Value Based Reimbursement: The New Reality

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Value Based Reimbursement: The New Reality


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Objectives

Definitions

Measures for 2015

Results

Challenges

MedPAC recommendations

Discuss latest announcements on Value Based1

Status of CMS programs2

Preparation for VBP3



From 2015 Health leaders media industry survey

Survey Results

10%

28%

33%

6%

11%

4%3%

4%

0%

5%

10%

15%

20%

25%

30%

35%

Not pursuing Investigating Pilot underway Pilot done,rollout notscheduled

Pilot done,rollout

scheduled

Rollout nearlydone

Full rollout Do not know

Organization Status on Value Based Payment

N=580

http://www.healthleadersmedia.com/slideshow.cfm?cont

ent_id=312213&pg=2© 2015 Health Leaders Media

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Kaufman Hall Survey Update April 2015

Announcements

22%

42%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Aug 14 Feb 15

7%

22%

0%

5%

10%

15%

20%

25%

Aug 14 Feb 15

Hospitals Currently >10% Value BasedHospitals Expectation Within 24 months

>50% Value Based

Source: Kaufman, Hall & Associates, LLC, Media release, April 2015



Announcements

CMS in January

30 percent of payments will be tied to alternative payment models (ACOs or

bundled payment arrangements) by the end of 2016. Payments related to

these models will increase to 50 percent by the end of 2018.

85 percent of all traditional Medicare payments will be tied to quality or value

by 2016 and 90 percent by 2018 through programs such as Hospital Value

Based Purchasing and Hospital Readmissions Reduction.

Commercial in January

The Health Care Transitional Task Force stated that 75 percent of their

respective businesses will be operating under value-based payments by 2020.

5



CMS current state

Currently, the nation is at about 50% for value-based

spending, and 20% in bundles, episodes, or ACOs.

"We have about 30% of Medicare beneficiaries in

Medicare Advantage, 20% in alternative payment

models like ACOs, and growing. The minority of

Medicare patients, right now, are in traditional-fee

for-service," Patrick Conway, MD, CMS acting

principal deputy administrator

6



Announcements

Congress in April 2015

SGR (Sustainable Growth Rate), Repealed and Revamped with Value

Based Purchasing

“Mayo Clinic is pleased with today’s bipartisan action,” President and

CEO John Noseworthy, MD. “Mayo has actively supported the repeal

and replacement of the SGR for years. This ends 17 years of

uncertainty for hospitals and physicians and moves

Medicare towards paying for quality and efficiency. This is important for

patients, taxpayers and long-term solvency of Medicare. The road to

value-based payment will be challenging. We believe the next step

must be to develop performance measures that accurately differentiate

levels of care and complexity of patients.”

7



Improve health and save money

Bruce Broussard, Humana President and CEO

Key to change

8

New paradigm

Take my company. At Humana, results for more than 1

million Medicare Advantage members in pay-for-value

agreements reflected better quality, outcomes and costs:

better HEDIS [Healthcare Effectiveness Data and

Information Set] scores and Star ratings, fewer trips to the

emergency department among our members, and a 19

percent cost reduction.

http://www.businesswire.com/news/home/20141209005894/en/Accountable-Care-Supports-Improved-Population-Health-Results



Poll Question #2

Which would be your preferred payment system

for your organization? 352 respondents

Fee for service – 23%

Bundled payment – 20%

Accountable care organization – 43%

None of the above – 15%

9



MedPAC

Medicare Payment

Advisory Commission

Policy formulation

Recommendations to congress

(March 2015)

Complex and

fragmented system,

multiple coverage,

payments and different

rules for each setting

Payment Reform

Implement more broadly

Coordinate across settings-rate

determined by most efficient

setting to deliver care

Delivery system

reforms

Monitor performance

Adopt on broader scale



Fun Facts

11,000 Baby Boomers are

aging into Medicare daily.

The U.S. population is

about 320 million, which

makes 2015 "the first year

healthcare spending will

reach $10,000 per person,"

according to a Forbes

report.

11

Source: Your Favorite Seuss written and illustrated by Dr. Seuss, Random House, 2014



Measure

12

WSJ: How should quality in health care be measured and are we looking at the

right things?

Scott Wallace, visiting profession at Dartmouth.

The quality programs grew out of two realizations: Health care is unsafe and outcomes

are poor. But there is no single measure of a doctor’s or hospital’s quality that will fix

those problems. Instead, we’re measuring processes. Of the 123 different metrics in

the government’s Hospital Compare website, 102 measure processes. That’s

important, but it has become too burdensome for the benefit it delivers.

http://www.medicare.gov/hospitalcompare/search.html



Core Goals for NQF

13

Align quality measures among all payers

Identify more actionable, meaningful measures

Achieve greater consistency and rigor with consumer information

Leverage new technology and big data to identify and assess

quality metrics

Make sure measure reflect actual clinical quality, not factors like

socioeconomic status that are out of health systems' control

Attribute results to specific providers

Improve consumer engagement

Christine Cassel, MD, President and CEO of

National Quality Forum



Models

14

Payment Methodology Quality Cost

Cost low low

Fee for Service low medium

Per case / outpatient grouping low medium

% of charges low low

Add quality metrics medium medium

Shared savings (+, +/-) medium/high medium/high

Bundled payment low medium/high

Add quality metrics medium/high high

Shared savings (+, +/-) medium/high high

Capitation medium/high high

Add quality metrics high high

Shared savings (+, +/-) high high

Incentive for Improvement



Fee for Service

15

Definition:

Payment received for each “necessary” service, generally

prospective in nature, rates set for each case or grouping

History: Hospital DRGs initiated in 1983 by CMS for

cost control

Inpatient

MSDRG

Outpatient

APC

Professional

Fee schedule



Fee for Service

16

Incentive: Little for quality, ability to keep surplus if

payment above cost

1

23

4

Success

factors

Know your costs

Document severity

Work with providers within

facility

Analytical capabilities



Medicare FFS payments by venue 2008 to 2012

17

OutpatientClinic Care Inpatient SNF Home Hlth Hospice

$ 152 Billion

11.8%372 Billion

28.7%

447 Billion

34.5%

$ 133 Billion

10.3%$ 90 Billion

6.9%$ 48 Billion

3.7%

LTCH/IRF

$ 53 Billion

4.1%

Clinic Care Outpatient Inpatient SNF LTCH/IRF Home Health Hospice

75%



Hospital Medicare Margins

18

-20%

-15%

-10%

-5%

0%

5%

10%

15%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Hospital Medicare Margins

IP OP OverallSource: MedPAC report March 2015



Performance of hospitals

19

Relatively Efficient

(268)

Other (1,846)

Relatively Efficent…Other (1,846)

Number and Share of Hospitals

13%

87%

2%

8%

6%

-6%

8%

5%

-8%

-6%

-4%

-2%

0%

2%

4%

6%

8%

10%

Overall Medicaremargin, 2013

NonMedicare margin,2013

Total margin, 2013

Relativity Efficient Other

Margin

Performance Metrics 2013 Risk Adjusted

84%

97%90%

102% 101% 102%

0%

20%

40%

60%

80%

100%

120%

Composite 30 daymortality

Readmission rates Standardized Mediarecost per disharge

Relatively Efficient Other

There are hospitals with positive

Medicare margins and high quality

results.



High cost, high variability

20



Variation

21



High cost, high variability

22



Inpatient vs Outpatient

23

-20%

-10%

0%

10%

20%

30%

40%

2006 2007 2008 2009 2010 2011 2012 2013

Medicare Per Beneficiary

OP Services per Beneficiary IP Discharges per Beneficiary



Physician Payment in 2013

MedPAC Concerns

24

876,000

Providers

573,000 Physicians

Undervalue primary care

Preserve access

Repeal SGR (Sustainable Growth Rate)

Increase shared savings opportunities



MedPAC survey results

25

0% 10% 20% 30% 40% 50% 60% 70% 80%

Very Satisfied

Some Satisfied

Some Dissatisfied

Very Dissatisfied

Medicare (>65)

Private Insurance (50-64)

Satisfaction with quality of healthcare in 2014

Excludes don’t know, no healthcare in past 12 months

Source: MedPAC telephone survey 2014



SGR Dead, Value Based Plan

2015 to 2019 annual .5% increase

2019 5% bonus for participation in innovate care

delivery model. At least 25% (this threshold

increases over time) of the Medicare revenue from

alternative payment models like patient-centered

medical homes and accountable care organizations.

Streamline the quality report requirements for various

programs like EHR Incentive Programs and

Physician Quality Reporting System(PQRS).

26



Patient Centered Medical Home

27

Demonstrate

6 standards for NCQA

Enhance access and continuity

Identify and manage patient population

Plan and manage care

Provide self-care and community support

Track and coordinate care

Measure and Improve care



Affordable Care Act - 5 years old

Number of new payment models that move the needle further toward

paying health care providers for the quality of the care they give

patients, instead of the quantity of care. In these alternative payment

models, providers have a financial incentive to coordinate care for

their patients and get the right care to the right patient the first time.

Progress

More than 400 Medicare ACOs participating in the Shared Savings

Program and the Pioneer ACO Model have generated a combined

$417 million in savings for Medicare.

Improve the quality of health care, contributing to 50,000 fewer

patient deaths in hospitals due to avoidable harms, like an infection

or medication error, and 150,000 fewer preventable Medicare

hospital readmissions.

28



Hospital Programs- Readmission

29

• Third year of program, 3% maximum penalty

• Conditions: Heart failure, AMI, pneumonia,

hip/knees, COPD, CABG (2017)

• Proposed to expand definition of pneumonia

39 71

428

2,100

840

0

500

1000

1500

2000

2500

-3% -2 to -2.99% -1 to -1.99% -.01 to -.99% 0%

2015 Readmit Penalty



Results

Touting encouraging progress toward improving

quality and lowering healthcare costs, the Centers for

Medicare & Medicaid Services' chief medical officer

attributed a 2% decline in admissions and emergency

department visits.

30



Reduced Heart Failure Readmissions

31

29% reduction in 30-day readmits

14% reduction in 90-day readmits

120% increase in f/u appointments

78% increase in med reconciliation

87% increase in f/u phone calls

84% increase in teach back

http://www.healthcatalyst.com/wp-content/uploads/Academic_Medical_Center_HF_Readmissions_3pg.pdf

http://www.healthcatalyst.com/wp-content/uploads/Academic_Medical_Center_HF_Readmissions_3pg.pdf



Value Based PurchasingBudget Neutral Program

1.75% At risk/Bonus for 2016

32

160

1,541

1,381

7 -

200

400

600

800

1,000

1,200

1,400

1,600

1,800

>1% .01 to .99% .0 to -.99% >-1%

2015 Value Based Purchasing



VBP Clinical Measures

33

Active

Inactive

Key:

FY 2013 FY 2014 FY 2015 FY 2016 FY 2017

AMI-7aFibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival Going away

AMI-8aPrimary Percutaneous Coronary Intervention (PCI) Received Within 90 Minutes of Hospital Arrival

HF-1 Discharge Instructions

IMM-2 Influenza Immunization Going away

PN-3b

Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital

PN-6Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patient

SCIP-Inf-1Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients

SCIP-Inf-3Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time

SCIP-Inf-4Cardiac Surgery Patients with Controlled 6:00 a.m. Postoperative Serum Glucose

SCIP-Card-2

Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period

SCIP-VTE-1Surgery Patients with Recommended Venous Thromboembolism (VTE) Prophylaxis Ordered

SCIP-VTE-2

Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

SCIP-Inf-9Postoperative urinary catheter removal on postoperative day 1 or2

PC-01Elective Delivery Prior to 39 Completed Weeks

Gestation .



VBP- continued

34

Outcome Measures FY 2013 FY 2014 FY 2015 FY 2016 FY 2017

Mort-30-AMI AMI 30 day mortality rate

Mort-30-HF HF 30 day mortality rate

Mort-30-PN Pneumonia 30 day mortality rate

AHRQ PSI compositeComposite for patient safety

CLABSI Cental line blood associated infection

CAUTI Catheter-Associated Urinary Tract Infection

SSI Surgical site infection- colon and abdominal hysterectomy

Efficiency Measures FY 2013 FY 2014 FY 2015 FY 2016 FY 2017

MSPB-1 Medicare spending per beneficiary

Patient experience of care measure FY 2013 FY 2014 FY 2015 FY 2016 FY 2017Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)

Communication with nurses

Communication with physicians

Responsiveness of Hospital Staff

Pain Management

Communication about Medicine

Cleanliness and Quietness of Hospital Environment

Discharge Information

Overall rating of hospital

Propose adding care coordination in 2017



Metric weights by year

Value Based Purchasing

35

70%

45%

20%10% 10%

30%

30%

30%

25% 25%

25%

30%

40% 40%

20% 25% 25%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FY 2013 FY 2014 FY 2015 FY 2016 FY 2017Clinical Process Patient Experience

Outcome Measures Efficiency Measures

AchievementMy hospital compared to all hospitals

ImprovementMy hospital compared to my baseline performance

Hospital National

Measure Baseline Performance Benchmark Threshold Achieve Improve Points

SCIP-1 -prophylactic ABX received w/n 1 hr prior to surgical incision

98.55 99.22 99.98 97.35 7 4 7

Proposed update for 2016

Safety 20%

Efficiency 25%

Clinical process 30%

Patient experience 25%



Hospital Acquired Conditions

36

FY 2014 Final Inpatient PPS Rule

Creates HAC Reduction Program

with two Domain measurements that

overlaps in its entirety with existing

HAC program and VBP.

2015

723 Hospitals received 1% penalty

2016

1% Penalty

Proposed –reweight domain, add

more measures to PSI-90, add more

measures to domain 2



Study at Adventist Health, FL

Researchers found that a patient who suffers

temporary harm during a hospital stay costs the

provider $2,187. If the patient suffers a greater harm,

the cost to the hospital is $4,617.

The Adventist study followed more than 21,000

patients treated by its 24 hospitals between 2009 and

2012. By increasing patient safety and reducing harm

incidents, it was able to save $108 million in total

costs and $18 million in negative contributions to its

margins.

Journal of Patient Safety, March 23, 2015

37



Growing Dollars At Risk- Hospital

38

Source: CMS website

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

2013 2014 2015 2016 2017

Medicare $ At Risk

HAC

Readmit

VBP

MU



PQRS

39

The Physician Quality Reporting

System (PQRS) has been using

incentive payments, and will begin to

use payment adjustments in 2015, to

encourage eligible health care

professionals (EPs) to report on

specific quality measures.

EPs who do not participate in 2013 and

receive a payment adjustment will be

paid 1.5% less than the Medicare

PFS(Physician Fee Schedule) amount

for services provided in 2015.

Increases to 2% in 2016.



Value Based Modifier

Matrix for payments

40

Low cost Average cost High cost

High quality +2X* +1X* 0

Medium quality +1X* 0 -0.5%

Low quality 0 -0.5% -1.0%

*Eligible for additional payments

X value depends on negative adjustments



California Program for Physicians

41

P4P

Began in 2003, public report,

common measures

10 Health Plans, 200 Physician

Groups, 9M members

Focus on measure/improve

quality, costs continue to rise

2013 Transition to Value Based,

Shared savings program for

quality and resource use (cost).



Metrics for Physician Practices

42



American Academy of Orthopaedic Surgeons (AAOS)

43

Across the various meetings, one message rings loud:

there is an increasing need to achieve and demonstrate

value in orthopedics.

The transition from a fee-for-service model towards

value-based care increasingly ties financial

reimbursement to a physician’s performance. As a result,

physicians are calling on their colleagues to play a

greater role in value-based care by employing evidence-

based practices and tracking quality outcomes.

Source: Service Line Strategy Advisor



Bundled Payment

44

Definition: Single comprehensive rate for entire

episode of care generally within defines time limits

and includes all providers of care. Provider takes

accountability for episode.

History: Demonstration projects in 90’s and early

2000’s

Popular with employers

CMS started in 2013



Bundled Payment

45

Incentive: Quality relates to readmissions, ability coordinate care

For example, the Lewin Group recently released the first analysis of

the Medicare bundled payment program. The conclusion was

decidedly inconclusive: “We are limited in our ability to draw

conclusions about the effects of (the Bundled Payments for Care

Improvement program) because of the small sample sizes and short

time-frames.”

Know your

costs, team

includes

clinical and

financial

Know the

conditions

and your

population

Work with

providers to

see big

picture of

care

May be

good

starting

point

Success factors:



Bundled Payment

46

Acute Acute/Post Post Acute

Payment Retrospective Retrospective Retrospective ProspectiveParticipants 3 44 14 37

Organizations 12 2180 4727 17

Episode All acute patients, all DRGsSelected DRGs, hospital

plus post-acute period

Selected DRGs, post-acute

period only

Selected DRGs, hospital

plus readmissions

Services included

in the bundle

All Part A services paid as

part of the MS-DRG

payment

All non-hospice Part A and

B services during the initial

inpatient stay, post-acute

period and readmissions

All non-hospice Part A and B

services during the post-

acute period and readmits.

All Part non-hospice A and

B services (including the

hospital and physician)

during initial inpatient stay

and readmissions

48 Bundled Payment GroupingsMajor joint upper extremity

483 Major joint and limb reattachment procedure of upper extremity with

complication or comorbidity or major complication or comorbidity



Spine

47

Bundled Payment

Covers preoperative to post operative

Results: ALOS 6 to 4.89

Readmit down 14%

IP Rehab 41% to 29%



New programs and payment

Medicare continues to pay the “old” way and do a reconciliation at

the end for ACO/Bundled Payment- Retrospective

Hospital paid based on IP MSDRG and OP APC, fee schedules.

Physician paid on fee schedule.

48

Cost Trend

Benchmark

Actual

Potential

savings



Tracking for bundled payments

49



Capitation

50

Definition: Specific amount paid in advance for all health

care services of a population. Usually paid on a per

member per month (PMPM) basis. Provider has total

accountability and risk.

History: Used by managed care organizations in late

1990’s. Huge consumer backlash. Medicare started new

models in 2012. CMS models:

Pioneer 19 participants

MSSP (Medicare shared Savings) 404 participants

Next generation ACO



Capitation

51

Incentive: Quality metrics and cost benchmarks,

providers can elect upside only or upside and downside

for shared savings.

Know your

costs

Document

severity

Work with

providers

across

continuum

Have good

data for

analysis

Success factors:



CMS ACO results

52

Higher quality, patient

experience than benchmarks

Improvement in quality and

patient experience measures

Generated $417 M in savings for Medicare Qualified for

shared savings

payments of $460 M



Analysis in ACO

53





Framework

54



= Negative Impact = Positive or Negative = Positive Impact

Knowledge Asset

Type

Discounted

FFS Per Diem

Per Case Bundled Per CaseCondition

Capitation

Full

CapitationCMS Commercial CMS Commercial

Workflow

Diagnostic Variation

Standing Orders

Medication Selection

Triage

Patient Safety

Ambulatory Treatment

and Monitoring

Indications for Referral

Indications for

Intervention

Considerations

Workflow

Diagnostic Variation

Standing Orders

Substance Selection

Triage Criteria

Patient Safety

Treatment and

Monitoring Algorithms

Indications for Referral

Indications for

Intervention

25



Poll Question #3

Which payment system best aligns quality and

cost?

Fee for service

Bundled payment

Accountable care organization

None of the above

56



Framework for Value Capture

Category Strategy Example

Change to price setting

mechanism

Value Based Pricing Fasteners

Auction Google adwords

Demand driven pricing Airlines

Name your own price/pay

what you want

Priceline

Change the payer Two sided market 20 Minuten

Change payer in value

constellation

Carbon for water

Internal budgeting Executive education

Change the price

carrier

Change the carrier Netflix

Bundle/unbundle Telecommunication

All inclusive Cruise

Change the timing Installed base pricing Gillette

Futures contracting Presold hotel rooms

Changing the segment Target costing Xiameter

Self-segmented fencing Coupons

57

Source:

Innovation is not

worth much if you

do not get paid for

it.

Stefan Michel

HBR Oct 2014



Preparation/Assessment

58

What is not in alignment metrics, incentives, compensation?

What do we need to learn for new environment?

How do we get there? What is success?

Where do we want to be?

Where are we now with payers, network?



Starting Point

59



$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

2012 2013 2014 2015 2016

Mill

ion

s

Medicaid

Employee group

Medicare advantage

Commercial

4% 5% 6%

15%

17%

60

At Risk Net Revenue to 46% by 2016

29%

Medicare

Shared Savings

At risk- Develop Plan



Contracting strategy. Contracting analysis should be

informed by data-driven criteria, such as:

At-risk tools

Volume “Directability” Alignment

How much member

volume does the

payer have to drive

to your provider

network?

How strong is the

payer’s health

benefit program

gradient (delta

between plan

payment for in-

network vs. out-of-

network services)

How exclusive is

the contract with the

your provider

network?



Transformation accelerators

62

Content Accelerators

Deployment Accelerators

Analytic Accelerators

How do we change?What are we doing?

What should we be doing?



Final questions

Can we measure the value equation both the cost and the quality pieces?

Are we focused on outcomes?

Are we creating value for the patient? Have we eliminated waste?

Do you have a cost accounting system to support this measurement?

Do we triage to least expensive treatment center with best outcomes?

Do we focus on the consumer?

Thanks to Dale Sanders for these ideas.



Choosing Wisely

Wise imaging

Wise medications

Wise labs

Preventative

Care Visits

According to the Institute of Medicine, up to 30% of

healthcare delivered in the U.S. is unnecessary and

may cause harm.

Intermountain Health Care has guides for adults

and children on their website.

Adults:

https://intermountainhealthcare.org/ext/Dcmnt?ncid=52

2448817

Children:


2448814

Underused

Care http://www.choosingwisely.org/





Thank you.

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Value Based Reimbursement: The New Reality

Healthcare

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