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One foot in two canoes: Preparing for Value-Based Care in a Fee-Sor-Service World Strategic Healthcare Partners, LLC
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Agenda Define Value-Based Care (VBC)
Why Should I care? Define Value-Based Care (VBC) Address quality-based difficulties Anticipate impact Market Realities National, Regional, and Local VBC Trends Perspectives What’s Happening Now? What’s the Strategy Prepare for quality/VBC despite Fee-For-Service constraints Keys To Value-Based Care Success Value-Based Care Game plan Tying the phrases VBC & ‘Quality’ early on
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First and Foremost There is no easy-button for defining value-based healthcare, understanding it, and implementing an effective strategy, especially in a FFS dominant market 1 Health Affairs
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Value Equation Start with a basic high level conceptual definition, but then lead into the various definitions…
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VBC Defined Cleveland Clinic
Value-based care is simply the idea of improving quality and outcomes for patients. Reaching this goal is based on a set of changes in the ways a patient receives care. We’re looking to make healthcare proactive instead of reactive, preventing problems before they start. Revenue Cycle Intelligence Value-based care is a form of reimbursement that ties payments for care delivery to the quality of care provided and rewards providers for both efficiency and effectiveness. CMS Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for. Value-based programs also support our three-part aim: Better care for individuals, Better health for populations, Lower cost. UVA Sponsored – State Healthcare Cost Containment Committee Report (2014) The goal is straightforward but ambitious: Replace the nation’s reliance on fragmented, fee-for-service care with comprehensive, coordinated care using payment models that hold organizations accountable for cost control and quality gains. All this to emphasize the first bullet on the next slide….no single definition.
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Defining Value Based Care
Value Based Care has no single definition At its most basic, VBC is ‘intended’ to be improved outcomes for less money. Who’s Doing the Defining – Patients / PCP’s / Specialists / Payors / Health Systems ? Variables: Type of population: Medicare/Medicaid/Commercial Type of Insurance: HMO, PPO, Narrow Network Type of Provider: PCP, Specialist, Hospital Market environment / pulse
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VBC Defined By and For Who?
Patients Ideally: Efficient patient-centered care with organized dedicated care team for chronic conditions. Realistically: Increased consumerism, transparency, out-of-pocket burden, and network understanding. Primary-Care Providers Ideally: Reimbursement built upon effectiveness of care, open to nontraditional service offerings rather than reimbursement reliant on (burnout inducing) office-visit maximization. Realistically: More coding expectations, complicated attribution models, ‘population health’ demands likely to occur ahead of resource capacity to handle shifting priorities. Who’s doing the defining: Patients Ideally: efficient patient-centered care with organized dedicated care team for chronic conditions. Realistically: increased expectations of consumerism, transparency, out-of-pocket burden, and network understanding. Primary-Care Providers Ideally: reimbursement built upon effectiveness of care, open to nontraditional service offerings rather than reimbursement reliant on (burnout inducing) office-visit maximization. Realistically: more coding expectations, complicated attribution models, ‘population health’ demands likely to occur ahead of resource capacity to handle shifting priorities. Specialists Ideally: payment bundles that enhance presurgical and post-acute care pathways, ultimately improving the patient experience and outcomes. Realistically: practice variation scrutiny including focus on financial outcomes outside of the specialists capacity to influence. Health Systems Ideally: contracting options that reward high quality, low value care driven by centralized data resources. Realistically: compounding pressure to provide ‘value’ to all other entities by executing data-driven strategic initiatives often utilizing data that is often inaccurate or incomplete, and usually difficult to interpret. Payors Ideally: big data capabilities to pressure providers into reducing “low value” care that results in high utilization of unnecessary services through shared savings programs. Realistically: more narrow networks, continued prior authorizations, and high likelihood of complicated quality program rollouts. Chronically Ill Ideally: high quality integrated care with prospective outreach. Realistically: screening programs, increased reliance on patient portals and more outreach from provider organizations. 1 Understanding Value-Based Healthcare
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VBC Defined By and For Who? Cont’d
Specialists Ideally: Payment bundles that enhance presurgical and post-acute care pathways, ultimately improving the patient experience and outcomes. Realistically: Practice variation scrutiny including focus on financial outcomes outside of the specialists capacity to influence. Payors Ideally: Big data capabilities to pressure providers into reducing “low value” care that results in high utilization of unnecessary services through shared savings programs. Realistically: More narrow networks, continued prior authorizations, and high likelihood of complicated quality program rollouts. Who’s doing the defining: Patients Ideally: efficient patient-centered care with organized dedicated care team for chronic conditions. Realistically: increased expectations of consumerism, transparency, out-of-pocket burden, and network understanding. Primary-Care Providers Ideally: reimbursement built upon effectiveness of care, open to nontraditional service offerings rather than reimbursement reliant on (burnout inducing) office-visit maximization. Realistically: more coding expectations, complicated attribution models, ‘population health’ demands likely to occur ahead of resource capacity to handle shifting priorities. Specialists Ideally: payment bundles that enhance presurgical and post-acute care pathways, ultimately improving the patient experience and outcomes. Realistically: practice variation scrutiny including focus on financial outcomes outside of the specialists capacity to influence. Health Systems Ideally: contracting options that reward high quality, low value care driven by centralized data resources. Realistically: compounding pressure to provide ‘value’ to all other entities by executing data-driven strategic initiatives often utilizing data that is often inaccurate or incomplete, and usually difficult to interpret. Payors Ideally: big data capabilities to pressure providers into reducing “low value” care that results in high utilization of unnecessary services through shared savings programs. Realistically: more narrow networks, continued prior authorizations, and high likelihood of complicated quality program rollouts. Chronically Ill Ideally: high quality integrated care with prospective outreach. Realistically: screening programs, increased reliance on patient portals and more outreach from provider organizations. 1 Understanding Value-Based Healthcare
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So, Essentially…
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However… All roads lead in and out of the billing department…
All tenants of value-based care directly tie to medical coding Quality Measures almost certainly rely on coding specifications Population-based metrics such as diabetes “Hemoglobin A1c Poor Control” patient populations are defined by diagnostic coding Compliance is almost entirely calculated by coding specifics Hierarchical Condition Categories (HCC) tie payment rates directly to diagnostic coding All forms of similar patient risk-stratification models depend on coding specificity Chronic Care Management Services and all attribution-models rely heavily on certain coding patterns
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Industry Trends Theory: Taking on risk will incentivize change.
CMS Administrator slams non-risk bearing ACOs MACRA rollout effectively hustles people from MIPS into Advanced APMs Hierarchical Condition Categories (HCC) Risk-stratified payments solidify Partnerships Partnership to Empower Physician-Led Care (PEPC) PEPC Objectives: Development of physician-led APM’s An equitable feasible policy and framework for independents Opportunities in MA and other commercial markets Assisted with the ‘consumerism’ of healthcare delivery Payer Acquisition/IT Consolidation Aetna/CVS Merger IBM Watson Acquisition of Phytel, Truven Analytics, Merge Healthcare Allscripts Acquisition of McKesson Accreditations NCQA Population Health Accreditation Theory: Taking on risk will incentivize change. Reordered based on importance. PEPC: Advocacy group formed in 2018 to support solo practices in the transition to VBC. Six provider organizations – Aledade Inc., American Academy of Family Physicians (AAFP), California Medical Association (CMA), Florida Medical Association, MGMA, and Texas Medical Association / Practice Edge.
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National Trends Easy quick graph
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National Trends Another quick lead-in graph
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National Trends DHS / CMS Response
To combat, CMS goals of having traditional FFS payments linked to VBC models by Some of the common models listed below: Accountable Care Organizations (ACO’s) MIPS Alternative Payment Models (APM) Comprehensive Primary Care Plus (CPC+) Bundled Payments (i.e. Episode-based payment) Bundled Payments for Care Improvement Advanced Program (Oct 1, 2018 launch date) Pay For Performance (Hospital Value-Based Purchasing) “The healthcare system is complex, and we enter into this challenge open-eyed about the degree of difficulty,” said Jeff Bezos, Amazon founder and CEO. “Hard as it might be, reducing healthcare’s burden on the economy while improving outcomes for employees and their families would be worth the effort. Success is going to require talented experts, a beginner’s mind, and a long-term orientation.” “Our people want transparency, knowledge and control when it comes to managing their healthcare,” said Jamie Dimon, Chairman and CEO of JPMorgan Chase. “The three of our companies have extraordinary resources, and our goal is to create solutions that benefit our U.S. employees, their families and, potentially, all Americans,” he added.
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National Commercial Trends
United Healthcare CEO plans to move from 15m ‘value-based’ covered lives to 150m by UHC VBC contracts reduced hospitalizations by 17% and costs by 8%. BCBS is scaling their VBC operations up into a network now covering 19 million beneficiaries. BCBS touts a 35% decrease in costs and improved provider performance above national standards of care. National Business Group on Health Survey 26% of large employers are considering offering ACOs by 40% of large employers have already incorporated value-based benefit designs. Amazon, JPMorgan, and Berkshire Hathaway partner up to ‘address the health needs of their employees.’ “The healthcare system is complex, and we enter into this challenge open-eyed about the degree of difficulty,” said Jeff Bezos, Amazon founder and CEO. “Hard as it might be, reducing healthcare’s burden on the economy while improving outcomes for employees and their families would be worth the effort. Success is going to require talented experts, a beginner’s mind, and a long-term orientation.” “Our people want transparency, knowledge and control when it comes to managing their healthcare,” said Jamie Dimon, Chairman and CEO of JPMorgan Chase. “The three of our companies have extraordinary resources, and our goal is to create solutions that benefit our U.S. employees, their families and, potentially, all Americans,” he added.
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1 Understanding Value-Based Healthcare
Marketplace Trends “New Money” Physician Scorecarding GA Market Saturation: VBC saturation is low; especially south of Macon. Emphasis on Primary Care Models: Payers do not understand / appreciate how specialists move the dial. “We don’t know what we don’t know” - Plan infrastructure is lacking with the payers as much as providers; resulting in an issue with the “flow of dollars.” Should your $1m incentive actually be $2m……? Proper capturing and subsequent payment of codes submitted to payors. Partnerships are key, whether it’s ACOs, software providers, other networks, etc. 1 Understanding Value-Based Healthcare
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What’s Happening Now – The Providers Perspective
Black Book 2018 Study: Study of 877 physician organizations / practices 93% have no plan for population health or VBC and no in-house expertise to help with transformation 95% do not believe they have the proper IT infrastructure, analytics, or staff to support VBC 88% of the Practice Managers stated their practices are not prepared for the impact of VBC Oliver Wyman Report: 22 payer-provider partnerships in 1Q 2018 with a trend towards co-branded or JV. 44 such arrangements in 2017 total 90% of payer-provider initiatives over the past two years have included value-based reimbursement as a component National Business Group on Health: 40% of employers surveyed have incorporated some type of value-based design in their benefit plans Evidence displayed with IBM Watson and AHRQ data the impact admission rates and decline in hospital-acquired conditions
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What’s Happening Now – What Payors are saying
Change Healthcare / ORC International (Survey released 6/18/2018): Included 120 payers including Managed Medicare, Managed Medicaid, and commercial plans. Pure fee-for-service now accounts for 37% of reimbursement, a figure expected to go below 26% by 2021. Almost 80% reported quality improvements. Only 21% of payers claimed they were capable of rolling out a new episode of care program in three to six months. Over 33% of payers claimed they need up to a year to launch a new program. 13% said they need up to 24 months or more. 43% to 58% reporting it is very or extremely difficult to generate interest among providers to participate, to agree on episode definitions and gain consensus on budgets, risk/gain sharing and performance metrics. 66 % of payers plan to invest in administrative staff to support future growth of episode-of-care programs. Over 50% of payers are not very satisfied with their current value-based analytics, automation, and reporting capabilities.
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What’s Happening in the RHC world
National Advisory Committee on Rural Health and Human Services Aimed to revise the 30 year old statutory authorization that is not in line with today’s market. Policy Brief & Recommendations: Modernizing Rural Health Clinic Provisions. 6 Key Recommendations - #2 Program Support: To provide grants to State Offices of Rural Health to support a state program that would provide technical assistance on quality reporting and other services to support the transition of RHC’s to value-based care. FQHC’s and RHC’s not set up to participate effectively in the redesigned payment and delivery system focused on quality and value / cost as the determinant of payment. Not prepared to take on risk and/or not seen as viable partners to larger organizations such as ACO’s or CIN’s. RHC’s lack the administrative capacity to respond to such changes and culture shifts.
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What’s Happening in the RHC world – NQF
The NQF's Measure Applications Partnership (MAP) Rural Health Workgroup Identify over 59 million Americans, 19% of the population live in rural areas These diverse, sparsely populated regions require customized measures, defined as “rural relevant They recommend these quality measures should be: Cross-cutting (not condition- or procedure- specific) Resistant to low-case volume Care transition focused They’re May 2018 draft report, widely known, of course, as the “ MAP 2018: Recommendations for a Core Set of Rural-Relevant Measures for Hospitals and Selected Ambulatory Care Settings and Measuring and Improving Access to Care” Redirected focus on the following issues pertinent to rural regions: Mental Health Substance Abuse Medication Reconciliation Diabetes, hypertension, and chronic obstructive pulmonary disease (COPD) Hospital readmissions Perinatal and pediatric conditions and services The NQF has launched an initiative to better understand the challenges rural providers face in reporting on quality measures and engaging in quality initiatives. You better joke about how ridiculously long their report name is.
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How to prepare? The NQF has launched an initiative to better understand the challenges rural providers face in reporting on quality measures and engaging in quality initiatives. You better joke about how ridiculously long their report name is.
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Rural Relevant Sample Quality Performance Scorecarding
First get familiar – Performance Scorecarding Using rural-relevant measure recommendations. Different metrics have different eligibility requirements These metrics are becoming very common across the industry Eventually weighted payment values will be tie PMPM reimbursement to performance
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Sample Quality Reporting Cont’d
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CMS' Desired Path to VBC Fee For Service Shared Savings
Reactive “What brings you in today?” Visit-Based Dominant Population Assessed “Who is our attributed patient population? Predictive “Who do we need to outreach to prevent poor outcomes?” Fee For Service Shared Savings Bundled Payments Partial Capitation Global Payments Reactive – Symptomatic, acute care, unit-based payment, no financial ‘risk’ Population Assessment – Episode focused, common conditions, efficiency-based, partial financial risk Predictive – Population health, outcome-based, full financial risk
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Quality Game plan Identify your starting line
Which payors, if any, need quality data? Which metrics overlap? Create yourself a simple matrix. What quality metrics can your practice automate both technically and logistically? Specify your internal target(s) What are your performance goals? 50% in year one, 80% in year two? Ultimately – every patient, every time? What are your related reimbursement/contracting goals? Continuously re-define clinical workflow Outreach? Team-based care approach? Pre-visit prep? Time constraints? The key is to bring upfront REALISTIC definitions. Vague or undefined objectives lead to unnecessary wheel-spinning, stress, and ambiguity
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Short Term Initiatives
Value-Based Playbook Focus (FFS) Patient Loyalty Drive Accessibility & Efficiency Prepare (FFV) Specify Quality Goals Track ‘Care Gaps’ Uncover barriers Revisit clinical workflow Monitor Leverage existing IT Address clinicians’ pain points Build on ‘Easy Wins’ Long Term Stability Short Term Initiatives Each gear can fit FFS, to FFV, to Financial Stability (Focus=FFS), (Prepare=FFV), (Monitor=Bottom Line) Focus on what you can control. Not the headline, regardless of FFS or FFV, craft your 1-3 year objective to remain agnostic to payment method while crafted to thrive in either There still is no ‘That was easy button’
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Real end to end value based transformation requires:
Keys to VBC Success Real end to end value based transformation requires: Education – Key measures, your EMR capabilities, partnership opportunities, MIPS Technology optimization & support - actionable data and analytics Scorecard internal performance Staff training Provider engagement Culture change Patient engagement / communication / satisfaction Community and clinical collaboration Expect change to be slow. VBC Readiness Tool - Assessment tools, such as the University of Iowa Rural Health Value Assessment Tool, can help states and RHCs better understand existing capacity for value-based purchasing. This online tool helps the organization assess readiness for the shift of healthcare payments from volume to value. The resulting report may be used to guide the development of action plans. Patient engagement Behind renaming of MIPS component to “Promoting Interoperability” AHIMA Survey 82% in 2017, increased from 5% in 2013 33% view lab results, 22% request appointments, 19% Rx refills 52% of patients were offered access in 2017 vs 42% in 2014 63% access at the prompting of their provider BNJ Quality & Safety – Better patient to provider communication and higher patient satisfaction can reduce hospitalization likelihood by 39%
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Thank You Jason Crosby jcrosby@shpllc.com (912) 691-5711
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