Thriving in the New Health Care Landscape:

Payment Reform, Data and Patient Engagement

Deborah Huber, RN, MHSA Executive Director, HealthInsight Nevada

HealthInsight’s Annual Quality Conference November 2016

What You’ll Learn Today

By attending this session, participants will be able to: • Discover how new and ongoing health care

initiatives impact health care providers and patients

• Identify opportunities for change and a plan for action

• Identify resources for learning more along with colleagues and the HealthInsight team

Key Topics

• Payment reform and the alternative payment movement

• The data imperative • Patient engagement

PAYMENT REFORM AND THE ALTERNATIVE PAYMENT MOVEMENT

What Is The Problem?

• Our health care costs keep going up and are a much greater percentage of gross domestic product (GDP) than other countries

• Wage increases are being eaten up by insurance cost

• Even spending all that money, our quality outcomes are mediocre at best

• This decreases our global competitiveness

Health Care Cost-Shifting Makes U.S. Businesses Uncompetitive

Huge Increases In Costs For Both Employers And Workers

How Health Care Stole Your Pay Raise

What We Are Paying For

Who Is Impacted?

Payers Providers

Patients Purchasers

Why Does It Matter?

What Is Being Done?

Public and Private Payment Reforms

• Federal Programs – MACRA – Bundled payments for joint replacements

• State Initiatives – Medicaid Managed Care

• Private Models – Accountable Care Organizations (ACOs) – Primary Care Medical Homes

Center For Medicare & Medicaid Services Innovation Center (CMMI)

• Funds projects that test various payment and service delivery models that aim to: – Achieve better care for patients – Better health for our communities – Lower costs through improvement

• https://innovation.cms.gov/initiatives/

CMMI-Funded Projects in Nevada

• Medicare Care Choices – Nathan Adelson Hospice, Procare Hospice

• Community Resource Planning – Regional Emergency Medical Services Authority

(REMSA)

• Strong Start for Mothers and Babies – HealthInsight Nevada

CMMI-Funded Projects In Nevada

(Continued) • Bundled Payments for Care Improvement

Initiative (BPCI) – Numerous Nevada hospitals awarded

• Enhanced Care Coordination Providers – HealthInsight Nevada: Admissions & Transitions

Optimization Program (ATOP) • Medicaid Incentives for the Prevention of

Chronic Diseases Model – State of Nevada

More Recent Cost Projections

CMS Framework For Payment Models

CMS Target Percentage Of Payments In Fee-For-Service Linked To Quality And Alternative Payment

Models

Federal Program: MACRA

• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

• Focuses on Part B Medicare (outpatient) • Intent is:

– Improve care for Medicare beneficiaries – Change our payment system from focus on

volume to value

Quality Payment Program(QPP)

Payment for Medicare Outpatient Services

• Merit-Based Incentive Program (MIPS) • Advanced Alternative Payment Models (APMs)

A First Step: MIPS

Clinicians will be scored under MIPS using a single composite score that will factor in performance in four weighted categories for Year 1.

MIPS Payment Adjustments

2019 2020 2021 2022 (and beyond)

Positive Adjustment

+4% (12% for top performers)

+5% (15% for top performers)

+7% (21% for top performers)

+9% (27% for top performers)

Negative Adjustment -4% -5% -7% -9%

Alternative Payment Models

• Alternative payment models (APMs) – Providers receive incentive payments for high-quality and

cost-efficient care. – APMs can apply to a specific clinical condition, a care

episode or a population. • Advanced APMs (AAPM)

– Subset of APMs – practices can earn higher payment but bear risk for lower

payment if quality and cost goals are not met – EHR usage and quality requirements – Must cover 25% of their Medicare payments or 20% of their

Medicare patients.

Advanced APMs

• Shared Savings Program: Tracks 2 and 3 • Next Generation ACO Model • Comprehensive End Stage Renal Disease Care

(CEC): Large dialysis organization arrangement • Comprehensive Primary Care Plus (CPC+) • Oncology Care Model (OCM): Two-sided risk track

available in 2018

Where Does MACRA Fit In The Big Picture?

• Where CMS goes others will follow • Track/report quality of care • Understand and act on cost information • Use technology to support improvement and

care coordination across the continuum • Very likely leading to changes in patient

engagement and experience

When Should Clinicians Start To Work On MACRA? Now!

• Get educated about the requirements

• Assess practice’s strengths and weaknesses

• Used certified EHRs and participate in the

HIE (HealtHIE Nevada)

• Participate in Meaningful Use Program

When Should Clinicians Start To Work On MACRA? Now! (Continued)

• Report quality data through the Physician Quality Reporting System (PQRS)

• Obtain Quality and Resource Use Reports

(QRUR) and learn how to use them • Build capacity in quality improvement and

care process redesign

So, Where Are You?

THE DATA IMPERATIVE

Data Reports

• Audiences • Purposes • See your organization • See other organizations • Target areas for

improvement • Determine additional data

needs • Public/private data

collection • Availability/transparency • Sources

Sources

• Centers for Medicare & Medicaid Services (CMS) – Medicare Compare websites (star ratings) – Value-Based Purchasing Reports – Minimum Data Set Reports (MDS) – Outcome and Assessment Information Set (OASIS) – Outcome-Based Quality Improvement Reports

(OBQI) – Quality and Resource Utilization Reports (QRUR) – Program for Evaluating Payment Patterns Electronic

Report (PEPPER)

Sources (Continued)

• Centers for Disease Control and Prevention (CDC) – National Healthcare Safety Network (NHSN)

• Agency for Healthcare Research and Quality (AHRQ) – Quality and Safety Indicators – Healthcare Cost and Utilization Project (HCUP) – Consumer Assessment of Healthcare Providers

and Systems (CAHPS®) – Clinical guidelines

Sources (Continued)

• State/County – Health Care Facilities Data – Hospital Discharge Data – County Health Rankings Report

• Nevada Hospital Association – Quality and Safety Indicators, sentinel events

• HealthInsight

– National performance rankings by setting on our website – Performance feedback reports

Home Health Agencies

• CMS – Home Health Compare – OASIS – Medicare Provider Utilization and Payment Data – Home Health Quality Improvement Data Access

Reports

• HealthInsight – National performance rankings on our website – Performance feedback reports

Skilled Nursing Facilities

• CMS – Nursing Home Compare – Certification and Survey Provider Enhanced Reporting

system (CASPER) – Cost Report Data

• HealthInsight – National performance rankings – Composite scores provided to participating facilities – ATOP reports

Hospitals

• CMS – Hospital Compare – Utilization and Payment Data reports

• State-based reports – Inpatient, ambulatory surgery, emergency department – FLEX program reports for critical access hospitals

• NV Hospital Association – nvhospitalquality.net • HealthInsight

– National Performance Rankings – Performance Feedback Reports

Clinical Practices

• CMS – Physician Compare – Physician Quality Reporting System (PQRS)

feedback reports – Medicare Provider Utilization and Payment Data – Quality and Resource Use Report (QRUR)

Quality And Resource Use Report (QRUR)

• Shows how a practice performed on quality and cost measures

• Based on care provided to Medicare fee-for-service beneficiaries attributed to the practice

• Composite scores: Compares a practice’s average score to national mean on – Quality across six domains of care – Cost attributed to care of key conditions

QRUR Scatter Plot

QRUR Utility

The QRUR provides information to physicians regarding: • Areas where their care is more costly than

peers • Referral patterns • High-risk patients that need more attention • Post-acute care partners

Health Information Exchange

• Real time clinical data • View a patient’s history and encounters with

the health care system • Alerts can be set up to notify on your patient’s

access of health care • A resource to enhance individual patient and

organizational decision making

Health Information Exchange (Continued)

• May reduce (costly) duplication of lab and radiology tests

• Improves – Decision-making – Timeliness, effectiveness and quality of care

• Meets reporting requirements – meaningful use

Data To Ensure Success

PATIENT ENGAGEMENT

Source: Health Affairs 32, no.2 (2013):223-231 Patient And Family Engagement: A Framework For Understanding The Elements Adams, Christine Bechtel and Jennifer Sweeney Kristin L. Carman, Pam Dardess, Maureen Maurer, Shoshanna Sofaer, Karen doi: 10.1377/hlthaff.2012.1133

What Is Patient Engagement?

Why Patient Engagement?

• Improved patient satisfaction

• Improved quality and safety

• Improved financial and operations efficiency

Patient Engagement Chronic Diseases

• Educational and self-help programs that are actively supported by clinicians improve health outcomes for patients with chronic diseases

• Chronic Disease Self-Management Programs – Diabetic self-management education (DSME) – Available to patients statewide

• Contact HealthInsight if you: – Have patients to refer to a DSME class – Have space where DSME classes can be held – Want to train your staff to deliver self-management education

Shared Decision-Making Tool

Source: The Ottawa Hospital

Patient And Family Advisory Councils

• Benefits to patients and families: – Gain a better understanding of the health care system – Appreciate being listened to and having their opinions

valued – Become advocates for the patient and family-centered

healthcare in their community – Understand how to become an active participant in

their own health care – Provide an opportunity to learn new skills (facilitating

groups, listening skills, telling their story)

Patient And Family Advisory Councils (Continued)

• Benefits to health care organizations – Provide an effective mechanism for receiving and

responding to patient/family input – More efficient planning to ensure that services really

meet consumer needs and priorities – Transform the culture toward patient-centered care – Strengthen community relations – Recognize that collaboration leads to better self-

management of chronic conditions and improved adherence to medication regimens

How Might Payment Reform Impact Patients?

• Patients may start seeing changes as their care providers participate more in payment reform

• For clinicians to succeed they need to: – Know their patients problems and needs – Understand where unnecessary cost are incurred – Engage patients more fully in their own health and

health care and in joint decision making

New Things Patients May Experience

• New kinds of visits – Wellness visits – Phone calls for chronic

conditions

• New screenings (depression)

• Greater focus on self-management and prevention

• Education

So, Where Are You?

Principles Needed To Be The Change

1. It's all about the patient 2. Bad processes beat good people every time 3. Eliminate waste 4. “Run to space” 5. Don't fear failure 6. Respect the limits of rules and incentives 7. Restore joy in work 8. Culture eats strategy for breakfast

HealthInsight’s Helping Hands

Thank You

Deborah Huber HealthInsight Nevada Executive Director

dhuber@healthinsight.org 702-933-7305

This material was prepared by HealthInsight, the Medicare Quality Innovation Network -Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents

presented do not necessarily reflect CMS policy.11SOW-CORP-16-119-NV