Assessing Impact and Measuring
Effectiveness of New Payment Models
WEDI Innovation Summit
Erik Pupo – Senior Manager - Deloitte
Assessing New Payment Models
• PCMH in New York
• “Increased detection and/or
management of previously
undetected diseases associated with
an increased focus of PCMH providers
on assessment and prevention could
be driving increased inpatient
utilization as is sometimes seen with
individuals who are newly insured and
have previous unmet need”
• PCMH in Pennsylvania
• “Widespread implementation of the
PCMH with limited data may lead to
failure”
Role of Politics in Assessment
• Administration of government programs can be influenced to greater or
lesser degrees by politics
Ponder the following questions:
• What condition or set of conditions is the new payment model targeting?
• Who makes up the pool of patients in the payment model?
• How are payment penalties, bonuses, and discounts applied in the model?
What are we trying to assess?
The problems with measuring payment models:
1. Is care patient-centered?
2. Is care safe and effective?
3. Is care timely and accessible?
4. Is care efficient?
5. Is care coordinated?
6. Is care continuous?
7. Is care optimized?
8. Are patients engaged in their care?
9. Is health information flowing as part of care coordination?
10. Is the care accountable?
11. Is the care innovative?
12. Is learning occurring as care is delivered?
Defining Effective
Role of Population in Effectiveness
Paul Taylor’s The Next America: Boomers, Millennials, and the Looming
Generational Showdown predicts economic battle between Millennials and
Baby Boomers:
“Every family, on some level, is a barter between the generations…If I care
for you when you’re young so you’ll care for me when I’m old…But
many Millennials won’t be able to afford that…The young today are
paying taxes to support a level of benefits for the old that they
themselves have no prospect of receiving when they become old.”
Why does assessing matter?
Source – AHIP
Why does effectiveness matter?
Newer payment models have not been fully exposed to levels of variability
within the health system – there are a LOT of variables that go into a payment
model. Judgments of effectiveness thus are very subjective
Source – StateHealth.org
What newer approaches work?
1.
Transitional, partial bundle models
2.
Broader competitive pricing
3.
Use of predictive modeling
4.
Application of hybrid models
A. Working within inefficiencies of multi-payer
B. Relaxed reporting requirements/subjective reporting
5.
Supply Chain
A. Moving beyond Value Based Purchasing to Value Based Staffing
Outpatient OR Inpatient Excluded
A physician practice (or health system) would receive a single (severity-adjusted)
payment per patient to cover all of the services provided within the practice that
would previously have been billed under individual fee codes, e.g., E&M codes,
immunizations
Other outpatient services (e.g., lab tests) and inpatient care (hospitalizations)
would con- tinue to be paid separately, but the physician practice would receive
a pay-for-performance (P4P)-style bonus/penalty payment based on the level of
utilization of those services (on a severity-adjusted basis).
Advantage:
Health IT can be focused on specific domains of care and outpatient and
inpatient services where health IT effectiveness is more variable
Outpatient or Inpatient Only
The physician practice or health system would receive a single payment to cover
all outpatient OR inpatient costs, but the other level of care would still be paid
separately. The practice would receive a bonus/penalty payment based on the
rate of utili- zation of inpatient services.
Administrative Pricing vs. Competitive
Pricing
• Under competitive pricing, providers (who know a lot about the cost of care)
tell payers (who unavoidably know much less) about the resources that are
required to provide a given product or service. In administrative pricing,
information flows in the other direction
Source – StateHealth.org
Pricing for the Skewed Level of
Conditions
Source – Massachusetts Cost
Trends Report 2013
Dealing with Cost Skew
Source – Massachusetts Cost
Trends Report 2013
Pricing for wide comorbidity range
Source – Massachusetts Cost
Trends Report 2013
Leveraging Predictive Models
Medical homes may be more likely to succeed if they are paired with predictive
modeling to proactively identify and intervene on their patients who are most
likely to have ambulatory-sensitive hospitalizations most likely to have
ambulatory-sensitive hospitalizations
Source – Optum
Triaging (Payment Model as a “Scout”)
Assigning a readmissions risk
score and estimating resource
use based on clinically relevant
classifications.
Applying that score throughout
the payment model
Applying that score as a
measurement for reporting
Source – JAMA Internal
Medicine 2013
Patient vs. Bureaucracy Reporting
“33 required quality measures that are part of the quality performance
standard, including the Consumer Assessment of Healthcare Providers and
Systems (CAHPS) patient experience survey measures, claims-based measures,
the Electronic Health Record (EHR) Incentive Program measure, and the required
Group Practice Reporting Option (GPRO) web interface quality measures that
are required for purposes of ACO participants earning a Physician Quality
Reporting System (PQRS) incentive under the Medicare Shared Savings
Program.”
Vs.
Is the patient care “centered”
Patient Journey Maps
AT A GLANCE
The JourneyMap
includes appointment
scheduling, education &
information sharing,
check lists, alerts, social
media feeds, dashboards
and monitoring to
facilitate a positive
outcome for the patient
on the road to recovery.
Providing a coordinated,
comprehensive view of
the patient, the app
provides real-time
feedback and enables
on-the-go changes to the
patient’s care plan.
ISSUE Lack of effective coordinated care for patients and their
families which prohibits positive recovery.
IMPACT The JourneyMap gives the patient greater control and
allows them to be more engaged in their care through real-time
feedback, creating unified visibility across multiple providers.
19
Supply Chain and Risk
20
Source – Optum
VBP and Risk
21
Source – Optum
Summary Characteristics for VBP
Source – Optum
Value Based Staffing
• Emphasizing outpatient over
inpatient
• Inclusion of staffing levels
and/or use of hospital-based
staffing plans in VBP programs
• Many of the identified
preventable Hospital Acquired
Conditions (HACs) - such as falls
and nosocomial infections- have
been tied, at least in part, to
nurse staffing
• Measuring “intensity” in
payment models
Summary Conclusions
• Geography matters – innovate to your area
• Something that works in one area may not work more broadly
• People matter – don’t ignore behavior in payment innovation
• Some doubt on whether the medical home works outside of integrated
delivery settings and with high risk patient populations
• Medicare bureaucracy cannot support the introduction and assessment of
multiple payment models
• The innovation angle – target young people for payment model reform
• They want a local health care system that’s simple: paperless, treatments
that are necessary and easily understood, prices that are sensible and
transparent, and caregivers who listen and connect.
• Little political will to change delivery of care to seniors
Takeaways for WEDI
1.
How can we align our standards work in support of these trends?
2.
What is the potential business opportunity for WEDI and its constituents?
3.
How can WEDI’s new focus on interoperability fit into payment model
assessment and effectiveness (how can WEDI
4.
How can WEDI “find its voice” on innovation in payment reform,
interoperability
5.
How can WEDI promote innovation in its work on healthcare administrative
standards?