Building the Bridge to Future Healthcare Reimbursement -

1. Building the Bridge to Future Healthcare Reimbursement - Leveraging Non Acute Care Services Margie Namie, RN, MPH, CPHQ Principal, M.W. Namie, LLC

2. What is innovation in this era of health reform versus transformation or transition?

3. Innovation (noun): Implementation of something completely new.

4. Transformation (noun): A thorough or dramatic change.

5. Transition (noun): The process or period of changing from one state or condition to another.

6. For innovative or transformational change, we don’t know what the end product looks like.

7. “Margie, it’s a gray, gray world….” Alden Willard, Senior Year at Vanderbilt University

8. “May you live in interesting times….” Ancient Chinese Curse

9. …But just how interesting is it? • 1860’s: Civil War • 1960’s: Establishment of Medicare Program • 1980’s: Introduction of DRGs • 2000’s: Medicare Modernization Act, APR-DRGs, MS-DRGs • March 2010: Passage of Patient Protection and Affordable Care Act

10. 1860s Health Care • At the onset of the Civil War: • Few hospitals, aimed mostly at insane and indigent care • Rudimentary medical education • No understanding of basic hygienic principles • For every soldier lost to a bullet, two were lost to disease.

11. 1860s Health Care • Substantial improvements in sanitation • Establish of the U.S. Sanitary Commission (1861) • Mortality decreased by half during the course of the War. • Establishment of the essential value of nurses in war effort. • Infrastructure was built including mechanisms to transport wounded, field and general hospitals.

12. Establishment of the U.S. Health System • Acute care focused, matching the diseases of the population even after the War. • Advances in sanitation, pain management, triage, anesthesia

13. Establishment of Medicare • Established as part of the Social Security Act of 1965 • Prior to Act, approximately 35% of people over the age of 65 had no health insurance. • Reimbursement contingent on racial integration. • Multiple changes since enactment: • Populations covered • Services covered • Payment models

14. And yet….

15. May you live in (new) interesting times • 1900s: Top 3 Causes of Mortality • Influenza • Pneumonia • Gastroenteritis • 1990s: Top 3 Causes of Mortality • Cardiovascular Disease • Stroke • All cancers

16. Chronic Disease Burden • 75¢ of every health care dollar spent • Two thirds of the increase in healthcare spending for chronic disease • Taxpayer-funded programs: • 96¢ of every Medicare dollar • 83¢ of every Medicaid dollar • Combined productivity reduction and treatment of chronic disease estimated to cost the U.S. economy $1 trillion annually. (Milken Institute) www.fightingchronicillness.org

17. Is the system of care created for the Civil War still valid?What strategy—innovative, transformational, or transitional—is needed now?

18. How much are we spending? www.oecd.org

19. …And what do we get? www.oecd.org

20. And what do we get? The Commonwealth Fund

21. The Scales are Unbalanced Desirable Health Outcomes Disease Burden in the US Healthcare Costs Chronic Disease Risky Behaviors Uninsured

22. Marching towards insolvency in 2030 www.thehill.com

23. Tests of ChangeKey Lesson:Incremental policy changes have huge (and often totally unintended) consequences….

24. Early Efforts: Controlling Cost • 1983: Establishment of DRG payment system • Aim to control over-use, unnecessary hospitalizations and procedures • Downside: Created huge systems of work to justify, maximize and defend coding

25. More Health Policy “oops”

27. Players Behind the ACA: The Desire to Create Health Care Transformation

28. 2010 Patient Protection & Affordable Care Act • Initial bipartisan effort set aside in political maneuvering • Inciting public panic over end of life decision-making still with lasting reverberations on the Hill. • Many last minute exclusions increased the “flaw factor” of the Act.

29. Current State: The ACA and its Implementation

30. Core Part of the ACA: The Three-Part Aim

31. ACA Content • Payment Cuts and Cost Shifting • Pay for Performance • Geographic Adjustments • Transparency • Coverage Expansion • Health Care System Redesign***

32. Health Care Redesign: The Medicare Innovation Center

33. CMMI Innovation Center • Partnership for Patients • Accountable Care Organizations • Community Based Care Transitions • Comprehensive Primary Care Initiative • CMMI Innovation Advisors Program • Bundled Payments • Innovation Challenge Grants

34. CMMI Innovation Advisors • Established by Acting CMS Administrator Donald Berwick • Vision: Create a cadre of dedicated clinicians across the country to test innovative health care models that would promote better health, better outcomes at reduced total cost of care. • Application process rigorous and plan was to create multiple cohorts of 76-80 clinicians each, with a total of about 2,000 in the U.S.

35. CMMI Innovation Advisors • Initial RFP resulted in over 920 applications. • 73 chosen, 3 from Ohio (1 Dayton, 2 Cincinnati) • Intense training of quality improvement methodology, testing and expanding individual projects. • IAs wanted to self-organize and made efforts to do so. • In spite of continued promises to recruit the next cohort, political winds stopped the work after the first cohort.

36. My Learnings • Tremendous pressure—as well as a sense of eagerness and anticipation—within CMMI. • Pressure translated to political fear of making the wrong move and justifying its existence. • My cohort representatives are courageous, innovative, demonstrating incredible results frequently buried in peer-reviewed journals, and committed to creating a “more rational health care model.”

37. John A. Hartford Foundation Practice Change Leaders Program • Competitive bidding for ten slots offered to IAs alone. • Project and leadership based (not institutional) and focused on care of older Americans • One year of intensive mentorship to develop us as national leaders • Private Foundations have a freedom to innovate and transform outside the government

38. My Internal Truths

39. Internal Truths • Wag the dog—he’s too big to wag it himself. • Innovative solutions must involve both clinical and financial folks working on shared solutions. • Accountability must also spread both ways, supporting the Three-Part Aim. • Communities, private foundations and payers can find viable solutions together. • The only lasting solutions provide alignment between success at the organizational, community and national level.

40. Tragedy of the Commons First described in 1833 by William Forster Lloyd examining a common area in England for grazing cows and sometimes sheep. Widespread acceptance after Garrett Hardin published a paper in the journal Science in 1968, noting the disconnect between “rational self interest” and the “common good.”

41. Where Are We? (And where do we go from here…..)

42. Everett Rogers. Diffusion of Innovation

43. Meet Your Neighbors • Bridging the gap of the Acute and Non-Acute World • Nomenclature • Technology Support • Measures Standardization • Accountability: Preferred Partner Status • Bring the Cake • Read only access to EMR • Intermittent case conferences • Shared projects

44. Engage Your Patients • Skill building in patient engagement (takes investment) • Audit patient engagement skills • Grow beyond the patient satisfaction questionnaire

45. Reduce Cost • Patient Harm • Look beyond your walls • Readmissions • High cost / low ROI populations • End of Life • Self pay / Medicaid / Dual eligibles • Standardize work flows, processes

46. Focus on the ED—to Focus Away • Move non-urgent, primary care issues to appropriate setting. • Increase capacity for primary care, dental care, mental health interventions. • ED Fast Track • Triage and treat appropriate urgent care • Triage with alternative follow up for non-urgent • Leverage Case Management, Social Work, Palliative Care • Partner with LTC for respite beds

47. Engage Physicians • Increase proportion of salary at risk • Quality/financial balanced scorecard for incentive payment. • Start gently, but with a plan to make it real and pertinent • Standardize metrics • Create infrastructure for physician to physician oversight • Don’t just play at risk—link institutional financial success with individual success, starting with physician leadership

48. Payer Negotiation • True quality incentives—mutual skin in the game with shared learning and growth • Innovative programs at the community level. • Demand accountability • Stratify post-acute support services to link patients with most appropriate resource • Leverage negotiations to include not just pricing but services

49. Raise All Ships • Shared Services Organization, community benefit where it makes sense to address the “wicked problems” together: • Narcotic use • Mental health issues

50. Encourage Innovation • Set aside “Innovation Bank” • Create internal competitive bank for funding of innovative ideas • Demand accountability in RFPs: proforma, business case, outcomes for measurement • Agree on which successful outcomes would result in long term funding • Spread internally, with other payers