Bending the Cost Curve Through
Organized Systems:
Possible Models to Foster Performance Improvement
at the Regional Level
Aaron McKethan, PhD
Beacon Community
y Program
g
Office of the National Coordinator for Health IT (ONC)
June 28, 2010
Three Organizational Developments for Discussion
• Medicare Healthcare Quality Demonstration
• Accountable Care Organizations
• Beacon Community Program
2
Medicare Healthcare Quality Demonstration
Section 646 of the Medicare Modernization Act (2003)
•
Two large
T
l
regions
i
– geographic
hi configurations
fi
ti
tied
ti d to
t practice
ti patterns
tt
– Indianapolis Health Information Exchange
– Community Care of North Carolina
•
Provider-led care coordination for dual-eligibles and FFS Medicare benes
•
One-sided shared savings over a “savings threshold”
– Payments tied to spending growth and performance on quality measures
•
Evaluation framework based on identifying control counties
•
Framework for quality improvement and care coordination programs
– Including medical homes, targeted disease management, population-level
interventions
3
Accountable Care Organizations
Medicare Shared Savings Program Starts Jan. 1, 2012 (Sec. 3022)
•
Wide range off provider
Wid
id groups meeting
ti certain
t i criteria
it i can participate
ti i t
– Minimum number of attributed beneficiaries
– Primary
y care physicians
p y
•
Payment Models
– One-sided
One sided and two
two-sided/symmetric
sided/symmetric shared
shared-savings
savings models
– Range of partial capitation models can be established to replace a
portion of FFS payments
•
Evaluation methods based on pre-specified benchmarks
– Benchmark based on p
projected
j
absolute g
growth in national p
per capita
p
expenditures
•
New law authorizes pre-post
pre post budget projection approach
– Uses historical spending and utilization data to develop quantitative,
pre-specified targets to track ACO performance
4
The Beacon Community Program
HITECH Act (2009)
•
Lead organizations comprise a range of community-level stakeholders
– Providers, health plans, employers, state/local gov’t, consumer groups,
universities quality improvement organizations
universities,
•
Specific, consensus-based performance improvement goals and
measures for each community
– Cost/efficiency (e.g., readmissions)
– Quality (e.g., well-controlled blood sugar/pressure for certain patients)
– Population Health (e
(e.g.,
g improvements in vaccines/immunization rates)
•
Development of robust “Action Plans” to achieve those goals
– IT-enabled
IT
bl d medical
di l h
homes, ttargeted
t d di
disease management,
t care
coordination, value-based benefit design, remote monitoring/telehealth
•
“Sustainability
“S
t i bilit plans”
l
” tied
ti d to
t future
f t
paymentt reforms
f
– Payments aligning with performance improvement goals
5
15 Beacon Communities
Lead Organization
Location
C
Community
it S
Services
i
C
Councilil off T
Tulsa
l
T l
Tulsa,
OK
Delta Health Alliance
Stoneville, MS
Eastern Maine Healthcare System
Brewer, ME
Geisinger Clinic
Danville, PA
HealthInsight
Salt Lake City, UT
Indiana Health Information Exchange
Indianapolis, IN
Inland Northwest Health Services
Spokane, WA
Louisiana Public Health Institute
New Orleans, LA
y Clinic College
g of Medicine
Mayo
Rochester,, MN
The Regents of the University of California, San Diego
San Diego, CA
Rhode Island Quality Institute
Providence, RI
Rocky Mountain Health Maintenance Organization
Grand Junction,
Junction CO
Southern Piedmont Community Care Plan
Concord, NC
University of Hawaii at Hilo
Hilo, Hawaii
Western New York Clinical Information Exchange
Buffalo, NY
66
The Beacon Communities
7
Beacon Community 90-Day Workplan
Program Goals
Community
Objectives
CO
Measured
Outcomes
Beacon “Community Objectives” encompassing
cost, quality, and population health
CO
MO
MO
MO
MO
Well-defined measurable improvement goals
Defining
g risks and barriers and establishing
gp
plans to p
prevent or mitigate
g
them
Operational and process results of core activities
Outputs
O
O
O
O
O
O
Activities
A
A
A
A
A
A
Tasks/interventions leading to outputs
R R
R R
Resources needed to support activities and meet
stated outcome goals
Resources
R R R R
R R R R
Sustainability plan outlining provider reimbursement
reimbursement,
program revenue, and other strategies
8
Geisinger Clinic (Keystone Beacon Program)
Program Goals
Community
Objectives
Improve
quality
among ttargeted
I
lit and
d efficiency
ffi i
t d patients
ti t with
ith Chronic
Ch i
Obstructive Pulmonary Disease (COPD) and Heart Failure (HF)
CO
Measured
Outcomes
Summary of 1 out of 10 Beacon/Geisinger Community
Objectives (Logic Models)
MO
Reductions in hospital
p
admissions,, avoidable 30-day
y hospital
p
readmissions, and ED visits among target patients; increased access
to/utilization of primary care services among same patients
MO
Specific
p
plans
p
to prevent
p
or mitigate
g
implementation
p
risks and barriers
Outputs
Activities
Resources
O
A
O
A
R R R R
O
A
O
A
R R R R
Medication reconciliation outputs, hospital discharge counseling,
targeted case management contact, web-based portals, others
Comprehensive HIT-enabled care model includes care process redesign
and teaming; integration across all systems of care, care protocols;
performance feedback to patients and clinicians, and reminder systems
Specific funding allotments to core activities phased in over new areas
and over time; dedicated administrative, IT, and clinical teams
Sustainability plan: integration of new payment models aligned with
health IT-enabled performance improvement goals
9
Big Issues for these Organizational Models
•
Regional “Accountable Care” models
– Can they support medical homes and promote greater coordination
across the care continuum?
– Can different configurations of providers find ways to actually slow
spending growth and improve quality?
– Will these models strengthen
g
p
provider consolidation and p
pricing
gp
power?
– Who will participate?
– What happens after shared savings?
– What role will primary care play?
•
Beacon Communities
– Can regional collaborations achieve specific cost and quality
improvements?
– Will there be lessons that are replicable to other communities?
– Can performance improvements
improvements, once achieved
achieved, be sustainable?
10