Title: Healthcare Reform: Improving the Healthcare World in Cleveland
1Healthcare 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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8Life Expectancy at Birth vs.Spending by Country
Source OECD Health Data 2010
9U.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
10U.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
11U.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
12Ensuring 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
13Contemporary 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.
14Transparency 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
15Incentives
- 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 ?
16VBP 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
17Regulation
- 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
18Affordable 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
19Affordable 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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21High 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
22High 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
23Center 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
24CMMI 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
25CMMI 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
26Staging of Innovation Development, Demonstration,
and Translation
2 To 3 years Design to Program Translation Cycle
Time
27Driving 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
28Driving Healthcare Delivery System Reform and
Transformation 2011-2019
2014-2019
2012-2019
2011-2019
29CMMI 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
30Accountable 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
31CMS 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
32Reaction 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
33Whats An Accountable Care Organization?
34Whats An Accountable Care Organization?
35CMS 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
36Overall 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
37Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
38Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
39Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
40Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
41ACA 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)
42ACA 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
43ACA 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.
44ACA 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?
45Conclusions
- 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
46Conclusions
- 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
47Conclusions
- 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
48Conclusions
- 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
49Conclusions
- 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
50Conclusions
- 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?)
51Conclusions
- 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