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Healthcare Reform & Women in Surgery:Opportunities & ChallengesBarry M. Straube, M.D.Immediate Past (Retired) Chief Medical Officer,Centers for Medicare & Medicaid ServicesOctober 23, 2011Association of Women Surgeons1

Shifting of the Poles The Healthcare Quality/Value ChallengesIn the U.S. we spend more per capita on healthcare than any other country in the worldIn spite of those expenditures, U.S. Healthcare quality is often inferior to that of other nations and often doesnt meet expected evidence-based guidelinesThere are significant variations in quality and costs across the nation with increasing evidence that there may be an inverse relationship between the twoHealthcare expenditures account for a larger section of the U.S. economy over the years and funding those expenditures is increasingly more difficult44The HealthcareQuality/Value ChallengesThere continues to be considerable waste in the delivery of healthcare, as well as fraud & abuseCMS/HHS, and the executive branch is responsible for the healthcare of a growing number of persons in the public sector, and influences healthcare quality in the private sectorCMS/HHS, in partnership/collaboration with other healthcare leaders, must address these issuesAcademic Medical Centers & Surgeons could provide great valueHealth Information Technology is indispensable in thisThe Affordable Care Act of 2010 is a major step forward to address the healthcare quality/value challenges5Better Health forthe PopulationBetter Carefor IndividualsLower CostThrough ImprovementThe Triple Aim6IOM Aims for Quality ImprovementSafetyEffectivenessPatient-centerednessTimelinessEfficiencyEquity

778Federal Stakeholders in the U.S. Healthcare SystemDepartment of Health & Human ServicesVeterans AffairsDepartment of DefenseDepartment of LaborDepartment of Housing & Urban DevelopmentUnited States Coast GuardOffice Personnel ManagementFederal Bureau of PrisonsFederal Trade CommissionOffice of Management & BudgetDepartment of CommerceNational Highway Transportation & Safety Administration 9Department of Health & Human Services:AgenciesSecretary of HHSAdministration for Children and FamiliesAdministration on AgingAgency for Healthcare Research & QualityAgency for Toxic Substances & Disease RegistryCenters for Disease ControlCenters for Medicare & Medicaid Services (CMS)Food & Drug AdministrationHealth Resources & Services AdministrationIndian Health ServiceNational Institute of HealthProgram Support CenterSubstance Abuse & Mental Health Services AdministrationMultiple other Assistant SecretariesCenters for Medicare & Medicaid Services (CMS)Will provide health benefits for over 114 million Americans in FY 2011 PP BudgetMedicare 48.1 million beneficiariesMedicaid 56.1 million beneficiariesCHIP 10 million beneficiariesWill spend $784 billion in FY 2011 PP BudgetMedicare - $476 billionMedicaid - $297 billionCHIP - $11 billionEffective January, 2011 incorporated the Office of Consumer Information and Insurance Oversight (OCIIO) as part of CMS

101011Ongoing CMS Core Medicare WorkProvider payment-focused activitiesEfficient, timely, accurate payment of claimsOngoing demonstrations and pilots of alternative payment methodologies and systemsAddressing fraud & abuseBeneficiary focused activitiesBenefit educationHealth promotion and disease management educationBeneficiary protection and advocacyMultiple tools to improve quality, efficiency and valueData collection & availability111111Partners/Targets For AdvocacyFederal GovernmentCongressHouse: Ways & Means, Energy & CommerceSenate: Finance, HELPA variety of caucusesWhite HouseMany senior advisorsOffice of Management & BudgetPartners/Targets For AdvocacyExecutive Branch AgenciesU.S. Department of Health & Human Services (HHS)Office of the Secretary, Office of the Assistant Secretary of HealthCenters for Medicare & Medicaid Services (CMS)Agency for Health Research & Quality (AHRQ)Centers for Disease Control (CDC)Food & Drug Administration (FDA)Health Resources and Service Administration (HRSA)National Institutes of Health (NIH)Office of the National Coordinator (ONC) for HITMany other HHS and other federal agencies have influence over surgical topics and issues

Partners/Targets For AdvocacyCenters for Medicare & Medicaid ServicesOffice of the AdministratorKey Surgery AreasOffice of Clinical Standards & Quality (OCSQ)Conditions of Participation, Conditions for CoverageQuality Improvement and MeasurementQuality Improvement Organizations (QIOs) and ESRD NetworksInformation Services: Clinical Data systemsCoverage decision makingCenter for MedicarePaymentCenter for MedicaidState Survey Agencies and regulatory oversight processesRegional Offices (10)Innovation CenterPartners/Targets For AdvocacyState GovernmentsDialysis Providers/OrganizationsProfessional AssociationsRenal Physicians AssociationAmerican Society of NephrologyAmerican Nephrology Nurses AssociationNational Renal Administrators AssociationAmerican Medical AssociationKidney Care PartnersKidney Care Quality AlliancePrivate health plansPatient Advocacy Organizations: Should probably be #1 stopSome Personal Notions & ExperienceKnow the framework of the regulatory system that affects you, the people who run it, and work with themCongress passes laws (statutes) that direct federal agencies what to do and defines their authoritiesThe President can sign or veto any law passedAgencies implement laws, following Congressional directives and intent, but if unclear have discretion to interpret the law as the agency (and executive branch leadership sees fitRegulations, through public rulemakingAdministrative rulings, sometimes, with or without public commentGuidance and directives through manuals, letters, and other mechanismsThere are multiple points at which advocates can effectively influence the aboveSome Personal Notions & ExperienceAdvocates can and do have major influence on the federal frameworkWith regards to federal rulemakingNotice of Proposed Rule Making (NPRM)30-90 days of public commentAgency reviews comments, responds to all comments, and revises the proposed rule as indicatedFinal Rule is issued, published and implementedCycles of rulemaking at CMSIf final rules are unacceptableInfluence subsequent laws and regulationsJudicial challengesElect new leadersEnsuring Quality & Value:CMS Tools/Drivers/EnablersContemporary Quality ImprovementTransparency: Public Reporting & Data SharingIncentives: Financial through payment reformRegulatory vehiclesNational & Local Coverage DecisionsDemonstrations, pilots, research, innovation

1818Contemporary Quality ImprovementNeed to set priorities, goals and objectives, strategic framework firstEvidence-Based goals, metrics, interventions, evaluationsIncludes conformance with evidence-based guidelines, balanced with patient-centered considerationsCost-effectiveness, let alone comparative effectiveness, has not yet been addressed adequatelyRapid-cycle development, implementation and change methodologyLeveraging of resources and efforts: Current and future models-collaboration, alignment, synergy, prioritiesMany 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, etc.1919Contemporary Quality Improvement: Collaboratives & CommunitiesQuality Improvement Organization (QIO) 9th SOWCare Transitions ThemeEvery Diabetic CountsMississippi Health First (expanding to Texas)Links to:ACA Section 3025: Hospital Readmissions Reduction ProgramACA Section 3026: Community-Based Care Transitions Program20Transparency: Public Reporting & Data AvailabilityCMS Compare WebsitesHospital CompareNursing Home CompareHome Health CompareDialysis Facility CompareMA Health Plan and Medi-Gap ComparePrescription Drug Plan CompareNew under ACAPhysician CompareVBP Programs: Above plus ASCs, LTCHs, IRHs, Hospices, othersMyMedicare.govHHS/CMS Data Dissemination Efforts: www.data.gov, www.healthcare.govPotential explosion of federal government data availability for private sector to drive data use innovation in previously unimaginable ways21Surgical Care Improvement Project Process of Care22Hospital Process of Care Measures TablesAverage All U.S.Average All CASTANFORDUCSFUCDAntibiotic within one hour before surgery92%90%93%94%89%Appropriate pre-operative antibiotic94%92%96%92%94%Patients taking beta blockers prior to the hospital kept on the beta blockers pre- & post-op92%91%93%99%92%Patients given appropriate prophylactic antibiotics97%97%99%98%97%Patients with prophylactic antibiotics stopped appropriately (within 24 hours after surgery) 94%92%97%99%95%Heart surgery patients with blood glucose kept under good control post-op93%93%91%84%88%Surgery patients with safe hair removal pre-op99%99%100%100%100%New Surgery patients whose urinary catheters were removed on the 1st or 2nd day post-op89%89%97%83%86%Surgery patients whose doctors ordered treatments to prevent blood clots94%91%99%95%97%Patients treated (within 24 hours before or after their surgery) to help prevent blood clots92%90%99%92%96%Heart Attack-Chest Pain Process of Care23Hospital Process of Care Measures TablesAverage All U.S.Average All CASTANFORDUCSFUC DAVISAverage number of minutes before transferred to another hospital (lower is better)62 Minutes66 MinutesN/AN/AN/AAverage number of minutes to an ECG (lower is better)9 Minutes8 Minutes8 Minutes6 MinutesN/ADrugs to break up blood clots within 30 minutes of arrival (higher is better)54%55%N/AN/AN/AAspirin within 24 hours of arrival (higher is better)95%96%100%100%N/AAspirin at Arrival98%99%100%100%98%Aspirin at Discharge98%98%99%99%99%ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)96%96%92%88%93%Smoking Cessation Advice/Counseling99%100%100%100%100%Beta Blocker at Discharge98%98%96%97%99%Fibrinolytic Medication Within 30 Minutes Of Arrival54%61%N/AN/AN/APCI Within 90 Minutes Of Arrival89%90%93%95%79%Heart Failure Process of Care24Hospital Process of Care Measures TablesAverage All U.S.Average All CASTANFORD UCSFUC DAVISHeart Failure Patients Given Discharge Instructions87%90%93%93%54%Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function98%98%99%100%100%Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)94%95%92%93%93%Heart Failure Patients Given Smoking Cessation Advice/Counseling98%99%100%100%100% Pneumonia Process of Care25

Hospital Process of Care Measures TablesAverage All U.S.Average All CASTANFORDUCSFUC DAVISPneumonia Patients Assessed and Given Pneumococcal Vaccination92%92%91%91%64%Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics95%95%95%93%88%Pneumonia Patients Given Smoking Cessation Advice/Counseling97%97%98%100%100%Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival95%95%96%93%90%Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s)91%92%91%92%88%Pneumonia Patients Assessed and Given Influenza Vaccination91%91%85%96%74%Outcomes Measures: Mortality26National Heart Failure Mortality: 11.2%Better ThanNo DifferentWorse ThanSTANFORDYesUCSFYesUC DAVISYesNational Hospital Mortality: Pneumonia - 11.6%Better ThanNo DifferentWorse ThanSTANFORDYesUCSFYesUC DAVISYesNational Heart Attack Mortality: 16.2%Better ThanNo DifferentWorse ThanSTANFORDYesUCSFYesUC DAVISYes27

Outcome Measures: Readmission Rates28National Heart Attack Readmission Rate: 19.9%Better ThanNo DifferentWorse ThanSTANFORDYesUCSFYesUC DAVISYesNational Heart Failure Readmission Rate: 24.7%Better ThanNo DifferentWorse ThanSTANFORDYesUCSFYesUC DAVISYesNational Pneumonia Readmission Rate: 18.3%Better ThanNo DifferentWorse ThanSTANFORDYesUCSFYesUC DAVISYes29

Medicare Payment & Volume Data30Measure DescriptionUC DAVISUC DAVISUCSFUCSFSTANFORDSTANFORDMedian Medicare Payment to HospitalNumber of Medicare Patients TreatedMedian Medicare Payment to HospitalNumber of Medicare Patients TreatedMedian Medicare Payment to HospitalNumber of Medicare Patients TreatedCoronary bypass w/o cardiac cath w/o MCC MS-DRG 236$39,777 18 Medicare Patients $25,547 (*)f$40,994 22 Medicare PatientsCoronary bypass w/o cardiac cath w MCC MS-DRG 235$54,000 11 Medicare Patients $67,469 11 Medicare Patients $64,678 14 Medicare Patients Medicare Payment & Volume Data31Measure DescriptionUC DAVISUC DAVISUCSFUCSFSTANFORDSTANFORDMedian Medicare Payment to HospitalNumber of Medicare Patients TreatedMedian Medicare Payment to HospitalNumber of Medicare Patients TreatedMedian Medicare Payment to HospitalNumber of Medicare Patients TreatedCoronary bypass w/o cardiac cath w/o MCC MS-DRG 236$39,777 18 Medicare Patients $25,547 (*)f$40,994 22 Medicare PatientsCoronary bypass w/o cardiac cath w MCC MS-DRG 235$54,000 11 Medicare Patients $67,469 11 Medicare Patients $64,678 14 Medicare Patients IncentivesCurrent: Pay for Reporting and Adoption ProgramsP4R: Hospital Inpatient/Outpatient , PQRI, e-PrescribingARRA /HITECH: EHR adoption and meaningful useValue-based Purchasing (VBP)Hospital VBP Report to Congress (Nov 2007)Physician VBP RTC (2010)ESRD Quality Incentive Program (QIP) January 1, 2012Hospital VBP (ACA Section 3001) by October 1, 2012ACA mandates VBP in many additional settingsCompetitive bidding, gain sharing, shared savings, bundled payment, ACOs, medical homes, salaries, integrated delivery, etc. 323233Incentives:CMS Hospital Quality InitiativeNational Voluntary Hospital Reporting Initiative (NVHRI) public-private initiativeFederation of American HospitalsAHAAAMCCMS , JCAHO, othersHospital Quality AllianceMedicare Modernization Act of 2003: Section 501b Financial incentive of 0.4%3333Other Pay for Reporting ProgramsHospital Inpatient Quality Reporting ProgramHospital Outpatient Quality Reporting ProgramPhysician Quality Reporting System (PQRS)E-prescribing ProgramHITECH Meaningful Use ProgramsHome Health Reporting Program34PQRS 2011 Overview35Toward Value-Based PurchasingVBP2007 TRHCA 74 measures Claims-based only

2008 MMSEA 119 measures Claims 4 Measures Groups Registry

2009 MIPPA 153 measures Claims 7 Measures Groups Registry EHR-testing eRx2010 MIPPA 175 individual measures Claims 13 Measures Groups Registry EHRs eRx Large Groups 2011 ARRA and ACA 190 individual measures Claims 14 Measures Groups Registry EHRs eRx Large Groups Small Groups Maintenance of Certification Physician Compare Web Site

Goals for Value Based PurchasingIncentivize the best care and improve transparency for Beneficiaries Transform CMS from a passive payer to an active purchaser of careLink payment to quality outcomes and stimulate efficiencies in careRecognize and address potential unintended consequences for Beneficiaries

36Hospital Value Based Purchasing : BackgroundHospital Value Based Purchasing Report to Congress 2007Premier Demonstration and other DemosExperience with other reporting programs Hospital Inpatient and Outpatient Quality Reporting ProgramsPhysician Quality Reporting SystemESRD Quality Incentive Program beginning January 1, 2012 3737Hospital Value Based Purchasing Program (HVBP)Affordable Care Act (ACA), Section 3001Effective date: FY2013 payment for discharges on or after October 1, 2012Criteria:Must be a Hospital Inpatient Quality Reporting Program participantMeets quality metrics by demonstrating improvement or high levels of achievement

3838Hospital Value Based Purchasing FY2013 Medicare payment based on quality measure performance5 Clinical topicsAcute Myocardial InfarctionHeart FailurePneumoniaSurgeries and Hospital Acquired Infections (HAIs)HCAHPS patient survey

3939Hospital Value Based PurchasingReplace current 2% with HVBP in a 5-year phased in approach between FY 2013 and FY 2017.

40Payment Year RHQDAPU*HVBP**FY13 1%1%FY140.75%1.25%FY150.50%1.50%FY160.25%1.75%FY17 0%2.0%*Annual Payment Update**Reduction from the Base DRG payment for all hospitals 40RegulationConditions of Participation or Conditions for CoverageCOPs are minimum health and safety standards set by CMS for facilities that may receive Medicare payments17 separate provider/supplier settings have COPsSurvey & CertificationU.S. healthcare facilities certified must be in compliance with current Medicare regulations & applicable state lawsS&C process uses interpretive guidelines to assess compliance with regulationsIn combination, a powerful tool for quality/value4141Other ToolsNational Coverage Decisions, Payment Policy, Benefit DesignDeciding whether a device, service or therapy is paid for (or not) can influence quality of careE.g., Non-payment for Hospital Acquired Conditions (HACs)E.g., Non-coverage of Never Events for both hospitals or physiciansE.g., limitation of services to qualified facilities or providers, such as ICD implantation, etc.CED and use of registries collects further quality informationPatient incentives: Waiver of co-paysDemonstrations, pilots, researchNumerous CMS Demonstrations in past and going forward with the ACA4242ConclusionsCMS Statutory Authority provides powerful tools to focus on improving quality, value & patient safetyQI by providers, payers, collaboratives, othersTransparency: Public Reporting and Data DisseminationIncentivesRegulatory complianceCoverage, benefit, and utilization purposesResearch and DemonstrationsHealth Information Technology essential to aboveOpportunities for input & alignment abound43ConclusionsCMS Statutory Authority provides powerful tools to focus on improving quality, value & patient safetyQI by providers, payers, collaboratives, othersTransparency: Public Reporting and Data DisseminationIncentivesRegulatory complianceCoverage, benefit, and utilization purposesResearch and DemonstrationsHealth Information Technology essential to aboveOpportunities for input & alignment aboundAcademic Medical Centers have a potential major leadership role44Affordable Care Act (ACA) of 2010Patient Protection & Affordable Care Act (PPACA)Health Care & Reconciliation Act of 2010 (HCERA)Affordable Care Act of 2010 (ACA)

45Affordable Care Act (ACA) of 2010Title I: Quality, Affordable Health Care for all AmericansTitle II: Role of Public ProgramsTitle III: Improving the Quality & Efficiency of Health CareTitle IV: Prevention of Chronic Disease & Improving Public HealthTitle V: Health Care Work Force46Affordable Care Act (ACA) of 2010Title VI: Transparency and Public ReportingTitle VII: Improving Access to Innovative Medical TherapiesTitle VIII: Community Living Assistance Services & Support (CLASS) ActTitle IX: Revenue ProvisionsTitle X: Strengthening Quality, Affordable Health Care for All Americans (Amendments)47ACA & WomenSearch term women145 instancesMostly relate to womens health and women as patientsFrequent linkage to pregnant or young modifiersSearch term surgeon41 instances, most Surgeon General2 instances: American College of Surgeons-trauma center accreditation and guidelines5 Instances: General surgeons-rural, committees48ACA & SurgeonsSearch term surgery10 total instances4 instances: Cosmetic surgery-5% tax3 instances: General Surgery servicesSearch term surgicalAmbulatory Surgical Centers (8): VBP plan mandated to Congress by 1/1/2011Surgical specialties

49High Profile ACA TopicsGreater Access to healthcare coverageNational Priorities & Strategic PlanHHS Interagency Quality Work GroupQuality Measurement comment by NQFData collection and national work planFocus on outcomes, efficiencyPatient CenterednessHigh-cost Chronic Disease ManagementCare coordination & care transitions

50High Profile ACA TopicsHealthcare Acquired Conditions (HACs)Healthcare Acquired InfectionsPatient safety & medical errors reductionPrevention and Patient SafetyPopulation Health: Obesity, Smoking Cessation, etc.Reduction of unnecessary admissions & readmissionsAccountable Care Organizations, Medical HomesInnovation in payment, delivery systems, careRapid cycle change quality improvementBest practices and learning environments

51Center for Medicare & Medicaid Innovation:CMMICMMI establishment mandated by January 1, 2011 (Section 3021)Consultation & input from broad healthcare sector in implementationThe Innovation CenterDevelop patient-centered payment modelsRapid piloting/testing of new payment programsEncourage evidence-based, coordinated care for Medicare, Medicaid, CHIPFocuses on populations for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures

52CMMI: Statutory DescriptorsRisk-based comprehensive payment or salary-based payment modelsGeriatric assessments and comprehensive care plansinterdisciplinary care teamsmultiple chronic conditionstransition health care providers away from fee-for-service-based reimbursement and towards salary-basedhealth information technology-enabled provider network that includes care coordinators, chronic disease registry, home telehealth technology

53CMMI: The Innovation CenterOther key characteristics in the statute for payment modelsVarying payment for advanced diagnostic imaging servicesMedication therapy management servicesCommunity-based health teams to assist in care managementPatient decision-support toolsState flexibility for dual-eligibles and all-payer payment reform demonstrationsCollaboratives of high-quality, low-cost institutions$10 billion over 10 years funding54Staging of Innovation Development, Demonstration, and Translation55Trend AnalysisPrototype Design and Modeling Collaborative Design LabBest Practice AnalysisPublication and Collaborative LearningCollaborative Innovation LaboratoryStageProgram trials and Demo developmentTechnology beta testingResults evaluationFindings and RecommendationsPublicationsDemonstration and Program Trial StageProgram Policy Translation Analysis and EvaluationLegislation/policy developmentRegulation and Rule Development Policy Execution and ImplementationRe Evaluation/ Publication Program Policy Translation Evaluation and DiffusionStage2 To 3 years Design to Program Translation Cycle Time55Accountable CareCoordinated CareOrganized care deliveryAligned incentivesLinked by HITIntegrated Provider NetworksFocus on cost avoidance and quality performancePC Medical HomeCare managementTransparent Performance ManagementIntegratedHealthPatient CenteredPatient Care CenteredPersonalized Health CareProductive and informed interactions between Patient and ProviderCost and Quality Transparency Accessible Health Care ChoicesAligned Incentives for wellnessMultiple integrated network and community resourcesAligned reimbursement/care management outcomesRapid deployment of best practices Patient and provider interactionInformation focusAligned self care managementE-health capableFee For ServiceInpatient focusO/P clinic careLow ReimbursementPoor Access and QualityLittle oversight No organized networksFocus on paying claimsLittle Medical ManagementUn-managedDriving Healthcare SystemTransformation 56Fee for Service56Driving Healthcare Delivery System Reform and Transformation 2011-2019572011-20192012-20192014-201957Innovation FellowshipDetails (still pending) at conference58Accountable Care Organizations (ACOs)Medicare Shared Savings Program (Section 3022)ACO Program must be implemented by January 1, 2012ACO Notice of Proposed Rulemaking (NPRM) issued March 31, 2011Public comment ended June 6, 2011Final rule publication date not determined (publicly)Encourages providers of services and supplies to:Create ACOsBe accountable for health & experience of care for individualsImprove population healthReduce rate of healthcare spending5959ACO Proposed Rule ProvisionsProviders must notify beneficiary of participationIncludes description of program, quality/cost focusBeneficiary can opt-out & seek non-ACO careBeneficiary to be notified of data sharingPurpose: Coordinate care betterBeneficiary cant be required to see ACO providersBeneficiary may opt-out of data sharing arrangementsFor those opting in, data sharing has limitationsPatient selection controls to avoid cherry picking

60ACO Proposed Rule ProvisionsTypes of providers & suppliersProfessionals (physicians, hospitals) in group practice arrangementsNetworks of individual practices of professionalsPartnerships or joint ventures of hospitals & physiciansHospitals employing ACO professionalsOthers, as determined by the SecretaryGoverning body of ACO professionals and beneficiariesApplication with detailed submission requirementsMinimum responsibility for 5,000 beneficiaries61ACO Proposed Rule ProvisionsRigorous (& complicated) monitoring planIn order to qualify for financial shared savings, must meet specified quality standards (65 proposed in NPRM)Quality reports to CMS, feedback to providers50% of PCPs must meet meaningful use standards by year 2Pubic reporting requirementsTermination by CMS if:Avoidance of at-risk patientsFailure to meet quality standards

62ACO Proposed Rule Provisions3 year agreement at minimumPrimary care-driven model for organizationSpecialty-driven ACO founders not proposed in NPRMTwo shared savings risk models - original proposalOne-sided Risk: ACO shares in any savings in first 2/3 years; Third year can lose money if costs >Medicare norm.Two-sided Risk: ACO at risk all three years; can have greater % of savings share, however.Waivers allowedFTC of DOJ and IRS issues63Reaction to ACO NPRMLargely negativeToo complicated, too restrictiveToo much undefined riskNo specialty-focused ACOsNegative comments about each criteria componentCMS responded in interimPioneer ACO Model: Applications being acceptedAdvance Payment ACO Model: Public commentsAccelerated Development Learning SessionsFinal rule pending review of comments & policy decisions

64ACO Final RulePending: Details (if available) at conference65Will ACOs be the Answer?Probably not, in the short-to-intermediate termThe concept is intriguing, but whether it is translational is in doubtCan you replicate existing likely ACOs in other communities without requisite infrastructure?The model is untested, will it achieve the goals of better quality at lower costs?ACO program under ACA is a voluntary program that is essentially a demonstrationFinancial risk may not be assumable for manyConsolidation, reduced competition?2nd Generation Managed Care?66ACA: Academic Medical CentersACA Section 3025: Hospital Readmission Reduction ProgramACA Section 3026: Community Based Care Transition ProgramHealthcare Delivery Research (Section 3501, AHRQ coordinating with CMS)Identifies best practice institutions, organizations, etc.Supports innovation in health care delivery system improvementQuality Improvement Technical Assistance (Section 3501)67ACA: Academic Medical CentersEstablishing 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 & paymentDemonstration 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, retention68ACA: Academic Medical CentersNational Center for Health Care Workforce Analysis (Section 5103)Multiple student loan programs, various training & retention programs, & demonstration programs establishedPrimary careNurse-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.

69ACA: Academic Medical CentersUnited States Public Health Services Track (Part D, Section 271)Centers of Excellence-additional fundingMedical Residency funding enhancementsTeaching grants and demonstrations in graduate medical educationThe 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?

70ConclusionsThe Affordable Care Act provides innumerable opportunities to improve the quality, value and efficiency of healthcare in the United StatesCMS is a major implementation center for this historic piece of legislationImplementation crosses Medicare, Medicaid, CHIP and the entire health care sector, including the private sectorImplementation affects fee-for-service as well as managed care models, plus untested new models71ConclusionsThere are numerous opportunities and needs for involvement of academic medical centers in implementation of ACA and further health reform in the future:Design of and leadership in contemporary quality improvement initiativesHuge gap in comparative- & cost-effective analysis/improvement, let alone basic clinical knowledgeOngoing input in review and improvement in clinical guidelinesBalancing evidence-based population RCT viewpoint with need for individual patient-centered concerns72ConclusionsEducation of multiple audiences in evidence-based medicine use:Clinicians: Current/future, academic/communityPolicy makersPayersPatients, consumers and their familiesDevelopment and use of quality and value metricsMultiple perspectives: Clinicians, patients, payers, etc.Relevance, actionability, accountability, attribution7373ConclusionsCollection, analysis, reporting and use of healthcare dataHealth Information Technology development, adoption and meaningful use via EHRsOther forms of data collection: Registries, claims, encounter data, telehealth, chart review, surveys, etc.Balance of scientific rigor vs.. information efficiencyMinimization of burdenPrivacy & securityDissemination of data for widest possible appropriate use7474ConclusionsDevelopment of and participation in new reimbursement and delivery systemsAchieve the Triple AimHigher quality leading to overall lower costsInnovation, rapid change & adaptabilityCare transitions and coordinationIntegration of delivery systemsPatient-Centered, all of IOM Quality AimsPublic health focus, as well as individual health75ConclusionsWe cannot continue to cover and pay for everything thats available without considering:Evidence-based coverage & payment decision makingComparative effectiveness and cost effectiveness analysisOverall costs involved, including global costs of lost productivity, quality of life, etc.But are Academic Medical Centers ready?Rapid-cycle change, integrated systems (no departmental silos), authenticity & will to change (e.g., academic tenure?)76ConclusionsThe under-emphasized topics (?ignored):End-of-life care & Palliative CareHealth disparities reduction, not talkRacial/ethnicGeographicAgeGenderSocioeconomicLGBTMedical Conditions77Healthcare Reform, Politics & SurgeryHealthcare Reform in context of budget deficitACA originally estimated by CBO to generate Joint Steering Committee must come up with $1.2 trillion in savingsIf not, reverts to sequestration processCurrent projections are that JSC may come up with $500-700 billion of savingsShortfall of same amount will lead to additional sequestration cuts of $100-200 billion from Medicare, Medicaid, CHIP78Healthcare Reform, Politics & SurgeryLikely targets for further cuts:Post-acute care setting: Long-term care (SNFs), Home Health, Hospitals (especially GME)DMESustainable Growth Rate (SGR)Tort Reform2012 Election79Thank you for your contributions in improving the American healthcare system!

Questions?Discussion & DialogueEmail: bstraube@marwoodgroup.com80Sheet1