High Value Care and It’s Impact on Cost Dr Greenlee Matt Keelin TcpI program mANAGER

Goals Understand need and movement toward Value Based payments Goals of TCPi Nationally Areas of focus for TCPi in Colorado and resources in TCPi

QPP Do you feel like this ? MACRA MIPS ACO APMs ACI CEHRT CPIA QRUR QPs QIO/QIN MACRA MIPS ACO APMs ACI CEHRT QPP CPIA QRUR ACA

Goals Understand reasons for movement toward Value Based payments Goals of TCPi Nationally Areas of focus for TCPi in Colorado and resources in TCPi

Exhibit 1. Health Care Spending as a Percentage of GDP, 1980–2013 * 2012. Notes: GDP refers to gross domestic product. Dutch and Swiss data are for current spending only, and exclude spending on capital formation of health care providers. Source: OECD Health Data 2015.

Exhibit 8. Health and Social Care Spending as a Percentage of GDP Notes: GDP refers to gross domestic product. Source: E. H. Bradley and L. A. Taylor, The American Health Care Paradox: Why Spending More Is Getting Us Less, Public Affairs, 2013.

Why Now? Some Reasons Current payment models are problematic Fee for service – pay for a service without regard to quality or value Block payments – similar issues Healthcare costs are high and rising Variable quality and outcomes Inefficient system Misaligned incentives All of this seen in complex members with high costs Current payment models do not support healthcare reform Fee for service does not encourage team play Difficult to transform the system without changing how providers are paid 11/22/2018 DRAFT

Target Medicare expenditures Overall physician costs What Is “MACRA”? The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is bipartisan legislation signed into law on April 16, 2015. Repeals & Replaces the Sustainable Growth Rate (SGR) Formula (anticipated 21% cut in 2015) Established in 1997 to control the cost of Medicare payments to physicians Target Medicare expenditures Overall physician costs

What is the Quality Payment Program (QPP)? What Is “MACRA”? Replaces the SGR with change in how Medicare pays clinicians toward payment for value over just volume (“how well you ring the bell not just how much you ring it”) What is the Quality Payment Program (QPP)? The “rule” or operational plan for the Act (MACRA) Provides two tracks for participation Advanced Alternative Payment Models (APMs) Merit-based Incentive Payment System (MIPS) (adds or subtracts from FFS payments based on performance on your composite score)

CMS Framework for Advancing Value Based Payments: Think “Taking it in Steps” APM = Alternative Payment Model EM Merit Based Incentive Payment System- MIPS C “get house in order” Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.

MIPS adjustments to FFS payments Based on a CPS, clinicians will receive +/- or neutral adjustments up to the percentages below. +9% +7% +5% +4% Adjusted Medicare Part B payment to clinician +/- Maximum Adjustments So what does this payment adjustment look like? MIPS will adjust payments positively OR negatively based on a composite performance score for each clinician. The potential maximum adjustment percentage begins at +/- 4% in 2019 and will increase each year from 2019 to 2022. In 2022, the adjustment will be as high as +/- 9% [TRANSITION] -4% -5% -7% -9% The potential maximum adjustment % will increase each year from 2019 to 2022 2019 2020 2021 2022 onward

Value Based Purchasing (VBP) What is it? HealthCare.Gov Definition Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers. 11/22/2018 DRAFT

Value Based Purchasing (VBP) What is it? Another way to consider VBP = purchasing based on value Value What someone is willing to pay for a good or service A consideration of quality and price Mathematically Value = Quality/Price In healthcare, Value = Outcomes/Costs Outcomes Simple and practical Clinical, psychosocial, satisfaction, utilization/cost 11/22/2018 DRAFT

“The Journey” Acute care model Physician centered Silos of care Staccato care ER model Physician centered Physician carries the load & responsibility Staff supports physician Silos of care Separated care providers Disconnected care Chronic Care Model Care that is Comprehensive, continuous & coordinated Patient-Centered Team Care Shared accountability for what is best for the patient Medical Neighborhood-System of Care Connected, coordinated care The Right Care at the Right Time in the Right Place

Your payments will reflect the “Value” of the care you provide The Move to Value Based Payment…intended to drive the move to value based care Your payments will reflect the “Value” of the care you provide Value = Quality (Benefit)/Cost Goal = “get the most for the money” Who should bear the ultimate risk for high medical expenses, individuals or society at large? Get the best patient outcomes for the best cost Ensure patients get care that benefits them (improves outcome) = higher quality Reduce care that adds cost without adding benefit (or that may potentially cause harm) = lower costs

Primary Drivers for Transformation of Health Care Delivery Design care & care delivery to be person & family centered Use data to continuously drive & ensure better care, better health & smarter spending…and discovery of new & better ways of delivering care Ensure financial viability of practices while reducing burden & increasing joy, to keep practices open for business & serving the people in their communities

It is not just reporting… Need to achieve higher VALUE Improved outcomes Reduced costs …And need a way to do that Can’t really succeed well in Value Based Payment model with a volume based practice model…need to provide better care consistently

Attempting to Control Total Cost of Care while improving care for the patient PCPs in Population payment model will need to assess which specialty services provide a good ROI vs drive costs Will the specialty service improve outcomes and help reduce ED & Hospital admissions Will specialist “load up” on visits & expensive but maybe unnecessary testing (FFS mindset) vs efficient/effective care Will the specialist utilize other specialists appropriately or add to the “black hole” of referrals Will specialty share the care and share the information (e.g. results of screening tests, imaging)

Take a minute … Think about what you have to offer to primary care practices in these models Do you provide great ROI ?

From Disconnected Care → High Value, Connected Care Duplicate tests/ unnecessary tests Additional visits Misdiagnosis Delayed diagnosis and treatment Confusion, errors Access backlog / workforce needs Not Patient-Centered Increased Stress, burden, dissatisfaction Eliminate wasteful testing Make visits as productive as possible Avoid misdiagnosis and treatment delays Patient-centered focus Better match of specialty utilization to patient needs Improve the patient and clinician experience

It is about a new approach… Using practice data to measure how we are doing Using data as information about care (as an indicator) Actionable and meaningful…there needs to be a “ WHY” Having a method to make the improvements Include entire staff/team in the process Having Aims or Goals Culture of continuous improvement Working as a team To make the changes (transformation team) (how to do it at the clinic level) To provide care (care team) (shared accountability) “Re-centering” for patient-centered care (partnership) Enhanced Patient & Family Engagement in care Improving care coordination & communication Improving access-Connecting care (working as part of a system, not a silo)

Value Based Purchasing A continuum of models with increasing Risk/reward Provider control Integration and collaboration Alignment of incentives Need for providers to self manage Less external administrative burden Different purchasing models can be applied to different delivery system models Pay for Performance Sharing Savings and Risk Bundled payments Capitation 11/22/2018 DRAFT

High Impact Cost and Utilization National Focus of TCPi High Impact Cost and Utilization

National TCPi Cost and Utilization Focus Reducing unnecessary readmissions Risk stratification and care management support for those at highest risk Managing care transitions Appropriate interventions during hospitalization Timely follow-up post-discharge

National TCPi Cost and Utilization Focus Reducing unnecessary ED visits Assign accountability to a care team Remove access barriers Coordinating care across all care givers

National TCPi Cost and Utilization Focus Reducing unnecessary admissions that could be handled on an ambulatory basis Decrease care gaps Consideration of the whole person Establishing a medical neighborhood Defining specialty and primary care roles

National TCPi Cost and Utilization Focus Managing high cost pharmaceuticals Manage medications Use evidence-based protocols  

National TCPi Cost and Utilization Focus Reducing unnecessary high cost imaging and other diagnostic services Use evidence base, best practices, and protocols Ensuring high quality referrals

Colorado Cost and Utilization Focus

Colorado Cost and Utilization Focus Reduce Emergency Department Visits Discharge Summaries Post procedure follow up Patient Education 

Denver Health ENT Intervention $64,658 Potential Yearly Savings from Denver Health ENT

Colorado Cost and Utilization Focus   High Value Referrals American College of Physicians High Value Referral Project Research has shown this could save over $10,000/provider/year

Colorado Cost and Utilization Focus   Pharmaceutical Review and Benchmarking Medication Management Use of generic where clinical appropriate Reduce antibiotics

Areas of Focus across TCPi Eliminating routine tests and standing orders Ultrasounds MRI for low back pain routine ECG for all surgery Surgical Tray review Choosing Wisely benchmarking  Same day urgent care appointments

TCPi Resources ACEP (E-QUAL Network) https://www.acep.org/Advocacy/Reduce-Avoidable-Imaging-Initiative https://www.acep.org/Advocacy/Chest-Pain-Imaging-Initiative American College of Physicians High Value Care https://www.acponline.org/clinical-information/high-value-care American College of Radiology https://rscan.org/resources/topic-specific-resources http://www.acr.org/quality-safety/appropriateness-criteria/acr-select AMA STEPS Forward https://www.stepsforward.org/modules/choosing-wisely https://www.stepsforward.org/modules/cds-imaging

TCPi Resources Choosing Wisely Consumer Health Choices http://www.choosingwisely.org/ Consumer Health Choices http://consumerhealthchoices.org/campaigns/choosing-wisely/ Network for Regional Healthcare Improvement (NRHI) http://www.nrhi.org/work/multi-region-innovation-pilots/choosing-wisely/ CMS Medicare Quality and Resource Use Reports (QRUR) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2016- QRUR.html

Transforming Clinical Practice Initiative Contact Matthew Keelin Transforming Clinical Practice Initiative Program Manager Matthew.keelin@state.co.us