Healthcare Reform: Improving the Healthcare World in Cleveland

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Healthcare ReformImproving the Healthcare World
in Cleveland Beyond

• Barry M. Straube, M.D.
• Director, The Marwood Group
• Former Chief Medical Officer,
• Centers for Medicare Medicaid Services
• October 27, 2012
• University Hospitals Case Medical Center
• Medical Quality Summit Moving Forward

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Life Expectancy at Birth vs.Spending by Country
Source OECD Health Data 2010
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U.S. Healthcare Quality/Value Challenges

• In the U.S. we spend more per capita on
  healthcare than any other country in the world
• In spite of those expenditures, U.S. Healthcare
  quality is often inferior to that of other
  nations and often doesnt meet expected
  evidence-based guidelines
• There are significant variations in quality and
  costs across the nation with increasing evidence
  that there may be an inverse relationship between
  the two
• Healthcare expenditures account for a larger
  section of the U.S. economy over the years and
  funding those expenditures is increasingly more
  difficult
• Heretofore we have not addressed the problem of
  45 million uninsured Americans
• Cost Effectiveness Analysis is resisted as a tool

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U.S. Healthcare Quality/Value Challenges

• Care is uncoordinated
• Care is not patient-centered, it is more provider
  centered
• Care is inefficient
• There continues to be considerable waste
  (overuse) in the delivery of healthcare, as well
  as overt fraud abuse
• Insufficient emphasis is placed on major problems
  of
• Patient safety
• Healthcare Acquired Conditions
• Prevention
• Unnecessary admissions and readmissions
• Palliative End-of-life Care
• Health disparities
• Health Information Technology has a critical
  unfulfilled role in this

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U.S. Healthcare Quality/Value Challenges

• The private and public sectors collectively have
  failed to reform healthcare using conventional
  healthcare delivery and payment models
• Traditional Fee-for-Service is a major reason
  Pays for quantity, not quality
• Managed care has intermittently controlled costs
  gt quality
• Regardless of payment system we havent publicly
  measured compared cost or quality, and
  payers/providers are not held sufficiently
  accountable
• All healthcare is local means integrated health
  systems have a significant role to play, Academic
  Centers special
• The Affordable Care Act of 2010 has great
  potential to address the healthcare quality/value
  challenges

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Ensuring Quality ValueTools/Drivers/Enablers

• Contemporary Quality Improvement
• Transparency Public Reporting Data Sharing
• Incentives Payment reform by All Payers
• Regulatory vehicles State Federal
• Payer Benefit Design and Coverage Decision Making
• Demonstrations, pilots, research, innovation

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Contemporary Quality Improvement

• Need to set priorities, goals and objectives,
  strategic framework first
• Evidence-Based goals, metrics, interventions,
  evaluations
• Includes conformance with evidence-based
  guidelines, balanced with patient-centered
  considerations
• Cost-effectiveness, let alone comparative
  effectiveness, has not yet been addressed
  adequately
• Rapid-cycle development, implementation and
  change methodology
• Leveraging of resources and efforts Current and
  future models-collaboration, alignment, synergy,
  priorities
• Many examples Hospital Quality Initiative, Organ
  Donation Campaign, QIOs, ESRD Networks, IHI,
  Bridges to Excellence, NCQA, Nursing Home
  Health Campaigns, many health plan
  collaboratives, local collaboratives, Partnership
  for Patients, etc.

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Transparency Public Reporting Data
Availability

• CMS Compare Websites
• Hospital Compare
• Nursing Home Compare
• Home Health Compare
• Dialysis Facility Compare
• MA Health Plan and Medi-Gap Compare
• Prescription Drug Plan Compare
• New under ACA
• Physician Compare
• VBP Programs Above plus ASCs, LTCHs, IRHs,
  Hospices, others
• Other comparative websites
• www.WhyNotTheBest.org

• MyMedicare.gov
• HHS/CMS Data Dissemination Efforts www.data.gov,
  www.healthcare.gov
• Potential explosion of federal govt. private
  sector data availability for private sector to
  drive data use innovation in previously
  unimaginable ways

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Incentives

• Pay for Reporting and Adoption Programs
• P4R Hospital Inpatient/Outpatient , PQRI,
  e-Prescribing, Home Health
• ARRA /HITECH EHR adoption and meaningful use
• Value-based Purchasing (VBP)
• ESRD Bundled Payment System January 1, 2011
• ESRD Quality Incentive Program (QIP) January 1,
  2012
• Hospital VBP (ACA Section 3001) October 1, 2012
• VBP in many additional settings in pipeline
• Competitive bidding, gain sharing, shared
  savings, bundled payment, ACOs, medical homes,
  salaries, integrated delivery, etc.
• Will any of these be effective ?

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VBP Issues for Future

• Alignment of multiple programs in existence or in
  pipeline
• Goals and objectives, priorities
• What do we want to accomplish other than plain
  measurement?
• Public-Private alignment
• Measures
• Many not actionable or likely to lead to
  improvement
• Process to develop and gain consensus too long,
  too contentious, too academic looking for the
  perfect
• Financial Incentives
• Balance of penalties, bonus/rewards, shared
  savings, etc.
• How much?
• Phase out P4R and adoption of outcomes-based VBP

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Regulation

• Conditions of Participation or Conditions for
  Coverage
• COPs are minimum health and safety standards set
  by CMS for facilities that may receive Medicare
  payments
• 17 separate provider/supplier settings have COPs
• Survey Certification
• U.S. healthcare facilities certified must be in
  compliance with current Medicare regulations
  applicable state laws
• SC process uses interpretive guidelines to
  assess compliance with regulations
• In combination, a powerful tool for quality/value

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Affordable Care Act (ACA) of 2010

• Title I Quality, Affordable Health Care for all
  Americans
• Title II Role of Public Programs
• Title III Improving the Quality Efficiency of
  Health Care
• Title IV Prevention of Chronic Disease
  Improving Public Health
• Title V Health Care Work Force

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Affordable Care Act (ACA) of 2010

• Title VI Transparency and Public Reporting
• Title VII Improving Access to Innovative Medical
  Therapies
• Title VIII Community Living Assistance Services
  Support (CLASS) Act
• Title IX Revenue Provisions
• Title X Strengthening Quality, Affordable Health
  Care for All Americans (Amendments)

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High Profile ACA Topics

• Greater Access to healthcare coverage
• National Quality Priorities Strategic Plan
• National Prevention Priorities Strategic Plan
• Attention to not only Medicare Commercial
  healthcare, but Medicaid and Dual-Eligibles
• Prevention and Patient Safety
• Numerous prevention initiatives
• Population Health Obesity, Smoking Cessation,
  etc.
• Patient safety medical errors reduction
• Healthcare Acquired Conditions (HACs), Infections
• Focus on better outcomes, greater efficiency

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High Profile ACA Topics

• Patient Centeredness
• High-cost Chronic Disease Management
• Care coordination care transitions
• Reduction of unnecessary admissions
  readmissions
• Accountable Care Organizations, Medical Homes
• Integration of conventional providers with public
  health, community, and non-traditional sites of
  care
• Innovation in payment, delivery systems, care
• Rapid cycle change quality improvement
• Best practices and learning environments
• Attack on healthcare Fraud, Abuse, and
  waste/overuse

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Center for Medicare Medicaid InnovationCMMI

• CMMI establishment mandated by January 1, 2011
  (Section 3021)
• Consultation input from broad healthcare sector
  in implementation
• Develop patient-centered payment models
• Rapid piloting/testing of new payment programs
• Encourage evidence-based, coordinated care for
  Medicare, Medicaid, CHIP
• Focuses on populations for which there are
  deficits in care leading to poor clinical
  outcomes or potentially avoidable expenditures

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CMMI Statutory Descriptors

• Risk-based comprehensive payment or salary-based
  payment models
• Geriatric assessments and comprehensive care
  plansinterdisciplinary care teamsmultiple
  chronic conditions
• transition health care providers away from
  fee-for-service-based reimbursement and towards
  salary-based
• health information technology-enabled provider
  network that includes care coordinators, chronic
  disease registry, home telehealth technology

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CMMI The Innovation Center

• Other key characteristics in the statute for
  payment models
• Varying payment for advanced diagnostic imaging
  services
• Medication therapy management services
• Community-based health teams to assist in care
  management
• Patient decision-support tools
• State flexibility for dual-eligibles and
  all-payer payment reform demonstrations
• Collaboratives of high-quality, low-cost
  institutions
• 10 billion over 10 years funding

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Staging of Innovation Development, Demonstration,
and Translation
2 To 3 years Design to Program Translation Cycle
Time
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Driving Healthcare SystemTransformation
Un-managed
Coordinated Care
Accountable Care

• Fee For Service
• Inpatient focus
• O/P clinic care
• Low Reimbursement
• Poor Access and Quality
• Little oversight
• No organized networks
• Focus on paying claims
• Little Medical Management

• Organized care delivery
• Aligned incentives
• Linked by HIT
• Integrated Provider Networks
• Focus on cost avoidance
• and quality performance
• PC Medical Home
• Care management
• Transparent Performance Management

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Driving Healthcare Delivery System Reform and
Transformation 2011-2019
2014-2019
2012-2019
2011-2019
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CMMI Programs

• Initiative to Reduce Avoidable Hospitalizations
  Among Nursing Home Residents
• Innovations Advisors Program
• Medicaid Emergency Psychiatric Demonstration
• Medicaid Incentives for the Prevention of Chronic
  Diseases
• Million Hearts
• Partnership for Patients Care Transitions
  Community-based
• State Innovations Models
• Strong Start for Mothers Newborns

• ACO Programs
• Bundled Payment
• Comprehensive Primary Care Initiative
• Financial Alignment Initiative
• FQHC Advanced Primary Practice Demonstration
• Graduate Nurse Education Demonstration
• Health Care Innovation Awards
• Independence at Home Demonstration

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Accountable Care Organizations (ACOs)

• Medicare Shared Savings Program (Section 3022)
• Implementation of the Medicare ACO Program
  mandated by January 1, 2012
• Encourages multiple providers of services and
  supplies to
• Join together and create ACOs
• Be jointly accountable for health experience of
  care for individuals over a period of time
• Improve population health, overlap with community
• Reduce rate of healthcare spending, improve
  quality

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CMS ACO Proposed Rule

• ACO Notice of Proposed Rulemaking (NPRM) issued
  March 31, 2011
• An ACO is an organization of healthcare providers
  that agrees to be accountable for the quality,
  cost, and overall care of assigned Medicare
  beneficiaries who are enrolled in Medicare FFS
• Eligible organizations
• Physicians in group practice arrangements
• Physicians in networks of practices
• Partnerships or joint venture arrangements
  between physicians and hospitals
• Hospitals employing physicians
• Other forms that the HHS Secretary deems
  appropriate

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Reaction to ACO NPRM

• Largely negative
• Too complicated, too restrictive
• Too much undefined risk
• No specialty-focused ACOs
• Negative comments about each criteria component
• CMS responded in interim
• Pioneer ACO Model
• Advance Payment ACO Model
• Accelerated Development Learning Sessions
• Final rule issued November 2, 2011 Many
  revisions, less complicated, more options

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Whats An Accountable Care Organization?
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Whats An Accountable Care Organization?
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CMS ACO Status Update

• Medicare Shared Savings Program ACOs 153
• 27 named in April, 2012
• 88 named in July, 2012
• 32 Pioneer ACOs
• 6 Physician Group Practice Demo
• Half are physician-driven groups serving lt 10,000
  patients
• Serve 2.4 million Medicare beneficiaries
• 33 Quality Measures
• Care coordination and patient safety
• Preventive health services
• Improved care for at-risk populations
• Patient and caregiver experience of care

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Overall U.S. ACO Status Report

• The number and types of ACOs are expanding
• Growth is centered in larger population centers
• Hospital systems appear to be the primary backers
  of ACOs, but physician groups are playing an
  increasingly larger role
• Non-Medicare ACOs are experimenting with more
  diverse models than Medicare-backed ACOs
• The success of any particular ACO model is still
  undetermined

Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
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Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
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Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
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Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
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Source Leavitt Partners report Growth and
Dispersion of Accountable Care Organizations, May
2012
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ACA Academic Health Systems

• ACA Section 3025 Hospital Readmission Reduction
  Program
• ACA Section 3026 Community Based Care Transition
  Program
• Healthcare Delivery Research (Section 3501, AHRQ
  coordinating with CMS)
• Identifies best practice institutions,
  organizations, etc.
• Supports innovation in health care delivery
  system improvement
• Quality Improvement Technical Assistance (Section
  3501)

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ACA Academic Health Systems

• Establishing Community Health Teams to Support
  the Patient-Centered Medical Home (Section 3502)
• Medication Management Services in the Treatment
  of Chronic Diseases (Section 3503)
• Emergency medicine regionalized systems and
  research, trauma care centers access payment
• Demonstration to integrate quality improvement
  and patient safety education into healthcare
  worker education (Section 3508)
• National Health Care Workforce Commission
  (Section 5101)
• Recruitment, education and training, retention

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ACA Academic Health Systems

• National Center for Health Care Workforce
  Analysis (Section 5103)
• Multiple student loan programs, various training
  retention programs, demonstration programs
  established
• Primary care
• Nurse-led care, advanced practice nursing, etc.
• Allied health, public health, dental, pediatric,
  direct care professionals, geriatric, mental
  health, cultural competency in disabilities,
  mid-career, etc.

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ACA Academic Health Systems

• United States Public Health Services Track (Part
  D, Section 271)
• Centers of Excellence-additional funding
• Medical Residency funding enhancements
• Teaching grants and demonstrations in graduate
  medical education
• The list goes on and on and on.
• But, will ACA survive the legal, political and
  funding challenges in its entirety?
• If not, which sections?
• Whether or not, will savings estimates be
  achieved?

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Conclusions

• The Affordable Care Act provides innumerable
  opportunities to improve the quality, value and
  efficiency of healthcare in the United States
• CMS/HHS is a major implementation center for this
  historic piece of legislation, but the private
  sector has an equally important role
• Individual integrated health systems,
  particularly those with a focus on innovation and
  evidence, are essential to the success of
  healthcare reform
• Implementation affects fee-for-service as well as
  managed care models, plus untested new models

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Conclusions

• There are numerous opportunities and needs for
  involvement of integrated/academic health systems
  in implementation of ACA and further health
  reform in the future
• Design of and leadership in contemporary quality
  improvement initiatives
• Huge gap in comparative- cost-effective
  analysis/improvement, let alone basic clinical
  knowledge
• Ongoing input in review and improvement in
  clinical guidelines
• Balancing evidence-based population RCT viewpoint
  with need for individual patient-centered concerns

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Conclusions

• Additional roles for integrated/academic health
  systems
• Education of multiple audiences in evidence-based
  medicine use
• Clinicians Current/future, academic/community
• Policy makers
• Payers
• Patients, consumers and their families
• Development and use of quality and value metrics
• Multiple perspectives Clinicians, patients,
  payers, etc.
• Relevance, actionability, accountability,
  attribution
• Alignment/integration of traditional community
  healthcare resources and models

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Conclusions

• Additional roles for integrated/academic health
  systems
• Collection, analysis, reporting and use of
  healthcare data
• Health Information Technology development,
  adoption and meaningful use via EHRs
• Other forms of data collection Registries,
  claims, encounter data, telehealth, chart review,
  surveys, etc.
• Balance of scientific rigor vs.. information
  efficiency
• Minimization of burden
• Privacy security
• Dissemination of data for widest possible
  appropriate use

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Conclusions

• Additional roles for integrated/academic health
  systems
• Development of and participation in new
  reimbursement and delivery systems
• Higher quality leading to overall lower costs
• Innovation, rapid change adaptability
• Care transitions and coordination
• Integration of delivery systems
• Patient-Centered, all of IOM Quality Aims
• Public health focus, as well as individual health

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Conclusions

• We cannot continue to cover and pay for
  everything thats available without considering
• Evidence-based coverage payment decision making
• Comparative effectiveness and cost effectiveness
  analysis
• Overall costs involved, including global costs of
  lost productivity, quality of life, etc.
• But are Academic Health Systems ready?
• Rapid-cycle change, integrated systems (no
  departmental silos), authenticity will to
  change (e.g., academic tenure?)

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Conclusions

• The under-emphasized topics (?ignored)
• End-of-life care
• Health disparities reduction Action needed, not
  talk
• Racial/ethnic
• Geographic
• Age
• Gender
• Socioeconomic
• LGBT
• Medical Conditions

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• Thank you for your contributions in improving the
  American healthcare system!
• Questions?
• Discussion Dialogue