presentation to mass neurologic association
DESCRIPTION
Presentation to neurologists on "staying relevant" in the changing healthcare world.TRANSCRIPT
Remaining Relevant in the Changing Health Care Payment and Care
Delivery Systems Daniel Hoch, Ph.D., MD, FAAN
OutpaAent Medical Director Department of Neurology
MassachuseCs General Hospital
MassachuseCs Neurologic AssociaAon
November 7, 2013
Source: OMB
Life Expectancy Per Capita Spending (PPP$) Australia 81.2 3122 Belgium 79.4 3183 Canada 80.7 3678 France 80.7 3554 Germany 79.4 3328 Greece 79.5 3101 Ireland 78.9 3082 Italy 80.5 2623 Japan 82.6 2512 Netherlands 79.8 3383 Norway 80.2 4521 Portugal 78.1 2080 Spain 80.9 2388 Sweden 80.9 3119 Switzerland 81.7 4312 U.K. 79.4 2764 U.S.A. 78. 6714
Copyright Marc J Roberts 2012
NaAonal Health System Performance 06/07
Copyright Marc J Roberts 2012
How do you squeeze $ 800 billion out of a system where labor is the main cost?
• Coordinated care for chronic condiAons • Enhance horizontal integraAon • EMR adopAon (as decision support and for communicaAon)
• Reduce hospital readmissions • IncenAves to reduce cost, increase quality through sharing
• Cap the rate of medical inflaAon (1% over CPI)
Other Reasons to Care? The SGR Fix (Senate Finance, House Ways and Means) • permanently repeal the SGR update • Reform fee-‐for-‐service (FFS) through
– focus on value over volume – encourage parAcipaAon in alternaAve payment models (APM)
A new “value-‐based performance (VBP) payment program” would be used to adjust payments beginning in 2017. This new VBP program essenAally combines all the current incenAve and penalty programs (e.g., value-‐based modifier, meaningful use, PQRS) into one budget-‐neutral program. Payments could be increased or decreased significantly, depending on how well a physician scores relaAve to others on a composite performance score
SGR Fix-‐ ConAnued
• Physicians parAcipaAng in certain alternaAve payment models, including the paAent-‐centered medical home, would be exempt from the VBP program
• HHS would publish uAlizaAon and payment data for physicians on the Physician Compare web site
Goals of this presentaAon: • Be able to assess your readiness to take part in new
payment and delivery systems • Know where to find resources that can help with this
transiAon • Understand the data that is available as part of new care
delivery systems • Know where to find quality measures, their role, and how
you can use them • Understand potenAal roles for your pracAce in medical
homes/neighborhoods, and how to add value to that collaboraAon
• Understand the role of paAent engagement in these new processes of care
New Payment Models
Pay for reporAng
Pay for performance
Shared Savings
Bundled payments
CapitaAon
Method of Delivery
ACOs • Hospital Created • Physician Created • Insurer Founded • CMS inspired
ACO-‐like
New PracAce Models • PCMH • PCMH-‐N
Gemng Ready-‐ Look Around At What Is Happening In Your Area
• There are almost certainly novel pracAce and payment efforts in your area. Find out about them. – How many faciliAes – How many clinicians – Primary Care vs. specialists
• Governance – Are specialists, specifically neurologists, engaged in leadership – Has the organizaAon or pracAce reached out to neurologists
• What is the role of payers – Are there exisAng collaboraAve care models with payers
• Are other Neurologists in the area taking part in the new models
Consider Your Role In New Models
• What are the proposed or exisAng new roles. – How will the neurologist be integrated into the new model – Will the processes of care be a big change – Is there an expected Ame table – Are some neurologists already changing pracAce processes
• Possible roles • Curbside consultaAon/Pre-‐consultaAon (telephone, email, other)
• Teleneurology • On or off site collaboraAve care • Do you have to work with a hospital? If not, how will your pracAce change?
Assess Your Value to the Community
• Consider paAent and physician surveys. • Determine your market share. • Do you have outcome measurements? • What is your relaAonship to the hospital (s) • What is your primary care group referral base?
• What is the exisAng technology infrastructure that you contribute?
Value = Cost/Quality New models will be Value based. • You can reduce costs without reducing quality • You can increase quality without increasing costs
It will be excepAonally difficult to integrate, collaborate and increase value without shared data • EHR, outcomes measurement and cost accounAng systems must support the new mode relaAonship between providers.
You Have An Impact On Value
• Tests – guidance to care team on appropriateness of studies
• UAlizaAon-‐ Is a given test or intervenAon necessary • PopulaAon management: – PotenAal model in the way generalists have worked together with endocrinologists on diabetes management
– Registries
Quality Will be Measured and Used to Determine Value
• NaAonal push for meaningful outcomes measures, not process measures
• AAN must idenAfy meaningful paAent outcomes
• Neurologists must take accountability for helping paAents reach meaningful outcomes
Payment will be Modified Based on Value
Quality Score § Payment adjustment to begin in 2017 for all providers (based on 2015
reporAng data) – Certain ACOs excepted
• Quality of care is a composite score – CombinaAon of quality measures
• Clinical care • PaAent experience • PaAent safety • Care coordinaAon • Efficiency • PopulaAon/Community Health
• Assigned a level of high, average, or low quality • Measured against naAonal mean
Modified From J. Fritz and D. Evans, 2012
Payment will be Modified Based on Value
Cost Score • Total costs • Total costs for beneficiaries with specific condiAons (COPD, heart failure, coronary artery disease, diabetes)
• Assigned a level of high, average, or low • Measured against naAonal mean
Modified From J. Fritz and D. Evans, 2012
Value-‐Based Payment Modifier • For Groups of 25 or more • Quality Aers – 9 combinaAons – VBPM ranges from 2% to -‐1%
Low cost Average cost High cost
High quality +2.0x* +1.0x* +0.0%
Average quality +1.0x* +0.0% -‐0.5%
Low quality +0.0% -‐0.5% -‐1.0%
The AAN has an Aggressive Program to IdenAfy Quality Measures
• AAN has embarked on an intensive program to develop quality measures – Measures available now: DemenAa, Parkinson’s Disease, Epilepsy, Stroke
– Measures available in 2013 -‐ ALS, Distal Symmetric Neuropathy
– Measures available in 2014-‐ Headache, Muscular Dystrophies, update to PD
– Measures available in 2015 – MS, update to Epilepsy
• See hCp://www.aan.com/go/pracAce/quality/measurements
Federal Programs Encourage Quality Measurement
The AAN has requested, and views as criAcal, the inclusion of neurologist developed measures • Meaningful Use Stage 2
– DemenAa CogniAve Assessment Physician Quality ReporAng System (PQRS) Applicable neurology measures for 2013 reporAng: • Epilepsy – 3 individual measures for claims or registry reporAng • DemenAa – 9 measures in group for claims or registry reporAng • Parkinson’s disease – 6 measures in group for registry only
reporAng • Sleep – 4 measures in group for registry only reporAng • Stroke – 5 InpaAent measures for claims or registry reporAng • Low back pain – 4 measures in group for claims or registry reporAng
ReporAng is Being Simplified UnAl this year, quality reporAng as part of Meaningful Use and under PQRS were not well coordinated. BUT • StarAng in 2013, you may saAsfy the meaningful use Clinical Quality Measures by parAcipaAng in the PQRS –Medicare EHR incenAves pilot.
• In 2014 the two quality reporAng systems will have essenAally merged, – MU and PQRS will have overlapping measures – PQRS and MU will share a reporAng mechanism.
Quality ReporAng Is Local as Well AAN has a partnership with CE City to report measures through a registry
– The 2013 sets were live in late May – CE City -‐ hCp://info.cecity.com/about.html – Registry info hCps://aan.pqriwizard.com/default.aspx
• All payers have quality reporAng programs that feed into their pay-‐for-‐performance or value-‐based contracAng programs. – AAN Staff are reviewing the cost and quality measures being
used in private payer programs, – MeeAng with private payers to understand their programs – AAN \will have a resource for members that outlines the cost
and quality metrics used in programs by Fall 2013.
Based on the latest reports available, in 2011, only 20.8% of eligible neurologists parAcipated in PQRS.
The Choosing Wisely Campaign Engages PaAents in Quality
• A campaign to make paAents AND physicians aware of some common procedures that are clearly of liCle value
• The AAN suggesAons for neurologic care – EEGs are not helpful in headache – CaroAd US should not be done in simple syncope (no other associated signs or symptoms)
– Do not use bubalbital or opioids in migraine except as a last resort
– Don’t prescribe interferon-‐beta or glaAramer acetate to paAents with disability from progressive, non-‐relapsing forms of mulAple sclerosis.
– Don’t recommend CEA for asymptomaAc caroAd stenosis unless the complicaAon rate is low (<3%)
You Should be Engaged in ReporAng AND CreaAng Metrics
• There will be opportuniAes to shape local efforts to improve quality – Payers want to know that efforts are underway to measure and improve quality
– Internal efforts in large groups may rely on unique process or outcome measures and reporAng
Examples-‐ – Timely communicaAon to referring physicians – Wait Ames for an appointment – Average wait once in the doctors office – And many more…
These Changes in Healthcare Require New PracAce RelaAonships
• The PaAent Centered Medical Home (PCMH) exemplifies many of the ideas that will guide new relaAonships criAcal to the future payment and delivery systems
– Pa:ent Centered-‐ RelaAonship based, with aCenAon to the whole person
– Comprehensive care-‐ The Primary care home will meet a majority of the paAents medical and mental health needs
– Coordinated care-‐ engaging with all parts of the health care system from specialists to hospitals and nursing homes
– Accessible services-‐ shorter wait Ames, in-‐person and electronic availability.
– Quality and Safety-‐ commitment to measurement of quality and process improvement, use of decision support and evidence-‐based pracAce.
Specialists Will Be Part Of The Medical Home Neighborhood
• Specialists can work together with the PCMH in many possible ways. – TradiAonal ConsultaAon – Off-‐site collaboraAve care – On-‐site collaboraAve care – Principle care
– The NCQA has developed a set of principles for the PCMH neighbor hCp://ow.ly/kYHlx
Greater CommunicaAon and CollaboraAon
Off-‐Site • Neurologist is available by phone, email, specialized IT portal.
– Curbside or “pre consultaAon” may be all that is needed – PCP/team ozen managed meds, intervenAon – Complexity and comfort zone of PCPs drive process.
On-‐site • Embedded with the PCMH
– More real-‐Ame interacAons – Great opportunity for educaAon – Co-‐management A “stepped approach” may dictate who manages the paAent in either model.
“Principle Care” May Be a Model for Some PaAents/Neurologists
Neurologist/Team serve as the principle care providers • Response to the younger, otherwise healthy paAent who
feels they only need a neurologist. – MS, Epilepsy, etc.
PCP is the “neighbor”
• The neurology pracAce will need addiAonal resources to help with tasks that PCMH teams may normally do
• Neurologist will want to have experience with populaAon management concepts
As paAent ages, and health issues expand, PCP becomes the “home”, Neurologist the “Neighbor”
Providing Principle Care as a “Medical Home” Will Not Be Easy
• Access and ConAnuity – – Azer hours and electronic access – Provide culturally and linguisAcally appropriate services
• IdenAfy and Manage PaAent PopulaAons – – Registries to proacAvely remind paAents of overdue care
• Plan and Manage Care – – Implement evidence-‐based guidelines using point-‐of-‐care reminders – IdenAfy high risk paAents – Manage medicaAons
• Provide Self-‐Care Support – – Provide educaAonal resources – IdenAfy and refer to community resources – Provide self-‐management tools and plans – Include paAents and their families
• Track and Coordinate Care – – tesAng and referral tracking – managing care transiAons
• Measure and Improve Performance – – Quality metrics and reporAng – Include the paAent experience of care
The Way You Work With Pateints Will Change
• In addiAon to new professional relaAonships and payment models, there will be new relaAonships with paAents
• “Engagement” – Partnering with paAents so that they are drivers of their care, rather than passive passengers
• There are many organizaAons that can help – Consumers Advancing PaAent Safety
• hCp://www.paAentsafety.org/ – Informed Medical Decisions FoundaAon
• hCp://informedmedicaldecisions.org/ – InsAtute for PaAent and Family Centered Care
• hCp://www.ipfcc.org/ – Society for ParAcipatory Medicine
• hCp://parAcipatorymedicine.org/
Most Medical Care Occurs Outside the Office or Hospital Ferguson’s inverted pyramid
Why You Should Collaborate with PaAents
• PaAents are already collaboraAng with each other, and doctors! – They are online in vast numbers – They talk to each other online – They do research online – They include medical professionals in their social networks (even if we don’t know it)
– Some rate doctors and hospitals. – Almost 70% feel that coordinaAon of care is a problem, 30% feel it is a major problem.
The Pew Internet Project Finds: • 34% of Internet users have read descripAons of other
people’s experience with health • 25% of Internet users have watched health related videos
online. • 24% of Internet users have looked up informaAon about
drugs online • 18% of Internet users have looked for other paAents with
their concerns • 16% of Internet users have consulted doctor raAngs. • 15% of Internet users have consulted raAngs for hospitals or
faciliAes.
PaAents Can Be Integrated Into The Workflow: Experience At Kaiser
Zhou, Y. Y., et. Al (2010). Improved quality at Kaiser Permanente through e-‐mail between physicians and paAents. Health affairs (Project Hope), 29(7), 1370-‐5. doi:10.1377/hlthaff.2010.0048
Compared Provider–PaAent e-‐mail users and nonusers ( >35,000 paAents) Found improved HEDIS measures in those with hypertension and diabetes BeCer HA1C values BeCer screening Lower BP
There Are Many Other Examples Of Impact Of PaAent Engagement
• Bedside presentaAons reduce apprehension in paAents and may increase accuracy of data
• Sharing of notes with paAents is rare, but when it is promoted, paAents express “considerable enthusiasm and few fears” about sharing notes.
• Walker et al. AIM 2011
• Why is this important? We know coordinaAon of care is a problem, but paAents also see it..
There are Many Tools You Can Use to Increase Engagement
• Shared decision aids-‐ – Informed Medical Decisions FoundaAon – Programs to aid paAents in understanding risks, outcomes and the views of other paAents
• Portals, and other IT – MeeAng MU – “Engaging” paAents in your pracAce
• Behavioral Health/Behavior Change – MoAvaAonal interviewing
• Style of interacAng helps paAent take control of their health on their terms
Summary Points • Health care reform will include major changes in how neurologists are paid and the way they provide care
• CoordinaAon of care, use of teams, and new processes of care will proliferate
• You can make the transiAon by understanding your present processes, costs and outcomes.
• Focus on the value you bring to the paAent’s care.
• Do not be afraid to jump in and work with our colleagues who are pioneering these changes.
Resources for Assessing the Delivery Models
• Overview – hCp://www.aan.com/go/pracAce/models – hCp://cp.neurology.org/content/2/3/224.full
• Accountable Care OrganizaAons – hCp://www.aan.com/go/pracAce/models/aco – hCp://ow.ly/kOdQH
• PaAent Centered Medical Homes – hCp://www.aan.com/go/pracAce/models/pcmh – hCp://cp.neurology.org/content/3/2/134.full
• Webinars from AMA – hCp://ow.ly/kOe35
The AAN will launch a new website to help keep many resources in one place, someAme in June.
Resources for Assessing Payment Models
• Overview from the AMA – hCp://www.ama-‐assn.org/resources/doc/psa/payment-‐opAons.pdf
• Bundled Payments – hCp://www.aan.com/go/pracAce/models/bundled
• Global Payments – hCp://www.aan.com/go/pracAce/models/comprehensive
• Pay for Performance – www.aan.com/go/pracAce/models/performance
• Pay for ReporAng – hCp://www.aan.com/go/pracAce/pay