edifecs value based reimbursement 2017 01 27
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Pathways to PartnershipsValue Based Reimbursement – paying for health outcomes
Erasmus MC, 27 januari 2017
Remko Manders, AchmeaMichiel Walsteijn, Edifecs
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Some Definitions
Quality (in medicine):
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990)
Value:
Outcomes Achieved divided by Resources Expended
Health
Cost
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Value Based ReimbursementA Continuum of Provider Risk
Fee for Service
Fee for Service Plus P4P or
Shared Savings
Episode ofCare / Payment
Bundling
Partial Capitation
Global Capitation
Provider Sophistication
Pro
vide
r R
isk
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
VBR: Prostate
VBR Models Examples of Performance Measures
• P4P• Bundled
Payments• Full Risk
1. Mortality rate2. Impotency3. Incontinence4. Anesthesiology and Critical Care: Prevention of Catheter-Related Bloodstream Infections (CRBSI) –
Central Venous Catheter (CVC) Insertion Protocol5. Febrile Neutropenia Risk Assessment Prior to Chemotherapy6. Gains in Patient Activation (PAM) Scores at 12 Months7. Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections8. Prostate Cancer - Cancer Surveillance9. Prostate Cancer: Adjuvant Hormonal Therapy for High or Very High Risk Prostate Cancer Patients10.Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients11. Prostate Cancer: Three-Dimensional Radiotherapy12.American Medical Association - Physician Consortium for Performance Improvement (AMA-13.Radical Prostatectomy Pathology Reporting14.Shared Decision Making Process15.Assesses whether men 70 years of age and older were screened unnecessarily for prostate cancer
using prostate-specific antigen (PSA)-based screening.
Market Participant Examples
Comments • Prostate programs are directed primarily at over-screening that leads to needless follow and false positives, and steering patients to identified centers of excellence (COE)
• Treatment decisions and outcomes vary significantly but a standard set of best practices is emerging
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
VBR: In Vitro FertilizationVBR Model Examples of Performance Measures
• VBID/ Steerage to COE
• Bundled payment per cycle
Primarily facility success/failure measures related to two factors:1. Live birth event or a take home baby2. Success/Failure ratio of IVF cycles per cumulative live births Measures are Milestone Measures of success or failure3. Cycle Started4. Patient achieving trigger5. Oocyte retrieval6. Patient w/sufficient embryos7. Transfer procedure8. Embryo transferred9. Course of treatment started10.Time to pregnancy resulting in birth
Market Participant Examples
Comments • Adherence to best practices and track record of success establish an IVF Center as a COE• The leverage held by payers to negotiate for bundled payments per cycle and unit cost discounts
varies dramatically from region to region• Lack of precise data makes it difficult at this time to apply true value based outcome measures to
IVF services. Patient experience reporting and process measures are the current state of the art• In US, full coverage of a limited number of IVF cycles is mandated in eight states, seven more have
a more limited but mandated infertility treatment benefit
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Creating a win for the patient New Contract for OBs
Pay for Performance:
Physicians who follow guidelines earn a bonus
payment for following criteria consistently
New Contract for OBs
Shared Savings:
Physicians who follow guidelines earn 50% of savings, if other quality measures remain high
1) Information Only
2) Pay for Performance
3) Shared Savings
Pathways to Partnerships | Bridging Connections For Valueedifecs confidential
Implementing Value-Based Care
Payers and providers are evolving end-to-end capabilities to scale Value-Based Care
Target Populations
Design Contracts
Assemble Integrated Patient Records
Coordinate Care
Measure Outcomes
Pay for Value
Pre - Contracting Post - Contracting
Target Interventions
100 Fastest Growing Companies in WA
Washington’s 100 Best Places to Work For
4 consecutive years
Inc. 5000 Fastest- Growing Private Companies in the US
6th consecutive year
Deloitte Technology Fast 500, North America
5th Consecutive year
Puget Sound Business Journal, Washington Best Workplaces
3rd consecutive year
Seattle Business Magazine’s, Tech Impact Award
Fierce innovation award
Top 3 FinalistBest In BizBest Place to work:
Silver
HCI 100 Healthcare Informatics
Ranking #78
Pathways to Partnerships | Bridging Connections For Value
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Appendix: Value-Based Care Solution
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
Pathways to Partnerships | Bridging Connections For ValuePathways to Partnerships | Premier Partnership Solutions for Healthcare
How are PMPM Costs
changing?
What is your budget to
date performance?
What savings might you anticipate?
How is your attribution changing?
What is your leakage?
How is your quality
performance so far?
What is your performance
against KPIs?
What is driving your
costs?
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