William Shrank: Payment reform activities at CMS

William Shrank, MD MSHS

Division of Pharmacoepidemiology and Pharmacoeconomics

Harvard Medical School

Brigham and Women’s Hospital

An Update on Payment Reform

Activities at CMS and How Data

Analytics and Rapid-Cycle

Evaluation Support Transformation

The Innovation Center

The charge: Identify, Test, Evaluate, Scale

“The purpose of the Center is to test innovative

payment and service delivery models to reduce

program expenditures under Medicare, Medicaid,

and CHIP…while preserving or enhancing the

quality of care furnished.”

“preference to models that improve the coordination, quality, and

efficiency of health care services.”

Resources: $10 billion funding for FY2011 through 2019

Opportunity to “scale up”: The HHS Secretary has the

authority to expand successful models to the national level

Innovation Center Initiatives

Coordinated Care:

Accountable Care Organizations

Pioneer ACO Model

Advance Payment ACO Model

Primary Care/Medical Homes

Comprehensive Primary Care Initiative

(CPCI)

Federally Qualified Health Center Advanced

Primary Care Practice Demonstration

Multi-Payer Advanced Primary Care

Practice (MAPCP) Demonstration

Right Care:

• Partnership for Patients

• Community-Based Care Transitions

• Bundled Payment for Care Improvement

Innovation Infrastructure:

• Healthcare Innovation Challenge

• Innovation Advisors Program

State/Medicaid/Duals:

• State Demonstration to Integrate care for

Dual Eligible Individuals

• Financial Alignment to Support State Efforts

to Integrate Care

• Demonstration to Reduce Avoidable

Hospitalizations of Nursing Facility Residents

• Medicaid Health Home State Plan Option

• State Innovation Models

Preventive Care:

• Million Hearts Campaign

• Strong Start

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Partnership for Patients

Bundled Payment

Pioneer ACOs

Global Payment for Dual- Eligibles

ACOs -Advance Payment

Comprehensive

Primary Care

Innovation

Challenge

Providers can choose from a range of care

delivery transformations and escalating

amounts of risk, while benefitting from

supports and resources designed to

spread best practices and improve care.

Coordinated Care Initiatives

Accountable Care Organizations

• Pioneer ACO Model

• Advance Payment ACO Model

Primary Care/Medical Homes

• Comprehensive Primary Care Initiative (CPCI)

• Federally Qualified Health Center Advanced Primary Care

Practice Demonstration

• Multi-Payer Advanced Primary Care Practice (MAPCP)

Demonstration

The Pioneer ACO Model

GOAL: Test the transition from a shared-savings payment model to a population-based payment.

Designed for health care organizations and providers that are already experienced in coordinating care.

Focused on improving the health and experience of care for individuals, improving population health, and reducing the rate of growth in health care spending.

CMS will publicly report the performance of Pioneer ACOs on quality metrics.

Awardees announced, programs have begun

Advance Payment Model

GOAL: Test whether pre-paying a portion of future shared savings will

increase participation and success of physician-based and rural ACO’s in

the Medicare Shared Savings Program.

Three ways in which participating ACOs may receive payment:

1. Upfront fixed payment

2. Upfront payment based on number of Medicare

patients served

3. Monthly payment based on number of Medicare

patients

Application deadlines were consistent with Medicare Share Savings

Program.

GOAL: Test a multi-payer initiative fostering collaboration

between public and private health care payers to strengthen

primary care.

• Requires investment across multiple payers, because individual health plans,

covering only their members, cannot provide enough resources to transform

primary care delivery.

CMS has invited public and private insurers to collaborate in purchasing high

value primary care in communities they serve.

• Medicare will pay approximately $20 per beneficiary per month (PBPM) then

move towards smaller PBPM to be combined with shared savings opportunity.

• 7 markets selected where majority of payers commit to investing in

comprehensive primary care; approximately 75 practices per market.

Comprehensive Primary Care initiative (CPCi)

Multi-payer Advanced

Primary Care Practice Model

GOAL: Test the effectiveness of offering providers a common

payment method from Medicare, Medicaid, and private health plans.

Medicare will participate in existing State multi-payer health reform initiatives.

• Must include participation from Medicaid and private health plans.

Monthly care management fee for beneficiaries receiving primary care from

Advanced Primary Care practices.

Eight states selected: Maine, Vermont, Rhode Island, New York,

Pennsylvania, North Carolina, Michigan and Minnesota.

Federally Qualified Health Center

Advanced Primary Care Demonstration

GOAL: Evaluate impact of the advanced primary care practice

model in the Federally Qualified Health Center (FQHC) setting.

Open to FQHCs that have provided medical services to at least 200 Medicare

beneficiaries in previous 12-month period.

FQHC receives care management fee for each Medicare beneficiary enrolled.

Striving to meet NCQA level 3 medical home status.

500 FQHCs were selected.

Performance year started Nov 1st 2011.

Right Care Initiatives

• Partnership for Patients

• Community Based Care Transitions Program

• Bundled Payment for Care Improvement

Improving Patient Safety

GOAL: Testing intensive programs of support hospitals as they

make care safer.

• Provide training, support, and technical assistance for hospitals and other

care providers.

• Establish and implement a system to track and monitor hospital progress

towards attaining quality improvement goals.

• Engage patients and families in the process of improving patient safety.

• Establish a network of “Vanguard Hospitals” to work on new ways to

reduce all-cause harm in hospitals.

$500 million for hospitals and other providers to improve patient safety.

Awards given in the late 2011.

Partnership for Patients:

Better Care, Lower Costs

New nationwide public-private partnership to tackle all forms of harm to

patients.

GOALS:

40% Reduction in Preventable Hospital Acquired Conditions over three years.

1.8 Million Fewer Injuries

60,000 Lives Saved

20% Reduction in 30-Day Readmissions in Three Years.

1.6 Million Patients Recover Without Readmission

$35 Billion Dollars Saved in Three Years

Over 3,800 hospitals have signed pledge.

Community-based Care

Transitions Program (CCTP)

$500 million available for community-based organizations partnered

with hospitals to reduce 30-day hospital readmissions.

GOALS:

• Improve transitions of beneficiaries from inpatient hospitals to home or

other care settings.

• Reduce readmissions for high risk beneficiaries.

• Document measurable savings to the Medicare program.

Bundled Payments for Care

Improvement

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Innovation Infrastructure

• Healthcare Innovation Challenge

• Innovation Advisors Program

Health Care Innovation

Awards

To identify and support a broad range of innovative service delivery

and payment models that achieve better care, better health and lower costs

through improvement in communities across the nation.

Round 1: Around $900 million committed, with individual awards ranging from

approximately $1M to $30M.

Innovation Advisors

Program

GOAL: Support the Innovation Center’s development

and testing of new models of payment and care delivery

in their home organizations and communities.

•Opportunity to deepen key skill sets in:

o Health care economics and finance

o Population health

o Systems analysis

o Operations research and quality improvement

1 year commitment; 6 months of intensive training.

Up to $20K Stipend available to home organizations.

Up to 200 individuals will be selected within the first year.

For further information, see: www.orise.orau.gov/IAP

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State/Medicaid/Duals

Initiatives

• State Demonstration to Integrate Care for Dual Eligible

Individuals

• Financial Alignment to Support State Efforts to Integrate

Care

• Demonstration to Reduce Avoidable Hospitalizations of

Nursing Facility Residents

• Medicaid Health Home State Plan Option

Financial Models to Support State

Efforts to Coordinate Care for

Medicare-Medicaid Enrollees

GOAL: Align financing and improve care for dual eligible

populations

Two models:

Capitated Model

• State, CMS, and a health plan enter into three-way contract.

• Health plan receives a prospective blended payment.

Managed Fee-for-Service Model

• State and CMS enter into an agreement.

• State could benefit from savings resulting from initiatives designed to

improve care for dual eligible beneficiaries.

All states that meet program standards and conditions will have the option to

pursue either or both of these models.

CMS State Innovation Models

Purpose : To test whether new payment and service delivery

models will produce greater results when implemented in the context

of a state-sponsored Comprehensive Health System Transformation

Plan.

States are expected to:

Apply all state policy levers, including things such as scope of practice

credentialing, provider licensing, public health activities;

Ensure multi-payer participation in new integrated payment and service delivery

models;

Drive transformation of state hospitals and medical schools;

Coordinate multiple ACA-supported activities, including insurance exchanges,

CMMI models, and Medicaid waiver activities; and,

Promote prevention and integrate community health services to address the

determinants of poor health.

Preventive Health: Strong Start

Strong Start I A nationwide public awareness effort working to improve the health of moms and

babies by encouraging mothers and practitioners to let labor begin on its own: CMMI based initiative

Goal: Reduce incidence of early elective deliveries (scheduled induction or cesarean without medical indication before 39 weeks)

Strong Start II MIHOPE-SS (home visiting through Nurse Family Partnership and Healthy

Families America) HRSA project with ACA mandate; evaluation funds from CMMI

Three approaches to enhanced prenatal care: CMMI based initiative

Goal: Reduce incidence of preterm birth among high risk Medicaid beneficiaries

Preventive Care Initiatives

• Million Hearts Campaign

Rapid-Cycle Evaluation

“Be part of the solution”: Gather information and leverage

our claims data to promote and support continuous quality

improvement in the marketplace.

Speed: Improve our data systems and our ability to use data so

that we can frequently and rapidly assess effectiveness and

provide feedback to providers.

Rigor: Use advanced epidemiologic methods to measure

effectiveness to meet a high standard of evidence and allow for

certification.

No “Turnkey” Solutions

The models require fundamental changes

in the structure of healthcare delivery

Realigning incentives for health systems,

primary care, hospitals, home-care

Substantial learning and adaptation will be

necessary before achieving the greatest

efficiencies

Healthcare delivery in these models will be

maturing once implemented

RCTs not feasible in most cases

Blurring the Lines Between Formative

and Summative Evaluation

Feedback to clinicians includes

comparisons against controls and other

participants

Impact assessments early after

implementation in hopes of identifying and

scaling successful programs as soon as

possible

Key Features of Formative

Evaluation and Feedback

Understand the context: Gather qualitative data from providers

and health systems to assess perceptions/barriers/enablers of

success

Study the process: We will ask providers to report how they

implement different models

Regularly measure performance: Frequently apply automated

measurements of effectiveness using claims data

Developing capacity to perform these analyses faster

in-house

Key Features of Formative

Evaluation and Feedback

Provide frequent feedback and reports to

providers/systems:

Collaborate with Learning and Diffusion team to deliver

data to providers in ways that can be easily interpreted

Deliver data to promote more helpful self-evaluation

Develop learning collaboratives to spread effective

strategies for each model as well as to identify failing

approaches

Summative Evaluation – Speed

without Sacrificing Rigor

Program Design: Evaluation team participates in all

phases of design

Sample selection for intervention (generalizability)

Availability of control groups

Sample size (power)

Measurement:

Standardized priority outcome metrics across models

Unique metrics for each intervention

Patient and provider experience metrics

Develop population-based metrics; equity; access

Specific metrics unintended consequences

Summative Evaluation – Speed

without Sacrificing Rigor

Methods: Time-series analyses that allow us

to assess both changes in level and slope of

improvement

Includes transition phase to account for time to

“learn”

Partnership: Communicate early and often

with the actuaries

Consider how soon we can expect changes and

when a model can be deemed certifiable

New Methods

Automating and improving performance

reporting

Selecting comparison groups

Aligning, improving and harmonizing measures

Establishing clear thresholds for evidence

standards needed to scale models

Developing a “kill switch” for failing programs

Disentangling multiple program effects

Adjusting for multiple sources of selection bias

Primary Goal: To Promote

Value in Healthcare

At the core of our models a fundamental

realignment of incentives to promote:

Improved Quality

Greater Efficiency

Less Waste and Variability

And NOT Greater Volume