A NEW REIMBURSEMENT STRUCTURE FOR AMERICA ADVANCED DISEASE CONCEPTS

OVERVIEW OF RECENT FEDERAL REPORT HEALTH CARE PAYMENT AND LEARNING ACTION NETWORK (HCPLAN) ALTERNATIVE PAYMENT MODELS (APM) FRAMEWORK Draft White Paper Written by: Alternative Payment Model Framework and Progress Tracking (APM FPT) Work Group

OBJECTIVES: 1. Learn how health care is transitioning reimbursement from VOLUME to VALUE 2. Review the US health care systems approach to POPULATION BASED PAYMENT 3. Describe provider incentives to promote PATIENT CENTERED OUTCOMES 4. Identify the role of community collaboration between all health care providers to promote HEALTH and WELLNESS 5. Recognize that the AFFORDABLE CARE ACT is here to stay!

THE AFFORDABLE CARE ACT THE GOAL: BETTER CARE SMARTER SPENDING HEALTHIER PEOPLE

POPULATION CHANGES 80 MILLION BABY BOOMERS – 10,000 ENTERING INTO MEDICARE SYSTEM DAILY UNTIL 2050

POPULATION CHANGES IN 2010, 70% OF THE AMERICAN POPULATION HAD MORE THAN ONE CHRONIC CONDITION – IN 2012 THIS INCREASED TO 75% - AND CONTINUES TO ESCALATE

THE AFFORDABLE CARE ACT THE US DEPARTMENT OF HEALTH AND HUMAN SERVICES HAS FUNDED MULTIPLE INITIATIVES FOCUSING ON MULTIPLE CHRONIC CONDITIONS

THE AFFORDABLE CARE ACT  CENTERS FOR MEDICARE AND MEDICAID INNOVATION CENTER  PATIENT CENTERED OUTCOMES RESEARCH INSTITUTE  AGENCY FOR HEALTH RESEARCH AND QUALITY – CURRICULUM ON MULTIPLE CHRONIC CONDITIONS

THE AFFORDABLE CARE ACT COMPARATIVE EFFECTIVENESS RESEARCH WHERE THE RUBBER HITS THE ROAD – REAL TIME, REAL LIFE DATA TO SUPPORT BEST PATIENT-CENTERED OUTCOMES

VALUE VS. VOLUME JANUARY 2015 PRESIDENT OBAMA ANNOUNCED THE HEALTHCARE PAYMENT & LEARNING ACTION NETWORK (HCPLAN) ALTERNATIVE PAYMENT MODEL (APM) FRAMEWORK

VALUE VS. VOLUME Incentive Health Outcomes and Value over Volume 30% of fee-for-service reimbursement in APMs end of % APM reimbursement end of 2018

VALUE VS. VOLUME Reward Providers who implement patient-centered care and patient responsive delivery systems

PATIENT-CENTERED OUTCOMES Health Care Payment and Learning Action Network (HCPLAN) defines patient-centered care as: “High quality are that is delivered in an efficient manner where the patient’s or consumers informed choices, values, priorities and individual circumstances are paramount.”

PATIENT CENTERED OUTCOMES  Quality Care through the use of evidence-based practice guidelines  Cost Effectiveness to include social determinants  Patient Engagement and shared decision making

TRANSITION  Moving away from anecdotal practice and volume vs. value  Moving away from fee-for-service to population based payments

CURRENT MEDICARE SYSTEM  Current fee-for-service reimbursement is not sustainable at the rate of 10,000 Americans entering into the Medicare system daily.  Unhealthy Americans living with more than one chronic condition

FUTURE PROVIDERS  Providers must be committed to POPULATION BASED PAYMENT  Providing holistic approach to medical care

PRIMARY CARE PROVIDER  PCP is the “gate keeper” with incentives to provide comprehensive care management.  Chronic care model – PCP ensures 24/7 patient access

POPULATION BASED PAYMENT  Population based payment is intended as course correcting feedback loop between innovation, implementation and evaluation  Align Stakeholders and the public and private sectors to help implement patient-centered payment systems

HCPLAN WHITE PAPER  White paper serves as a framework – not unlike the Multiple Chronic Conditions Framework.  Four Priorities  Self Management – patient engagement and accountability

HCPLAN WHITE PAPER 1. Fee-for-service that is not linked to quality – phasing out 2. Fee-for-service that is linked to quality, portion of payment reimbursed vary based on quality and efficiency

HCPLAN WHITE PAPER 3. Alternative Payment Models – in the form of: Accountable Care Organization (ACO), Medical Home Models, and Bundled Services 4. Population Based Payment – volume not linked to payment. Providers and organizations reimbursed on care provided a beneficiary longer than one year

SHARED-DECISION MAKING  Shared decision making between patient and providers, implementation of self-management, engagement and accountability  Readiness to change

VALUE-BASED INCENTIVES  Value-based incentives will reach providers delivery quality patient-centered care  Payment models that do not take quality and value into account will be classified in the “inappropriate” category – if not value based excluded from tracking purposes and not reimbursed

VALUE BASED INCENTIVES  Provider risk and reward – will risk a percentage of reimbursement to support the global population  Centers of Excellence – ACOs and Medical Home Models of care will accommodate wide variety associated with risk- sharing payment models

VALUE BASED INCENTIVES  HCPLAN believe the new reimbursement models of care will demonstrate sustainability, drive care coordination and delivery improvements – enabling advanced payment models

CASE STUDIES  Anthem – Hospital incentive program – quality  Cigna – ACOs 134 collaborative initiatives – 1-3 million customers, 59,000 MDs, 28,000 PCPs and 31,000 specialists  Centers for Medicare and Medicaid – Comprehensive primary care initiatives – population based care models

MEDICARE SAVINGS PROGRAM  Shared Savings Program – ACO participation and collaboration. No hierarchy, awards ACOs with decrease costs of care and cost savings  33 individual measures of quality performance – used to determine if ACO qualifies for shared savings

QUALITY MEASURES 33 Measures span 4 domains: 1. Patient experience of care 2. Care Coordination – interdisciplinary care and patient safety 3. Preventative health 4. At risk population

QUALITY MEASURES  The Quality Measures align with other Affordable Care Act directed quality initiatives through CMS: Physician Reporting System, Electronic Medical Record Initiatives etc.

BUNDLED PAYMENTS 4 defined models – at risk if costs for the bundle are higher than historical benchmark costs

ARE YOU PREPARED?  Professionally  Personally  Academically  Clinically