MAH Grand Rounds July 2016

David Shein, MD Mount Auburn Hospital Reservoir Medical Associates

Assistant Professor, HMS Medical Director, MACIPA

Healthcare Policy: Novel Models for Healthcare Delivery

Disclosure Mount Auburn Hospital is accredited by The Massachusetts Medical Society

(MMS) to provide AMA PRA Category 1 CME Credits™ to hospital activities

developed to enhance and improve the practice of medicine. We endorse the

ACCME Standards for Commercial Support™ and hereby state that the

following individuals have disclosed relevant financial relationship(s) with

commercial interests:

No others in a position to control the content of the CME activity have any

relevant financial relationships to disclose.

Individual Role Commercial Interest Nature of Financial Relationship

David Shein, MD Speaker MACIPA Medical Director

Objectives

Participants will understand:

• Newer payment models and their impact on the delivery of healthcare

• Impact of federal healthcare legislation on models of care

• Measuring quality in modern healthcare

• Role of risk adjustment in clinical care

Payment

Models

Focus:

- AQC

- ACO

Quality

Risk

Adjustment

Outline

How Would You Reimburse for Healthcare Delivery?

• Fee For Service – Drives individual, short-term volume-based performance – No incentives for efficiency or quality at a system level – > Choosing Wisely

• Capitation 1.0 – Favors efficiency – Short timeline (contract year) – > “Drive-thru deliveries”

• Value-Based Purchasing – Considers efficiency/cost + outcomes/quality – Process can be intrusive; may be costly; not always accurate – > Outcomes that matter – > Physician burn out

Major Payers With Novel Models

• BCBS MA

– Alternative Quality Contract

• CMS / Medicare

– Affordable Care Act

• MIPS / MACRA / SGR

• Alternative payment models – ACO (Pioneer/NextGen) / Shared Savings

– Bundled payments

– Medicare Advantage (Part C)

Outcomes and Quality

•Process

•Outcomes

•Patient experience

•Patient-reported outcomes: PROM

• Toyota “lean”

• Does environment improve patient outcomes?

• “Teach to the test?”

• How does measurement improve patient outcomes?

What is Healthcare Quality?

• Claims data

• Clinical data

• Questionnaires and surveys

Quality Measures

Environment of

Quality

How Do We

Measure?

What Are We

Measuring?

Porter ME et al. N Engl J Med 2016;374:504-506.

Categories of Quality Measures Listed in the National Quality Measures Clearinghouse (NQMC).

Anatomy of A Measure

• Numerator = subpopulation with intervention/measure/outcome in question

• Denominator = entire population under consideration

• Exclusions = reasons a member would be excluded from the denominator

• Analysis period = time frame under consideration

• Result – %-age measure performance

– Absolute # of compliant / non-compliant members

Example of A Measure: Breast Cancer Screening

Numerator:

• Women with mammogram at least once in 24 months

Denominator:

• Women ages 50-75

Exclusions:

• Medical reason for not having mammogram: Bilateral mastectomy or 2 unilateral mastectomy procedures

Data Sources

Claims: See the world, limited detail

EMR / Chart: Detailed picture of local care, no reference to the outside world

(e.g. care with another institution)

Lab: Great detail, little context

Patient Surveys

• Clinical

– PHQ-9

– Fall Risk

• Satisfaction

– MHQP

– CAHPS Consumer Assessment of Healthcare Providers & Systems

Efficiency and Cost

Risk Adjustment

• How can we balance risk and cost across diverse populations?

– Critical when looking at efficiency

• Utilization

• Cost

• Case Mix

Verisk Health

DxCG: Predictive Risk Perspective

Prospective Risk Score 4.90

Age/Gender

45 - 54 Male 0.50

Condition Categories

Type I Diabetes 0.75

Hypertension -----

Congestive Heart Failure 2.13

Depression 0.92

Interaction

Type I Diabetes & CHF 0.60

John contributes additional risk to the group’s illness burden and is predicted to spend 4.9 times the plan average Individual average spending for medical services factors into aggregate medical costs for a defined fiscal period Provider contracts are based on the relative risk of their affiliated members

• Hypertension • Type I diabetes • Congestive heart failure • Drug/alcohol dependence

Age: 50 Gender: Male

Relative Risk Scores Derived from Hierarchical Condition Category (HCC) Predictive Models

Mt. Auburn Examples

• Risk score impact

– Why appropriate risk coding is so important

• Utilization

• Quality management

Payment Models

Budget

Surplus

Quality

Impact of coding on risk adjustment

Impact of cost and utilization: efficiency

Impact of quality measures

- Avoidable ED/admits - Unnecessary tests and procedures - High vs low cost providers - Leakage - Pharmacy formulary

Risk Coding

• Drives budgets (reimbursement)

• Enables identification of high-risk patients to manage utilization risk and improve care

– Risk identification

– Intervention

• Early outreach

COMPASS Program

• Criteria for identification and intervention

– Depression (PHQ-9 score > 9)

+

– Poorly controlled diabetes (HbA1c > 8%)

or

– Poorly controlled CVD risk (BP > 140 / > 90)

COMPASS Results: Identification and Intervention Improved Outcomes

PHQ9 score

% Baseline

PHQ-9 > 9

% Final PHQ-9 <5

10-14 1605 (48%) 30%

15-19 927 (28%) 21%

20-27 834 (25%) 16%

Baseline HbA1c % Baseline Poor Control

Final HbA1c < 8%

8.0 - <8.5 357 (21%) 38%

8.5 - <9.0 253 (15%) 33%

9.0 - <9.5 241 (14%) 20%

9.5+ 815 (49%) 14%

Baseline BP category % Baseline HTN

Final BP < 140 / < 90

Stage 1 HTN: SBP140-159 or DBP 90-99

331 (72%) 60%

Stage 2 HTN: SBP 160+ or DBP 100+

131 (28%) 53%

Diabetes Control

Depression Remission

BP control

Impact of Quality:

… On the bottom line

Members under quality contracts

• AQC

• Harvard Pilgrim

• Tufts

• TMP

• Medicare

… On the front line

– Tiered copayments

• Cost and Quality – TME, HEDIS, MHQP

– Medicare.gov

• Physician Compare

• Hospital Compare

– Consumer Reports

– Google yourself… • Healthgrades, etc

MACIPA Prelim BCBS AQC Performance

Antidepressant Med. Mgt. (84-Day) Antidepressant Med. Mgt. (180-Day)

Well Child Visits (15 Months) Well Child Visits (3-6)

Well Child Visits (12-21) Chlamydia Screening (16-20) Chlamydia Screening (21-24)

Testing for Pharyngitis Treatment for Acute Bronchitis (no Abx)

Appropriate Treatment for URI Colorectal CA Screening

Cervical CA Screening Breast CA Screening

Diabetes Mgt: Eye Exam Diabetes Mgt: Hba1c Test

Diabetes Mgt: Nephropathy Diabetes Mgt: Hba1c Out of Control Diabetes Mgt: BP Control

Hypertension Mgt: BP Control

Performance improved in most categories

Opportunities: - Cancer

screening - Engaging

specialists in their areas

2015

2015 QI Project Success Stories: Chlamydia Screening (16-24)

• 2 Pediatric PCP’s: QI Project Chlamydia Screening

AQC Screening Rate improved

Actions: Routine eCW Reports Component of PE Outreach to parents about requirement Patient Education STD Sheets

Leakage Prevention (Keepage) Patient Satisfaction

Urology • Patient Experience

Leakage Rate decreased

Dermatology • Patient Access

Leakage Rate decreased

Patient Experience Survey Patient/PCP Interaction Patient/Staff Interaction Communication

Actions: MACIPA Urgent Access Slots One Touch Appointment Cancellation

Utilization

Mechanic R, Tompkins C. N Engl J Med 2012;367:1873-1875.

Variation in Average 2009 Medicare Spending among Selected Hospitals for a 90-Day Episode of Congestive Heart Failure.

Impact on SNF ALOS

0

5

10

15

20

25

30

2011 2012 2013

ACO

MA

SNF #1

Population Management

• Manage utilization / cost risk – High risk scores

– High utilization

– Gaps in care (quality measures)

– Leakage

• Maximize quality performance – Manage the measures

• High-quality and efficient healthcare for our patients

Conclusion

• Healthcare reimbursement is evolving • Optimal models align patient outcomes and

reimbursement • Providers should understand the models and drivers of

payment • We are all responsible for and capable of delivering

high quality care • Continuous quality improvement remains critical

– Clinical quality – Patient experience – Patient access

NEJM Michael E. Porter, Ph.D., M.B.A., Stefan Larsson, M.D., Ph.D., and Thomas H. Lee, M.D.

“If we’re to unlock the potential of value-based health care for driving improvement, outcomes measurement must accelerate. That means committing to measuring a minimum sufficient set of outcomes for every major medical condition — with well-defined methods for their collection and risk adjustment — and then standardizing those sets nationally and globally”

JAMA Robert A. Berenson, MD

“The requirement for measurement as essential to management and improvement is a fallacy, not a self-evident truth and not supported by… management experts or common sense. There are many routes to improvement, such as doing things better based on experience, example, as well as evidence from research studies.”