eligibles
  • Prevention and Patient Safety
  • Numerous prevention initiatives
  • Population Health Obesity, Smoking Cessation,
    etc.
  • Patient safety medical errors reduction
  • Healthcare Acquired Conditions (HACs), Infections
  • Focus on better outcomes, greater efficiency

22
High Profile ACA Topics
  • Patient Centeredness
  • High-cost Chronic Disease Management
  • Care coordination care transitions
  • Reduction of unnecessary admissions
    readmissions
  • Accountable Care Organizations, Medical Homes
  • Integration of conventional providers with public
    health, community, and non-traditional sites of
    care
  • Innovation in payment, delivery systems, care
  • Rapid cycle change quality improvement
  • Best practices and learning environments
  • Attack on healthcare Fraud, Abuse, and
    waste/overuse

23
Center for Medicare Medicaid InnovationCMMI
  • CMMI establishment mandated by January 1, 2011
    (Section 3021)
  • Consultation input from broad healthcare sector
    in implementation
  • Develop patient-centered payment models
  • Rapid piloting/testing of new payment programs
  • Encourage evidence-based, coordinated care for
    Medicare, Medicaid, CHIP
  • Focuses on populations for which there are
    deficits in care leading to poor clinical
    outcomes or potentially avoidable expenditures

24
CMMI Statutory Descriptors
  • Risk-based comprehensive payment or salary-based
    payment models
  • Geriatric assessments and comprehensive care
    plansinterdisciplinary care teamsmultiple
    chronic conditions
  • transition health care providers away from
    fee-for-service-based reimbursement and towards
    salary-based
  • health information technology-enabled provider
    network that includes care coordinators, chronic
    disease registry, home telehealth technology

25
CMMI The Innovation Center
  • Other key characteristics in the statute for
    payment models
  • Varying payment for advanced diagnostic imaging
    services
  • Medication therapy management services
  • Community-based health teams to assist in care
    management
  • Patient decision-support tools
  • State flexibility for dual-eligibles and
    all-payer payment reform demonstrations
  • Collaboratives of high-quality, low-cost
    institutions
  • 10 billion over 10 years funding

26
Staging of Innovation Development, Demonstration,
and Translation
2 To 3 years Design to Program Translation Cycle
Time
27
Driving Healthcare SystemTransformation
Un-managed
Coordinated Care
Accountable Care
  • Fee For Service
  • Inpatient focus
  • O/P clinic care
  • Low Reimbursement
  • Poor Access and Quality
  • Little oversight
  • No organized networks
  • Focus on paying claims
  • Little Medical Management
  • Organized care delivery
  • Aligned incentives
  • Linked by HIT
  • Integrated Provider Networks
  • Focus on cost avoidance
  • and quality performance
  • PC Medical Home
  • Care management
  • Transparent Performance Management

28
Driving Healthcare Delivery System Reform and
Transformation 2011-2019
2014-2019
2012-2019
2011-2019
29
CMMI Programs
  • Initiative to Reduce Avoidable Hospitalizations
    Among Nursing Home Residents
  • Innovations Advisors Program
  • Medicaid Emergency Psychiatric Demonstration
  • Medicaid Incentives for the Prevention of Chronic
    Diseases
  • Million Hearts
  • Partnership for Patients Care Transitions
    Community-based
  • State Innovations Models
  • Strong Start for Mothers Newborns
  • ACO Programs
  • Bundled Payment
  • Comprehensive Primary Care Initiative
  • Financial Alignment Initiative
  • FQHC Advanced Primary Practice Demonstration
  • Graduate Nurse Education Demonstration
  • Health Care Innovation Awards
  • Independence at Home Demonstration

30
Accountable Care Organizations (ACOs)
  • Medicare Shared Savings Program (Section 3022)
  • Implementation of the Medicare ACO Program
    mandated by January 1, 2012
  • Encourages multiple providers of services and
    supplies to
  • Join together and create ACOs
  • Be jointly accountable for health experience of
    care for individuals over a period of time
  • Improve population health, overlap with community
  • Reduce rate of healthcare spending, improve
    quality

31
CMS ACO Proposed Rule
  • ACO Notice of Proposed Rulemaking (NPRM) issued
    March 31, 2011
  • An ACO is an organization of healthcare providers
    that agrees to be accountable for the quality,
    cost, and overall care of assigned Medicare
    beneficiaries who are enrolled in Medicare FFS
  • Eligible organizations
  • Physicians in group practice arrangements
  • Physicians in networks of practices
  • Partnerships or joint venture arrangements
    between physicians and hospitals
  • Hospitals employing physicians
  • Other forms that the HHS Secretary deems
    appropriate

32
Reaction to ACO NPRM
  • Largely negative
  • Too complicated, too restrictive
  • Too much undefined risk
  • No specialty-focused ACOs
  • Negative comments about each criteria component
  • CMS responded in interim
  • Pioneer ACO Model
  • Advance Payment ACO Model
  • Accelerated Development Learning Sessions
  • Final rule issued November 2, 2011 Many
    revisions, less complicated, more options

33
Whats An Accountable Care Organization?
34
Whats An Accountable Care Organization?
35
CMS ACO Status Update
  • Medicare Shared Savings Program ACOs 153
  • 27 named in April, 2012
  • 88 named in July, 2012
  • 32 Pioneer ACOs
  • 6 Physician Group Practice Demo
  • Half are physician-driven groups serving lt 10,000
    patients
  • Serve 2.4 million Medicare beneficiaries
  • 33 Quality Measures
  • Care coordination and patient safety
  • Preventive health services
  • Improved care for at-risk populations
  • Patient and caregiver experience of care

36
Overall U.S. ACO Status Report
  • The number and types of ACOs are expanding
  • Growth is centered in larger population centers
  • Hospital systems appear to be the primary backers
    of ACOs, but physician groups are playing an
    increasingly larger role
  • Non-Medicare ACOs are experimenting with more
    diverse models than Medicare-backed ACOs
  • The success of any particular ACO model is still
    undetermined

Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
37
Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
38
Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
39
Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
40
Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
41
ACA Academic Health Systems
  • ACA Section 3025 Hospital Readmission Reduction
    Program
  • ACA Section 3026 Community Based Care Transition
    Program
  • Healthcare Delivery Research (Section 3501, AHRQ
    coordinating with CMS)
  • Identifies best practice institutions,
    organizations, etc.
  • Supports innovation in health care delivery
    system improvement
  • Quality Improvement Technical Assistance (Section
    3501)

42
ACA Academic Health Systems
  • Establishing Community Health Teams to Support
    the Patient-Centered Medical Home (Section 3502)
  • Medication Management Services in the Treatment
    of Chronic Diseases (Section 3503)
  • Emergency medicine regionalized systems and
    research, trauma care centers access payment
  • Demonstration to integrate quality improvement
    and patient safety education into healthcare
    worker education (Section 3508)
  • National Health Care Workforce Commission
    (Section 5101)
  • Recruitment, education and training, retention

43
ACA Academic Health Systems
  • National Center for Health Care Workforce
    Analysis (Section 5103)
  • Multiple student loan programs, various training
    retention programs, demonstration programs
    established
  • Primary care
  • Nurse-led care, advanced practice nursing, etc.
  • Allied health, public health, dental, pediatric,
    direct care professionals, geriatric, mental
    health, cultural competency in disabilities,
    mid-career, etc.

44
ACA Academic Health Systems
  • United States Public Health Services Track (Part
    D, Section 271)
  • Centers of Excellence-additional funding
  • Medical Residency funding enhancements
  • Teaching grants and demonstrations in graduate
    medical education
  • The list goes on and on and on.
  • But, will ACA survive the legal, political and
    funding challenges in its entirety?
  • If not, which sections?
  • Whether or not, will savings estimates be
    achieved?

45
Conclusions
  • The Affordable Care Act provides innumerable
    opportunities to improve the quality, value and
    efficiency of healthcare in the United States
  • CMS/HHS is a major implementation center for this
    historic piece of legislation, but the private
    sector has an equally important role
  • Individual integrated health systems,
    particularly those with a focus on innovation and
    evidence, are essential to the success of
    healthcare reform
  • Implementation affects fee-for-service as well as
    managed care models, plus untested new models

46
Conclusions
  • There are numerous opportunities and needs for
    involvement of integrated/academic health systems
    in implementation of ACA and further health
    reform in the future
  • Design of and leadership in contemporary quality
    improvement initiatives
  • Huge gap in comparative- cost-effective
    analysis/improvement, let alone basic clinical
    knowledge
  • Ongoing input in review and improvement in
    clinical guidelines
  • Balancing evidence-based population RCT viewpoint
    with need for individual patient-centered concerns

47
Conclusions
  • Additional roles for integrated/academic health
    systems
  • Education of multiple audiences in evidence-based
    medicine use
  • Clinicians Current/future, academic/community
  • Policy makers
  • Payers
  • Patients, consumers and their families
  • Development and use of quality and value metrics
  • Multiple perspectives Clinicians, patients,
    payers, etc.
  • Relevance, actionability, accountability,
    attribution
  • Alignment/integration of traditional community
    healthcare resources and models

48
Conclusions
  • Additional roles for integrated/academic health
    systems
  • Collection, analysis, reporting and use of
    healthcare data
  • Health Information Technology development,
    adoption and meaningful use via EHRs
  • Other forms of data collection Registries,
    claims, encounter data, telehealth, chart review,
    surveys, etc.
  • Balance of scientific rigor vs.. information
    efficiency
  • Minimization of burden
  • Privacy security
  • Dissemination of data for widest possible
    appropriate use

49
Conclusions
  • Additional roles for integrated/academic health
    systems
  • Development of and participation in new
    reimbursement and delivery systems
  • Higher quality leading to overall lower costs
  • Innovation, rapid change adaptability
  • Care transitions and coordination
  • Integration of delivery systems
  • Patient-Centered, all of IOM Quality Aims
  • Public health focus, as well as individual health

50
Conclusions
  • We cannot continue to cover and pay for
    everything thats available without considering
  • Evidence-based coverage payment decision making
  • Comparative effectiveness and cost effectiveness
    analysis
  • Overall costs involved, including global costs of
    lost productivity, quality of life, etc.
  • But are Academic Health Systems ready?
  • Rapid-cycle change, integrated systems (no
    departmental silos), authenticity will to
    change (e.g., academic tenure?)

51
Conclusions
  • The under-emphasized topics (?ignored)
  • End-of-life care
  • Health disparities reduction Action needed, not
    talk
  • Racial/ethnic
  • Geographic
  • Age
  • Gender
  • Socioeconomic
  • LGBT
  • Medical Conditions

52
  • Thank you for your contributions in improving the
    American healthcare system!
  • Questions?
  • Discussion Dialogue
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