Nurses: Crucial
Collaborators Across the
Continuum
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South Texas Annual Joint Healthcare Conference
Healthcare Landscape 2013
San Antonio, Texas
January 25, 2013
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Presented By:
Rhonda Anderson RN, DNSc, FAAN, FACHE
Chief Executive Officer
Cardon Children’s Medical Center, Mesa, AZ
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Objectives
The participant will be able to:
• Explain strategic transition plan to
move from illness to health.
• Explain role of nurse leader in care
coordination.
• Explain purposeful workforce
transitioning.
2
Important Implementation Dates
 Medicare market basket
update reductions
 Extends dependent coverage
for children up to age 26
 High-risk pool established
 Patient-Centered Outcomes
Research Institute (comparative
effectiveness research)
 Center for Medicare &
Medicaid Innovation
 Increased reporting
requirements for non-profit
hospitals
2010
2011
 Ban on physician ownership of
hospitals
 Medicare Advantage payment
cuts begin
 Payment adjustments for
hospital-acquired conditions
 Medicare Commission’s first
report to Congress
 Accountable Care Organization
pilot starts
 Hospital Value-Based
Purchasing begins
 Medicare productivity
adjustments
 Increased physician quality
reporting
2012
2013
 Reductions in payments for
select readmissions
 Bundled payment
demonstration projects start
 Increased Medicaid payments
for primary care
 Independent Payment Advisory
Board established
2014
2015
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2016
2017
Medicaid expands to 133% FPL
State Exchanges start
Individual mandate
Employer “play or pay”
Medicare & Medicaid DSH cuts
begin
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Health Care Reform – Key Themes
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Integrative payment models
o
o
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Accountable care organizations
Bundled payments
Health homes
Quality care / patient safety
• Comparative effectiveness
• Coordinated care experience
• Meaningful use
•
What’s an ACO?
An ACO is generally defined as
a local health care organization
with a network of providers such
as primary care physicians,
specialists, and hospitals that
are accountable for the cost
and quality of care delivered to
a particular population.
Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold
5
Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine,
October 2010, 12-13.
What’s an ACO?
The purpose is to deliver more
efficient and coordinated care
that is rewarded with a financial
bonus for achieving
performance benchmarks set
by the Centers for Medicare &
Medicaid Services (CMS).
Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold
6
Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine,
October 2010, 12-13.
What’s an ACO?
The Patient Protection and
Affordable Care Act (PPACA)
refers to an ACO as a legal entity
that includes both physicians and
hospitals, has at least 5,000
Medicare lives under contract, has
the ability to pay participants, and
includes both Medicare and
commercial lives.
Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold
7
Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine,
October 2010, 12-13.
Four Emerging ACO Models
Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold
Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine,
October 2010, 15.
1. Network
Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold
Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine,
October 2010, 15.
2. Organized medical group
Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold
Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine,
October 2010, 15.
3. Hospital systems
Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold
Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine,
October 2010, 15.
4. Collaborative
Source: Peter Boland, Phil Polakoff, Ted Schwab, “Accountable Care Organizations Hold
Promise, But Will They Achieve Cost and Quality Targets?” Managed Care Magazine,
October 2010, 15.
Provider Network
(Critical Success Factors)
Quality
• Top quality (measured by HEDIS/NCQA/Core Measures, 80% OP)
• Coordinated patient experience
• Standard models of care (evidence-based where applicable)
Technology
• Technology alignment and adoption (EMR, HIE, Portals, BI Tools)
Leadership Culture
• High engagement (culture of improvement, learning and accountability)
• Physician leadership to drive engagement
Coordinated Care
• Sharing of data between all parties to improve care and lower cost
• Broad geographic distribution and appropriate specialty accessibility and availability
• Coordinated Care
Low Cost Care
• Cost effectiveness (clinical and administrative)
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Nursing’s Role
• Quality Management
• Care Coordination
• Continuum Management
• Role Transitions
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Aligning Payment with Quality:
Accountable Care Organizations
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MEDICAID
Beginning January 1, 2012, establishes a 5-year ACO
demonstration project for pediatric providers to
share in cost savings achieved for Medicaid and
CHIP.
Providers would have to participate in pilot for a
minimum of 3 years.
MEDICARE
By January 1, 2012, requires DHHS to create a
program that would reward hospitals and physicians
(ACOs) that work together to manage patient costs
and quality of care to Medicare beneficiaries.
ACOs can include physicians, hospitals, nurse
practitioners, physician assistants and others.
ACOs would be rewarded for meeting quality of care
targets and cost reductions.
Preference may be given to ACOs already
contracting with the private market.
PPACA: Sec. 2706, 3022, 10307
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Aligning Payment with Quality: Health Homes
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MEDICAID
Beginning January 1, 2011, creates a Medicaid state plan option that allows a provider or
group of providers to be designated as a medical home for enrollees with at least two
chronic conditions.
The health home must have systems and infrastructure in place to provide:
o
o
o
o
o
•
•
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Comprehensive care management
Care coordination and health promotion
Comprehensive transitional care
Patient and family support
Referral to community and social services
The health home may be a free-standing, virtual or hospital-based, community health
center, community mental health center, clinic, physician’s office or physician group
practice.
Provides a 90% federal match to state for 2 years.
MEDICARE
Beginning January 1, 2012, creates a Medicare pilot targeting physician and nurse
practitioner-directed home based primary care teams.
Teams are responsible for providing comprehensive, coordinated, and continuous care to at
least 200 high-need beneficiaries at home.
May share savings in excess of 5 percent.
PPACA: Sec. 2703, 3024
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ALIGNING PAYMENT WITH QUALITY:
PAY FOR PERFORMANCE
• Beginning October 1, 2012, establishes a Medicare value-based purchasing
program for hospitals that ties a percent of payments to performance on
quality measures starting with:
Acute Myocardial Infarction, Heart failure, Pneumonia care, surgery infection
prevention, healthcare-associated infections and patient satisfaction.
• In 2014, will include efficiency measures & Medicare spending per
beneficiary
• Hospitals rewarded for attainment and improvement on performance.
• Incentive funding comes from reductions that apply to all MS-DRGs:
2013
2014
2015
2016
2017
1.0%
1.25%
1.5%
1.75%
2.0%
• Individual hospital performance on each measure will be publicly reported.
• Starting March 23, 2012, 3-year demonstration project to test for CAHs, small
hospitals, IRFs, psychiatric hospitals, cancer hospitals and hospice.
• Establishes value-based purchasing program for ASCs.
PPACA: Sec. 3001, 10335
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ALIGNING PAYMENT WITH QUALITY:
HOSPITAL READMISSIONS
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In June 2008, MedPAC recommended that Congress reduce payments to
hospitals with relatively high readmission rates for select conditions.
Beginning October 1, 2012, CMS will adjust inpatient payments for “higher-thanexpected” Medicare readmission rates based on 30-day readmissions for:
o Heart Attack
o Heart Failure
o Pneumonia
o In 2015, expands to COPD, CABG, PTCA and other vascular
Reduction is applied to all DRGs.
Reductions cannot exceed:
2013
2014
2015 and beyond
1.0%
2.0%
3.0%
DHHS may expand the policy to include additional conditions.
Readmission rates for certain conditions will be made available to the public.
CAHs are exempt.
PPACA: Sec. 3025
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ALIGNING PAYMENT WITH QUALITY:
PAYMENT BUNDLING
MEDICAID
In June 2008, MedPAC made
recommendations designed to improve
the efficiency of hospital episodes, such as
bundled payments for select services.
Inpatient
Stay
3 Days
Prior to
Admission
30 Days
Post
Discharge
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Coordination
Quality
Efficiency
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Beginning on January 1, 2012, establishes
a bundled payment pilot program under
Medicaid in up to 8 states.
Focus on episode of care that includes
hospitalization and concurrent physician
services.
MEDICARE
Beginning January 1, 2013, establishes a
5-year national, voluntary pilot program
for hospitals, physicians and post-acute
care providers to improve coordination,
quality and efficiency through bundled
payment models.
Pilot program will cover inpatient,
outpatient, post-acute care (IRFs, SNFs,
HHAs & LTCHs), & physician services.
PPACA: Sec. 2704, 3023, 10308
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●Care Coordination
●Case Rates
●Utilization
●Readmissions
F1.1
F1.2
Population Health
Ambulatory Strategy
Patient-Family
Engagement
Post-Acute Bundles
Avatar
Meaningful
Use
ACO
L3
Physician
Strategy
Value-Based Purchasing
Quality
Ambulatory Strategy
Safety
HAI
Fifteen Imperatives for success
under accountable care
Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under
Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.
Physician alignment
1. Focus physician alignment structures on premium
partners who share a common vision of success:
value creation, not the immediate upside of a
transactional liquidity moment.
2. Organize accountable care networks around
proceduralists who will comprise the efficient
surgical enterprise, and primary care physicians
and medical specialists who will operate the
effective ambulatory care management network.
3. Develop physician alignment strategies that
support joint contracting with all physicians who
will be “principals” of your accountable care
enterprise.
Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under
Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.
Clinical transformation
4. Engage stakeholders from multiple levels and sites
of care to engineer a dramatically more efficient
accountable care enterprise.
5. Begin clinical transformation initiatives within the
acute care enterprise to generate returns to
address performance risk and fund investments in
managing utilization risk.
6. Activate patients under your care by engaging
patients in decision-making both during acute
events and before acute events occur.
7. Develop an advanced primary care medical
home model that supports proactive chronic care
and longitudinal patient management.
Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under
Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.
Payment transformation
8.
Synchronize clinical transformations that reduce
demand with changes in fee-for-service payments to
capture value created and to avoid accepting too
much risk too soon.
9. Pilot population management strategies with the
hospital’s own self-insured employee base to perfect
the clinical model and capture early value created.
10. Implement new payment innovations from the “inside
out,” focusing on changes that maximize the
profitability of existing businesses to fund investment in
longer-term changes in capabilities and incentives.
11. Design a roadmap for payer contracting strategy
based on value creation for purchasers rather than the
exercise of leverage.
Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under
Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.
Information-powered health care
12. Maximize physician engagement in performance
improvement with investments in technologies that
identify improvement opportunities connected to
contractual incentives.
13. Re-orient clinical operations around process design and
care standardization in order to unlock the full value of
greater IT investment.
14. Inform clinical model redesign, population risk
assessment, and targeted patient management
through sophisticated data analytics and business
intelligence.
15. Support population management through investments
in technologies that provide remote and virtual access
to medical advice and monitoring.
Source: Chas Roades, “Health Care’s “Accountability Moment”: 15 Imperatives for Success Under
Accountable Care,” The Advisory Board Company, Washington Update, November 2, 2010.
What is YOUR piece of the
puzzle?
Acute
Care ?
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Workforce Transformation
• Current acute
care mentality
• Transition planning
• Redistribution of
clinicians
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~Questions
~Thank you
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