1 / 22

Value-Based Care

Value-Based Care. Outcomes and Reimbursements. Lecture a – Foundations of Outcomes and Reimbursements.

paulg
Download Presentation

Value-Based Care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Value-Based Care Outcomes and Reimbursements Lecture a – Foundations of Outcomes and Reimbursements This material (Comp 23 Unit 7) was developed by Normandale Community College funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0003. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

  2. Outcomes and ReimbursementsLearning Objectives • Compare the strategy of HMO and capitation to the ACO strategy and explain why quality measurements play such an important role in shared risk contracts. • Describe how the three main elements of CMS pay-for-performance models (quality measures, attribution, and risk stratification) work together to drive quality while reducing costs. • Outline common issues faced when collecting measures of quality and cost. • Discuss the administrative burden of reporting on various CMS payment models and insight on how practices may reduce this burden.

  3. Outcomes and Reimbursements Overview

  4. Reminder of Concepts • Triple Aim: better population health, better patient experience, and lower costs • Definitions of quality: • The IOM defines quality as care that is “Safe, effective, patient-centered, timely, efficient and equitable.” • AHRQ defines quality as “Doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results.” Sources: IOM, 2001; AHRQ, 2006.

  5. Background: Health Maintenance Organizations (HMOs) Experience Failings in the HMOs of the 1990s led to a backlash • Capitated payments were intended to drive cost containment • Growth of health care costs did flatten • Model had the negative consequence of incentivizing less care, regardless of need Sources: Frakt and Mayes, 2012; Gawande, A., May 11, 2015

  6. ACO Design – Differences from HMOs The design of ACOs includes key differences from the earlier HMO model • ACO beneficiaries are not limited to receiving care within the ACO • The scope of capitation is more limited for the Medicare Shared Savings Program (MSSP) ACOs • ACO arrangements include quality metrics Source: Frakt and Mayes, 2012

  7. ACO Model and Quality The ACO model measures quality and includes incentives to avoid quality problems: • Discourage overuse • Discourage underuse Source: Gawande, A., May 11, 2015

  8. Checks and Balances in Pay-for-Performance Model Design Source: Checks and Balances in Pay-for-Performance Model Design

  9. Foundation for CMS Value-Based Models Sources: CMS, 2016; NextGen ACO Model, 2016, Dawe, 2016; Foundation of Value-Based Models

  10. National Quality Strategy National Quality Strategy sets six priorities: • Making care safer by reducing harm caused in the delivery of care. • Ensuring that each person and family is engaged as partners in their care. • Promoting effective communication and coordination of care. • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. • Working with communities to promote wide use of best practices to enable healthy living. • Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models. Source: AHRQ, 2015

  11. ACO Quality Measures Table 7.1: Measures for Use in Establishing Quality Performance Standards that ACOs Must Meet for Shared Savings Legend: PY = Performance Year; R = Pay for Reporting; P = Pay for Performance Source: Medicare Learning Network, March, 2016.

  12. Importance and Use of Risk Stratification Risk stratification plays roles in measurement, payment, and care • Prevents unintended consequence of providers avoiding high-needs patients • Promotes accuracy and fairness in measurement and reimbursement • Enables targeted care for high-needs patients Sources: Johnson, et al, 2015; Medicare Learning Network, 2016; Payment Reform Glossary; Romano, 2010.

  13. Risk Stratification and Social Determinants Sources: Rice, S., Jan. 12, 2016; CMS, 2015; Social Determinants of Health, Healthy People 2020

  14. Challenges in Producing Accurate Quality Reporting The design and use of the EHR can result in reporting problems • System design and implementation • Workflow steps • Provider training • Overcoming resistant behavior

  15. Burdens of Measurement Current quality measurement places burdens on providers and their staff. • Large number of total measures • Difficulties in producing measures from EHRs • Criticisms of current measure sets Sources: Casalino, L.P., et al, 2016; IOM, 2001

  16. Potential Solutions to Current Challenges with Reporting • Metric alignment between payers • Optimizations of EHRs • Workflow and process improvements • Additional Health IT solutions Source: CMS Fact Sheet, 2016

  17. Outcomes and ReimbursementLecture a – Summary • Compare the strategy of HMO and capitation to the ACO strategy and explain why quality measurements play such an important role in shared risk contracts. • Describe how the three main elements of CMS pay-for-performance models (quality measures, attribution, and risk stratification) work together to drive quality while reducing costs. • Outline common issues faced when collecting measures of quality and cost.

  18. Outcomes and ReimbursementsLecture a – References 1 References Accountable Health Communities Model. (2016). Centers for Medicare and Medicaid Services. Agency for Healthcare Research and Quality (AHRQ). (July 26, 2006). Understanding health care quality. AHRQ. 2015 Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care. Blumenthal, D., Malphrus, E., and McGinnis, J.M. Editor. (2015). Vital Signs: Core Metrics for Health and Health Care progress. Committee on Core Metrics for Better Health at Lower Cost; Institute of Medicine. DOI 10.17226/19402 Casalino, L.P., Gans, D., Weber, R., Cea, M., Tuchovsky, A., Bishop, T.F., Miranda, Y., Frankel, B.A., Ziehler, K.B., Wong, M. and Evenson T.B. (2016). U.S. Physician Practices Spend More Than $15.4 Billion Annually to Report Quality Measures. Health Affairs 35, No. 3. doi: 10.1377/hlthaff.2015.1258 Center for Healthcare Quality & Payment Reform (CHQPR). The Payment Reform Glossary: Definitions and Explanations of Terminology Used to Describe Methods of Paying for Healthcare Services. 1st edition.

  19. Outcomes and ReimbursementsLecture a – References 2 References Core Quality Measures Collaborative Release [Fact Sheet]. (February 16, 2016). Centers for Medicare and Medicaid Services. Dawe, C., Lewine, N., and Miesen, M. (April 15, 2016). Today’s Most Attractive National ACO Model Is Offered by…CMS. HealthAffairs Blog. Entoven, A. (April 10, 2005). “The Rise and Fall of HMOs Shows How a Worthy Idea Went Wrong.” CommonWealth magazine. Frakt, A.B., and Mayes, R. (2012). Beyond Capitation: How New Payment Experiments Seek To Find The 'Sweet Spot' In Amount Of Risk Providers And Payers Bear. Affairs 31, no.9 (2012):1951-1958. doi: 10.1377/hlthaff.2012.0344. Gawande, A. (May 11, 2015). “Overkill.” The New Yorker. Retrieved from: http://www.newyorker.com/ Institute of Medicine (IOM). (March 1, 2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. Johnson, T.L., Brewer, D., Estacio, R., Vlasimsky, T., Durfee, M.J., Thompson, K.R., Everhart, R.M., Rinehart, D.J, and Batal, H. (2015). "Augmenting Predictive Modeling Tools with Clinical Insights for Care Coordination Program Design and Implementation." eGEMs (Generating Evidence & Methods to improve patient outcomes): Vol. 3.1, Article 14. DOI: http://dx.doi.org/10.13063/2327-9214.1181

  20. Outcomes and ReimbursementsLecture a – References 3 References Medicare Learning Network (March 2016). Improving Quality of Care for Medicare Patients: Accountable Care Organizations. ICN 907407. Miller, T.P., Brennan, T.A., and Milstein, A. (September/October 2009). “How Can We Make Progress in Measuring Physicians’ Performance to Improve the Value of Care?” Health Aff vol. 28 no. 5 1429-1437. Next Generation ACO Model. (2016). Centers for Medicare and Medicaid Services. Retrieved from: https://innovation.cms.gov/ Rice, S. (Jan 12, 2016). Adjusting for Social Determinants in Value-Based Payments Still Fuzzy. Modern Healthcare. Romano, P.S., Hussey, P., Ritley, D. (May 2010). Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives. Agency for Healthcare Research and Quality (AHRQ). AHRQ Publication No. 09(10)-0073. Shared Saving Program – Financial and Beneficiary Assignment Methodology. (2015). Centers for Medicare and Medicaid Services. Tarlov, A.R. (1999). Public Policy Frameworks for Improving Population Health. Annals of the New York Academy of Sciences, 896.

  21. Outcomes and ReimbursementsLecture a – References 4 Tables Table 7.1 Medicare Learning Network (March 2016). Improving Quality of Care for Medicare Patients: Accountable Care Organizations, ICN 907407 Images Slide 3: Health Care and Health Care Costs, CC NC-BY-SA, 4.0 Slide 8:Checks and Balances in Pay-for-Performance Model Design, created for use in program. Slide 9: Foundation of Value-Based Models, created for use in program. Slide 13: Social Determinants of Health (n.d.). Office of Disease Prevention and Health Promotion (ODPHP). Healthy People 2020 Retrieved from: https://www.healthypeople.gov

  22. Outcomes and ReimbursementsLecture a This material was developed by Normandale Community College funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0003.

More Related