Quality Initiatives › Healthcare Delivery Systems › Payment Methodologies › Value Partnerships

K n o w l e d g e , I n s I g h t s , a n d B e s t P r a c t I c e s t o h e l P Y o u r o r g a n I z at I o n P r e Pa r e f o r t h e f u t u r e

Driving Change in Health Care

Introduction

The government, via the 2010 Affordable Care Act (ACA), accelerated the development of new quality initiatives, adding to the scope of programs and measures already in place. Many of these new initiatives are driven by the Centers for Medicare & Medicaid Services (CMS) because a major focus of healthcare reform is on these government programs. The ACA, CMS, and a range of quality initiatives are driving innovations in healthcare delivery systems, payment methodologies, and value partnerships, all with the goal of improving patient outcomes and, at the same time, reducing healthcare costs.

At Ortho-McNeil-Janssen Pharmaceuticals, Inc. (OMJPI), a Johnson & Johnson company, Our Credo challenges us to put the needs and well-being of the people we serve first. We are committed to supporting the development and implementation of strategies for improving the quality and efficiency of healthcare delivery. As a reflection of this commitment, OMJPI has been designated the sole pharmaceutical industry representative in the National Priorities Partnership (NPP) program.2

As part of our continuous effort to improve the quality and efficiency of healthcare delivery, OMJPI is launching a comprehensive program developed to inform, align, and support key healthcare stakeholders on 4 key areas: quality initiatives, healthcare delivery systems, payment methodologies, and value partnership initiatives. This brochure is the first in a series of resources that will provide your organization with strategic insights, valuable information, and actionable tools and approaches to meet the challenges of health care today.

“The time for reform is now.”1

—Kathleen Sebelius, Secretary, US Department of Health and Human Services

Quality Initiatives

Inside this brochure, you’ll find knowledge, insights, and several best practices regarding the current topics of:

› Affordable Care Act quality initiatives

› Centers for Medicare & Medicaid Services involvement in quality initiatives

› The National Priorities Partnership

› Growth of accountable care organizations

› Proliferation of patient-centered medical homes

› Regional Health Improvement Collaboratives

› Medicare and Medicaid episodes-of-care participation

› Medicare Shared Savings Program model and other new payment methodologies

› Development of value partnership initiatives

Projected medical costs, better access of analytic tools for estimating risk, the government’s mandate for Medicare payment and organizational reform, and the overwhelming challenges of managing chronic conditions have fundamentally impacted the healthcare landscape.3 Efficacy must be partnered with efficiency and safety. The top 3 initiatives driving today’s reinvigorated focus on healthcare quality include the ACA, the NPP, and CMS involvement.

ACA Quality Initiatives

Although quality initiatives have been in place for over 20 years, the provisions of the 2010 ACA have increased the focus on improvements—some mandatory, some incentive-based— in the quality, effectiveness, and efficiency of health care in the United States, all while addressing the accelerating costs of health care.

Did You Know?Healthcare expenditures are projected to grow 6.1% each year from 2009 through 2013.4

National Healthcare Expenditures, 20085

Source: “U.S. Health Care Costs—Background Brief,” The Henry J. Kaiser Family Foundation. March 2010.The information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a nonprofit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible analysis and information on health issues.

Physician/clinicalservices

21%

Hospital care31%

Otherprofessional

services6%

Dental4%

Nursinghome care

6%

Home health3%

Rx drugs10%

Other retailproducts

3%

Programadministration

7%

Govt. publichealth activities

3%

Investment7%

Total =$2.3 Trillion

Driving Change...Quality Initiatives

The focus of new healthcare legislation includes:

› Improvements in quality and efficiency. Higher quality and better efficiency translate into a more cost-effective healthcare system. An estimated 30% of health care may be unnecessary, creating a need to streamline health systems5

› Provider compensation adjustments. In addition to pay for performance (P4P), new legislative proposals suggest revamping provider payments to reward better outcomes5

› The ACA also utilizes comparative effectiveness research (CER) to determine which treatments are the most effective for a specific condition. CER can be used as a guide to better outcomes and more cost-effective treatment5

› Investments in health information technology (HIT). Nineteen billion dollars in federal funds have been allocated to upgrade HIT to more efficiently share information and reduce overhead as part of the American Recovery and Reinvestment Act (ARRA) in addition to the ACA6

“ Real change to the healthcare system requires a focused and combined effort from those who receive, give, and pay for healthcare.”7

—National Quality Forum

CMS Involvement in Quality Initiatives

The challenge to curb costs without sacrificing care under Medicare and Medicaid may become critical in the next few years:

› Medicare spending grew 8.1% in 2009 and, although expected to average slightly less (6.9%) per year for the next 10 years, the percentage per year remains high4

› Medicaid spending grew approximately 10% in 2009, a rate also expected to average less per year (7.9%) for the next 10 years4

› 1 in 5 Americans will be 65 years of age or older by 20308

To make an impact on these accelerating costs, CMS has developed numerous quality initiatives across the healthcare system spectrum, including public reporting of measure results at long-term care facilities, home healthcare agencies, hospitals, and kidney dialysis facilities. CMS also partners with federal and state agencies, researchers and academic experts, stakeholder and consumer organizations, providers and advocates, and federal contractors, such as quality improvement organizations (QIOs) that can help Medicare beneficiaries and their caregivers better understand the various CMS quality initiatives in place.9

In addition, CMS has identified 20 medical conditions (see above) that account for 95% of Medicare’s costs. By creating initiatives across multiple channels, CMS is hoping to contain their costs.10

In 2010, under the auspices of the National Quality Forum (NQF) and the Department of Health and Human Services (HHS), the Measure Development and Endorsement Agenda developed a variety of measures that could be utilized to address care gaps and cost inefficiencies associated with these medical conditions.11

CMS also required the establishment of the Physician Quality Reporting Initiative in 2006, which provides financial incentives to providers who utilize and report the use of quality improvement measures on all Medicare-covered medical conditions.12

The NPPThe NPP was convened by the NQF to address the need for healthcare change via a collaboration of 42 different influential stakeholders working together to address the major challenges of today’s healthcare system. These challenges are13:

› Eliminate harm

› Eradicate disparities

› Reduce disease burden

› Remove waste

› Increase patient-centric focus and family engagement

› Improve care for patients of all ages

› Align the interests of public and private sectors

› Acute myocardial infarction

› Alzheimer’s disease and related disorders

› Atrial fibrillation

› Breast cancer

› Cataract

› Congestive heart failure

› Chronic kidney disease

› Colorectal cancer

› Chronic obstructive pulmonary disease

› Diabetes

› Endometrial cancer

› Glaucoma

› Hip/pelvic fracture

› Ischemic heart disease

› Lung cancer

› Major depression

› Osteoporosis

› Prostate cancer

› Rheumatoid arthritis and osteoarthritis

› Stroke/transient ischemic attack (TIA)

The 20 High-Priority Conditions Identified by CMS10

Infrastructure SupportsAddress underlying system changesthat will be necessary to attain the goals of the other priority areas

Population HealthHealth Index;Quality Measurement of Health & Wellness

Adapted from NQF.

Equitable AccessEnsure all patients have access to affordable, timely, and high-quality care

Patientand Family

Engagement

Decision-makingtools

Care CoordinationReducing hospitalreadmission rates

Safety

Reducing infectionsin the perioperative

period

Overuse

Focused on unnecessary medical interventions

Palliative Care

Improved assessment and management of pain

Reflecting its basic credo that in order to achieve healthcare change, the work of many is necessary, the NPP encompasses organizations representing the interests of13:

› Consumers, such as the Consumers Union

› Purchasers, such as the Pacific Business Group on Health

› Healthcare providers, such as the American Board of Medical Specialties

› Healthcare professionals, such as the American Nurses Association

› State-based associations, such as the National Governors Association

› Community collaborative and regional alliances, such as the Alliance for Pediatric Quality

› Government agencies, such as the National Institutes of Health

› Health plans, as represented by America’s Health Insurance Plans

› Accreditation and certification groups, such as the Joint Commission

› Supplier and industry groups, such as Johnson & Johnson Health Care Systems

There are 8 priorities that will enable the NPP to focus on high-leverage areas to achieve greater return on investment, align efforts of the multiple groups around common goals for improvement, and address the urgent need to drive fundamental change in the healthcare delivery system.13 The NPP goals within these 8 priorities are to be achieved within the next 3 to 5 years.13

The 8 NPP Priorities13

Did You Know?Care coordination for all medical conditions is a top priority for NPP. One in five patients discharged from the hospital experiences an adverse event and is readmitted within 30 days.14 Half the nonsurgical patients who are readmitted have not seen a doctor in follow-up.14 Combine this fact with the statistic that approximately 157 million Americans will have at least one chronic condition by the year 2020,15 and the critical need for accurate communication between one care setting to another becomes clear.

Taking the InitiativeThe NQF Coordination of Care Standardized Framework16

To improve coordination across the fragmented and disjointed US healthcare system, NQF has endorsed 10 performance measures and 25 preferred practices for more streamlined and effective coordination of care. Previously, care across settings was difficult to navigate and created too much waste. This new framework addresses the need for better patient outcomes, less waste, and more seamless coordination by putting patients and their families at the center of health care.

Two examples of the 10 performance measures are:

› Proactive plan of care and follow-up. A facility should measure the percentage of patients with a recent emergency department (ED) visit for a transient ischemic attack (TIA) and any physician visit within 14 days of the acute event

› Transitions. A facility should measure the percentage of patients discharged from the ED to ambulatory care, home health care, or their caregiver, and who receive a transition record at the time of ED discharge

Two examples of the 25 preferred practices are:

› Healthcare home. A preferred practice or sponsoring organization becomes the central point for coordinating strategies for continuity of care

› Access. Communication between the healthcare team, insurance plan, patient, and patient caregiver must always be available

For the full list of endorsed measures and practices, please visit: http://www.qualityforum.org/projects/care_coordination.aspx.

Due to the ACA and rising healthcare costs, there is a sharper focus on improving the quality of health care.

Driving Change...Healthcare Delivery SystemsOne of the most prominent drivers of change in the ACA is the way health care is delivered in the United States. To help ensure better patient outcomes, reduce waste, streamline the treatment process, provide more efficient care, and increase cost-effectiveness, the future of health care is focused on delivery systems. Three new delivery systems are highlighted here: accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and Regional Health Improvement Collaboratives.

Growth of ACOs

Restructuring the delivery and payment systems used by hospitals and physicians becomes necessary to reduce costs without sacrificing care quality.3

ACOs are currently being drafted in response to this need. ACOs are organized networks of primary care physicians, specialists, and hospitals that are accountable for the cost and delivery of care for a specific population.3

When the members of an ACO achieve performance benchmarks set by CMS via more efficient and coordinated care, the member entity will receive a financial bonus. In order to qualify as an ACO, a network must3:

› Include both hospitals and physicians

› Include a Medicare patient population of at least 5000

› Have the ability to pay the providers, hospitals, and other healthcare professionals within the network

› Service both Medicare and commercial patients

› Have the potential to provide leadership and management structures that include clinical and administrative protocols

› Have the capability to put processes in place that promote evidence-based medicine, report quality evaluation and cost measurement data, and demonstrate patient-centric operations—which can be shared by the payers, hospitals, and physicians within the ACO, as well as with CMS

Did You Know?

› 75% of healthcare expenses are currently attributed to chronic disease management. ACOs may help reduce these expenses by helping patients make better treatment and lifestyle choices and by assisting physicians in their care of the chronically ill3

› Reducing potentially preventable events via implementation of ACO best practices may result in savings of $100 billion per year3

Healthcare D

elivery System

s

The 4 Emerging ACO Models3

Network Model› Physician independence and

single-specialty groups

› Umbrella legal entity and governance structure

› Clinical redesigns performed by providers and hospitals in network

› Physician groups jointly contract with health plans

Examples: Dartmouth-Hitchcock; Atrius Health; Monarch

Organized Medical Group Model› Multispecialty medical

group as core element

› Provides full complement of clinical services

› Drives redesign via partnership or ownership of hospitals and ancillary service providers

› Contracts with multiple health plans

Examples: Geisinger; Mayo; Permanente

Hospital Systems Model› Hospital collaboratives

formed through organized initiatives

› Hospitals and physicians closely aligned to create a risk-bearing organization

› More future-oriented focus on risk sharing and clinical redesign

Examples: Premier; Sutter; Scripps

Collaborative Model› Partnership between

integrated hospital systems, large physician groups, corporate employers, and national health plans

› Virtual model with decentralized control; most complicated model

Example: Iowa Health System/United/John Deere

Dartmouth-Hitchcock

Permanente

Sutter

Sharp

ScrippsAmerican Medical Group Association

Geisinger

Health PartnersIntermountain

Mayo

“ Perhaps the biggest challenge will be for providers and payers to see themselves now as partners and collaborators after decades of adversarial relationships.”3

— Boland et al. Manag Care. 2010;19(10):12-16,19. Used with permission from Managed Care.

Medical Home Team Characteristics17

Personal The driver: first-contact, continuous, and physician comprehensive care for each patient

Team practice The driver’s team for ongoing care and prevention at the practice level

Whole-person Personal physician has responsibility for orientation arranging care with other healthcare

professionals throughout all stages of life

Coordinated › Coordination across medical systems,care including specialists, hospitals, home

health agencies, and nursing homes › Coordination among patient’s family and

public and private community-based services

HIT and › Facilitated care via electronic health recordsanalytical and other technologytools › Tools for patient tracking, clinical monitoring,

specialist follow-up, population-based decision making, and predictive modeling

Expanded Open scheduling; expanded and after-hoursaccess to health access to personal physician and team via practitioners telephone or secure e-mail

Effective Rewards providers for supporting medical homeuse of features, such asfinancial › Additional payments for achieving cost savingsincentives › Measurable and continuous quality

improvements

Proliferation of Patient-Centered Medical Homes (PCMHs)

In today’s healthcare environment, the overdependence on specialists versus primary care physicians has helped create poor access, care fragmentation, and inconsistent results. A central “home” is needed, where patient information; communication between providers, payers, and patients; and quality of care can be identified, stored, and analyzed.17

Enter the PCMH: a virtual community–based, interdisciplinary system that supports primary care through coordination and collaboration among providers. Its enhanced primary care foundation is designed to17:

› Facilitate more accessible and coordinated care

› Involve the patient in the decision-making process

› Provide accountability for more successful outcomes

Did You Know?The concept of the PCMH first appeared in 1967, but it was not until 2007 that it evolved into a preferred delivery system with requirements set down by the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association. It is endorsed by a large number of physician groups, payers, and employers.17

Taking the InitiativePhysician Practice Connections®—Patient-Centered Medical Home™18

Sponsored by the National Committee for Quality Assurance (NCQA), the Physician Practice Connections®—Patient-Centered Medical Home™* (PPC-PCMH) program is an extension of NCQA’s highly acclaimed Physician Practice Connections (PPC) Recognition Program, initiated in 2003 with support from such esteemed organizations as the Robert Wood Johnson Foundation, the Commonwealth Fund, and Bridges to Excellence.18

The purpose of the PPC-PCMH is to determine whether physician practices are working as medical homes utilizing standards developed by primary care specialty societies; some of the PCMHs that meet the requirements are payer-supported, such as the Chronic Care Commission in southeastern Pennsylvania.18,19

As an extension of the PPC-PCMH, NCQA has created a recognition program, an incentive for practices that successfully use patient-centered, coordinated care processes and HIT to enhance their patients’ quality of care.18

“ The patient-centered medical home has the potential to change the interaction between patients and physicians. Patients can no longer be silent partners in their care—they are active participants in managing their health with a shared goal of staying as healthy as possible.”18

—Margaret E. O’Kane, NCQA president

Emerging Regional Collaborations

The US healthcare landscape varies across regions, states, and communities. In order to more efficiently provide quality care to all individuals, regional-level collaborations have become an emerging element of healthcare delivery.20 These regional collaborations perform data aggregation and public reporting of quality measures; they also develop incentive and P4P programs at a more local level.20

Regional Health Improvement Collaboratives are20:

› Led and/or controlled by multiple stakeholders that may vary by region; they may include government health quality agencies, consumer groups, payers, business health coalitions, and/or provider professional associations

› Consensus-driven directives

› Implemented via voluntary cooperation, not government mandates; many of their programs are driven by private payers

› Focused on improving healthcare quality

› Continuing to evolve as the structure and healthcare industry priorities change

› Funded by membership dues, grants, and fees for services

Did You Know?No two regional health improvement collaboratives are exactly alike because no two areas of the country are alike. Each state, city, community, and region has its own unique qualities and healthcare needs.20

“ Regional Health Improvement Collaboratives are advancing initiatives to control overuse, identify quality problems and disparities in care, and build consensus on payment reform.”21

—Regional Health Improvement Collaboratives News item

Taking the InitiativeIndiana Health Information Exchange

The largest health information exchange network in the country—the nonprofit Indiana Health Information Exchange (IHIE)—was created in 2004 to address Indiana’s high healthcare costs and its poor rankings in health indicators, including obesity, smoking, diabetes, and heart disease.22

IHIE connects 70 stakeholders, including patients, hospitals, long-term care facilities, physicians, local and state health departments, employers, and payers across Indiana, addressing both long-term and short-term healthcare issues.23 The IHIE’s secure and robust HIT network enables information to follow the patient—rather than being housed in one physician office or a single hospital.23

IHIE assembles its data so that providers can achieve better health outcomes for their patients in a program called Quality Health First, which utilizes real-time tracking, early intervention support, and comparisons of care within the Indiana physician community.24 It also collects lab results, immunizations, diagnoses, procedures, and medication information, which are then organized and summarized for the physician to facilitate patient care. The program also supports payers so that reimbursement aligns with treatment outcome.24 Quality Health First specifically focuses on24:

› Cancer screenings › Asthma management

› Diabetes management › Well-child visits

› Cardiovascular health › Care interventions

In 2010, HHS selected IHIE to be a Beacon Community—a regional collaboration that successfully utilizes an HIT network to better serve patients and improve outcomes—because of IHIE’s capability to help enhance patient care and improve outcomes while also providing a more efficiently run health system.24

* Physician Practice Connections is a registered trademark and Patient-Centered Medical Home is a trademark of the National Committee for Quality Assurance.

There is a drive toward delivery systems that are more accessible, better integrated, more cost-effective, and, ultimately, more capable of providing successful patient outcomes.

The new healthcare delivery model is based on a multisetting

delivery system, which necessitates new payment methodologies.

Instead of condition-specific, single-site fees, payments need to

be reevaluated for better efficiency and reduced cost. There are

3 key provisions in the new payment reforms: Medicare and

Medicaid episodes-of-care participation, the Medicare Shared

Savings Program model, and new cost-saving initiatives.

Medicare and Medicaid Episodes-of-Care Participation

Due to the high cost of hospital care, CMS has been focusing not

only on the hospital visit itself, but on the entire package of

services required to treat an episode of illness.25 The rationale

behind “episodes of care” is that making one payment, or

“bundled payment,” for the entire care of a particular illness or

condition instead of paying for each step of that care would

ultimately provide better clinical results and lower cost overall.26

Financial characteristics of episodes of care are:

› Reimbursement for multiple providers will be bundled into a

single, comprehensive payment that covers all of the services

involved in the patient’s care within multiple settings27

› Bundled payment throughout a patient’s care for a particular

condition helps avoid medical complications, optimizes clinical

outcomes, and avoids unnecessary services and waste.27 For

example, if patients are admitted to a hospital for a knee

replacement, the usual procedure when admitted is for them

to go directly to radiology. But with a bundled payment tied to

episodes of care, there would be no need for the x-ray; the hospital would have the results of the latest film from the provider—even if the patient has forgotten to bring his or her film26

› One size doesn’t fit all. Payment methodologies for different episodes of care will require different standards. An elderly oncology patient, for example, would have different episodes-of-care guidelines than would a person who comes to the ED with a broken leg26

› Appropriate infrastructure, such as HIT, for episodes of care will avoid manual management of claims for payers—which impacts waste, time consumption, and inconsistency in results26

› Episodes-of-care standards need to be clear and should contain a description of the condition and its ICD-9 code, time frames, bundled payment inclusions and exclusions, and included and excluded services (along with CPT codes)26

Did You Know?The CMS recently developed quality incentives for a new prospective bundled payment for end-stage renal disease.27

Episodes-of-care standardization may also help prevent readmissions and longer hospital stays.27

Seamless transitions can occur only if there is coordination during all episodes of care in different settings and with different healthcare professionals. Quality care coordination for a specific

Driving Change...Payment Methodologies

episode of care can mean more robust recordkeeping, which, in turn, can create more efficiency in patient interaction and dialogue— ultimately helping to avoid dangerous and costly consequences.26

“ For too long, health care in the United States has been fragmented—failing to meet patients’ basic needs, and leaving both patients and providers frustrated. Payment systems often fail to reward providers for coordinating care and keeping their patients healthy, reinforcing this fragmentation.”28

— Donald Berwick, MD, Centers for Medicare & Medicaid Services Administrator

Medicare Shared Savings Program ModelThe growth of ACOs predicates the need for a more efficient, incentive-based payment system. The Medicare Shared Savings Program gives participating ACOs that meet specified quality performance standards a percentage of savings in a 12-month period. These quality performance standards include3,29:

› A decrease in patient preventable events. Examples include fewer hospital readmissions due to hospital-acquired conditions, never events, or poor transitions of care, preventable complications, and preventable emergency room visits and hospital admissions

› More efficacious and efficient chronic illness management. This may include efforts such as the creation of a diabetes clinic, better controls in place for home-based congestive heart failure treatment, or treating cancer in ancillary settings

› Administrative restructuring that creates significant cost reduction. Some of the restructuring may involve PCMHs, hospice programs, telehealth and e-visits, and complex case management

Other New Payment Methodologies

Through examination of quality of care, outcome, and cost of a particular illness throughout its life cycle, costs other than from the illness itself can be curtailed. In addition to the Shared Savings Programs, other new payment model reforms include:

› Elimination of beneficiary cost sharing30

› For some preventive care

› Primary care incentive payments through 201530

› Applies to primary care offices and clinics, skilled nursing facilities, and home healthcare services

› Health plan provisions for preventive care services without cost sharing30

› Includes vaccines, colorectal screenings, and bone mass measurements

Paym

ent M

ethodologies

› Value-based purchasing linking payment to performance31

› Incentive payments for demonstrating increased quality of care and decreased cost

› Incentives for effectively coordinating reimbursement to enhance quality and efficiency

› Incentives for utilizing hospital quality-based measurements for congestive heart failure, diabetes, and chronic kidney disease

Taking the InitiativeBridges to Excellence

In 2001, the Institute of Medicine (IOM) pubished a report entitled “Crossing the Quality Chasm,” which outlined deficiencies in healthcare quality. The OIM identified 6 key attributes around which the healthcare system should be redesigned to improve quality. The attributes, known as STEEEP, were32:

Safe Timely Effective Efficient Equitable Patient-centered

Achieving STEEEP goals required extensive changes and

healthcare redesign. To meet these challenges, a group of

physicians, employers, health plans, and patients came together

to create Bridges to Excellence. Its purpose is to create programs

that will realign everyone’s incentives around higher quality. They

were guided by 3 principles32:

› Purchasers need to create incentives in order to reengineer care

to reduce mistakes

› Reductions in misuse, underuse, and overuse to minimize waste

and inefficiencies in the healthcare system

› Increased accountability and quality improvements via the

release of provider performance comparisons to consumers

Several programs guided by these principles have developed,

including Physician Office Link, Diabetes Care Link, and Cardiac

Care Link.

Action-oriented and innovative payment models are emerging from the ACA and will be implemented within the next 3 years.

Driving Change...Value Partnerships

“ There has never been more transparency in the healthcare system: a record number of health plans reported HEDIS [Healthcare Effectiveness Data and Information Set] data, exceeding 1000 for the first time.”18

—Margaret E. O’Kane, president of the NCQA

For the new payment and delivery systems created as a result of the Patient Protection and Affordable Care Act of 2010, transparency is critical to success. Stakeholders across the continuum of care must be involved—especially C-suite leaders who lead the new designs.3

Key Elements in Successful Value Partnership InitiativesKey decision makers must join together to oversee seamless transitions of care and to ensure that quality initiative benchmarks are met and surpassed. Some of the key elements involved in successful value partnership initiatives are:

› Transparent integration of patient and provider data to more effectively manage long-term chronic illness20

› Clinical transformation to ensure efficacy, safety, and guidelines usage20

› Financial management to help reduce cost by linking payment to performance for hospitals and transforming Medicare into an active purchaser of services33

› Collaboration among competing stakeholders for the benefit of patients20

› The Primary Care Incentive Payment Program, whereby primary care service charges must be at least 60% of all Medicare Part B charges (based on claims data 2 years prior to the incentive payment year)34

› P4P incentives within hospital systems that include performance metrics in the process and outcomes of care, patient satisfaction, adoption of HIT by medical groups, and efficiency20,35

› Physician and short-term acute-care hospital reward incentives for utilizing quality initiatives and avoiding unnecessary cost and care33

› Collaborative quality initiatives whereby national medical organizations work with private health plans to evaluate and improve the quality of hospital care while reducing costs via reduced infections, illness, or death from surgical procedures36

› Incremental reimbursement to providers and reward payments based not just on service performed, but on quality initiative measures, such as safety and efficacy, as they are implemented20

More and more financial incentives are driven by measured value in safety, efficacy,

process, HIT utilization, and collaboration among stakeholders.

Value Partnerships

1. US Department of Health & Human Services. Secretary Sebelius releases new state by state reports highlighting urgent need for health reform [press release]. http://www.hhs.gov/news/press/2009pres/06/20090626c.html. Published June 26, 2009. Accessed January 27, 2011.

2. National Quality Forum. New partners appointed to national priorities partnership [press release]. http://www.qualityforum.org/ News_And_Resources/Press_Releases/2009/New_Partners_Appointed_to_National_Priorities_Partnership.aspx. Published July 22, 2009. Accessed December 2, 2010.

3. Boland P, Polakoff P, Schwab T. Accountable care organizations hold promise, but will they achieve cost and quality targets? Manag Care. 2010;19(10):12-16,19.

4. Centers for Medicare & Medicaid Services. National health expenditure fact sheet. CMS Web site. http://www.cms.gov/NationalHealthExpend Data/25_NHE_Fact_Sheet.asp. Updated November 23, 2010. Accessed November 11, 2010.

5. Kimbuende E, Ranji U, Lundy J, Salganicoff A. US health care costs: background brief. Kaiser Family Foundation Web site. http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx#footnote. Updated March 2010. Accessed October 29, 2010.

6. Kaiser Commission on Medicaid and the Uninsured. American Recovery and Reinvestment Act (ARRA): Medicaid and health care provisions. Kaiser Family Foundation Web site. http://www.kff.org/medicaid/upload/7872.pdf. Accessed October 29, 2010.

7. National Quality Forum. Addressing national priorities. NQF Web site. http://www.qualityforum.org/Setting_Priorities/Addressing_National_Priorities.aspx. Accessed November 17, 2010.

8. National Institute on Aging. Dramatic changes in U.S. aging highlighted in new census, NIH report [press release]. NIA Web site. http://www.nia.nih.gov/NewsAndEvents/PressReleases/PR2006030965PlusReport.htm. Published March 9, 2006. Accessed November 12, 2010.

9. Centers for Medicare & Medicaid Services. Overview: quality initiatives—general information. CMS Web site. http://www.cms.gov/QualityInitiatives GenInfo. Updated October 7, 2010. Accessed December 2, 2010.

10. National Quality Forum. Synthesis of Evidence Related to 20 High Priority Conditions and Environmental Scan of Performance Measures. NQF Web site. http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=20604. Published January 13, 2010. Accessed December 2, 2010.

11. National Quality Forum. Measure development and endorsement agenda. NQF Web site. http://www.qualityforum.org/MeasureDevelopmentand EndorsementAgenda.aspx. Accessed November 12, 2010.

12. Centers for Medicare & Medicaid Services. Overview: Physician Quality Reporting Initiative. CMS Web site. http://www.cms.gov/PQRI/01_Overview.asp. Updated September 16, 2010. Accessed November 15, 2010.

13. National Priorities Partnership. Input to the Secretary of Health and Human Services on Priorities for the 2011 National Quality Strategy. National Quality Forum Web site. http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=43235. Published October 14, 2010. Accessed December 2, 2010.

14. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.

15. Care coordination. National Priorities Partnership Web site. http://www.nationalprioritiespartnership.org/PriorityDetails.aspx?id=606. Accessed October 24, 2010.

16. National Quality Forum. New set of NQF-endorsed practices and quality measures support coordinated healthcare for patients [press release]. NQF Web site. http://www.qualityforum.org/News_And_Resources/Press_Releases/2010/New_Set_of_NQF-Endorsed_Practices_and_Quality_Measures_Support_Coordinated_Healthcare_for_Patients.aspx. Published September 27, 2010. Accessed November 15, 2010.

17. Patient Centered Primary Care Collaborative. Joint principles of the patient-centered medical home. PCPCC Web site. http://www.pcpcc.net/printpdf/14. Published February 2007. Accessed December 2, 2010.

18. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home. NCQA Web site. https://ncqa.org/Portals/0/PCMH%20brochure-web.pdf. Accessed December 2, 2010.

References

References

19. National Committee for Quality Assurance. Patient-centered medical home resources. NCQA Web site. http://www.ncqa.org/tabid/948/Default.aspx. Accessed November 17, 2010.

20. Network for Regional Healthcare Improvement. Strategies for Building Partnerships Between Pharmaceutical Companies and Regional Health Improvement Collaboratives. Pittsburgh, PA: Network for Regional Healthcare Improvement; 2009.

21. Highlights. Regional Health Improvement Collaborative News. Pittsburgh, PA: Network for Regional Healthcare Improvement; May 2009.

22. Indiana Health Information Exchange. History. IHIE Web site. http://www.ihie.com/About/History.php. Accessed November 17, 2010.

23. Indiana Health Information Exchange. About IHIE. IHIE Web site. http://www.ihie.com/About/default.php. Accessed November 17, 2010.

24. Indiana Health Information Exchange. Quality Health First Program. http://www.ihie.com/Solutions/quality-health-first.php. Accessed November 17, 2010.

25. Menke TJ, Wray NP, Ashton CM, Rabeneck L. Defining episodes of care. Association for Health Services Research. Abstr Book Assoc Health Serv Res Meet. 1999;16:360.

26. Moeller DJ, Evans J. Episode-of-care payment creates clinical advantages. Manag Care. 2010;19(1):42-45.

27. American Hospital Association Committee on Research. Bundled Payment: AHA Research Synthesis Report. Chicago, IL: American Hospital Association; May 2010.

28. Centers for Medicare & Medicaid Services. CMS introduces new center for Medicare and Medicaid innovation, initiatives to better coordinate health care [press release]. http//www.cms.gov/apps/media/press/release.asp?Counter=3871. Published November 16, 2010. Accessed February 16, 2011.

29. Centers for Medicare & Medicaid Services. Medicare “accountable care organizations” shared savings program—new section 1899 of Title XVIII. Preliminary questions and answers. CMS Web site. https://www.cms.gov/OfficeofLegislation/Downloads/AccountableCareOrganization.pdf. Accessed December 3, 2010.

30. Preventive care and services under the Affordable Care Act. HealthCare.gov Web site. http://www.HealthCare.gov/law/provisions/preventive/index.html. Published September 23, 2010. Accessed November 24, 2010.

31. Centers for Medicare & Medicaid Services. Medicare extends demonstration to improve care of high cost patients and create savings. CMS Web site. http://www.cms.gov/apps/media/press/release.asp?Counter=3399. Published January 13, 2009. Accessed December 3, 2010.

32. National Committee for Quality Assurance. Bridges to Excellence. NCQA Web site. http://www.ncqa.org/tabid/431/Default.aspx. Accessed November 16, 2010.

33. Pay for performance. Vermont Program for Quality in Health Care Web site. http://www.vpqhc.org/uploads/1251732671.pdf. Accessed December 3, 2010.

34. “Better Ways to Pay for Health Care” recommended by National Health Care Quality Coalition [press release]. Robert Wood Johnson Foundation Web site. http://www.rwjf.org/healthpolicy/product.jsp?id=37449. Published November 14, 2009. Accessed December 3, 2010.

35. Centers for Medicare & Medicaid Services. Incentive payment program for primary care services, section 5501(a) of the Affordable Care Act. MLN Matters. CMS Web site. http://www.cms.gov/MLNMattersArticles/downloads/MM7060.pdf. Accessed November 30, 2010.

36. The Centers for Medicare & Medicaid Services’ quality improvement roadmap. Alliance for Health Reform Web site. http://www.allhealth.org/briefingmaterials/CMSQualityImprovementRoadmap-77.pdf. Published July 2005. Accessed November 30, 2010.

37. Clancy CM. Testimony on health care quality initiatives. Agency for Healthcare Research and Quality Web site. http://www.ahrq.gov/news/qtest319.htm. Accessed December 3, 2010.

February 2011© Ortho-McNeil-Janssen Pharmaceuticals, Inc. 2011 02RXP10012

As part of our continuous effort to improve the quality and efficiency of healthcare delivery, OMJPI is launching a comprehensive program developed to inform, align, and support key healthcare stakeholders on 4 key areas: quality initiatives, healthcare delivery systems, payment methodologies, and value partnership initiatives.

Go to www.QualitySolutions360.com for more information about Quality in Action. You can also find important information on healthcare policy, general disease state information, current and relevant best practices, and much more.

“ To improve quality, you need strong measures, good data, and somebody with strong reason to use them.”37

—Carolyn M. Clancy, MD, Director, AHRQ