Transcript Slide 1

The Affordable Care Act and Education:
Refresh, Renew, Revamp
NOW!
Nancy L Fisher, RN, MD, MPH
Oct 31, 2014
Chief Medical Officer, Region X, Centers for Medicare & Medicaid Services
Practice Variation
Source: http://www.dartmouthatlas.org/atlases
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An Unsustainable Status Quo
• 50 million uninsured Americans
• Health insurance premiums for family coverage at a
small business increased 85% since 2000
• 17.6% of economic output tied up in health care
system
• Without reform, by 2040, 1/3 of economic output tied
up in health care--15% of GDP devoted to Medicare
and Medicaid
• Without reform, number of uninsured would grow to
58 million in 2020*
*Source: Urban Institute: “The Cost of Failure to Enact Health Reform: 2010-2020” March
15, 2010
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•
Health Care Delivery System Transformation
Healthcare Delivery
System 2.0
Healthcare Delivery
System 1.0
Accountable
Care
Episodic
Non Integrated
Care
Episodic Health Care
– Sick care focus
– Uncoordinated care
– High Use of Emergency Care
– Multiple clinical records
– Fragmentation of care
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•
Lack integrated care networks
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Poorly Coordinate Chronic Care
Management
Lack quality & cost performance
transparency
•
Transparent Cost and Quality
Performance
– Results oriented
– Access and coverage
•
Accountable Provider Networks
Designed Around the patient
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Healthcare Delivery
System 3.0
Integrated
Health
• Patient/Person Care Centered
– Patient/Person centered Health Care
– Productive and informed interactions
between Family and Provider
– Cost and Quality Transparency
– Accessible Health Care Choices
– Aligned Incentives for wellness
• Integrated networks with community
resources wrap around
Focus on care management
and preventive care
• Aligned reimbursement/cost Rapid
– Primary Care Medical Homes
deployment of best practices
– Utilization management
• Patient and provider interaction
– Medical Management
– Aligned care management
– E-health capable
– E-Learning resources
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Excess Expenditures in
U.S. Healthcare System
Unnecessary Services
•
Overuse, Defensive medicine, Unnecessary choice of higher cost services
Inefficiently Delivered Services
•
$190 Billion
Insurance-related administrative costs and inefficiencies, Care documentation requirement
inefficiencies
Excessive Prices
•
$130 Billion
Mistakes, Care fragmentation, Unnecessary use of higher cost providers, Operational
inefficiencies at care delivery sites
Excess Administrative Costs
•
$210 Billion
$105 Billion
Service or product prices beyond competitive benchmarks
Missed Prevention Opportunities
$55 Billion
Fraud
$75 Billion
Source: Institute of Medicine 2010. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary.
Washington, DC: The National Academies Press.
Note: Estimates are lower bound totals of various estimates, adjusted to 2009 total expenditure level
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Patient Protection and Affordable Care
Act
New Policy Tools
•
Quality and Affordable Health Care for All American
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– Health Insurance Reform
– Expanding Coverage Choices
– Shared Responsibilities for Health Care
Public Programs
•
– Expansion of Medicaid
– Improvement in Medicare
– Tools for cost containment, quality and public accountability
Improving the Quality and Efficiency of Health Care
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Value Based Purchasing
Quality Incentives
Prevention and Health Promotion
Program Integrity
Health Insurance Reforms
• Preventive Care
• Pre-existing Conditions
• Donut Hole
• MLR 80/20
• Drop Coverage-Fraud only
• Lifetime and Annual Limits
• Dependents until 26 yo
Using Data to Target Interventions
Ambulance transport to hospital
no hospital bill or record
for services or stabilization
Physical Therapist
billing as individual
more than 24 hours per day
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INNOVATION
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Transformation of Health Care at the
Front Line
• At least six components
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–
–
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Quality measurement
Aligned payment incentives
Comparative effectiveness and evidence available
Health information technology
Quality improvement collaboratives and learning networks
Training of clinicians and multi-disciplinary teams
Source: P.H. Conway and Clancy C. Transformation of Health Care
at the Front Line. JAMA 2009 Feb 18; 301(7): 763-5
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How do we ensure quality care?
• Improvement as a
Strategy
• Customer-Mindedness
• Outcomes Focus
• Statistical Thinking
• Continual Improvement
(PDSA)
• Leadership
Improvement as a
Strategy
Our Vision
TO OPTIMIZE HEALTH OUTCOMES BY LEADING
CLINICAL QUALITY IMPROVEMENT AND
HEALTH SYSTEM TRANSFORMATION
Strategy Logic
Strategic
Altitude
30,000 ft.
What do we exist to do?
Mission
What is our picture of the future?
Vision
What are our main focus areas for
improvement?
Goals
What results are needed to satisfy
stakeholders?
Objectives &
What continuous improvements are
Desired Outcomes
needed to get results?
How will we know if we are
Performance Measures
achieving desired results?
and Targets
15,000 ft.
Initiatives
Activities
Ground Level
What actions could contribute
to the desired results?
What will support the initiatives?
The “3T’s” Road Map to
Transforming U.S. Health Care
Basic biomedical
science
T1
Clinical efficacy
knowledge
T2
Clinical effectiveness
knowledge
Key T1 activity to test
what care works
Key T2 activities to test
who benefits from
promising care
Clinical efficacy research
Outcomes research
Comparative effectiveness
Research
Health services research
T3
Improved health
care quality &
value &
population health
Key T3 activities to test
how to deliver high-quality
care reliably and in
all settings
Quality Measurement and
Improvement
Implementation of
Interventions and health
care system redesign
Scaling and spread of
effective interventions
Research in above domains
Source: JAMA, May 21, 2008: D. Dougherty and P.H. Conway, pp. 2319-2321. The “3T’s Roadmap to Transform U.S. Health Care:
The ‘How’ of High-Quality Care.”
Population Health at CMMI
Measure
• Develop robust set of measures for tracking changes in
population health
Test New Models of Payment and Service
• Strengthen population health focus in all models
• Identify and support innovations which integrate clinical care
with community based focus on determinants of health
Build Collaborations
• State
• Private payers
• Federal Partners (e.g., CDC, AOA, HRSA, DOD)
• Public health: e.g. ASTHO, NACCHO
• Public/private coalitions
Promote and Teach
• Catalyst , exemplary case studies, IAP, relentless drum beat
National Quality Strategy promotes better
health, better healthcare, and lower costs
through
Six Priorities
• Make care safer by reducing harm caused in the delivery of
care
• Ensure that each person and family are engaged as
partners in their care
• Promote effective communication and coordination of care
• Promote effective prevention and treatment practices for
the leading causes of mortality, starting with cardiovascular
disease
• Work with communities to promote wide use of best
practices to enable healthy living
• Make quality care more affordable for individuals, families,
employers, and governments by developing and spreading
new health care delivery models
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Quality can be measured and improved at multiple
levels
Increasing commonality among providers
Increasing individual accountability
Community
•Population-based denominator
•Multiple ways to define
denominator, e.g., county, HRR
•Applicable to all providers
Practice setting
•Denominator based on practice setting,
e.g., hospital, group practice
Individual physician
•Denominator bound by patients cared for
•Applies to all physicians
•Greatest component of a physician’s total
performance
•Three levels of
measurement critical to
achieving three aims of
National Quality Strategy
•Measure concepts should
“roll up” to align quality
improvement objectives at
all levels
•Patient-centric, outcomes
oriented measures preferred
at all three levels
•The “five domains” can be
measured at each of the
three levels
Challenges, Opportunities
Future Directions
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The Measurement Imperative
Not everything that counts can be counted,
and not everything that can be counted counts
Albert Einstein
(William Bruce Cameron)
But…..
You can’t improve what you don’t measure
~ W. Edwards Deming
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Pillars of Meaningful Use
Privacy &
Security
Patient &
Coordinated
Family
Care
Engagement
Quality
Safety &
Efficiency
Improved
Public &
Population
Health
CUSTOMER-MINDNESS
Essential Elements of The Patient
Experience in a Transformed
Healthcare System
Informed,
Activated
Patient
Requires new web based
Health E-Learning, Electronic Care
Planning and
Self Care Management Tools
Productive
Interactions
Common
Set of Patient
Health Information
Prepared
Clinical
Team
Electronic Health Records
and Exchange of Health
Information
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OUTCOMES FOCUS
Raising the Bar
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Higher Thresholds
Continuous Quality Improvement
Increase Depth
Test -> Ongoing Submission
Results: Per Capita Spending Growth at Historic
Lows
28%
27%
12%
*Medicare Part D prescription drug
benefit implementation, Jan 2006
*27.59%
11%
10%
9%
9.24%
8%
7.64%
7.16%
7%
6%
5.99%
5%
4.91%
4.63%
4.15%
4%
3%
2%
2.25%
1.98%
1.36%
1%
0%
2001
2002
2003
2004
2005
2006
2007
Medicare Per Capita Growth
Source: CMS Office of the Actuary
2008
2009
2010
2011
Medical CPI Growth
1.13%
0.35%
2012
2013
Medicare All Cause, 30 Day Hospital
Readmission Rate
19.5
Percent
19.0
18.5
18.0
17.5
17.0
Jan-10
Jan-11
Rate
Jan-12
CL
UCL
Source: Office of Information Products and Data Analytics, CMS
LCL
Jan-13
CLABSIs per 1,000 central line
days
National Bloodstream Infection Rate
2.5
41 %
Reduction
2
1.5
1
1.133
0.5
0
Baseline
Q1
Q2
Q3
Q4
Q5
Q6
Quarters of participation by hospital cohorts,
2009–2012
Over 1,000
ICUs
achieved an
average
41% decline
in CLABSI
over 6
quarters (18
months),
from 1.915
to 1.133
CLABSI per
1,000
central line
days.
Hospital Acquired Condition (HAC) Rates Show Improvement
• 2010 – 2012 - Preliminary data show a 9% reduction in HACs across all
measures
• Represents 15K lives saved, 540K injuries, infections, and adverse events
avoided, and over $4 billion in cost savings
• Many areas of harm dropping dramatically (2010 to 2013 for these leading
indicators)
VentilatorAssociated
Pneumonia
(VAP)
Early
Elective
Delivery
(EED)
Obstetric
Trauma
Rate (OB)
Venous
thromboembolic
complications
(VTE)
Falls and
Trauma
Pressure
Ulcers
55.3% ↓
52.3% ↓
12.3% ↓
12.0% ↓
11.2% ↓
11.2% ↓
Hospitals Continue to Generate Increases in Reporting,
Improvement, and Achievement on More Harm Areas,
September 2012 – January 2014
CMS Innovations Portfolio:
Testing New Models to Improve Quality
Accountable Care Organizations (ACOs)
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Medicare Shared Savings Program (Center for
Medicare)
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Pioneer ACO Model
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Advance Payment ACO Model
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Comprehensive ERSD Care Initiative
Capacity to Spread Innovation
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Partnership for Patients
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Community-Based Care Transitions
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Million Hearts
Health Care Innovation Awards
Primary Care Transformation
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Comprehensive Primary Care Initiative (CPC)
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Multi-Payer Advanced Primary Care Practice
(MAPCP) Demonstration
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Federally Qualified Health Center (FQHC) Advanced
Primary Care Practice Demonstration
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Independence at Home Demonstration
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Graduate Nurse Education Demonstration
Bundled Payment for Care Improvement
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Model 1: Retrospective Acute Care
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Model 2: Retrospective Acute Care Episode &
Post Acute
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Model 3: Retrospective Post Acute Care
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Model 4: Prospective Acute Care
State Innovation Models Initiative
Initiatives Focused on the Medicaid Population
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Medicaid Emergency Psychiatric Demonstration
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Medicaid Incentives for Prevention of Chronic
Diseases
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Strong Start Initiative
Medicare-Medicaid Enrollees
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Financial Alignment Initiative
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Initiative to Reduce Avoidable Hospitalizations of
Nursing Facility Residents
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Partnership for Patients:
Better Care, Lower Costs
New nationwide public-private partnership to tackle all forms of harm to
patients.
GOALS:
40% Reduction in Preventable Hospital Acquired Conditions over three years.
• 1.8 Million Fewer Injuries
• 60,000 Lives Saved
20% Reduction in 30-Day Readmissions in Three Years.
• 1.6 Million Patients Recover Without Readmission
• $35 Billion Dollars Saved in Three Years
Over 3,100 hospitals have signed pledge.
Ten Areas of Focus
Hospital Engagement Networks are required to address ten areas of focus and
Ohio Solutions for Patient Safety is the national pediatric network
• Adverse Drug Events
• Catheter-Associated Urinary Tract Infections
• Central Line Associated Blood Stream Infections
• Injuries from Falls and Immobility
• Obstetrical Adverse Events
• Pressure Ulcers
• Surgical Site Infections
• Venous Thromboembolism
• Ventilator-Associated Pneumonia
• Preventable readmissions
Who will make the case for
nursing homes?
Demonstration to Improve Quality of
Care for Nursing Facility Residents
GOALS: Reducing preventable inpatient hospitalizations among
residents of nursing facilities. Providing preventive care and
treatment without hospital visits.
• 40 percent of hospital admissions among dual eligible nursing facility
residents were preventable in 2005.
• That’s 314,000 potentially avoidable hospitalizations.
• This cost $2.6 billion in unnecessary Medicare expenditures.
 Open to independent organizations, who will implement evidencebased interventions at interested facilities.
Million Hearts™ : Getting to Goal
Intervention
Baseline
Target
Clinical target
Aspirin for those at high
risk
47%
65%
70%
Blood pressure control
46%
65%
70%
Cholesterol management
33%
65%
70%
Smoking cessation
23%
65%
70%
Sodium reduction
~ 3.5 g/day
20% reduction
Trans fat reduction
~ 1% of calories
50% reduction
Unpublished estimates from Prevention Impacts Simulation Model (PRISM)
Adjustments
Clinical Quality Measures
Clinical Quality Measures
CMS Program Overlap
STATISTICAL
THINKING
Challenge: Data Deluge
 Data Variety
Managing structured, semi-structured, and growing
unstructured data (for example, audio, video, Social
Media feeds, e-mails, PDF, Word, spreadsheets,
presentations, etc.)
 Data Volume


Data Growth in 5 Years is 650% (80% of it will be
unstructured!).*
Struggling to store and analyze; System data is
out-pacing Business Transaction data.
 Data Velocity
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
Data growth is out-pacing processing power.
Analysis of data occurs increasingly closer to
real-time, with lesser control over changing
data formats and quicker response to ingestion
of new data types.
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2012
• Stage 1
• EH/CAH Attest for FY 2012
• EH/CAH Starting MU for FY 2013 to Avoid Payment
Adjustment in 2015
• EP in 1st Year MU in 90 day Reporting Period
Comparisons: ICD-9 CM to ICD-10 CM
• ICD-9
– Pain in Knee: 719.46
– Pain in Limb: 729.5
• ICD-10
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–
–
–
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M25.561: pain in R knee
M25.562: pain in L knee
M79.601: pain in R arm
M79.604: pain in R leg
M79.606—M79.673 specific parts of each limb
CONTINUAL IMPROVEMENT
(PDSA)
Financial Instruments and models that might
incentivize lifelong health management
• Consumer incentives (value-based insurance design)
• “Warranties” on specific services
• Bundled payment for suite of services over longer
period
• Loyalty programs rewarding preventive service
• Community health trusts
• Accountable Care Organizations could evolve toward
community accountable health systems that have a
greater stake in long-term population health outcomes
LEADERSHIP
Innovation Advisors Program
GOAL: Support the Innovation Center’s development and testing of new
models of payment and care delivery in their home organizations and
communities.
• Opportunity to deepen key skill sets in:
o
o
o
o
Health care economics and finance
Population health
Systems analysis
Operations research and quality improvement
• 1 year commitment; 6 months of intensive training.
• Up to $20K Stipend available to home organizations.
• 73 Advisors selected in December 2011; up to 200 individuals will be
selected within the first year.
• For further information, see: www.orise.orau.gov/IAP
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Thank you for Listening!
? ? ? ?
[email protected]
206-615-2390