1. Consumer and Patient Perspectives: APM Framework Listening Session
November 13, 2015
10:00 – 11:00 am ET

2. Welcome
Welcome and Introductions Anne Gauthier LAN Project Leader, CMS Alliance to Modernize Healthcare (CAMH)
Overview of the LAN
Mark D. Smith, MD, MBA LAN Guiding Committee Co-Chair
Visiting Professor
University of California at Berkeley, and
Clinical Professor of Medicine
University of California at San Francisco
Anne Gauthier
Good morning and welcome. I am Anne Gauthier, Project Leader of the Health Care Payment Learning and Action Network –or LAN for short. The LAN project is led by the CMS Alliance to Modernize Healthcare, known as CAMH, which is operated by the MITRE Corporation on behalf of CMS.
This is our first consumer and patient focused conversation. We’ve been planning this kind of opportunity for some time, and I’m delighted to be with you today.
Mark Smith, co-chair of the LAN Guiding Committee, is going to provide an overview of the LAN for those of you who are not familiar with this initiative. Then Mark will introduce Jim Guest who will provide an overview of the APM Framework. Following that, Jim will open the call to questions and comments.
Mark, over to you.
APM Framework Draft White Paper
Jim Guest
APM FPT Work Group Member
Former President and CEO,
Consumer Reports

3. The Health Care Payment Learning and Action Network (LAN) was launched because….
We want better care, smarter spending, and healthier people.
In order to achieve this, we need to improve our payment structure by building one that incentivizes quality and value over volume.
Such alignment requires the participation of the entire health care community. The LAN is a collaborative network of public and private stakeholders.
Mark Smith
HHS launched the LAN in March of this year to help advance the work being done across sectors to increase the adoption of value-based payments and alternative payment models. The mission of the LAN is focused on payment reform, and specifically on accelerating the transition already underway by aligning stakeholders across sectors. The LAN is not only about changing health care payment, but also identifying what is needed for an APM to succeed.

4. Goals
2016
30%
In 2016, at least 30% of U.S. health care payments are linked to quality and value through Alternative Payment Models (APMs).
2018
50%
In 2018, at least 50% of U.S. health care payments are so linked.
Mark
HHS set a goal of tying at least 30 percent of Medicare payments to quality or value through alternative payment models by 2016 and at least 50 percent by 2018.
The LAN extends those Medicare goals to the private sector and states, and is working on steps toward these goals that can be delivered in the next two years, while establishing a foundation for success well beyond.
These payment reforms are expected to demonstrate better outcomes and lower costs for patients.

5. Guiding Committee Leadership
Mark McClellan, MD, PhD
Director of the Robert J Margolis Center for Health Policy and the Margolis Professor of Business, Medicine and Health Policy, Duke University
Mark D. Smith, MD, MBA Visiting Professor
University of California at Berkeley, and
Clinical Professor of Medicine
University of California at San Francisco
Mark
The Guiding Committee provides executive leadership for the LAN.
Mark McClellan, of Duke University and I are co-chairs of the Guiding Committee.
The Committee is responsible for laying out a strategy to achieve the LAN’s goals and works to:
Identify, prioritize, and launch work and affinity groups.
Develop and oversee plans to actively engage stakeholders, share and disseminate results, and accelerate learning and action.
And serve as liaisons to the communities in which they participate.
Guiding Committee members represent diverse stakeholder groups, including providers, health plans, purchasers, consumers/patients, and state, regional, and federal perspectives.

6. LAN Operational Model Convene Agree Collaborate Develop Approaches
Drive Adoption
Convene health plans, purchasers, providers, consumers, states, and federal partners to establish a common pathway for success
Identify areas of agreement around movement to APMs
Collaborate with partners and LAN participants to identify and use existing successes, best practices, and lessons learned
Develop and agree on approaches to core issues, such as risk adjustment, benchmarking, and attribution
Collaborate with partners to adopt models and measure progress
Mark
Through its activities, the LAN is about ‘force amplifying’ successful innovations in the field in order to accelerate change. All payers, providers, purchasers, states, consumer groups, individual consumers, and others are invited to participate. To date over 4500 individuals are participating in the LAN.

7. Work Groups Work groups: Build on existing successes.
APM Framework and Progress Tracking
Work groups:
Build on existing successes.
Identify and address critical barriers to adoption.
Address key technical components of selected payment models.
Harvest and share best practices.
Incorporate perspectives of patients and consumers as models are defined and recommendations are developed.
Clinical Episodes Payment Model
Population-Based Payment Model
Mark
We convene work groups in order to identify areas of alignment in payment reform that can be leveraged to drive adoption. The APM and Framework Progress Tracking work group began its work in July. It has developed a Framework for categorizing APMs and is beginning work on the charge of developing an approach for measuring progress in our goals. Jim Guest will share more on this group’s work in a moment.
The Population-Based Payment group is addressing payment models based on populations of patients, that is, payments designed to support better care and lower costs at the level of longitudinal, comprehensive, whole-person care. This work group had its kickoff meeting last week.
The Clinical Episode Payment Work Group had its kickoff meeting earlier this week. It seeks to align incentives across providers within a single clinical episode, major surgical procedures, so that everyone is responsible for doing what is best for the patient, such as avoiding duplication and unnecessary services and complications, creating seamless transitions to other providers or home, etc. The goal is to break down the silos of care. This group will initially focus on joint replacement with other clinical areas to follow.
We want your early input on work products across all of our work efforts. You can expect to hear from us again in the January timeframe for input on the work of the population-based payment work group.
Future work groups will be established as need arises.

8. APM Framework Overview
Jim Guest
Former President and CEO of Consumer Reports
Mark
Now I’m going to turn it over to Jim Guest, who is the former President and CEO of Consumer Reports and a member of the APM Framework Progress Tracking Work Group.
Jim will describe the APM Framework and focus on some issues that we are looking forward to your comments on.

9. So What is an APM? Jim Thanks Mark.
Alternative payment models seek to incentivize quality, health outcomes and value over volume. On an earlier slide you saw the goals of shifting payment toward quality and value through APMs. There are many models already in existence and new ones continue to be developed by both the public and private sectors.

10. Alternative Payment Models Framework and Progress Tracking (APM FPT) Work Group Overview
A team of 14 public and private stakeholders
Work Group
Charged with assessing APMs in use across the nation and defining terms and concepts essential for understanding, categorizing, and measuring APMs
Charge
Jim
Mark noted the launch of the APM work group, which is doing foundational work for the entire LAN enterprise.
The APM work group is comprised of members representing key stakeholder groups. Physicians/health care providers, private payers, CMS, consumer/patient groups, purchasers, and state government representatives.
Since July it has been working hard and has made great progress towards achieving its first objective - development of a Framework for categorizing the many types of APMs.
The work group released the draft of the paper to provide the LAN and other stakeholders the opportunity to engage and influence the process early on. The work group is already considering how to utilize the Framework to track and measure progress across the field in the adoption of APMs, and you’ll have opportunities to provide input in the future on these next areas.
Draft APM Framework released last month—feedback requested by November 20 (next Friday)
Objective 1

11. What is the APM Framework?
The framework situates existing and potential APMs models into a series of categories in order to create a common language and way to measure progress over time.
Category 1
Fee-for-Service – No Link to Quality
Category 2
Fee-for-Service – Link to Quality
Category 3
APMs Built on Fee-for-Service Architecture
Category 4
Population-Based Payment
JIM
Let’s turn first to the draft framework itself. The framework builds on the CMS proposed framework, depicted here, which includes a trajectory of categories, with category 1, fee for service without a link to quality, being the predominant model today – and a progression to category 4, which includes population based payment models.
Payments are based on volume of services and not linked to quality or efficiency.
At least a portion of payments vary based on the quality or efficiency of health care delivery.
Some payment is linked to the effective management of a segment of the population or an episode of care.
Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk.
Payment is not directly triggered by service delivery so volume is not linked to payment.
Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g. >1 year).

12. Draft APM Framework Jim12
Draft APM Framework
Jim
Here we show the draft APM framework developed by the work group. I know it’s very dense. We won’t be discussing this in detail on the phone today but I wanted you to understand it.
Each category includes sub-categories, which further stratify the categories that CMS has already created. For example, within category 3, which includes APMs built on fee for service architecture, the work group proposes to differentiate between those models which have only upside risk, for example, the ability to obtain a bonus payment for achieving a quality or cost target, from those which include both upside and downside risk, for example, those which have bonus payment opportunities, as well as payment penalties for poor performance.
The work group has invited feedback from the entire LAN community to help refine this draft framework. While we welcome input from consumers and patients on the framework, their input will be especially valuable on the principles and on the elements of care that need to be incentivized.

13. Work Group’s Goals for Health Care Reform
This is the direction we want to go. Over time, payments shift from Categories 1 and 2 into Categories 3 and 4.
Additionally, the work group expects that over time, APMs within a particular category will make a greater impact on quality and cost performance, increase integration and coordination in delivery systems, and, ultimately, result in more patient-centered care.
Figure 2 also implies that overall spending will diminish over time. For example, compared with present Category 3B APMs, future Category 3B APMs will employ larger risk corridors and more extensive sets of quality measures; they will offer further opportunities for providers to develop innovative delivery models; and, they will provide additional support for coordinating care across multiple providers. For the reasons discussed above, the work group believes that these advancements will also result in more patient-centered care.

14. Why is this Important to Consumers and Patients?
Shifting from traditional fee-for-service payments will be essential to sustain health care systems that value quality, cost-effectiveness, and patient engagement.
APMs, together with other reforms, can result in a shift to more patient-centric care.
It will become possible to track progress in improving the health system in which we all purchase and receive care
Jim
The efforts of the work group affect you in several ways…..
We believe that shifting from traditional fee-for-service (FFS) reimbursements to population-based payments will improve the quality and safety of care and improve the overall performance and sustainability of our health system.

15. Key Questions For Consumers and Patients
Does the draft paper adequately reflect the interests and needs of consumers and patients?
If not, what concrete suggestions do you have?
What attributes of care do you think are most important to consumers and patients to achieve truly patient-centered care?
What are your thoughts on how to incentivize these attributes?
Does the draft paper capture what consumers and patients would understand by “paying for value”?
Jim
Rather than focus on the framework itself during our limited time, we’d prefer to get the benefit of your perspective on some more fundamental questions. [READ SLIDE]
I’ll go over a bit more background and then Anne will open it up for discussion.

16. APMs and Patient-Centeredness
“The Work Group understands patient-centered care to mean high- quality care that is delivered in an efficient manner, where the patient’s or consumer’s informed choices, values, priorities, and individual circumstances are paramount.”
Patient-centered care rests on three pillars:
Quality
Cost-Effectiveness
Patient Engagement
Alternative payment models should incentivize systems and providers to deliver care that reflects these.
JIM
The first few sections of the draft white paper emphasize that payment reform seeks to promote a patient-centered health care system. It will be helpful if you can comment on whether the draft supports that goal.
Here is the WG’s definition of patient centeredness, and their view that it rests on three pillars. They define the three pillars as follows:
“Quality: This term indicates that patients receive appropriate and timely care that is consistent with evidence-based guidelines and patient goals, and that results in positive patient outcomes. Ideally, quality should be evaluated using a harmonized set of process and outcome measures that matter to patients and consumers.” Some people would add the patient and family care experience, patient-reported outcomes.
“Cost Effectiveness: This term indicates that the actual costs of care should not exceed what would be expected when a set of services are provided to a particular patient population.” Some would add links to wise use of resources and also the burden of out-of-pocket costs. Others add that it’s more than just monetary burdens—includes the opportunity costs to patients of one treatment over another.
“Patient Engagement: Engaged patients and consumers are informed of their health improvement and share in their own care; they are able easily to access appointments and clinical opinions; they possess the information they need to identify high-value providers and to tailor treatment plans to individual health goals; they provide ongoing feedback that providers can use to improve patient experience; and they can move seamlessly between providers who are engaged in different aspects of their care.” We know this term means a lot to different people. It needs to involve them as partners in their care and provide them with the support they need to be “engaged.” It also should include the concept of both patients and family caregivers as part of the care team.
Your feedback on what should be included in “patient-centeredness, quality, cost-effectiveness and patient engagement” could help the WG frame its recommendations in ways would effectively support these goals.

17. Principle #1
The Work Group recognizes that changing the financial reward to providers is only one way to stimulate and sustain innovative approaches to the delivery of patient-centered care.
In the future, the Work Group believes it will be important to monitor progress in initiatives that empower patients (via meaningful performance metrics, financial incentives, and other means) to seek care from high-value providers and become active participants in clinical and shared decision-making.
JIM
I want to call your attention also to the first principle in the draft paper.
The WG will focus on financial incentives for providers as a critical first step, but recognizes that additional efforts to engage patients and consumers will be needed to achieve a patient-centered, coordinated health care system.
While the WG is not seeking comments now about these future steps, input on how to target payment incentives to help “move the needle” will be very helpful.

18. Q&A
Jim
Now let’s go back to those questions we raised earlier and hear from you.
But we welcome comments or questions on other issues that you think are important too.
I’ll turn it over to Anne to facilitate the discussion.
Anne:
Thanks for the good presentation Jim.
To our listeners: You may use the chat window of your webinar dashboard to submit your comments and questions or you may raise your hand in your dashboard to be called upon.
I’m going to show each of the questions separately.
[Anne triages questions]

19. Questions for Discussion
Does the draft paper adequately reflect the interests and needs of consumers and patients?
If not, what concrete suggestions do you have?
Anne
Here’s the first question.

20. Questions for Discussion
What attributes of care do you think are most important to consumers and patients?
What are your thoughts on how to incentivize these attributes?
Anne: and the next

21. Questions for Discussion
Do the proposed APM categories outlined here capture what consumers and patients would understand by “ paying for “value”?
Anne:
And here’s the last question.
This has been a great discussion, and we are so appreciative of your input.
We’ll be synthesizing all your comments and questions today and share them with the APM work group.

22. APM Framework Draft White Paper
The APM Work Group is collecting feedback through November 20.
Paper available at
Send comments by  directly
ANNE
Here is the information on how you can submit other comments. Please share this with your colleagues, the members of your organizations, and other consumer and patient stakeholders and encourage them to comment.
Again, while we will welcome your comments about the Framework categories themselves, we especially value your input on the issues we’ve discussed today.
[NOTE: May not be time to do the next two slides. If not, add closing comments and hand to Mark S. for closing comments.]

23. LAN Communications http://hcp-lan.org/
Visit the LAN website to learn more and find resources
Anne
We highly encourage all consumer and patient advocates to engage with the LAN as we go forward. Health care is transitioning to APMs, and by getting involved with the LAN, you can help ensure the transition to APMs results in health care that consumers and patients value. I would especially like to point out the LAN website and our bi-monthly bi-weekly newsletter are important communication channels by which we keep LAN participants informed on LAN activities and opportunities. We also have a monthly webinar during which we provide updates and share a promising payment practice and lessons learned from implementation.
Keep updated on the latest LAN info through our newsletter

24. Get Involved! Visit our site Register online Ask a question
Register online
Anne
Visit the LAN website and sign up to participate. Also, we are planning further activities specifically for consumers and patients, so please stay tuned. We would also like to hear from you how best to engage with you on these future opportunities. Was this webinar a good vehicle for you? Do you have other ideas? Send us an at with suggestions.
I’ll turn it back to Mark for some closing comments.
Mark
Thank you for being with us. We appreciate your participating. Have a good afternoon.
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