Transcript Paying for Quality Health Care: States’ Roles

Paying for Quality Health Care:
States’ Roles
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March 24, 2011
New Hampshire General Court
Concord NH
Ellen Andrews, PhD
Health Policy Consultant
www.csgeast.org
Health care spending
health costs vs. state budgets, US
National health exp.
20
state budgets nominal
increase
annual % change
15
10
5
2009
2007
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
0
-5
Sources: National Health Accounts, CMS, accessed 3/20/11, Fiscal Survey of States, NASBO, Fall 2010
And it’s going to get worse
Sources: National Health Accounts, CMS
State spending
Sources: National Health Accounts, CMS
State spending
Sources: National Health Accounts, CMS
Quality
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Only 39% of American adults are confident that they
can get safe, effective care when needed
Americans get only 55% of recommended care on
average
Half of Americans report poor coordination of care;
especially among those who see more than one doctor
One in three Americans reports getting unnecessary care
or duplicate tests.
Quality in the region
Sources: S. Jencks, et al, Rehospitalizations among Patients in the Medicare Fee-for-Service Program, New
England J Med, 4/2/09, Preventable hospitalizations US $30 billion/yr – AHRQ, National CVE meeting, 7/09
Quality in the region
Sources: 2007 National Survey of Children's Health, http://www.nschdata.org/Content/Default.aspx
Quality in the region
Sources: 2007 National Survey of Children's Health, http://www.nschdata.org/Content/Default.aspx
Quality in the region
Sources: 2007 National Survey of Children's Health, http://www.nschdata.org/Content/Default.aspx
If it’s not broken, don’t fix it
Well, it’s broken
Sources: National Health Accounts, CMS
Current incentives
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Pay the same for unequal quality services
Consumers have no information and no incentive to
choose higher quality/higher efficiency service providers
Encourages overuse, misuse of services
Higher spending not correlated with higher quality
Higher spending not correlated with better patient
satisfaction
Fee-for-service misaligned incentives
Fee for service encourages:
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More services
Less coordination
Incentives for duplication
Few incentives for prevention
Stifles innovation
Only pays for selected services - not email, group visits, phone
calls
No link to quality
Incentives to increase high profit services/patients and avoid low
profit
Value-based purchasing
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Rewards better outcomes
Payments based on quality and efficiency of care
Data driven
Remove incentives for more services
Flexibility for providers to customize care
Reward patient satisfaction
Remove fragmentation and conflicting incentives
Align provider, payer and consumer incentives to reward
quality, effectiveness and efficiency
Consumers support value-based
purchasing
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95% of Americans feel it is important to have information
about the quality of care provided by different doctors
and hospitals
88% feel it is important that they have information about
the costs of care to them before they actually get care
Federal VBP
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Strong feature in national reform
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Innovation Center, waivers
ACOs
Comparative effectiveness research
Medicare and Medicaid bundled payment pilots
Medicare
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23 programs – P4P, pay for reporting, never events, medical
home, gain sharing, removing regulatory barriers, e-prescribing,
data aggregation
Premiere Demonstration – hospital P4P
Physician Group Demonstration
Implementing differential payments based on readmission rates
Why should states implement VBP?
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State employee groups usually one of largest groups in
state – 42 states self-insure
Medicaid programs – covers one in five Americans
States regulate insurers, license providers, CON
Trusted source for consumer education, data collection,
research
Public health collaborations
Innovators – medical home, HIT, coverage programs
Provider training – promote primary care, emphasis on
accountability, transparency
Convener – can get people to the table, anti-trust
protections
Options: Transparency
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Data reporting
Report cards – hospitals, health plans, providers
Coalitions with other payers, providers for joint reporting
All payer data aggregation
State employee, Medicaid reporting
Improve consumer access to information
Options: P4P
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Widespread, but mixed results
Medicaid P4P in 28 states and growing
Federal Medicaid limits on incentive payments in riskbased systems
Target health plans and/or providers
Coordinate and join with other payers to make payments
salient to providers
Outcomes vs. process and teaching to the
test/cookbooks
Provider resistance, low Medicaid participation rates
Options: Payment system overhaul
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Never events
Market share – tier and steer
Shared savings
Episodes of care, bundled payments
Global capitation
Resistance
Barriers
Supportive options
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Medical home
Accountable care organizations
EMRs, health information exchange
Workforce development, esp primary care
Evidence based medicine
Maine value-based purchasing
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State employee plan leadership in larger multi-payer
collaborative – Maine Health Management Coalition
2005 adopted strategy to encourage consumers to make
informed choices, incentives to access higher quality care,
reward high quality providers
Hospital and physician tiering by quality, expanded program
over the years
Messaging to members, web-based, became a trusted source of
information
Engaged providers in development of standards, QI plans
First year diabetes disease management participants averaged
$1300 less in health care costs
Transitioning from FFS to bundled payments
Lessons from others
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Collaborate first
Go slowly
Start small and with strongest partners
Coordinate across payers -- standardize
Fair and open process
Everyone on same page, all have same understanding
Be clear on goals, single-minded dedication
Strong consumer education piece necessary
Plan for transitions
Don’t underestimate the power of disclosure and transparency, often
stronger motivator than $$$
Be brave
The time is right for transforming delivery and payment systems – the
status quo is not sustainable
For more information –
www.csgeast.org
[email protected]