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

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

3. 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

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

5. 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.

6. 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.

7. 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

8. Target Medicare expenditures Overall physician costs
What Is “MACRA”?
The Medicare Access and CHIP Reauthorization Act of (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

9. 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)

10. 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:

11. 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 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
onward

12. 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

13. 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

14. “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

15. 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

16. 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

17. 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

18. 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)

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

20. 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

21. 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)

22. 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

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

24. 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

25. 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

26. 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

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

28. 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

29. Colorado Cost and Utilization Focus

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

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

32. 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

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

34. 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

35. TCPi Resources ACEP (E-QUAL Network)
American College of Physicians High Value Care
American College of Radiology
AMA STEPS Forward

36. TCPi Resources Choosing Wisely Consumer Health Choices
Consumer Health Choices
Network for Regional Healthcare Improvement (NRHI)
CMS Medicare Quality and Resource Use Reports (QRUR)
QRUR.html

37. Transforming Clinical Practice Initiative
Contact
Matthew Keelin
Transforming Clinical Practice Initiative
Program Manager