Transcript Document

What Does Value-Based
Purchasing Mean for EMS?
Matt Zavadsky, MS-HSA, EMT
Public Affairs Director
MedStar Mobile Healthcare
Adjunct Faculty
University of Central Florida
College of Health and Public Affairs
What we’re gonna do…
• A word about value
• Payers & their value propositions…
• Value Based Purchasing
– Healthcare
– EMS?
Definition…
• The amount of money that something is
worth
• The price or cost of something
• Usefulness or importance
Value…
• In healthcare?
• Depends on the
audience
– Patient
– Practitioner
– Medical Director
– Elected official
– Regulatory official
Question…
• Does the U.S. Healthcare system deliver
‘value’?
Health survey ranks U.S. last among rich peers
Michael Winter, June 16, 2014
For the fifth time in a decade, the United States is the sick man of the rich
world.
That's according to the latest Commonwealth Fund survey of 11 nations,
which ranked the world's most expensive health care system dead last on
measures of "efficiency, equity, and outcomes." So too in 2010, 2007, 2006
and 2004.
The U.S. ranking reflects poor scores on measures of healthy lives —
"mortality amenable to medical care," infant mortality and healthy life
expectancy at age 60.
The other eight countries surveyed were Australia, Canada, France, Germany,
the Netherlands, New Zealand, Norway and Sweden.
http://www.usatoday.com/story/news/nation/2014/06/16/health-survey-uslast/10638811/
Attention Please!
• $8,600 per capita health expenditures!!
– Due in large part to quantity-based payments
Payer Perspective on Value
Payer Value Perspective
• Increasing number of ‘insured’ people
• Shift in plan sponsors
– Employer to individual
• Changing risk stratification
–  Medicaid
–  High-risk (moral hazard)
• Employers negotiating with providers
–  Utilization & costs
– Will employers need UM from Insurers?
Number of Americans Without Health Insurance Falls, Survey
Shows
By SABRINA TAVERNISE
SEPT. 16, 2014
Federal researchers reported on Tuesday that the number of Americans
without health insurance had declined substantially in the first quarter
of this year, the first federal measure of the number of uninsured
Americans since the Affordable Care Act extended coverage to millions of
people in January.
The number of uninsured Americans fell by about 8 percent to 41 million
people in the first quarter of this year, compared with 2013, a drop that
represented about 3.8 million people and that roughly matched what
experts were expecting based on polling by private groups, like Gallup.
The survey also measured physical health but found little evidence of
change.
http://www.nytimes.com/2014/09/16/us/number-of-americans-without-healthinsurance-falls-survey-shows.html
Small Firms Start to Drop Health Plans
Many View the Health Law’s Marketplace as Inviting and Affordable
By Anna Wilde Mathews, Angus Loten and Christopher Weaver
Oct. 29, 2014
Small companies are starting to turn away from offering health plans as they seek to
reduce costs and increasingly view the health law’s marketplaces as an inviting and
affordable option for workers.
WellPoint Inc. said Wednesday its small-business-plan membership is shrinking
faster than expected and it has lost about 300,000 people since the start of the year.
Going forward, with the health law’s marketplaces running and functioning well,
small employers will likely re-evaluate exchanges as an option for their employees,
said Wayne DeVeydt, WellPoint’s chief financial officer. “We think [that] will become
even probably a more prominent decision that they’ll make this quarter,” he said.
The law includes subsidies for lower-income workers that can sometimes be as
generous as the amounts small employers were paying toward health benefits.
Indeed, insurers and brokers say small employers in lower-income industries are far
more likely to switch.
http://online.wsj.com/articles/small-firms-drop-health-plans-1414628013
Employers Eye Moving Sickest Workers To Insurance Exchanges
By Jay Hancock - KHN Staff Writer
May 07, 2014
Can corporations shift workers with high medical costs from the company
health plan into online insurance exchanges created by the Affordable Care
Act? Some employers are considering it, say benefits consultants.
"It's all over the marketplace," said Todd Yates, a managing partner at Hill,
Chesson & Woody, a North Carolina benefits consulting firm. "Employers are
inquiring about it and brokers and consultants are advocating for it.“
The concept sounds too easy to be true, but the ACA has set up the ability for
employers and employees on a voluntary basis to choose a better plan in [the]
Individual Marketplace and save a significant amount of money for both!"
says promotional material from a company called Managed Exchange Solutions
(MES).
http://www.kaiserhealthnews.org/stories/2014/may/07/shifting-employees-to-exchanges.aspx
Health Insurers Are Trying New Payment Models, Study Shows
By Reed Abelson
July 9, 2014
The survey, released on Wednesday by the plans’ trade association, estimates that $1
out of every $5 in reimbursements is being paid under an arrangement in which
providers are rewarded for improving care and lowering costs.
The insurers say they are spending more than $65 billion a year in new “valuebased” payment models, according to the Blue Cross Blue Shield Association, which
looked at 350 programs in nearly every state.
Health insurers have long talked about changing the way they pay for care, but there
have been few tangible signs of just how enthusiastically they are embracing
alternatives.
But the Blue Cross executives say there is no choice but to move away from a system
that rewarded high-cost care over high-quality and efficient treatments.
http://www.nytimes.com/2014/07/10/business/health-insurers-are-trying-new-payment-models-study-shows.html
CMS…
This website will be CMS' official source of information about
the Hospital Value-based Purchasing (HVBP) Program for
hospitals, clinicians, and other stakeholders who share CMS'
commitment to transforming the quality of hospital care by
realigning hospitals' financial incentives to do so.
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-basedpurchasing/index.html
Hospital Value-based Purchasing Program
The Hospital Value-based Purchasing Program, applies beginning
in FY 2013 to payments for discharges occurring on or after
October 1, 2012.
Under the Program, CMS will make value-based incentive
payments to acute care hospitals, based either on how well the
hospitals perform on certain quality measures or how much the
hospitals' performance improves on certain quality measures from
their performance during a baseline period. The higher a
hospital's performance or improvement during the performance
period for a fiscal year, the higher the hospital's value-based
incentive payment for the fiscal year would be.
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/index.html
Process of Care Measures
Quality measures are used to gauge how well an entity provides
care to its patients.
Measures are based on scientific evidence and can reflect
guidelines, standards of care, or practice parameters. A quality
measure converts medical information from patient records
into a rate or percentage that allows facilities to assess their
performance.
0164 - Fibrinolytic Therapy received within 30 minutes of hospital arrival
STEWARD: Centers for Medicare & Medicaid Services
Measure Description:
Percentage of acute myocardial infarction (AMI) patients with ST-segment elevation or
LBBB on the ECG closest to arrival time receiving fibrinolytic therapy during the hospital
stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less.
Numerator Statement:
AMI patients whose time from hospital arrival to fibrinolysis is 30 minutes or less
Numerator Details:
Denominator Statement:
Principal diagnosis of AMI (International Classification of Diseases, 9th revision, Clinical
Modification [ICD-9-CM] principal diagnosis code of AMI: 410.00, 410.01, 410.10,
410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, 410.60, 410.61,
410.70, 410.71, 410.80, 410.81, 410.90, 410.91); and ST-segment elevation or LBBB on
the ECG performed closest to hospital arrival; and fibrinolytic therapy within 6 hours
after hospital arrival; and fibrinolytic therapy is primary reperfusion therapy
Value of EMS?
Police transport a good bet for shooting victims,
study finds
By Tom Avril, Inquirer Staff Writer
January 8, 2014
From 2003 through 2007, gunshot victims taken to city trauma centers
by police survived two-thirds of the time - the same rate as those taken
by emergency medical squads, according to a new University of
Pennsylvania study.
When the researchers took into account the severity of the injuries, the
survival rate for those taken to emergency rooms by police was slightly
better than for those delivered by ambulance.
When the authors considered all cases of "penetrating trauma" gunshots and stabbings - the survival rates for those taken by police and
those going by ambulance were statistically equivalent.
http://articles.philly.com/2014-01-09/news/45995105_1_gunshot-victims-police-car-shooting-victims
Think the E.R. Is Expensive?
Look at How Much It Costs to Get There
By ELISABETH ROSENTHAL
Published: December 4, 2013
Although ambulances are often requested by a bystander or
summoned by 911 dispatchers, they are almost always billed to
the patient involved. And the charges, as well as insurance
coverage, range widely, from zero to tens of thousands of dollars.
In such a fragmented system, it is hard to know how much highpriced ambulance transport contributes nationally to America’s
$2.7 trillion health care bill. And total out-of-pocket expenditures
by individuals are hard to tally.
http://www.nytimes.com/2013/12/05/health/think-the-er-was-expensivelook-at-the-ambulance-bill.html?hp&_r=1&
Medicare’s $5 Billion Ambulance Tab Signals Area
of Abuse
By Shannon Pettypiece
April 24, 2014
The patient smoked cigarettes in the passenger seat of the ambulance every week,
chatting with the driver while taxpayers foot the $1,000 bill to drive him four blocks for
his dialysis treatment.
The routine was part of a $1.5 million scheme to defraud Medicare by Penn Choice
Ambulance Inc., according to an indictment against the Philadelphia company. The case
helps explain part of why Medicare paid $5 billion to ambulance companies in 2012,
more than went to cancer doctors or orthopedic surgeons, according to newly released
federal data.
The U.S. Department of Health and Human Services has identified ambulance service as
one of the biggest areas of overuse and abuse in Medicare -- companies billing millions
for trips by patients who can walk, sit, stand or even drive their own cars.
http://www.bloomberg.com/news/2014-04-24/medicare-s-5-billion-ambulance-tab-signals-areaof-abuse.html
Fla. County Calls for Controversial EMS Cuts
February 5, 2014
Pinellas County is proposing that fire departments reduce the number of paramedics on
duty overnight when the volume of 911 calls drops.
At a heated meeting Tuesday, a majority of commissioners said they support cutting
$2.3 million from the $40.4 million the county pays every year to Pinellas' 18 fire
districts to serve as medical first responders.
The county is proposing that fire departments reduce the number of paramedics on
duty overnight when the volume of 911 calls drops, although it would be up to fire
departments to decide how they implement any changes.
But commissioners hope the plan can end a decades long battle between the county
and cities over EMS costs. The proposal is estimated to save the county up to $18
million in the first three years and as much as $60 million over 10 years. It would
enable commissioners to freeze EMS property taxes during the next four years,
officials said.
http://tbo.com/pinellas-county/pinellas-commission-calls-for-911-cuts20140205/
NY city to cut firefighters, auction ambulances
A private company will take over rescue calls as Lockport seeks to borrow $5 million to
keep the city afloat
Thomas Prohaska, The Buffalo News, N.Y.
August 28, 2014
LOCKPORT, N.Y. — The cash-strapped city plans to auction off its two ambulances and to
reduce Fire Department minimum staffing from nine firefighters per shift to six as of Sept.
15, Mayor Anne E. McCaffrey said Wednesday.
“I’m absolutely not surprised,” Lockport Professional Fire Fighters Association President
Kevin W. Pratt said. “The judge paved the way for this with his decision.” He was referring
to the June 25 ruling by State Supreme Court Justice Ralph A. Boniello III that canceled a
restraining order preventing the city from cutting minimum manning in the Fire
Department from nine to seven per shift.
The city budgets about $600,000 a year in revenue for ambulance billing, but McCaffrey
said last week it costs about $1 million to provide the service, counting salaries, overtime
and operating expenses.
http://www.buffalonews.com/city-region/lockport/lockport-plans-to-auction-off-ambulances-cutfire-staffing-minimum-20140827
Demonstrating Value for EMS
• What difference CAN we make in…
– Improving Patient Care
– Improving Population Health
– Reducing Cost
Clinical Process of Care Domain?
• STEMI example
– Recognition
– ASA administration
– NTG administration
– Transport to STEMI center
– 12L transmitted
– EMS Access to PCI Time
% of
compliance
Patient Experience of Care Domain?
•
•
•
•
•
•
Communication by medics
Communication by 9-1-1 call taker
Communication by business office staff
Pain control
Cleanliness of ambulance
Comparison
Ride of the ambulance
to Benchmark
Outcome Domain?
•
•
•
•
Cardiac arrest survival
STEMI survival
Infection rate for out of hospital procedures
Patient Safety
– Drops per 100,000 patient contacts
• Repatriation rate
– AMA’s the end up in the hospital
Efficiency Domain?
• Medicare cost per patient contact
• Medicare spending per beneficiary
– Transport
– ED visit
• Compared to alternate outcomes
EMS
Compare
“Mobile Integrated Healthcare is an
innovative and patient-centered approach
to meeting the needs of patients and their
families. The model does require you to
“flip” your thinking about almost everything
– from roles for health care providers, to
what an EMT or paramedic might do to care
for a patient in their home, to how we will
get paid for care in the future.
The authors teach us how to flip our thinking
about using home visits to assess safety and
health. They encourage us to segment
patients and design new ways to relate to
and support these patients. And they urge
us to use all of the assets in a community to
get to better care. This is our shared
professional challenge, and it will take new
models, new relationships, and new skills.”
Maureen Bisognano
President and CEO
Institute for Healthcare Improvement
Questions/Comments?
http://www.emsworld.com/article/11446135/performance-metrics-for-value-based-purchasing