Employers, Coalitions and
Health System Transformation
Presentation to
Florida Commission on Healthcare and Hospital Funding
Laurel Pickering, MPH
President & CEO
Northeast Business Group on Health
August 31, 2015
Agenda
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Why Employers Matter in Transformation
Coalitions and NEBGH
New York’s Health System Transformation
Commission Topics of Interest
Leapfrog: Transparency of hospital quality
and safety
Transforming Healthcare
Why Employers Matter
• Employers pay for healthcare
• Employers can improve access to high-value care
solutions
• Employers can implement health and wellness initiatives
• Employers can use benefit design
• Employers can engage employees and create a “culture
of health”
• Employers hire numerous vendors to fill gaps in the
system
Supporting Employers as Purchasers:
Regional Business Coalitions:
• Groups of employers within a local or regional community collaborate to
influence their healthcare delivery systems to achieve greater value
• Coalitions began in the early 1980’s; Now more than 50 local and regional
coalitions around the country
• Vary in size, model, and member composition
• Represented in Washington, D.C. by the National Business Coalition on
Health (NBCH)
What do coalitions do?
Education
Leverage
Commercial
Purchasers
Business
Community
Leadership
Products &
Services
Drive Value
And
Improvement
in the
System
Community
Stakeholder
Convenings
Delivery
System
Evaluation
Northeast Business Group on Health
• Represents 70 employers based in New York, New Jersey,
Connecticut and Massachusetts – many are large national, selfinsured employers
• Employer driven and multi-stakeholder: 180 members also include
health plans, providers, benefit consultants, suppliers and other
stakeholders
• Represents about 12 million covered lives
• Use employer purchasing leverage to drive value in the system
• Mission: Empowering our members to drive excellence in health
and achieve the highest value in healthcare delivery and the
consumer experience
NEBGH Employer Members
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NEBGH Activities
• Education
• Vendor Management
– Health plan evaluation (eValue8)
– User Groups: Aetna, Anthem, United, Kaiser and PBM
• Multi-Stakeholder Collaboration
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Diabetes
Weight Management
Cancer
Readmissions
Integrating Behavioral Health into Primary Care
• Leapfrog
• HealthPass
• Future: Direct Contracting
“You have to have a
collaborative force to push
back on the status quo”
Don Berwick, former Administrator of the Centers for
Medicare and Medicaid Services
• One of the nation’s oldest, most successful
small business, multi-carrier private exchanges
(est. 1999)
• 2-50 employees (expanding to 100)
• Public/private partnership; seed money from
City of New York
• Over 15 years, insured 14,000+ small
businesses and 175,000+ members
• Owned by NEBGH
New
York
State:
Charting a New Course
The Vision
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Healthier New Yorkers (population health)
Lower costs
Engaged consumers
Systems, programs, financing, policies that support
and value these goals
• Triple Aim
State Health Innovation Plan (SHIP) Goals
Identify and stimulate the spread of promising innovations in
health care delivery and finance that result in optimal health
outcomes for all New Yorkers.
Population Health Goal of the SHIP:
• Improve population health through strengthened capacity and
improved screening and prevention through closer linkages
between primary care, public health, and community based
supports.
• 2020 Goal: Achieve top quartile performance among states in
prevention and public health
Shift to Payment for Value
Fee-for-Service
Payment for Value
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More services and more complex
services drive higher payments
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Better practice of medicine and better
outcomes drive higher payments
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Time spent coordinating care
generally not paid for
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Coordination of care paid for
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No rewards for better quality and
outcomes; ‘re-work’ rewarded
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Focal point is the ‘whole person’
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Incorporates population health
management
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Focal point is the provider and the
procedure
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The Source of Funds (SHIP/DSRIP)
Strong, expert, coordinated state leadership can create value over the next four years
Advanced Primary Care
DSRIP
Capital
Restructuring
Common
Scorecard
Prevention
Agenda
SHIN-NY
Currently funded
NY SHIP
value-based
purchasing
Planned SIM funding
Multi-payer funding
Rate Review
SIM Testing Grant
▪ Statewide
leadership
▪ Stakeholder
alignment
▪ Multi-payer
business design
and support
NY State of
Health
PHIPs
Workforce
strategy
APD
The Acronyms
• ACA – Affordable Care Act
• ACO – Accountable Care
Organizations
• APC – Advanced Primary Care
• APD – All Payer Database
• DSRIP – Delivery System Reform
Incentive Payment Program
(Medicaid)
• PHIP – Population Health
Improvement Program
• SHINY-NY – Statewide Health
Information Network for New
York Systems
• SHIP – New York State Health
Innovation Plan (all payers)
• SIM – State Innovation Model (all
payers)
Why Advanced Primary Care?
Primary care is viewed as the foundation of valuebased care and the Triple Aim, focused on:
• Prevention
• Care coordination (particularly for chronic conditions)
• Management of complex/multiple conditions
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SIM Grant
• The Affordable Care Act (ACA) created State
Innovation Model (SIM) grants
• To qualify, States must demonstrate commitment to
multi-payer health care payment and delivery reform
to:
• Improve health system performance
• Increase quality of care
• Decrease costs
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SIM Grants
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New York State SIM Grant
• New York received a $100 million four-year grant
• Two-thirds ($67 million) of the funds will be invested in
practice transformation
• The New York SIM grant is focused on transforming and
strengthening primary care based on the Advanced Primary
Care (APC) approach
• State Goal: 80% of residents with access to primary care
under a value-based payment model by 2019
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Multi-Payer
Collaboration is key
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Greater impact on health care delivery
Less complexity for primary care practices – particularly smaller practices
More consistency for consumers/patients
“Successful multi-payer alignment can amplify the impact of payment
and delivery system reforms by sending consistent incentives to
health care providers and aligning performance measurement”
Millbank Memorial Fund/Pacific Business Group on Health
All Aboard: Engaging Self-Insured Employers in Multi-Payer Reform
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Role of NEBGH with NYS Reform
• How come about?
– No long standing relationship
– NEBGH had a vision and track record of working with self-insured
employers and multi-payer projects
• Our Role:
– Engage and gather input from payers (health plans and self-insured
employers) and regional collaboratives
– Help move towards multi-payer approaches
– Provide feedback to New York State
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SIM Structure
Integrated Care
Create an advanced primary care
delivery model, inclusive of behavioral
and population health, and payment
methodology that is reasonable,
workable, and sustainable and achieves
the Triple Aim to ensure access to high
quality, cost effective care for all New
Yorkers.
Workforce
HIT, Transparency
and Evaluation
Modernize care delivery to best maximize
new technologies that enable enhanced
communications between care providers and
that are able to utilize data to inform care,
assure quality and promote value.
Health Innovation
Council
Support training the next
generation of the healthcare
workforce who will function in a
system that is better integrated and
includes a strong focus on
behavioral and population health.
Access to Care
Elimination of financial,
geographic, cultural and
operational barriers to access
appropriate care in a timely
manner.
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This initiative will create benefits
across the system
Consumers
Employers
Primary Care
Providers
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Improved health
Better experience, more
coordination
More sustainable costs
More sustainable costs
Higher productivity
Less need for vendors to fill
in the gaps
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More focus on the patient
Better practice of medicine
Resources for practice
transformation and ongoing
support
More aligned measures and
reporting
Health Plans
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Greater impact from primary care initiatives
• Improved health
• More sustainable costs
Resources for practice transformation
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Topics of Interest to the
Commission
Convincing Providers to Share Data
• What’s in it for them?
• If data is just based on claims it will be inaccurate.
• No one wants inaccurate data to be used for public
reporting or payment
• Better ability to manage health of the patient if data
is collectively shared and used
Quality Measures
• How important is for payers to use consistent
measures? Critical, but very difficult
• Does NEBGH have an interest in quality measures in
Medicaid? Up until now we really haven’t. SIM
project changes a lot
• Readmissions…did we agree on a methodology
among payers? We focused on resources, not rates
initially
Challenges Measuring Quality
• Hospitals easier to measure than physicians
• Groups of physicians easier to measure than individual
physicians
• Individual physicians is what consumers care most about
• If individual physician data is publicly reported, data accuracy
is critical
• Not many public sites report individual physician performance
• Funding
APCD and Public Reporting
Reasons why All-Payer Databases are Critical
• Benefit to State
– Complete picture of what care costs, how much providers receive from
payers for same and similar services, the resources used to treat patients
and variations across the state and among providers in the total cost to
treat an illness or medical event
• Benefit to Providers
– Providers get a complete picture of their population
– If insurers provide their own reporting, providers may look different across
insurers. Particularly problematic when tiering
• Benefit to Consumers and Businesses
– Performance and cost data available regardless of insurer
– Can use information to make better-informed decisions about costeffective care
• Benefit to Insurers
– Comprehensive data to make better-informed decisions about cost –
effective care
Healthcare as a Business Challenge
• Cadillac tax has made healthcare a major business challenge.
• Employers at a crossroads: actively manage healthcare to get
reductions in costs (wellness, care management, value-based
benefit design, incentives, onsite clinics, work directly with
providers, reference-based pricing, etc.) or go to a defined
contribution approach and private exchange
• Almost all employers are offering high deductible health plans
• Purchaser-driven nonprofit publicly reporting on hospital quality and
safety
• Founded by purchasers in 2000 in response to 1999 IOM Report To Err is
Human
• The right care at the right price, while empowering consumer
decisionmaking
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The Leapfrog Hospital Survey
• One-of-a-kind
• A free, voluntary survey on measures of hospital performance
important to purchasers
• Completed annually by over 1,500 hospitals from across the
country
• Measures unavailable elsewhere on the national level
• Gold standard in transparency
• Used by plans, vendors, and purchasers
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What’s in the Leapfrog Hospital Survey
1.
How patients fare
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2.
Survival Predictors
Infection rates
Maternity measures
Resources used in caring for those patients
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3.
Readmission rates
Length of stay
Management practices that promote safety
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NQF-endorsed safe practices
Breakthrough Legislation in Michigan to
Require Hospitals Report to Leapfrog
On June 3rd , the Michigan Legislature passed a law effectively
requiring hospitals to fully complete the Leapfrog Hospital
Survey in order to be eligible to receive graduate medical
education funding. 57 Michigan Hospitals receive this funding,
and a good number of them currently decline to report. This is
the first time any state has required Leapfrog.
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Laurel Pickering
President & CEO
Northeast Business Group on Health
laurel@nebgh.org
212-252-7440 x224