Transcript Slide 1

Healthcare Reform & Women in
Surgery:
Opportunities & Challenges
Barry M. Straube, M.D.
Immediate Past (Retired) Chief Medical Officer,
Centers for Medicare & Medicaid Services
October 23, 2011
Association of Women Surgeons
Shifting of the Poles
The 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
4
The Healthcare
Quality/Value Challenges
• There continues to be considerable waste in the delivery
of healthcare, as well as fraud & abuse
• CMS/HHS, and the executive branch is responsible for
the healthcare of a growing number of persons in the
public sector, and influences healthcare quality in the
private sector
• CMS/HHS, in partnership/collaboration with other
healthcare leaders, must address these issues
• Academic Medical Centers & Surgeons could provide
great value
• Health Information Technology is indispensable in this
• The Affordable Care Act of 2010 is a major step forward
to address the healthcare quality/value challenges
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The “Triple Aim”
Better Health for
the Population
Better Care
for Individuals
Lower Cost
Through
Improvement
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IOM Aims for Quality Improvement
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Safety
Effectiveness
Patient-centeredness
Timeliness
Efficiency
Equity
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Federal Stakeholders in the U.S.
Healthcare System
• Department of Health
& Human Services
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Veterans Affairs
Department of Defense
Department of Labor
Department of Housing &
Urban Development
• United States Coast Guard
• Office Personnel
Management
• Federal Bureau of Prisons
• Federal Trade Commission
• Office of Management &
Budget
• Department of Commerce
• National Highway
Transportation & Safety
Administration
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Department of Health & Human Services:
Agencies
• Secretary of HHS
• Administration for Children
and Families
• Administration on Aging
• Agency for Healthcare
Research & Quality
• Agency for Toxic Substances
& Disease Registry
• Centers for Disease Control
• Centers for Medicare &
Medicaid Services (CMS)
• Food & Drug Administration
• Health Resources & Services
Administration
• Indian Health Service
• National Institute of Health
• Program Support Center
• Substance Abuse & Mental
Health Services
Administration
• Multiple other Assistant
Secretaries
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Centers for Medicare & Medicaid Services
(CMS)
• Will provide health benefits for over 114 million
Americans in FY 2011 PP Budget
– Medicare – 48.1 million beneficiaries
– Medicaid – 56.1 million beneficiaries
– CHIP– 10 million beneficiaries
• Will spend $784 billion in FY 2011 PP Budget
– Medicare - $476 billion
– Medicaid - $297 billion
– CHIP - $11 billion
– Effective January, 2011 incorporated the Office of
Consumer Information and Insurance Oversight (OCIIO)
as part of CMS
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Ongoing CMS Core Medicare Work
• Provider payment-focused activities
– Efficient, timely, accurate payment of claims
– Ongoing demonstrations and pilots of alternative payment
methodologies and systems
– Addressing fraud & abuse
• Beneficiary focused activities
– Benefit education
– Health promotion and disease management education
– Beneficiary protection and advocacy
• Multiple tools to improve quality, efficiency and value
• Data collection & availability
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Partners/Targets For Advocacy
• Federal Government
– Congress
• House: Ways & Means, Energy & Commerce
• Senate: Finance, HELP
• A variety of caucuses
– White House
• Many senior advisors
• Office of Management & Budget
Partners/Targets For Advocacy
• Executive Branch Agencies
– U.S. Department of Health & Human Services (HHS)
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Office of the Secretary, Office of the Assistant Secretary of Health
Centers for Medicare & Medicaid Services (CMS)
Agency for Health Research & Quality (AHRQ)
Centers for Disease Control (CDC)
Food & Drug Administration (FDA)
Health Resources and Service Administration (HRSA)
National Institutes of Health (NIH)
Office of the National Coordinator (ONC) for HIT
– Many other HHS and other federal agencies have
influence over surgical topics and issues
Partners/Targets For Advocacy
• Centers for Medicare & Medicaid Services
– Office of the Administrator
– Key Surgery Areas
• Office of Clinical Standards & Quality (OCSQ)
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Conditions of Participation, Conditions for Coverage
Quality Improvement and Measurement
Quality Improvement Organizations (QIOs) and ESRD Networks
Information Services: Clinical Data systems
Coverage decision making
• Center for Medicare
– Payment
• Center for Medicaid
– State Survey Agencies and regulatory oversight processes
• Regional Offices (10)
• Innovation Center
Partners/Targets For Advocacy
• State Governments
• Dialysis Providers/Organizations
• Professional Associations
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Renal Physicians Association
American Society of Nephrology
American Nephrology Nurses Association
National Renal Administrators Association
American Medical Association
• Kidney Care Partners
– Kidney Care Quality Alliance
• Private health plans
• Patient Advocacy Organizations: Should probably be #1
stop
Some Personal Notions & Experience
• Know the framework of the regulatory system that
affects you, the people who run it, and work with them
– Congress passes laws (statutes) that direct federal agencies
what to do and defines their authorities
– The President can sign or veto any law passed
– Agencies implement laws, following Congressional
directives and “intent”, but if unclear have discretion to
interpret the law as the agency (and executive branch
leadership sees fit
• Regulations, through public rulemaking
• Administrative rulings, sometimes, with or without public
comment
• Guidance and directives through manuals, letters, and other
mechanisms
– There are multiple points at which advocates can
effectively influence the above
Some Personal Notions & Experience
• Advocates can and do have major influence on the
federal framework
• With regards to federal rulemaking
– Notice of Proposed Rule Making (NPRM)
– 30-90 days of public comment
– Agency reviews comments, responds to all comments,
and revises the proposed rule as indicated
– Final Rule is issued, published and implemented
– Cycles of rulemaking at CMS
• If final rules are unacceptable
– Influence subsequent laws and regulations
– Judicial challenges
– Elect new leaders
Ensuring Quality & Value:
CMS Tools/Drivers/Enablers
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“Contemporary Quality Improvement”
Transparency: Public Reporting & Data Sharing
Incentives: Financial through payment reform
Regulatory vehicles
National & Local Coverage Decisions
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
models-collaboration, 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, etc.
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“Contemporary Quality Improvement”:
Collaboratives & Communities
• Quality Improvement Organization (QIO) 9th SOW
– Care Transitions Theme
– “Every Diabetic Counts”
– Mississippi Health First (expanding to Texas)
• Links to:
– ACA Section 3025: Hospital Readmissions Reduction Program
– ACA Section 3026: Community-Based Care Transitions Program
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Transparency:
Public Reporting & Data Availability
• CMS Compare Websites
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Hospital Compare
Nursing Home Compare
Home Health Compare
Dialysis Facility Compare
MA Health Plan and Medi-Gap
Compare
– Prescription Drug Plan Compare
– New under ACA
• Physician Compare
• VBP Programs: Above plus
ASCs, LTCHs, IRHs, Hospices,
others
• MyMedicare.gov
• HHS/CMS Data
Dissemination Efforts:
www.data.gov,
www.healthcare.gov
• Potential explosion of
federal government data
availability for private
sector to drive data use
innovation in previously
unimaginable ways
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Surgical Care Improvement Project
Process of Care
Hospital Process of Care Measures Tables
Antibiotic within one hour before surgery
Appropriate pre-operative antibiotic
Patients taking beta blockers prior to the
hospital kept on the beta blockers pre- & postop
Patients given appropriate prophylactic
antibiotics
Patients with prophylactic antibiotics stopped
appropriately (within 24 hours after surgery)
Heart surgery patients with blood glucose kept
under good control post-op
Surgery patients with safe hair removal pre-op
New Surgery patients whose urinary catheters
were removed on the 1st or 2nd day post-op
Surgery patients whose doctors ordered
treatments to prevent blood clots
Patients treated (within 24 hours before or after
their surgery) to help prevent blood clots
Average Average
All U.S.
All CA
STANFORD
UCSF
UCD
92%
94%
90%
92%
93%
96%
94%
92%
89%
94%
92%
91%
93%
99%
92%
97%
97%
99%
98%
97%
94%
92%
97%
99%
95%
93%
93%
91%
84%
88%
99%
99%
100%
100%
100%
89%
89%
97%
83%
86%
94%
91%
99%
95%
97%
92%
90%
99%
92%
96% 22
Heart Attack-Chest Pain Process of Care
Average Average
Hospital Process of Care Measures Tables All U.S. All CA
Average number of minutes before
transferred to another hospital (lower is
62
66
better)
Minutes Minutes
Average number of minutes to an ECG
9
8
(lower is better)
Minutes Minutes
Drugs to break up blood clots within 30
minutes of arrival (higher is better)
54%
55%
Aspirin within 24 hours of arrival (higher
is better)
95%
96%
STANFORD
UCSF
UC DAVIS
N/A
N/A
N/A
8 Minutes
6 Minutes
N/A
N/A
N/A
N/A
100%
100%
N/A
Aspirin at Arrival
98%
99%
100%
100%
98%
Aspirin at Discharge
ACE Inhibitor or ARB for Left Ventricular
Systolic Dysfunction (LVSD)
98%
98%
99%
99%
99%
96%
96%
92%
88%
93%
Smoking Cessation Advice/Counseling
99%
100%
100%
100%
100%
Beta Blocker at Discharge
Fibrinolytic Medication Within 30
Minutes Of Arrival
98%
98%
96%
97%
99%
54%
61%
N/A
N/A
N/A
PCI Within 90 Minutes Of Arrival
89%
90%
93%
95%
79%
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Heart Failure Process of Care
Hospital Process of Care Measures Tables
Average Average
All U.S. All CA STANFORD
UCSF
UC DAVIS
Heart Failure Patients Given Discharge
Instructions
87%
90%
93%
93%
54%
Heart Failure Patients Given an Evaluation
of Left Ventricular Systolic (LVS) Function
98%
98%
99%
100%
100%
Heart Failure Patients Given ACE Inhibitor
or ARB for Left Ventricular Systolic
Dysfunction (LVSD)
94%
95%
92%
93%
93%
Heart Failure Patients Given Smoking
Cessation Advice/Counseling
98%
99%
100%
100%
100%
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Pneumonia Process of Care
Hospital Process of Care Measures Tables
Average Average
All U.S. All CA
STANFORD
UCSF
UC DAVIS
Pneumonia Patients Assessed and Given
Pneumococcal Vaccination
92%
92%
91%
91%
64%
Pneumonia Patients Whose Initial Emergency
Room Blood Culture Was Performed Prior To The
Administration Of The First Hospital Dose Of
Antibiotics
95%
95%
95%
93%
88%
Pneumonia Patients Given Smoking Cessation
Advice/Counseling
97%
97%
98%
100%
100%
Pneumonia Patients Given Initial Antibiotic(s)
within 6 Hours After Arrival
95%
95%
96%
93%
90%
Pneumonia Patients Given the Most Appropriate
Initial Antibiotic(s)
91%
92%
91%
92%
88%
Pneumonia Patients Assessed and Given
Influenza Vaccination
91%
91%
85%
96%
74% 25
Outcomes Measures: Mortality
National Heart Failure
Mortality: 11.2%
Better Than
No Different
STANFORD
Yes
UCSF
Yes
UC DAVIS
Yes
National Heart Attack
Mortality: 16.2%
Better Than
No Different
STANFORD
Yes
UCSF
UC DAVIS
Yes
Yes
National Hospital Mortality:
Pneumonia - 11.6%
Better Than
No Different
STANFORD
Yes
UCSF
Yes
UC DAVIS
Yes
Worse Than
Worse Than
Worse Than
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Outcome Measures: Readmission Rates
National Heart Attack
Readmission Rate: 19.9%
STANFORD
Better Than
No Different
Yes
UCSF
Yes
UC DAVIS
Yes
National Heart Failure
Readmission Rate: 24.7%
Better Than
No Different
STANFORD
Yes
UCSF
Yes
UC DAVIS
Yes
National Pneumonia Readmission
Rate: 18.3%
STANFORD
UCSF
UC DAVIS
Worse Than
Better Than
No Different
Yes
Yes
Yes
Worse Than
Worse Than
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Medicare Payment & Volume Data
Measure
Description UC DAVIS UC DAVIS
UCSF
UCSF STANFORD
Median Number of Median Number of Median
Medicare Medicare Medicare Medicare Medicare
Payment Patients Payment Patients Payment
to Hospital Treated to Hospital Treated to Hospital
Coronary
bypass w/o
cardiac cath
18
w/o MCC
Medicare
MS-DRG 236 $39,777 Patients $25,547
(*)f
$40,994
Coronary
bypass w/o
cardiac cath
11
11
w MCC
Medicare
Medicare
MS-DRG 235 $54,000 Patients $67,469 Patients $64,678
STANFORD
Number of
Medicare
Patients
Treated
22 Medicare
Patients
14 Medicare
Patients
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Medicare Payment & Volume Data
Measure
Description UC DAVIS UC DAVIS
UCSF
UCSF STANFORD
Median Number of Median Number of Median
Medicare Medicare Medicare Medicare Medicare
Payment Patients Payment Patients Payment
to Hospital Treated to Hospital Treated to Hospital
Coronary
bypass w/o
cardiac cath
18
w/o MCC
Medicare
MS-DRG 236 $39,777 Patients $25,547
(*)f
$40,994
Coronary
bypass w/o
cardiac cath
11
11
w MCC
Medicare
Medicare
MS-DRG 235 $54,000 Patients $67,469 Patients $64,678
STANFORD
Number of
Medicare
Patients
Treated
22 Medicare
Patients
14 Medicare
Patients
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Incentives
• Current: Pay for Reporting and Adoption Programs
– P4R: Hospital Inpatient/Outpatient , PQRI, e-Prescribing
– ARRA /HITECH: EHR adoption and “meaningful use”
• Value-based Purchasing (VBP)
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Hospital VBP Report to Congress (Nov 2007)
Physician VBP RTC (2010)
ESRD Quality Incentive Program (QIP) January 1, 2012
Hospital VBP (ACA Section 3001) by October 1, 2012
ACA mandates VBP in many additional settings
• Competitive bidding, gain sharing, shared savings,
bundled payment, ACOs, medical homes, salaries,
integrated delivery, etc.
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Incentives:
CMS Hospital Quality Initiative
• National Voluntary Hospital Reporting Initiative
(NVHRI) public-private initiative
– Federation of American Hospitals
– AHA
– AAMC
– CMS , JCAHO, others
• Hospital Quality Alliance
• Medicare Modernization Act of 2003: Section
501b – Financial incentive of 0.4%
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Other Pay for Reporting Programs
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Hospital Inpatient Quality Reporting Program
Hospital Outpatient Quality Reporting Program
Physician Quality Reporting System (PQRS)
E-prescribing Program
HITECH Meaningful Use Programs
Home Health Reporting Program
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PQRS 2011 Overview
Toward Value-Based Purchasing
VBP
2007
2008
2009
2010
2011
• TRHCA
• MMSEA
• MIPPA
• MIPPA
• ARRA and ACA
• 74
measures
• 119
measures
• 153
measures
• 175 individual
measures
• 190 individual measures
• Claims
• Claims
• 7 Measures
Groups
• 13 Measures
Groups
• Registry
• Registry
• EHR-testing
• EHRs
• eRx
• eRx
• Claims• Claims
based only • 4
Measures
Groups
• Registry
• Large Groups
• Claims
• 14 Measures Groups
• Registry
• EHRs
• eRx
• Large Groups
• Small Groups
• Maintenance of Certification
• Physician Compare Web Site
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Goals for Value Based Purchasing
• Incentivize the best care and improve transparency
for Beneficiaries
• Transform CMS from a passive payer to an active
purchaser of care
• Link payment to quality outcomes and stimulate
efficiencies in care
• Recognize and address potential unintended
consequences for Beneficiaries
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Hospital Value Based Purchasing :
Background
• Hospital Value Based Purchasing Report to Congress
2007
• Premier Demonstration and other Demos
• Experience with other reporting programs
– Hospital Inpatient and Outpatient Quality Reporting
Programs
– Physician Quality Reporting System
• ESRD Quality Incentive Program beginning January 1,
2012
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Hospital Value Based Purchasing
Program (HVBP)
• Affordable Care Act (ACA), Section 3001
– Effective date: FY2013 payment for discharges on
or after October 1, 2012
– Criteria:
• Must be a Hospital Inpatient Quality Reporting
Program participant
• Meets quality metrics by demonstrating
improvement or high levels of achievement
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Hospital Value Based Purchasing
• FY2013 Medicare payment based on quality measure
performance
• 5 Clinical topics
– Acute Myocardial Infarction
– Heart Failure
– Pneumonia
– Surgeries and Hospital Acquired Infections (HAIs)
– HCAHPS patient survey
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Hospital Value Based Purchasing
• Replace current 2% with HVBP in a 5-year phased in
approach between FY 2013 and FY 2017.
Payment Year
RHQDAPU*
HVBP**
FY13
1%
1%
FY14
0.75%
1.25%
FY15
0.50%
1.50%
FY16
0.25%
1.75%
FY17
0%
2.0%
*Annual Payment
Update
**Reduction from the
Base DRG payment
for all hospitals
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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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Other Tools
• National Coverage Decisions, Payment Policy, Benefit Design
– Deciding whether a device, service or therapy is paid for (or not)
can influence quality of care
– E.g., Non-payment for Hospital Acquired Conditions (HACs)
– E.g., Non-coverage of “Never Events” for both hospitals or
physicians
– E.g., limitation of services to “qualified” facilities or providers, such
as ICD implantation, etc.
– CED and use of registries collects further quality information
– Patient incentives: Waiver of co-pays
• Demonstrations, pilots, research
– Numerous CMS Demonstrations in past and going forward with the
ACA
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Conclusions
• CMS Statutory Authority provides powerful tools to
focus on improving quality, value & patient safety
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QI by providers, payers, collaboratives, others
Transparency: Public Reporting and Data Dissemination
Incentives
Regulatory compliance
Coverage, benefit, and utilization purposes
Research and Demonstrations
– Health Information Technology essential to above
• Opportunities for input & alignment abound
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Conclusions
• CMS Statutory Authority provides powerful tools to
focus on improving quality, value & patient safety
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QI by providers, payers, collaboratives, others
Transparency: Public Reporting and Data Dissemination
Incentives
Regulatory compliance
Coverage, benefit, and utilization purposes
Research and Demonstrations
– Health Information Technology essential to above
• Opportunities for input & alignment abound
– Academic Medical Centers have a potential major leadership
role
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Affordable Care Act (ACA) of 2010
• Patient Protection & Affordable Care Act
(PPACA)
• Health Care & Reconciliation Act of 2010
(HCERA)
• Affordable Care Act of 2010 (ACA)
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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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ACA & Women
• Search term “women”
– 145 instances
– Mostly relate to “women’s health” and “women as
patients”
– Frequent linkage to “pregnant” or “young”
modifiers
• Search term “surgeon”
– 41 instances, most “Surgeon General”
– 2 instances: American College of Surgeons-trauma
center accreditation and guidelines
– 5 Instances: General surgeons-rural, committees 48
ACA & Surgeons
• Search term “surgery”
– 10 total instances
– 4 instances: Cosmetic surgery-5% tax
– 3 instances: “General Surgery” services
• Search term “surgical”
– Ambulatory Surgical Centers (8): VBP plan
mandated to Congress by 1/1/2011
– “Surgical specialties”
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High Profile ACA Topics
• Greater Access to healthcare coverage
• National Priorities & Strategic Plan
– HHS Interagency Quality Work Group
– Quality Measurement comment by NQF
– Data collection and national work plan
• Focus on outcomes, efficiency
• Patient Centeredness
• High-cost Chronic Disease Management
• Care coordination & care transitions
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High Profile ACA Topics
• Healthcare Acquired Conditions (HACs)
– Healthcare Acquired Infections
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Patient safety & medical errors reduction
Prevention and Patient Safety
Population Health: Obesity, Smoking Cessation, etc.
Reduction of unnecessary admissions &
readmissions
Accountable Care Organizations, Medical Homes
Innovation in payment, delivery systems, care
Rapid cycle change quality improvement
Best practices and learning environments
51
Center for Medicare & Medicaid Innovation:
CMMI
• CMMI establishment mandated by January 1, 2011 (Section
3021)
– Consultation & input from broad healthcare sector in
implementation
• “The Innovation Center”
• 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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–
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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
–
–
–
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
– 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
57
Innovation Fellowship
• Details (still pending) at conference
58
Accountable Care Organizations (ACOs)
• Medicare Shared Savings Program (Section 3022)
– ACO Program must be implemented by January 1, 2012
– ACO Notice of Proposed Rulemaking (NPRM) issued
March 31, 2011
• Public comment ended June 6, 2011
• Final rule publication date not determined (publicly)
– Encourages providers of services and supplies to:
• Create ACOs
• Be accountable for health & experience of care for individuals
• Improve population health
• Reduce rate of healthcare spending
59
ACO Proposed Rule Provisions
• Providers must notify beneficiary of participation
– Includes description of program, quality/cost focus
– Beneficiary can opt-out & seek non-ACO care
• Beneficiary to be notified of data sharing
– Purpose: Coordinate care better
– Beneficiary can’t be required to see ACO providers
– Beneficiary may opt-out of data sharing arrangements
– For those opting in, data sharing has limitations
• Patient selection controls to avoid “cherry
picking”
60
ACO Proposed Rule Provisions
• Types of providers & suppliers
– Professionals (physicians, hospitals) in group practice
arrangements
– Networks of individual practices of professionals
– Partnerships or joint ventures of hospitals &
physicians
– Hospitals employing ACO professionals
– “Others”, as determined by the Secretary
• Governing body of ACO professionals and beneficiaries
• Application with detailed submission requirements
• Minimum responsibility for 5,000 beneficiaries
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ACO Proposed Rule Provisions
• Rigorous (& complicated) monitoring plan
• In order to qualify for financial shared savings, must
meet specified quality standards (65 proposed in
NPRM)
• Quality reports to CMS, feedback to providers
• 50% of PCPs must meet “meaningful use” standards by
year 2
• Pubic reporting requirements
• Termination by CMS if:
– Avoidance of at-risk patients
– Failure to meet quality standards
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ACO Proposed Rule Provisions
• 3 year agreement at minimum
• Primary care-driven model for organization
– Specialty-driven ACO founders not proposed in NPRM
• Two shared savings risk models - original proposal
– One-sided Risk: ACO shares in any savings in first 2/3
years; Third year can lose money if costs >Medicare
norm.
– Two-sided Risk: ACO at risk all three years; can have
greater % of savings share, however.
• Waivers allowed
• FTC of DOJ and IRS issues
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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: Applications being accepted
– Advance Payment ACO Model: Public comments
– Accelerated Development Learning Sessions
• Final rule pending review of comments & policy
decisions
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ACO Final Rule
• Pending: Details (if available) at conference
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Will ACOs be the Answer?
• Probably not, in the short-to-intermediate term
• The concept is intriguing, but whether it is translational
is in doubt
– Can you replicate existing likely ACOs in other communities
without requisite infrastructure?
• The model is untested, will it achieve the goals of better
quality at lower costs?
– ACO program under ACA is a voluntary program that
is essentially a demonstration
– Financial risk may not be assumable for many
• Consolidation, reduced competition?
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• 2nd Generation Managed Care?
ACA: Academic Medical Centers
• 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 Medical Centers
• 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 Medical Centers
• 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 Medical Centers
• 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 is a major implementation center for this
historic piece of legislation
– Implementation crosses Medicare, Medicaid, CHIP
and the entire health care sector, including the
private sector
– 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 academic medical centers 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
• Education of multiple audiences in evidencebased medicine use:
– 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
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Conclusions
• 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
• Development of and participation in new
reimbursement and delivery systems
– Achieve the “Triple Aim”
– 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 Medical Centers 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 & Palliative Care
– Health disparities reduction, not talk
•
•
•
•
•
•
•
Racial/ethnic
Geographic
Age
Gender
Socioeconomic
LGBT
Medical Conditions
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Healthcare Reform, Politics & Surgery
• Healthcare Reform in context of budget deficit
– ACA originally estimated by CBO to generate
– Joint Steering Committee must come up with $1.2
trillion in savings
• If not, reverts to sequestration process
– Current projections are that JSC may come up
with $500-700 billion of savings
• Shortfall of same amount will lead to additional
sequestration cuts of $100-200 billion from
Medicare, Medicaid, CHIP
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Healthcare Reform, Politics & Surgery
• Likely targets for further cuts:
– Post-acute care setting: Long-term care (SNFs), Home
Health,
– Hospitals (especially GME)
– DME
• Sustainable Growth Rate (SGR)
• Tort Reform
• 2012 Election
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Thank you for your contributions in
improving the American healthcare
system!
Questions?
Discussion & Dialogue
Email: [email protected]
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