1. Telligen
March 25, 2015
This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-CO-QIN-03/15-051

2. Telligen QIN QIO
Telligen: Quality Innovation Network Quality Improvement Organization (QIN QIO) for Colorado, Illinois and Iowa

3. Agenda Overview The inevitability of healthcare transformation
Changing models of healthcare payment
Transparency for costs and quality
Health transformation and population health – preparing for the future
Join the Telligen QIN-QIO Network

4. Poll Question What type of organization do you represent?
None – I am a Medicare Beneficiary
Skilled Nursing Facility
Long Term Care
Hospital
Critical Access Hospital
Physician Office/Practice
Home Health Agency
Hospice/Palliative Care
Trade Association
Advocacy Group
Government Agency
Other, please specify

5. Healthcare in the Age of Public Accountability Moving from Volume to Value
Dale W. Bratzler, DO, MPH
Professor, Colleges of Medicine and Public Health
Associate Dean, College of Public Health
Chief Quality Officer – OU Physicians
March 25, 2015

6. Outline The inevitability of healthcare transformation
Changing models of healthcare payment
Transparency for costs and quality
Health transformation and population health – preparing for the future

7. The healthcare system is changing…. ..it was inevitable

8. Healthcare Transformation was Inevitable!
JAMA. 2013;310(18):

9. Medicare Part A Trust Fund
Projection: Health reform legislation will extend the life of the Medicare Part A Trust Fund from 2017 to 2029
Assets as a share of annual spending:
Post-health reform:
2029 projected insolvency date
Pre-health reform:
2017 projected insolvency date

10. Approximately 70% of spending on care facilities and professional services.

11. Where do we spend our healthcare dollar?
Hospitals and other care facilities, along with professional services are the primary target of most efforts to reign in healthcare spending.
JAMA. 2013;310(18):

13. Disconnect Between Spending and Outcomes
Spending on Health Care
Life Expectancy .

15. Rising “Consumerism” around Health Care
Consumer groups increasingly demanding data about the quality and costs of care (“transparency”)
Rising co-pays and deductibles
Costs for insurance growing much faster than incomes
Increased lay reports about quality issues in healthcare
Legislators responded

16. Growing Recognition US had the best “sick care” system in the world
High tech
Complex care
Heavily hospital- and specialty-based
Very costly
But………
Our population is not healthy

18. Many Quality and Payment Provisions in the ACA
Required by law….
Public quality reporting (transparency):
Hospitals, dialysis units, nursing homes, home health agencies, physician practices, cancer centers…..
Value-based payment
Reward high quality care – penalize poor quality care
Hold providers accountable for overall costs of care (“efficiency”)

19. Healthcare quality is in the public domain for most settings of care!

20. Move to “Value” Value = Quality/Costs
Value-based Payment
Move to “Value” Value = Quality/Costs
Goal: We want the highest quality of care at the lowest costs.

21. Range of Models in Existence or Development
Increasing assumed risk by provider
Increasing coordination/integration required
Bundled payments for chronic care/ disease carve-outs
Incremental FFS payments for value
Bundled payments for acute episode
Current State: Payments for Reporting
Accountability for Population Health
Pay for Volume
Pay for Value
To…. ..profiting by keeping your population of patients healthy, delivering high-quality care, and doing so at less cost
From…. ..get paid more for doing more 21

22. Hospital-acquired Conditions (HACs) Penalties

23. Readmission Penalties

24. Value-based Purchasing (VPB) Penalties
“A total of 1,375 hospitals…will have their Medicare payments docked next year.”

25. “Beginning fiscal year (FY) 2018 and each subsequent rate year, the Secretary shall reduce payment rates during such FY by 2 percentage points for any SNF that does not comply with data submission requirements for such a FY.”

26. “CMS received comments on a potential HHA VBP model that it may begin testing in CY CMS will review these comments as it considers testing a HHA VBP model.”

28. Cost Efficiency Measure Medicare Spending per Beneficiary
All Medicare Part A and Part Charges
3 d
Hospital Stay
30 days post-discharge
Medicare Part A costs
An “episode” of care
Admission
Discharge
Adjusted for beneficiary age, severity of illness, geographic payment differences such as wage index and geographic practice cost differences, and for Medicare payment differences resulting from hospital-specific rates, IME and DSH payments.
Ratio of individual Medicare spending per beneficiary amount divided by the median Medicare spending per beneficiary amount across all hospitals

29. Episode Treatment Groups
Providers are held accountable for all costs of care – across the continuum
Episode Treatment Groups

30. The Value-based Payment Modifier (Based on 2014 clinical data)
4.0% at risk (2% for PQRS and 2% for the value-modifier)!

31. Accelerating the move from Volume to Value

32. “Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by Perhaps even more important, our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of Alternative payment models include accountable care organizations (ACOs) and bundled-payment arrangements………”
Sylvia M. Burwell, January 26, 2015

33. February 2015
The goal of OCM is to utilize appropriately aligned financial incentives to improve care coordination, appropriateness of care, and access to care for beneficiaries undergoing chemotherapy. OCM encourages participating practices to improve care and lower costs through an episode-based payment model that financially incentivizes high-quality, coordinated care.

34. “…..shifting 75% of their business to contracts with incentives for quality and lower-cost healthcare.”

35. Price Transparency!

36. REPEALING THE SUSTAINABLE GROWTH RATE (SGR) AND IMPROVING MEDICARE PAYMENT FOR PHYSICIANS’ SERVICES.
(Introduced March 18, 2015)
..bipartisan bill…..the legislation would repeal the SGR “while instituting an 0.5 percent payment increases for five years while Medicare transitions doctors to a new system that emphasizes quality care over volume of care.” The bill also requires physicians to receive at least 25 percent of their Medicare payments through Alternative Payment Models by

37. How do we get ready for value-based care
How do we get ready for value-based care? Current models of care delivery can’t address the growing concerns of patients, employers, payers and policy makers. How do we achieve health?

38. In general…… We wait for patients to get sick before we intervene
We expect patients to make appointments so we can encourage even preventive services
We address their healthcare needs…. ..but we don’t routinely try to tackle the big problems that keep them from being healthy

39. So what do these conversations look like in practices or communities?
If you have too many children with asthma in your practice that are having to use the ED or are being admitted
Optimize controller medications for asthma
? Hire an exterminator to kill roaches in the patient’s home
If you have frequent hospitalizations of a low-income patient who is now homeless
Enroll them in care management to try to reduce admissions
Rent them an apartment?

40. Where we spend most of our national expenditures on health…. …
Where we spend most of our national expenditures on health…. ….but if you are responsible for the health of a population of patients, this may not be the most efficient use of funds.

41. Hennepin Health Social Accountable Care Organization
Reduced emergency department visits by more than 20% in year 1.
Reduced spending for some of the program’s top 200 users of medical services. County has reinvested $1 million in savings to fill service gaps and providing even better, cost-saving, care.
Savings have been reinvested in sobering center, vocational services for high-risk behavioral health patients, leasing transitional housing as an alternative to hospitalization for medically complex homeless patients.
Improved number of patients receiving optimal use of care for chronic diseases (7.6% increase in asthma, 10.8% in diabetes, 23.5% increase in patients receiving optimal vascular care)

42. It is changing our conversation.

44. Detailed information on per capita costs of care for specific services.

45. 8903 Medicaid patients used ED services

47. Things we can start with:
Practice based on evidence
Reduce unexplained clinical variation
Reduce slavish adherence to professional autonomy
Continuously measure and close the feedback loop
Engage with patients across the continuum of care

49. Dr. Bratzler’s contact information

50. Join the Telligen QIN-QIO Network
The Telligen QIN-QIO network offers expertise and support at local, regional and national levels
We believe the quality of healthcare can be transformed to better serve the people of all communities
How we serve our participants:
Assess and understand unique needs and opportunities
Provide opportunities to connect with
Align improvement efforts
Leverage expertise and relationships
Facilitate connections, sharing and learning
Bring you access to tools, resource, metrics, evidence based, collaboration, best practice, peer support, education

51. Learning and Action Networks
Telligen is engaging healthcare providers, stakeholders and patients in Learning and Action Networks (LANs) to lead rapid, large-scale change in health care quality.
What is a LAN?
LANs convene stakeholders, providers and improvement experts in an “all teach, all learn” model. Through LANs, Telligen will provide educational webinars and conferences, encourage peer sharing, rapid tests of change and support for adapting and spreading successful improvements.

52. Supporting Quality Reporting and Value-Based Incentives
Assistance with…
Quality Improvement Tools & Techniques
PQRS Reporting
QRUR Reports
Value-Based Modifier and Hospital Value-Based Purchasing Programs

53. Contact Information
Marcy Cameron, CO
Barbara Wilke, IA
Betty Wendford, IL

54. Will you join us? Provider Participation Agreements
Reach out via to one of the Team Members or visit our website
Additional Resources
Telligen QIN-QIO Newsletter – contact a Team Member
Health Care Payment and Learning Action Network
Upcoming Value Based LAN Events and Topics
June
September
December