1. The Alphabet Soup of Change
SIM
CPCI
TCPI
ENSW
ACC/RCCO
MU 1-2-3
MIPS
APM

2. Forget the Acronyms Colorado Health Extension Service:
One souce of information.
Clarity about who, what, where, when and how.
Ongoing and improving as it does.

3. HHS Announcement Better Care. Smarter Spending. Healthier People
In three words, our vision for improving health delivery is about better, smarter, healthier.
If we find better ways to pay providers, deliver care, and distribute information:
We can receive better care.
We can spend our health dollars more wisely.
We can have healthier communities, a healthier economy, and a healthier country.
Incentives
Focus Areas
Description
Care Delivery
Information
Encourage the integration and coordination of clinical care services
Improve population health
Promote patient engagement through shared decision making
Create transparency on cost and quality information
Bring electronic health information to the point of care for meaningful use
Promote value-based payment systems
Test new alternative payment models
Increase linkage of Medicaid, Medicare FFS, and other payments to value
Bring proven payment models to scale
In three words, our vision for improving health delivery is about better, smarter, healthier.
If we find better ways to deliver care, pay providers, and distribute information, we can receive better care, spend our dollars more wisely, and have healthier communities, a healthier economy, and a healthier country.
We understand that it’s our role and responsibility to lead … and we will.
What we won’t do – and can’t do – is go it alone. Patients, physicians, government, and business all stand to benefit if we get this right, and this shared purpose calls out for deeper partnership.
So we will continue to work across sectors and across the aisle for the goals we share: better care, smarter spending, and healthier people.
Source: CMS

4. Target percentage of Medicare FFS payments linked to quality and alternative payment models
All Medicare FFS (Categories 1-4)
FFS linked to quality (Categories 2-4)
Alternative payment models (Categories 3-4)
2016
2018
85%
30%
50%
90%
Source: CMS

5. CMS Payment Reform – 4 Categories
Category 1:
Fee for Service— No Link to Quality
Category 2:
Fee for Service— Link to Quality
Category 3:
Alternative Payment Models Built on Fee-for-Service Architecture
Category 4:
Population-Based Payment
Description
Payments are based on volume of services and not linked to quality or efficiency
At least a portion of payments vary based on the quality or efficiency of health care delivery
Some payment is linked to the effective management of a population or an episode of care. Payments still triggered by delivery of services, but opportunities for shared savings or 2- sided risk
Payment is not directly triggered by service delivery so volume is not linked to payment. Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (i.e., >1 year)
Medicare FFS
Limited in Medicare fee-for-service
Majority of Medicare payments now are linked to quality
Hospital value-based purchasing
Physician Value-Based Modifier
Readmissions/Hospital Acquired Condition Reduction Program
Accountable care organizations
Medical homes
Bundled payments
Comprehensive primary care initiative
Comprehensive ESRD
Medicare-Medicaid Financial Alignment Initiative Fee-For-Service Model
Eligible Pioneer accountable care organizations in years 3-5
Source: CMS

6. Current Law and SGR reform timeline
Sunset of existing quality value penalties under PQRS, VBM, EHR 12/31/2018
Permanent repeal of SGR
APM participating providers exempt from MIPS; receive annual 5% bonus ( )
Track 1
Current Law
2018 4%
Physician Quality Reporting System Penalty
2015
-1.5%
2016 & beyond
-2.0%
Value-based Payment Modifier penalty (up to %)
-1.0%
2016
2017
-4.0%
Merit-Based Incentive Payment System (MIPS) adjustments
2019
+/-4%
2020
+/- 5%
2021
+/- 7%
2022 & beyond
+/- 9%
MIPS exceptional performance adjustment; Up to 10% annually
( )
Updates in physician payments
0.5% (7/ )
0% ( )
0.25%
(2026 )
Meaningful Use Penalty (up to %)
-4.0%?
2019 & beyond
-5.0%?
-3.0%
2018 & beyond
???%
Track 2
0.75% update ( )
2022
2023
2024
2025
2026
SGR repeal & annual updates
0.5% increase in physician payments for 5 yrs (beginning June 2015); Freeze through 2025
Beyond 2025: physicians in advanced payment models (APMs) receive 1% annual updates, all others receive 0.5% (these out years not pictured in graph)
Time to develop quality measures & clinical improvement activities
Value-Based Performance (VBP) Payment Program
2017, payments adjusted for physicians’ performance in prior period
2018: Consolidate PQRS, VBM & EHR MU into VBP
4% tied to performance in 2019; 5% in 2020; 7% in 2021; 9% in 2022 & beyond. Secretary can increase funding pool in 2021 and beyond to no more than 12%
Maximum upside and downside adjustment equal to funding pool % (e.g. +/- 4% in 2019)
Professionals will be measured on:
Quality
Resource use
Clinical practice improvement activities
EHR MU
Encouraging provider participation in APMs
APM participating providers exempt from VBP; receive annual 5% ( )
Significant share of revenues must be from APM with 2-sided risk and quality measurement
Reimbursed according to payment arrangements of model
ANTHEM PROPRIETARY AND CONFIDENTIAL
Source: Premiere

7. “Change Concepts”: 10 Building Blocks
"Change concepts" are general ideas/directions for transforming a practice to stimulate
specific, actionable steps that lead to improvement. (Wagner et al, 2012; Commonwealth Fund)
Insights from PCPCC Accredidation Work Group
Demonstrating value & performance (continuous commitment to and skill at ongoing measurement of quality, costs, patient experience, organizational performance)
Access (acute/urgent care appointments, non-traditional hours, telehealth, someone on the care team who has patient information 24/7, interoperable EHR)
Process to include patients as partners (in quality improvement, care design, patient and family engagement, evaluation, peer support)
Population health management (empanelment, risk stratification, data-driven technology, evidence-based care guidelines, social determinants, health literacy, shared care planning)
Organized teams provide comprehensive care to include behavioral health support, health coaching, care coordination, shared decision making
Organizational Culture Change (leadership commitment, leadership skill in change management, coaching and developing the team, satisfied patients and staff, operational efficiency)
Bodenheimer et al (2014)

8. The Care Model

9. Medical Practice vs. Leadership Practice (Gordon Barnhart, O’Brien Group)
Physician
Leader
Prescribe and expect compliance
Immediate and short term focus and results
Procedures and/or episodes
Relatively well-defined problems
Consistently effective solutions, protocols, best practices, processes
Increasing focus on specialization
Focus on patient’s interests
Working with a person or family
Being “the” expert
Relating primarily to the physical being
Relating to sick/injured people
Working solo or with small teams
Receiving lots of thanks
Respect and trust of colleagues
Lead, influence and collaborate
Short, medium and long term focus and results
Complex processes over time
Ill-defined and messy problems
Frequent environmental shifts requiring complementary changes in solutions, processes, best practices, style and approaches
Increasing need for comprehensive and integrated approach
Focus on patients’ interests
Working with many diverse stakeholders
Being one of many experts
Relating to whole beings
Relating to healthy people
Working with larger teams and complex networks
Encountering lots of resistance
Suspicion of being “a suit”

10. Physician vs. Team Physician Self-sacrifice Physician-driven care
Individual hero
Ownership: “my patient”
Full control
Lone expert
Team
Building relationships
Collaborative health workers
Well-being of all team members
Collaborative responsibility: “our care”
Shared control
Team expertise

11. Important Components Align stakeholders Workflows Team based
Patient engagement
Technology
Physician engagement
Effectiveness

12. Risk Stratification Process1 2 3
Identification of Patients by Payor/ Program
Stratification of Patients by Risk
Allocation of Resources by Skill Set/Type of Intervention
Rising Risk
Moderate Risk
Low Risk
High Risk
# Chronic Conditions
Health Care Utilization
Clinical Risk
Social Risk
Behavioral Risk
Source: Mount Sinai Health System , Managing High Risk Populations - Adding Value While Aligning Care Coordinators, Patients and Physicians , slide 14

13. Value Based Payment vs. FFS Volume

14. Value Based Payment vs. FFS Volume

15. Isn’t the second pie bigger? No.
Total Cost PMPM
Advanced Practices
$479.30
Behavioral Health Payments
$4.35
Total
$482.85
Conventional Network Average
$505.83
Risk Normalized Difference
-4.54%

16. “The best way to predict the future is to invent it.”
~ Peter Drucker