Healthcare Reform:
Improving the Healthcare World in
Cleveland & Beyond
Barry M. Straube, M.D.
Director, The Marwood Group
Former Chief Medical Officer,
Centers for Medicare & Medicaid Services
October 27, 2012
University Hospitals: Case Medical Center
Medical Quality Summit: Moving Forward
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Life Expectancy at Birth vs.
Spending by Country
Source: OECD Health Data 2010
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U.S. Healthcare Quality/Value Challenges
• In the U.S. we spend more per capita on healthcare than
any other country in the world
• In spite of those expenditures, U.S. Healthcare quality is
often inferior to that of other nations and often doesn’t
meet expected evidence-based guidelines
• There are significant variations in quality and costs across
the nation with increasing evidence that there may be an
inverse relationship between the two
• Healthcare expenditures account for a larger section of
the U.S. economy over the years and funding those
expenditures is increasingly more difficult
– Heretofore we have not addressed the problem of 45+ million
uninsured Americans
• Cost Effectiveness Analysis is resisted as a tool
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U.S. Healthcare Quality/Value Challenges
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Care is uncoordinated
Care is not patient-centered, it is more provider centered
Care is inefficient
There continues to be considerable waste (overuse) in
the delivery of healthcare, as well as overt fraud & abuse
• Insufficient emphasis is placed on major problems of:
– Patient safety
• Healthcare Acquired Conditions
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Prevention
Unnecessary admissions and readmissions
Palliative & End-of-life Care
Health disparities
• Health Information Technology has a critical & unfulfilled
role in this
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U.S. Healthcare Quality/Value Challenges
• The private and public sectors collectively have failed to
reform healthcare using conventional healthcare delivery
and payment models
– Traditional Fee-for-Service is a major reason: Pays for quantity,
not quality
– Managed care has intermittently controlled costs > quality
– Regardless of payment system we haven’t publicly measured &
compared cost or quality, and payers/providers are not held
sufficiently accountable
• “All healthcare is local” means integrated health systems
have a significant role to play, Academic Centers special
• The Affordable Care Act of 2010 has great potential to
address the healthcare quality/value challenges
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Ensuring Quality & Value:
Tools/Drivers/Enablers
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“Contemporary Quality Improvement”
Transparency: Public Reporting & Data Sharing
Incentives: Payment reform by All Payers
Regulatory vehicles: State & Federal
Payer Benefit Design and Coverage Decision
Making
• Demonstrations, pilots, research, innovation
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“Contemporary” Quality Improvement
• Need to set priorities, goals and objectives, strategic framework
first
• Evidence-Based goals, metrics, interventions, evaluations
– Includes conformance with evidence-based guidelines, balanced with
patient-centered considerations
– Cost-effectiveness, let alone comparative effectiveness, has not yet been
addressed adequately
• Rapid-cycle development, implementation and change
methodology
• Leveraging of resources and efforts: Current and future modelscollaboration, alignment, synergy, priorities
• Many examples: Hospital Quality Initiative, Organ Donation
Campaign, QIOs, ESRD Networks, IHI, Bridges to Excellence, NCQA,
Nursing & Home Health Campaigns, many health plan
collaboratives, local collaboratives, Partnership for Patients, etc.
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Transparency:
Public Reporting & Data Availability
• CMS Compare Websites
• MyMedicare.gov
– Hospital Compare
• HHS/CMS Data
– Nursing Home Compare
Dissemination Efforts:
– Home Health Compare
– Dialysis Facility Compare
www.data.gov,
– MA Health Plan and Medi-Gap
www.healthcare.gov
Compare
• Potential explosion of
– Prescription Drug Plan Compare
– New under ACA
federal govt. & private
• Physician Compare
sector data availability for
• VBP Programs: Above plus
private sector to drive
ASCs, LTCHs, IRHs, Hospices,
others
data use innovation in
• Other comparative websites previously unimaginable
– www.WhyNotTheBest.org
ways
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Incentives
• Pay for Reporting and Adoption Programs
– P4R: Hospital Inpatient/Outpatient , PQRI, e-Prescribing,
Home Health
– ARRA /HITECH: EHR adoption and “meaningful use”
• Value-based Purchasing (VBP)
– ESRD Bundled Payment System January 1, 2011
• ESRD Quality Incentive Program (QIP) January 1, 2012
– Hospital VBP (ACA Section 3001) October 1, 2012
– VBP in many additional settings in pipeline
• Competitive bidding, gain sharing, shared savings,
bundled payment, ACOs, medical homes, salaries,
integrated delivery, etc.
• Will any of these be effective ?
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VBP: Issues for Future
• Alignment of multiple programs in existence or in
pipeline
– Goals and objectives, priorities
• What do we want to accomplish other than plain
measurement?
• Public-Private alignment
– Measures
• Many not actionable or likely to lead to improvement
• Process to develop and gain consensus too long, too
contentious, too academic looking for the perfect
– Financial Incentives
• Balance of penalties, bonus/rewards, shared savings, etc.
• How much?
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– Phase out P4R and adoption of outcomes-based VBP
Regulation
• Conditions of Participation or Conditions for Coverage
– COPs are minimum health and safety standards set by
CMS for facilities that may receive Medicare payments
– 17 separate provider/supplier settings have COPs
• Survey & Certification
– U.S. healthcare facilities certified must be in
compliance with current Medicare regulations &
applicable state laws
– S&C process uses interpretive guidelines to assess
compliance with regulations
• In combination, a powerful tool for quality/value
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Affordable Care Act (ACA) of 2010
• Title I: Quality, Affordable Health Care for all
Americans
• Title II: Role of Public Programs
• Title III: Improving the Quality & Efficiency of
Health Care
• Title IV: Prevention of Chronic Disease &
Improving Public Health
• Title V: Health Care Work Force
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Affordable Care Act (ACA) of 2010
• Title VI: Transparency and Public Reporting
• Title VII: Improving Access to Innovative Medical
Therapies
• Title VIII: Community Living Assistance Services &
Support (CLASS) Act
• Title IX: Revenue Provisions
• Title X: Strengthening Quality, Affordable Health
Care for All Americans (Amendments)
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High Profile ACA Topics
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Greater Access to healthcare coverage
National Quality Priorities & Strategic Plan
National Prevention Priorities & Strategic Plan
Attention to not only Medicare & Commercial
healthcare, but Medicaid and Dual-Eligibles
• Prevention and Patient Safety
– Numerous prevention initiatives
– Population Health: Obesity, Smoking Cessation, etc.
– Patient safety & medical errors reduction
– Healthcare Acquired Conditions (HACs), Infections
• Focus on better outcomes, greater efficiency
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High Profile ACA Topics
• Patient Centeredness
• High-cost Chronic Disease Management
• Care coordination & care transitions
– Reduction of unnecessary admissions & readmissions
• Accountable Care Organizations, Medical Homes
• Integration of conventional providers with public
health, community, and non-traditional sites of care
• Innovation in payment, delivery systems, care
• Rapid cycle change quality improvement
• Best practices and learning environments
• Attack on healthcare Fraud, Abuse, and
waste/overuse
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Center for Medicare & Medicaid Innovation:
CMMI
• CMMI establishment mandated by January 1, 2011
(Section 3021)
– Consultation & input from broad healthcare sector in
implementation
• Develop patient-centered payment models
• Rapid piloting/testing of new payment programs
• Encourage evidence-based, coordinated care for
Medicare, Medicaid, CHIP
• Focuses on populations “for which there are deficits
in care leading to poor clinical outcomes or
potentially avoidable expenditures”
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CMMI: Statutory Descriptors
• “Risk-based comprehensive payment or salary-based
payment” models
• “Geriatric assessments and comprehensive care
plans…interdisciplinary care teams…multiple chronic
conditions…”
• “transition health care providers away from fee-forservice-based reimbursement and towards salary-based”
• “health information technology-enabled provider
network that includes care coordinators, chronic disease
registry, home telehealth technology”
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CMMI: “The Innovation Center”
• Other key characteristics in the statute for payment
models
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Varying payment for advanced diagnostic imaging services
Medication therapy management services
Community-based health teams to assist in care management
Patient decision-support tools
State flexibility for dual-eligibles and all-payer payment reform
demonstrations
– Collaboratives of high-quality, low-cost institutions
• $10 billion over 10 years funding
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Staging of Innovation Development,
Demonstration, and Translation
2 To 3 years Design to Program Translation Cycle Time
• Trend Analysis
• Prototype Design and
Modeling
• Collaborative Design Lab
• Best Practice Analysis
• Publication and
Collaborative Learning
Collaborative
Innovation Laboratory
Stage
Demonstration and
Program Trial Stage
•Program trials and
Demo development
•Technology beta
testing
•Results evaluation
•Findings and
Recommendations
•Publications
• Program Policy Translation
Analysis and Evaluation
• Legislation/policy
development
• Regulation and Rule
Development
• Policy Execution and
Implementation
• Re Evaluation/ Publication
Program Policy Translation
Evaluation and Diffusion
Stage
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Driving Healthcare System
Transformation
Un-managed
Coordinated Care
Accountable
Care
Fee
for Service
• Fee For Service
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Inpatient focus
O/P clinic care
Low Reimbursement
Poor Access and Quality
Little oversight
• No organized networks
• Focus on paying claims
• Little Medical Management
Patient Centered
Integrated
Health
• Patient Care Centered
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• Organized care delivery
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Aligned incentives
Linked by HIT
• Integrated Provider Networks
• Focus on cost avoidance
and quality performance
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PC Medical Home
Care management
Transparent Performance
Management
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Personalized Health Care
Productive and informed interactions
between Patient and Provider
Cost and Quality Transparency
Accessible Health Care Choices
Aligned Incentives for wellness
• Multiple integrated network and
community resources
• Aligned reimbursement/care management
outcomes
• Rapid deployment of best practices
• Patient and provider interaction
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Information focus
Aligned self care management
E-health capable
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Driving Healthcare Delivery
System Reform and
Transformation
2011-2019
Program and
Policy Redesign
Successful
Payment and
Service Model
Innovation
Healthcare
Delivery System
Reform and
Transformation
2014-2019
2012-2019
2011-2019
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CMMI Programs
• ACO Programs
• Bundled Payment
• Comprehensive Primary Care
Initiative
• Financial Alignment Initiative
• FQHC Advanced Primary
Practice Demonstration
• Graduate Nurse Education
Demonstration
• Health Care Innovation
Awards
• Independence at Home
Demonstration
• Initiative to Reduce Avoidable
Hospitalizations Among Nursing
Home Residents
• Innovations Advisors Program
• Medicaid Emergency Psychiatric
Demonstration
• Medicaid Incentives for the
Prevention of Chronic Diseases
• Million Hearts
• Partnership for Patients: Care
Transitions: Community-based
• State Innovations Models
• Strong Start for Mothers &
Newborns
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Accountable Care Organizations (ACOs)
• Medicare Shared Savings Program (Section 3022)
– Implementation of the Medicare ACO Program
mandated by January 1, 2012
– Encourages multiple providers of services and supplies
to:
• Join together and create ACOs
• Be jointly accountable for health & experience of
care for individuals over a period of time
• Improve population health, overlap with community
• Reduce rate of healthcare spending, improve quality
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CMS ACO Proposed Rule
• ACO Notice of Proposed Rulemaking (NPRM) issued
March 31, 2011
• An ACO is an organization of healthcare providers that
agrees to be accountable for the quality, cost, and overall
care of assigned Medicare beneficiaries who are enrolled
in Medicare FFS
• Eligible organizations
– Physicians in group practice arrangements
– Physicians in networks of practices
– Partnerships or joint venture arrangements between physicians
and hospitals
– Hospitals employing physicians
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– Other forms that the HHS Secretary deems appropriate
Reaction to ACO NPRM
• Largely negative
– Too complicated, too restrictive
– Too much undefined risk
– No specialty-focused ACOs
– Negative comments about each criteria component
• CMS responded in interim
– Pioneer ACO Model
– Advance Payment ACO Model
– Accelerated Development Learning Sessions
• Final rule issued November 2, 2011: Many revisions, less
complicated, more options
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What’s An
Accountable
Care
Organization?
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What’s An
Accountable
Care
Organization?
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CMS ACO Status Update
• Medicare Shared Savings Program ACOs: 153
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27 named in April, 2012
88 named in July, 2012
32 Pioneer ACOs
6 Physician Group Practice Demo
• Half are physician-driven groups serving < 10,000 patients
• Serve 2.4 million Medicare beneficiaries
• 33 Quality Measures
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Care coordination and patient safety
Preventive health services
Improved care for at-risk populations
Patient and caregiver experience of care
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Overall U.S. ACO Status Report
• The number and types of ACOs are expanding
• Growth is centered in larger population centers
• Hospital systems appear to be the primary
backers of ACOs, but physician groups are playing
an increasingly larger role
• Non-Medicare ACOs are experimenting with
more diverse models than Medicare-backed
ACOs
• The success of any particular ACO model is still
undetermined
Source: Leavitt Partners report “Growth and Dispersion of
Accountable Care Organizations, May 2012
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Source: Leavitt Partners report “Growth and Dispersion
of Accountable Care Organizations, May 2012
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Source: Leavitt Partners report “Growth and Dispersion
of Accountable Care Organizations, May 2012
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Source: Leavitt Partners report “Growth and Dispersion
of Accountable Care Organizations, May 2012
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Source: Leavitt Partners report “Growth and Dispersion of
Accountable Care Organizations, May 2012
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ACA: Academic Health Systems
• ACA Section 3025: Hospital Readmission Reduction
Program
• ACA Section 3026: Community Based Care Transition
Program
• Healthcare Delivery Research (Section 3501, AHRQ
coordinating with CMS)
– Identifies best practice institutions, organizations, etc.
– Supports innovation in health care delivery system
improvement
• Quality Improvement Technical Assistance (Section 3501)
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ACA: Academic Health Systems
• Establishing Community Health Teams to Support the
Patient-Centered Medical Home (Section 3502)
• Medication Management Services in the Treatment of
Chronic Diseases (Section 3503)
• Emergency medicine regionalized systems and research,
trauma care centers access & payment
• Demonstration to integrate quality improvement and
patient safety education into healthcare worker
education (Section 3508)
• National Health Care Workforce Commission (Section
5101)
– Recruitment, education and training, retention
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ACA: Academic Health Systems
• National Center for Health Care Workforce
Analysis (Section 5103)
• Multiple student loan programs, various training
& retention programs, & demonstration programs
established
– Primary care
– Nurse-led care, advanced practice nursing, etc.
– Allied health, public health, dental, pediatric, direct
care professionals, geriatric, mental health, cultural
competency in disabilities, mid-career, etc.
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ACA: Academic Health Systems
• United States Public Health Services Track (Part D,
Section 271)
• Centers of Excellence-additional funding
• Medical Residency funding enhancements
• Teaching grants and demonstrations in graduate
medical education
• The list goes on and on and on…….
• But………, will ACA survive the legal, political and
funding challenges in its entirety?
– If not, which sections?
– Whether or not, will savings estimates be achieved?
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Conclusions
• The Affordable Care Act provides innumerable
opportunities to improve the quality, value and
efficiency of healthcare in the United States
• CMS/HHS is a major implementation center for
this historic piece of legislation, but the private
sector has an equally important role
– Individual integrated health systems, particularly
those with a focus on innovation and evidence, are
essential to the success of healthcare reform
– Implementation affects fee-for-service as well as
managed care models, plus untested new models
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Conclusions
• There are numerous opportunities and needs for
involvement of integrated/academic health
systems in implementation of ACA and further
health reform in the future:
– Design of and leadership in contemporary quality
improvement initiatives
• Huge gap in comparative- & cost-effective
analysis/improvement, let alone basic clinical knowledge
– Ongoing input in review and improvement in clinical
guidelines
• Balancing evidence-based population RCT viewpoint with
need for individual patient-centered concerns
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Conclusions
• Additional roles for integrated/academic health systems:
– Education of multiple audiences in evidence-based
medicine use:
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Clinicians: Current/future, academic/community
Policy makers
Payers
Patients, consumers and their families
– Development and use of quality and value metrics
• Multiple perspectives: Clinicians, patients, payers, etc.
• Relevance, actionability, accountability, attribution
– Alignment/integration of traditional & community
healthcare resources and models
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Conclusions
• Additional roles for integrated/academic health
systems:
– Collection, analysis, reporting and use of healthcare data
• Health Information Technology development, adoption and
“meaningful use” via EHRs
• Other forms of data collection: Registries, claims, encounter
data, telehealth, chart review, surveys, etc.
• Balance of scientific rigor vs.. “information efficiency”
• Minimization of burden
• Privacy & security
• Dissemination of data for widest possible appropriate use
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Conclusions
• Additional roles for integrated/academic
health systems:
– Development of and participation in new
reimbursement and delivery systems
• Higher quality leading to overall lower costs
• Innovation, rapid change & adaptability
• Care transitions and coordination
• Integration of delivery systems
• Patient-Centered, all of IOM Quality Aims
• Public health focus, as well as individual health
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Conclusions
• We cannot continue to cover and pay for everything
that’s available without considering:
– Evidence-based coverage & payment decision
making
– Comparative effectiveness and cost effectiveness
analysis
– Overall costs involved, including global costs of lost
productivity, quality of life, etc.
• But are Academic Health Systems ready?
– Rapid-cycle change, integrated systems (no departmental
silos), authenticity & will to change (e.g., academic tenure?)
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Conclusions
• The under-emphasized topics (?ignored):
– End-of-life care
– Health disparities reduction: Action needed, not talk
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Racial/ethnic
Geographic
Age
Gender
Socioeconomic
LGBT
Medical Conditions
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Thank you for your contributions in
improving the American healthcare
system!
Questions?
Discussion & Dialogue
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