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Published byJustina French Modified over 9 years ago
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March 10, 2011
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Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move toward both lower cost and higher quality
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Reduced payment per service, reduced trend/annual rate increases More efficient use of medically necessary services Elimination of unnecessary services Fewer complications/higher cost services due to improved quality and more coordinated care
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Shared savings Resources/support to initiate and maintain Investment in the tools to accomplish Ongoing monitoring and sharing of data Added value to provider, payer and employer/patient
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Payers - ◦ Achieve a savings they can pass on to their customers, investors, providers ◦ Hit metrics they can market – utilization, quality, and cost metrics Providers - ◦ Deliver the tools to better manage utilization ◦ Demonstrate willingness to invest in changes that will ultimately result in savings ◦ Share in savings
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Win-Win Structures ◦ Agreement on Goals that Benefit All Lower cost BEFORE lower reimbursement Improve quality BEFORE increasing reimbursement Common set of metrics and attainable goals Data everyone can trust/rely on Meaningful shared savings – dollars significant enough to generate/maintain interest
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Pay for Performance/Gainsharing Enhanced, data driven, primary care initiatives Global risk, bundled payments and other alternative financial arrangements
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Simple Method to Align and Achieve Physician and Hospital (and Payer) Goals Engages physicians, payments to docs within the year, collaboration/improvements begin immediately Not complicated - data is readily available & accepted as valid Flexible - adapt to special needs of hospital Perfect tool for any start up ACO and other “risk” entities 8
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Many efforts underway aimed at efficiency and quality improvements - BUT ◦ Getting the attention and involvement needed from physicians? ◦ Physicians have a true understanding of their role in achieving the goals – how to hit the benchmarks? ◦ Providers getting the right kind of data, on a regular basis, that give direction on behavior changes? Usually Not…..
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‣ 2006 Managed Care, 2008 Medicare demo ‣ Designed to compensate Physicians who improve quality and implement more efficient inpatient practice patterns ‣ Savings shared with physicians who move toward or hit benchmarks ‣ Upside bonus only, based on individual performance ‣ No change in current billing process or payment (and loss of income factor included in bonus)
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CHP Pay for Performance Basic Framework CHP Pay for Performance Basic Framework All cases severity adjusted to 4 levels using APR-DRGs to account for ‘sicker’ patients. Benchmarks established using CHP actual experience – average cost of the top 25 th percentile (lowest cost) performers. Monies to pay bonus come from hospital savings generated by improvements in efficiency. No savings - no bonuses paid out. Payments withheld from physicians who do not meet quality standards (Core Measures, Infection indicators, Readmission rates, medical record completion, patient complaints etc)
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Preliminary Results – Significant cost reductions and improved quality Shrinking gap between bottom 75 th percentile and top 25 th percentile Greater understanding of data and interest in clinical guidelines – moving toward standardization of care Incentives more closely aligned
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Enhanced, comprehensive data distribution among providers Primary care/patient focused medical home Stratification of high risk patients with directed case management Medical benefit redesign to incent greater compliance Directing patients toward provider networks sharing data/managing patients
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