2. Evolving Business Models: Preparing for Value-Based Payments
EvidenceNOW Southwest/Colorado SIM Collaborative Learning Session May 6, 2016
Aurora, Colorado
Presented by:
Pamela Ballou-Nelson, RN, MSPH, PhD, PCMH CCE
Senior Consultant, MGMA Health Care Consulting Group
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3. Objectives At the end of this session, you should be able to:
Examine your theoretical framework: view your practice through a new lens
Ask what am I doing with my population: population health management is here to stay
Understand the CMS terms of payment reform
Discuss the key components of value-based practice models
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4. Theoretical Framework
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5. Imperative for Change
Just because you need to change doesn’t mean you will change, even if you want to change
Understand your theoretical frameworks in place today
See healthcare, patients, through a “different lens”
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7. Here to stay — value-based model of care population health
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8. Collaboration Working together is success Keeping together is progress
Coming together is a beginning
Keeping together is progress
Working together is success
- Henry Ford
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9. Population Health is an Outcome
Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.
These groups are often geographic populations such as nations or communities, but can also be other groups such as insurance attributions, employees, ethnic groups, disabled persons, prisoners, or any other defined group.
Kindig, DA, Stoddart G. (2003). What is population health? American Journal of Public Health, 93,
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10. Managing Services for a Population
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11. Population Selection How will you know which segments to choose?
Large gaps in health outcomes
Size of population
Organization or community alignment with the work
Resources available for this work
Can you build a sustainable financial model for this population
Adequate return on investment
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12. Getting to Know Populations
It is not enough to choose populations.
You need to understand the needs and assets of the population you have chosen.
As you get to understand your population, better projects will naturally arise from a better understanding.
Attribution is key and often challenging
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13. Here to stay — Payment reform
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14. Payment Models Will Demand New Care Models
Used with permission from Deloitte
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15. Payment Reform
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16. Commercial Plans Included
75% of business in value-based payment arrangements by 2020 – Health Transformation Alliance
United will double value-based contracts by 2018 — this includes self-funded plans
Humana anticipates half of its Medicare Advantage membership will be enrolled in full-risk-bearing accountable care organizations by 2017
Aetna currently has 22% of spend running through contracts with a value-based component
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17. What is Value? Outcomes + Patient Experience
Since value is defined as outcomes relative to costs, it encompasses efficiency. Cost reduction without regard to the outcomes achieved is dangerous and self-defeating, leading to false “savings” and potentially limiting effective care.
Outcomes + Patient Experience
(safety, patient satisfaction outcome metrics)
Value = _____________________
Cost
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18. How Do We Get There? From FFS to performance-based payment
New measures — quality and cost
New shared data infrastructure
New incentives
Transparency
Alignment across payers
New care models
New community partners
New relationships
Clinical tied with business No silos
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19. Value-based practice models
Key components of
Value-based practice models
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20. A wise lumberjack once said that if he were given five minutes to chop down a tree or lose his life if he failed to do so, he’d spend three minutes sharpening his axe.
Take your time to prepare, sharpen your skills evaluate. Conduct an assessment of your practice Don’t panic BUT prepare Don’t follow the herd; unless it is your herd.
Before a health system starts that journey from volume to value, it must plan the transition, especially considering that the provider will have to run its business for a time with a mixed payment model, “That’s why you need a road map,”. “You can’t just feel your way into it.”
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21. Volume to Value OLD SUCCESS – Volume NEW SUCCESS – Value High volume
High compensation
High independence
NEW SUCCESS – Value
Outcomes to value (volume)
Modified compensation plans
Partnerships/teamwork
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22. Value Transformation
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23. Practice Assessment Examine your theoretical frameworks
Educate internally
Understand your contracts/risk
Manage total cost of care
Improve operational efficiency
New budget models
Create community and health system partnership
The focus of VBM should not be on
methodology. It should be on the why and how of changing your corporate
culture. A value-based manager sees the difference from 1960s-style planning systems. It focuses on better decision making at all levels in an organization. It
recognizes that top-down command-and-control structures cannot work well
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24. Practice Assessment
8. Optimize provider network, manage care transitions, and expand disease management to full attributable population
9. Invest in interventions in the high-acuity, post-acute population
10. Develop care pathways for consistency, continuity and effectiveness
11. Automated process to address prevention and wellness
12. Coding and documentation effectiveness: maximize ICD-10, continue on path to clinical documentation (care management codes)
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25. Value and Uses of TCOC Data
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26. Work Flow Redesign – Traditional Method
Courtesy of Bon Secours health system in Richmond Virginia
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27. Care Team: New Workflow Redesign
Delivery System: The Care Team
Division of Labor: Use every member of team to highest level of training/licensure/ability
Move all possible interventions away from the physical visit – Pre and post-visit encounter
Everything comes to the patient
Use of nursing-driven protocols
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28. CMS – MACRA – MIPS – APM – VM
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29. MACRA
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, What does MACRA do?
Repeals the Sustainable Growth Rate (SGR) formula
Changes the way that Medicare rewards clinicians for value over volume
Streamlines multiple quality programs under the new Merit-based Incentive Payment System (MIPS)
Provides bonus payments for participation in eligible alternative payment models (APMs)
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30. MIPS = Merit-Based Incentive Payment System
Streamlines multiple quality programs under the new Merit-Based Incentive Payments System (MIPS)
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31. MIPS
A single MIPS composite performance score will factor in performance in four weighted performance categories:
Direct form CMS
30 points
30 points
15 points
25 points
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32. Exceptions to MIPS
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33. APM = Alternative Payment Models
All we are going to say as this is still under development will have more information this fall
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35. CMS Value Modifier Currently being calculated 34
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36. Methodology 2018 Payment Adjustments
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37. Methodology 2018 Payment Adjustments
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38. How to Prepare My Practice for VBPM
Understand how your practice will be affected
Participate in PQRS. Participation is required, as the VBPM relies on PQRS measures reported by physicians for quality performance analysis. This also means that those providers who are impacted by the VBPM and do not participate as required in PQRS will see a double penalty — one reduction for non-PQRS participation as well as an additional reduction under the VBPM for not participating in quality reporting. PQRS and the VBPM are inter-related, but distinct programs and criteria must be satisfied in each separate program.
Access your practice’s QRUR. Authorized representatives of groups can access their QRURs using valid Enterprise Identity Management System (EIDM) log-in credentials to the CMS Enterprise Portal.
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39. “Success in life is based more on what others can do for you than on what you can do for yourself.”
— Al Ries
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40. questions
discussion
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