Presentation on theme: "Overview The health care payment system is shifting away from fee-for-service models to more aggregated, bundled and global payments These alternative."— Presentation transcript:
0 Payment Reform in Massachusetts: Impacts and Opportunities for the Health Care Workforce Metro North Regional Employment Board MeetingAnna Gosline and Jessica LarochelleJune 19, 2013BLUE CROSS BLUE SHIELD OF MASSACHUSETTS FOUNDATION
1 OverviewThe health care payment system is shifting away from fee-for-service models to more aggregated, bundled and global paymentsThese alternative payment models are spurring new models of care delivery, and creating new opportunities to pay for services that were previously not “reimbursable”These changes, along with other provisions of state and national reform laws, will impact the demand for health care professionals, both the number and the type
2 Massachusetts Has the Lowest Uninsurance Rate in the Country PERCENT UNINSURED, 2000–2011, ALL AGESU.S. AVERAGEMASS.200020022004200620072008200920102011NOTE: As of 2008, the state contracted with a new vendor (Urban Institute) to track insurance coverage rates in Massachusetts. The Urban Institute implemented methodological changes to the tracking survey which may affect comparability of the 2008, 2009, and 2010 results to prior years.The national comparison presented here utilizes a different survey methodology, the Current Population Survey , which is known to undercountMedicaid enrollment in some states.SOURCES: Massachusetts Division of Health Care Finance and Policy, Massachusetts Health Insurance Survey 2000, 2002, 2004, 2006, 2007, 2008, 2009, 2010, 2011; U.S. Census Bureau, Current Population Survey, Health Insurance Historical Tables (HIB Series).
3 But the Highest Per Person Health Care Spending in the World PER CAPITA PERSONAL HEALTH CARE EXPENDITURES, 2009NATIONAL AVERAGEStateNOTE: District of Columbia is not included.SOURCE: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2011.
4 Key Affordability/Cost-Related Developments in Massachusetts 2006200720082009201020112012Health reform passes (Ch. 58)Begins path to near universal coverageMuch of Chapter 58 enacted, e.g.:MassHealth expansionCommonwealth CareConsumer affordability scheduleNew health plan options for young adultsEmployer Fair ShareCost Containment Part 1 (Ch. 305) passesIncreased transparency about cost driversReports on health insurer and hospital “reserves”Special Commission on Payment ReformRecommends move to global paymentGovernment reports and hearings on cost driversGovernor rejects small group premiumsCost Containment Part 2 (Ch. 288) passesAims to control premiums for small businesses, individualsGovernor Patrick files payment reform legislationSpecial Commission on Provider Price ReformCost Containment Part 3 (Ch. 224) passesStatewide cost growth targets and payment reformsContinued focus on data transparencyISELIN
5 Chapter 224 of the Acts of 2012The law aims to reduce health care cost growth through:The creation of new agencies (the Health Policy Commission and the Center for Health Information and Analysis)Setting and monitoring statewide health care cost growth targetsNew scrutiny on health care market power, price variation and cost growth at the individual health care entity levelIncreased cost transparency for consumersA focus on wellness and preventionExpanding the primary care workforceOther provisions around health resource planning, HIT, medical malpractice reforms, and administrative simplification.Wide adoption of alternative payment methodologiesMassHealth must have 80% of enrollees in alternative payments by 2015All payers must, to the maximum extent feasible, move away from fee-for-service
6 Solving the Cost Problem Through Provider Payment Reform CURRENT FEE-FOR-SERVICE PAYMENT SYSTEMPATIENT-CENTERED GLOBAL PAYMENT SYSTEMTHE PROBLEMCare is fragmented instead of coordinated. Each provider is paid for doing work in isolation, and no one is responsible for coordinating care. Quality can suffer, costs rise and there is little accountability for either.THE SOLUTIONGlobal payments made to a group of providers for all care. Providers are not rewarded for delivering more care, but for delivering the right care to meet patient’s needs.$$$$$$PRIMARY CAREHOSPITALSPECIALISTHOSPITALSPECIALISTPRIMARY CAREHOME HEALTHHOME HEALTHGOVERNMENT, PAYERS AND PROVIDERS WILL SHARE RESPONSIBILITY FOR PROVIDING INFRASTRUCTURE, LEGAL AND TECHNICAL SUPPORT TO PROVIDERS IN MAKING THIS TRANSITION.6
7 The New Ways to Pay and Practice Global payment/budget – (eg. Accountable Care Organizations)Usually accepted by a group of providers (sometimes a hospital and it’s physician practices, sometimes just a physician group) accepting responsibility for the total cost of care for a set population or patient groupLarge variation in the exact details of the payment; providers may accept various levels of “risk” around meeting per person cost targetsPayments usually dependent on achieving quality metricsPatient Centered Medical HomesAccepted by a primary care practice with augmented abilities around managing care both within its own practice and coordinating with specialists and hospitals.Focus on team-based, patient-centered care and population managementPayments are usually structured as additional per-person care management fees on top of standard fee-for-service paymentsValue-Based PurchasingA bit of a catch-all phrase, mostly associated today with Medicare penalties for high rates of readmissions at hospitalsBundled and Episode-Based PaymentsA single payment to cover all care for a procedure or condition usually over a defined period of timeOften accepted by jointly be a hospital and it’s physician groupEg. Medicare Bundled Payment demonstration, just launched in 2013
8 Alternative Payments Are Spreading Quickly in Massachusetts HMO MEMBERSHIP IN BCBSMA’S GLOBAL PAYMENT CONTRACT75% of HMO membership646,048428,600359,000328,000
9 Global Payments Are Showing Positive Results on Both Cost and Quality
10 But there Is No Overall Link Between Global Payments and Total Spending – Likely a Reflection of Price DisparitiesBCBSMA RELATIVE HEALTH STATUS-ADJUSTED TOTAL MEDICAL EXPENSEPROVIDERS OPERATING UNDER GLOBAL PAYMENTSSOURCE: Office of Attorney General Martha Coakley, “Examination of Health Care Cost Trends and Drivers,” June 2011.
11 The Payment Reform Landscape is Spurring a New Wave of Market Consolidation, Potentially Increasing Prices FurtherCooley Dickinson Trustees Choose Massachusetts General Hospital02/28/ :07 AMPartners in talks with Hallmark HealthBy Steven SyreGLOBE COLUMNIST APRIL 17, 2012Steward Continues Buying Spree;Globe Reports Deal for Lowell HospitalApril 4, 2011 | 12:37 PM | By Carey GoldbergLahey, Northeast Health finalize mergerBoston Business JournalDate: Monday, May 7, 2012, 6:51am EDT
12 So What Does this All Mean for the Health Care Workforce? Demand for comprehensive, and community-focused primary care servicesContinued strong demand primary care physicians, NPs and PAsOpportunities for new kinds of lay health care professionals, eg. Community Health WorkersNeed for care management and case managementNew skills for primary care practitioners and beyondEmphasis on team-based care, collaboration and coordinationPromoting team-based care skills as part of medical education for physicians, nurses and other health care professionalsCapability with EHRs and population health data analysisPatient engagementCultural competenceBehavioral health integrationProvisions of state and national health reform support many of these goals
13 Primary Care Physicians: Landscape BERKSHIREFRANKLINHAMPSHIREHAMPDENWORCESTERMIDDLESEXESSEXNORFOLKBRISTOLPLYMOUTHBARNSTABLEDUKES‡NANTUCKET‡94.777.399.794.6120.254.559.690.3113.858.1249.7SUFFOLKPCP Density (per 100,000 residents)PRIMARY CARE PHYSICIAN DENSITY BY COUNTY PER 100,000 POPULATION, 2006‡Due to the relatively small number of physicians and total population size, caution should be taken when comparing rates in this County to rates in other Counties.Source: Health Resources and Services Administration (HRSA) update to the American Medical Association’s Master File – Physician Characteristics (2006). For more information, visit HRSA at 1Kay Lazar. “Many Continue to Rely on ER: 14% Used Hospital Before Family Doctor,” The Boston Globe (November 2008)
14 Primary Care Physicians: Landscape PERCENT OF INTERNAL MEDICINE PRACTICES ACCEPTING NEW PATIENTS AND WAIT TIME TO NEW PATIENT APPOINTMENTSource: Massachusetts Medical Society, 2012 Patient Access to Healthcare Study
15 Primary Care Physicians and Recent Legislation: More and/or Different? Chapter 224 and the Affordable Care Act (ACA)Primary care residency grant programs and loan forgiveness programsService obligations for federally supported student loans softenedPrimary care payment bumpMedicare will increase primary care reimbursement rates by 10% fromMedicaid reimbursement will be increased to at least Medicare levels fromMassHealth alternative payment methodologiesMassachusetts will likely not see the surge in primary care demand predicted nationwide in 2014, as the state already has a well-established universal access reform.But the fast pace of payment reform adoption and delivery system change will mean major changes, nonetheless.
16 Nurse Practitioners (NPs): Landscape NURSE PRACTITIONER DENSITY PER 100,000 POPULATION, 2011Source: Calculations based on The 2012 Pearson Report, The American Journal for Nurse Practitioners, NP Communications LLC.
17 Nurse Practitioners (NPs) and Recent Legislation: More and/or Different? Key Provisions in Chapter 224Global signature authority – NPs can now fulfill laws or rules that used to require a signature, stamp, verification, etc. by a physicianLimited service clinics – Expands to the scope to include all services within the scope and practice of NPsKey Provisions in the Affordable Care ActDedicated funds in the Prevention and Public Health Fund to train new NPsFamily NP training demonstration will support new graduates for a year of practice in a federally qualified health center or nurse-managed health clinic
18 Physician Assistants (PAs): Landscape US Average
19 Physician Assistants (PAs) and Recent Legislation: More and/or Different? Key Provisions in Chapter 224Carriers must now recognize PAs as participating providers and cover care provided by PAs for health maintenance, diagnosis, and treatmentPAs are now included in the definition of primary care provider; carriers that require designation of a primary care provider must allow members the option to choose a PAPhysicians are no longer prohibited from supervising more than four PAs at a timeThe Health Care Workforce Center’s scope has been broadened to include PAs; information on the status of the PA workforce will be included in its annual reportKey Provisions in the Affordable Care ActDedicated funds in the Prevention and Public Health Fund to train new PAs
20 Community Health Workers: Definition Community Health Workers (CHWs) are public health workers who apply their unique understanding of the experience, language and/or culture of the populations they serve in order to carry out one or more of the following roles:Providing culturally appropriate health education, information and outreach in community-based settings;Bridging/culturally mediating between individuals, communities and health and human services, including actively building individual and community capacity;Assuring that people access the services they need;Providing direct services, such as informal counseling, social support, care coordination and health screenings; andAdvocating for individual and community needs.
21 Community Health Workers and Recent Legislation: More and/or Different? Community Health Worker (CHW) Certification Process:Legislation passed in 2010; went into effect in 2012The Board will establish standards for:Education and training of community health workers and community health worker trainersEducation and training program curricula for community health workersRequirements for community health worker certification and renewal of certificationOther considerationsGrandfathering?Reimbursement considerations?
22 New Skills – Team-Based Care and Care Coordination Patient-Centered Medical HomesPractice redesign with an emphasis on patient communication, after-hours access, care planning, management and coordination, community support and performance measurementNew partnerships beyond the practiceCoordinating care with hospitals, specialists and post-acute care providersExample: Researchers have found that those with a primary care visit within 14 days of an admission for CHF are much less likely to be readmittedBehavioral health integrationPatients with mental health and substance abuse disorders, especially those with co-morbid chronic health conditions, are among the costliest patients in the systemDesigning innovative care management programs that address the particular needs of this population will be crucialWill require greater collaboration between providers with different specialties
23 New Skills – EHR and Population Data There are many forces aligning that will require more sophisticated use of data, electronic data use and sharingOne of the core capacities of NCQA certification for Patient-Centered Medical Home accreditation is the use of data for population managementEven more critical for practices accepting risk for the total cost of care for their patientsChapter 224 made EHR proficiency a condition of licensure for Massachusetts physiciansHIE data exchange for care coordination
24 New Skills – Patient Activation and Engagement As providers accept risk for the total costs and quality of care, they will have to build new types of relationships with patients, e.g. “shared decision-making”ACA identifies patient engagement as a critical component of accountable care organizations and patient-centered medical homes.When patients are engaged in their health care – more knowledgeable, more confident in managing their health and navigating they system – they experience better health outcomes and incur lower health care costs.Challenges for providers: overworked physicians, insufficient provider training, and clinical information systems that fail to track patients throughout the decision-making process.Source: Health Affairs, Health Policy Briefs: Patient Engagement, February 14, 2103
25 Questions/Comments Thank you! Anna Gosline, Director of Policy and ResearchJessica Larochelle, Director of Evaluation & Strategic Initiatives