1. Pay-for-Performance in Nursing Homes SUMR Presentation Mentor: Rachel Werner

2. Theory People respond to incentives. Current system: payment based on services/quantity, not health/quality Final goal of health care system: improve health Under P4P: Providers are rewarded for meeting pre-established targets in quality of care they deliver

3. Nursing Home Residents 2006: 1,375,661 Nursing Home Residents

4. States with P4P NH Program Red = Currently running P4P Pink = Planning

5. Types of Measures Staffing Levels Clinical Measures Resident Satisfaction Administrative Costs Medicaid Utilization Ratio Deficiencies

6. Models for Financial Incentives Attainment – establish a target level of performance (Payment > 80% Staff Retention) Ranking – measures performance against other providers (Payment > top 10%) Improvement – Payment for achieving improvement over previous period. Continuous – Payment each time appropriate care is delivered.

7. State Survey Results - Measures StateStaffing Levels Clinical Measures Resident Satisfaction DeficienciesUtilization Ratio IowaXXXX OklahomaXXXXX KansasXXX GeorgiaXXXX OhioXXXX MinnesotaXXXX

8. State Survey Results - Payment StateAttainmentRankingImprovementContinuous IowaXX OklahomaX KansasXX GeorgiaXX OhioX MinnesotaX

9. Iowa 1.Deficiency-free survey (2 pts) 2.Regulatory compliance with survey (1 pt) 3.Nursing hours provided (2 pts max) – 2 pts for >75 percentile 4.Resident satisfaction (1 pt) - >50 th percentile 5.Resident advocate committee resolution rate (1 pt) - > 60 th percentile 6.High employee retention rate (1 pt) - > 50 th percentile 7.High occupancy rate (1 pt) – at or above 95 th 8.Low administrative costs (1 pt) - >50 th percentile 9.Special licensure classification (1 pt) 10.High Medicaid utilization (1 pt) - > 50 th percentile  7 pts and higher: 3% increase in daily per diem reimbursement raet.  5-6 pts: 2% increase  3-4 pts: 1% increase Started: July 2002

10. Bigger Question Does P4P affect health outcomes in nursing homes? – Difference between Nursing Home and Hospitals? – Effect on health disparities?

11. The Road to Universal Health Care: A Look at Singapore Mentor: Arnold Rosoff

12. Singapore A rich history of public-funded health A strong Confucian philosophy Solidarity

13. The Singapore Model By the Numbers Infant Mortality2.30 per 1,0000 (1 st ) Life Expectancy81.8 (3 rd ) %GDP spent on Health Care3-4% WHO Ranking 6 th (out of 191)

14. Consumer-Directed Health Care The Republican “Ace in the Hole” Focuses on individual responsibility A free market solution for health care  Competition – drives down prices  Individual Choice – eliminates moral hazard

15. The Singapore Model Medisave (Medical Savings Accounts)  6 – 8 % of income is placed in a personal MSA.  Administered by the Central Provident Fund (CPF)  Rolls over from year to year Medishield (Catastrophic Medical Insurance)  Vast majority of Singaporeans buy in.  Low premiums, widely transparent benefits Other ‘safety nets’  Eldershield  Medifund

16. The Singapore Model Lowering Costs: Moral Hazard or Rationing?  Limits on everything: from drugs to MSA withdrawals  Moral Hazard Myth? e.g. Hospital Wards Responsibility: Individual or Family?  MSA funds – cover immediate family members

17. Additional Issues Means Testing  Screening applicants based on income/wealth to determine subsidies  Very unpopular – hot political issue Health Disparities  Haves vs. Have-nots? Rise of private insurance  Adverse selection

18. Singapore: A Model for the US? Distrust in the government Focus on individual Unwillingness to ration

19. Special thanks to the following people for their generous support: The University of Pennsylvania Provost’s Diversity Fund The Center for Health Equity Research and Promotion (CHERP) Pennsylvania Department of Health Office of Health Equity Arnold Rosoff and Rachel Werner SUMR and LDI