Transcript Slide 1

Payment Reform in Massachusetts:
Impacts and Opportunities for the Health
Care Workforce
Metro North Regional Employment Board Meeting
Anna Gosline and Jessica Larochelle
June 19, 2013
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Overview
• The health care payment system is shifting away from fee-for-service models to more
aggregated, bundled and global payments
• These alternative payment models are spurring new models of care delivery, and
creating new opportunities to pay for services that were previously not “reimbursable”
• These changes, along with other provisions of state and national reform laws, will impact
the demand for health care professionals, both the number and the type
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Massachusetts Has the
Lowest Uninsurance Rate in the Country
PERCENT UNINSURED, 2000–2011, ALL AGES
13.1%
13.9%
14.3%
15.2%
14.7%
14.9%
16.1%
16.3%
15.7%
U.S.
AVERAGE
5.9%
6.7%
7.4%
6.4%
5.7%
2.6%
2.7%
1.9%
3.1%
MASS.
2000
2002
2004
2006
2007
2008
2009
2010
2011
As of 2008, the state contracted with a new vendor (Urban Institute) to track insurance coverage rates in Massachusetts. The Urban Institute
implemented methodological changes to the tracking survey which may affect comparability of the 2008, 2009, and 2010 results to prior years.
The national comparison presented here utilizes a different survey methodology, the Current Population Survey , which is known to undercount
Medicaid enrollment in some states.
NOTE:
Massachusetts Division of Health Care Finance and Policy, Massachusetts Health Insurance Survey 2000, 2002, 2004, 2006, 2007, 2008, 2009, 2010, 2011;
U.S. Census Bureau, Current Population Survey, Health Insurance Historical Tables (HIB Series).
SOURCES:
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But the Highest Per Person Health Care
Spending in the World
PER CAPITA PERSONAL HEALTH CARE EXPENDITURES, 2009
$10,000
$9,000
$8,000
$7,000
NATIONAL AVERAGE
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
UT AZ GA ID NV TX CO AR CA AL VA SC TN NC OK MS OR KY MI MT NM IN IL KS WA LA HI IA MO WY NE SD OH FL WI MNMD NJ VT WV PA ND NH RI NY DE ME CT AK MA
State
NOTE:
District of Columbia is not included.
Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2011.
SOURCE:
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Key Affordability/Cost-Related
Developments in Massachusetts
2006
 Health
reform
passes
(Ch. 58)
– Begins path
to near
universal
coverage
ISELIN
2007
 Much of
Chapter 58
enacted, e.g.:
– MassHealth
expansion
– Commonwealth
Care
– Consumer
affordability
schedule
– New health
plan options for
young adults
– Employer Fair
Share
2008
2009
2010
2011
2012
 Cost
Containment
Part 1 (Ch.
305) passes
 Special
Commission
on Payment
Reform
 Government
reports and
hearings on
cost drivers
 Governor
rejects small
group
premiums
 Cost
Containment
Part 2 (Ch.
288) passes
 Governor
Patrick files
payment
reform
legislation
 Special
Commission
on Provider
Price
Reform
 Cost
Containment
Part 3 (Ch.
224) passes
– Increased
transparency
about cost
drivers
– Reports on
health
insurer and
hospital
“reserves”
– Recommends
move to
global
payment
– Statewide
cost growth
targets and
payment
reforms
– Continued
focus on data
transparency
– Aims to
control
premiums for
small
businesses,
individuals
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Chapter 224 of the Acts of 2012
The law aims to reduce health care cost growth through:
• The creation of new agencies (the Health Policy Commission and the Center for
•
•
•
•
•
Health Information and Analysis)
— Setting and monitoring statewide health care cost growth targets
— New scrutiny on health care market power, price variation and cost growth at
the individual health care entity level
Increased cost transparency for consumers
A focus on wellness and prevention
Expanding the primary care workforce
Other provisions around health resource planning, HIT, medical malpractice reforms,
and administrative simplification.
Wide adoption of alternative payment methodologies
— MassHealth must have 80% of enrollees in alternative payments by 2015
— All payers must, to the maximum extent feasible, move away from fee-for-service
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Solving the Cost Problem Through Provider Payment Reform
CURRENT FEE-FOR-SERVICE
PAYMENT SYSTEM
PATIENT-CENTERED GLOBAL
PAYMENT SYSTEM
THE PROBLEM
THE SOLUTION
Care is fragmented instead of
coordinated. Each provider is paid for
doing work in isolation, and no one is
responsible for coordinating care.
Quality can suffer, costs rise and there is
little accountability for either.
Global payments made to a group of
providers for all care. Providers are not
rewarded for delivering more care, but
for delivering the right care to meet
patient’s needs.
$
$
$
$
$
$
PRIMARY CARE
HOSPITAL
SPECIALIST
HOSPITAL
SPECIALIST
PRIMARY
CARE
HOME
HEALTH
HOME HEALTH
GOVERNMENT, PAYERS AND PROVIDERS WILL SHARE RESPONSIBILITY FOR PROVIDING
INFRASTRUCTURE, LEGAL AND TECHNICAL SUPPORT TO PROVIDERS IN MAKING THIS TRANSITION.
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The New Ways to Pay and Practice
 Global payment/budget – (eg. Accountable Care Organizations)
– Usually accepted by a group of providers (sometimes a hospital and it’s physician practices, sometimes just
a physician group) accepting responsibility for the total cost of care for a set population or patient group
– Large variation in the exact details of the payment; providers may accept various levels of “risk” around
meeting per person cost targets
– Payments usually dependent on achieving quality metrics
 Patient Centered Medical Homes
– Accepted by a primary care practice with augmented abilities around managing care both within its own
practice and coordinating with specialists and hospitals.
– Focus on team-based, patient-centered care and population management
– Payments are usually structured as additional per-person care management fees on top of standard feefor-service payments
 Value-Based Purchasing
– A bit of a catch-all phrase, mostly associated today with Medicare penalties for high rates of readmissions
at hospitals
 Bundled and Episode-Based Payments
– A single payment to cover all care for a procedure or condition usually over a defined period of time
– Often accepted by jointly be a hospital and it’s physician group
– Eg. Medicare Bundled Payment demonstration, just launched in 2013
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Alternative Payments Are Spreading Quickly in
Massachusetts
HMO MEMBERSHIP IN BCBSMA’S GLOBAL PAYMENT CONTRACT
75% of HMO
membership
646,048
428,600
359,000
328,000
2009
2010
2011
2012
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Global Payments Are Showing Positive Results
on Both Cost and Quality
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But there Is No Overall Link Between Global Payments and Total
Spending – Likely a Reflection of Price Disparities
BCBSMA RELATIVE HEALTH STATUS-ADJUSTED TOTAL MEDICAL EXPENSE
1.8
PROVIDERS OPERATING UNDER GLOBAL PAYMENTS
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
SOURCE: Office
of Attorney General Martha Coakley, “Examination of Health Care Cost Trends and Drivers,” June 2011.
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The Payment Reform Landscape is Spurring a New Wave of
Market Consolidation, Potentially Increasing Prices Further
Partners in talks with Hallmark Health
BY STEVEN SYRE
GLOBE COLUMNIST APRIL 17, 2012
Cooley Dickinson Trustees Choose
Massachusetts General Hospital
02/28/2012 10:07 AM
Steward Continues Buying Spree;
Globe Reports Deal for Lowell Hospital
April 4, 2011 | 12:37 PM | By Carey Goldberg
Lahey, Northeast Health finalize merger
Boston Business Journal
Date: Monday, May 7, 2012, 6:51am EDT
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So What Does this All Mean for the Health Care Workforce?
• Demand for comprehensive, and community-focused primary care services
• Continued strong demand primary care physicians, NPs and PAs
• Opportunities for new kinds of lay health care professionals, eg. Community Health Workers
• Need for care management and case management
• New skills for primary care practitioners and beyond
• Emphasis on team-based care, collaboration and coordination
• Promoting team-based care skills as part of medical education for physicians, nurses and other
health care professionals
• Capability with EHRs and population health data analysis
• Patient engagement
• Cultural competence
• Behavioral health integration
• Provisions of state and national health reform support many of these goals
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Primary Care Physicians: Landscape
PRIMARY CARE PHYSICIAN DENSITY BY COUNTY PER 100,000 POPULATION, 2006
ESSEX
FRANKLIN
77.3
MIDDLESEX
BERKSHIRE
HAMPSHIRE
94.7
WORCESTER
SUFFOLK
249.7
94.6
99.7
HAMPDEN
NORFOLK
120.2
PLYMOUTH
59.6
BRISTOL
54.5
BARNSTABLE
90.3
PCP Density (per 100,000 residents)
54.5 - 59.6
59.7 - 90.3
90.4 - 120.2
DUKES‡
113.8
120.3 - 249.7
NANTUCKET‡
58.1
‡Due
to the relatively small number of physicians and total population size, caution should be taken when
comparing rates in this County to rates in other Counties.
Source: Health Resources and Services Administration (HRSA) update to the American Medical Association’s Master
File – Physician Characteristics (2006). For more information, visit HRSA at
http://datawarehouse.hrsa.gov/pcsa2006.aspx. 1Kay Lazar. “Many Continue to Rely on ER: 14% Used Hospital
Before Family Doctor,” The Boston Globe (November 2008)
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Primary Care Physicians: Landscape
PERCENT OF INTERNAL MEDICINE PRACTICES ACCEPTING NEW PATIENTS AND WAIT TIME TO NEW PATIENT APPOINTMENT
Source: Massachusetts Medical Society, 2012 Patient Access to Healthcare Study
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Primary Care Physicians and Recent Legislation:
More and/or Different?
• Chapter 224 and the Affordable Care Act (ACA)
• Primary care residency grant programs and loan forgiveness programs
• Service obligations for federally supported student loans softened
• Primary care payment bump
• Medicare will increase primary care reimbursement rates by 10% from 2011-2016
• Medicaid reimbursement will be increased to at least Medicare levels from 2013-2014
• MassHealth alternative payment methodologies
• Massachusetts will likely not see the surge in primary care demand predicted nationwide
in 2014, as the state already has a well-established universal access reform.
• But the fast pace of payment reform adoption and delivery system change will mean
major changes, nonetheless.
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Nurse Practitioners (NPs): Landscape
NURSE PRACTITIONER DENSITY PER 100,000 POPULATION, 2011
140
116
120
103
100
96
82
80
80
66
58
60
40
20
0
Connecticut
Maine
Massachusetts New Hampshire
Rhode Island
Vermont
United States
Source: Calculations based on The 2012 Pearson Report, The American Journal for Nurse Practitioners, NP Communications LLC.
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Nurse Practitioners (NPs) and Recent Legislation:
More and/or Different?
• Key Provisions in Chapter 224
• Global signature authority – NPs can now fulfill laws or rules that used to require a signature,
stamp, verification, etc. by a physician
• Limited service clinics – Expands to the scope to include all services within the scope and
practice of NPs
• Key Provisions in the Affordable Care Act
• Dedicated funds in the Prevention and Public Health Fund to train new NPs
• Family NP training demonstration will support new graduates for a year of practice in a
federally qualified health center or nurse-managed health clinic
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Physician Assistants (PAs): Landscape
80
PHYSICIAN ASSISTANT (PA) DENSITY PER 100,000 POPULATION, 2011
70
60
50
40
Massachusetts
US Average
30
20
10
0
Sources: Physician Assistant Census Report: Results from the 2010 AAPA Census, American Academy of Physician Assistants, 2010
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Physician Assistants (PAs) and Recent Legislation:
More and/or Different?
• Key Provisions in Chapter 224
• Carriers must now recognize PAs as participating providers and cover care provided by
PAs for health maintenance, diagnosis, and treatment
• PAs are now included in the definition of primary care provider; carriers that require
designation of a primary care provider must allow members the option to choose a PA
• Physicians are no longer prohibited from supervising more than four PAs at a time
• The Health Care Workforce Center’s scope has been broadened to include PAs;
information on the status of the PA workforce will be included in its annual report
• Key Provisions in the Affordable Care Act
• Dedicated funds in the Prevention and Public Health Fund to train new PAs
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Community Health Workers: Definition
Community Health Workers (CHWs) are public health workers who apply their unique
understanding of the experience, language and/or culture of the populations they
serve in order to carry out one or more of the following roles:
• Providing culturally appropriate health education, information and outreach in
community-based settings;
• Bridging/culturally mediating between individuals, communities and health and human
services, including actively building individual and community capacity;
• Assuring that people access the services they need;
• Providing direct services, such as informal counseling, social support, care coordination
and health screenings; and
• Advocating for individual and community needs.
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Community Health Workers and Recent Legislation:
More and/or Different?
Community Health Worker (CHW) Certification Process:
• Legislation passed in 2010; went into effect in 2012
• The Board will establish standards for:
• Education and training of community health workers and community health worker
trainers
• Education and training program curricula for community health workers
• Requirements for community health worker certification and renewal of certification
• Other considerations
• Grandfathering?
• Reimbursement considerations?
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New Skills – Team-Based Care and Care Coordination
• Patient-Centered Medical Homes
• Practice redesign with an emphasis on patient communication, after-hours access, care
planning, management and coordination, community support and performance measurement
• New partnerships beyond the practice
• Coordinating care with hospitals, specialists and post-acute care providers
• Example: Researchers have found that those with a primary care visit within 14 days of an
admission for CHF are much less likely to be readmitted
• Behavioral health integration
• Patients with mental health and substance abuse disorders, especially those with co-morbid
chronic health conditions, are among the costliest patients in the system
• Designing innovative care management programs that address the particular needs of this
population will be crucial
• Will require greater collaboration between providers with different specialties
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New Skills – EHR and Population Data
• There are many forces aligning that will require more sophisticated use of data, electronic
data use and sharing
• One of the core capacities of NCQA certification for Patient-Centered Medical Home
accreditation is the use of data for population management
• Even more critical for practices accepting risk for the total cost of care for their
patients
• Chapter 224 made EHR proficiency a condition of licensure for Massachusetts
physicians
• HIE data exchange for care coordination
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New Skills – Patient Activation and Engagement
• As providers accept risk for the total costs and quality of care, they will have to build new
types of relationships with patients, e.g. “shared decision-making”
• ACA identifies patient engagement as a critical component of accountable care organizations
and patient-centered medical homes.
• When patients are engaged in their health care – more knowledgeable, more confident in
managing their health and navigating they system – they experience better health outcomes
and incur lower health care costs.
• Challenges for providers: overworked physicians, insufficient provider training, and clinical
information systems that fail to track patients throughout the decision-making process.
Source: Health Affairs, Health Policy Briefs: Patient Engagement, February 14, 2103
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Thank you!
Questions/Comments
Anna Gosline, Director of Policy and Research
[email protected]
Jessica Larochelle, Director of Evaluation & Strategic Initiatives
[email protected]
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