Transcript Slide 1

Update from the Innovation Center at
CMS: How is health care payment
going to change?
Richard J Baron, MD, MACP
Group Director
Seamless Care Models
Center for Medicare and Medicaid Innovation
CMS
4th Annual Primary Care Summit
Rocky Hill, CT
November 3, 2011
Wisdom on physician payment
“There are many mechanisms for paying physicians; some
are good, and some are bad. The three worst are fee-forservice, capitation and salary. Fee-for-service rewards the
provision of inappropriate services, the fraudulent upcoding of
visits and procedures, and the churning of “ping-pong”
referrals among specialists. Capitation rewards the denial of
appropriate services, the dumping of the chronically ill, and a
narrow scope of practice that refers out every time consuming
patient. Salary undermines productivity, condones on-the-job
leisure, and fosters a bureaucratic mentality in which every
procedure is someone else’s problem.”
James C Robinson, “Theory and
Practice in the Design of Physician Payment Incentives.
The Milbank Quarterly, Vol 79, No. 2, 2001, p. 149
Thank You
• For the hard work you are doing to improve our nation’s
healthcare system.
• For being a part of this critical dialogue.
• We’re ready as never before for a leap forward into the
healthcare system we want, need, and can have.
CMS Mission
CMS is a constructive force and a
trustworthy partner for the continual
improvement of health and health care for
all Americans.
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Measures of Success
Better healthcare - Improve individual patient experiences of care
along the IOM 6 domains of quality: Safety, Effectiveness,
Patient-Centeredness, Timeliness, Efficiency, and Equity
Better health - Focus on the overall health outcomes of
populations by addressing underlying causes of poor health,
such as: physical inactivity, behavioral risk factors, lack of
preventive care, and poor nutrition
Reduced costs - Lower the total cost of care resulting in reduced
monthly expenditures for Medicare, Medicaid or CHIP
beneficiaries by improving care
The Current System
• Greatest Acute Care in the World: People
come from around the world to be treated
• But: 49.9 Million Americans lack coverage
• Uncoordinated – Fragmented delivery systems with
variable quality
• Unsupportive – of patients and physicians
• Unsustainable – Costs rising at twice the inflation
rate
Innovation Will Transform
American Health Care
Current State
Producer-Centered
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Fragmented delivery systems
with variable quality
Costs rising at twice the inflation
rate
17 year lag between best
practice discovery and
widespread adoption
Clinicians dissatisfied
Patients often passive and
unengaged
PRIVATE
SECTOR
PUBLIC
SECTOR
Current payments –
part of the problem…
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Fragmented payment systems
(IPPS, OPPS, RBRVRS)
Fee-for-service payment model
Future State
People-Centered
INNOVATION
CENTER
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All Americans receive the right
care, in the right setting, at the
right time, all the time
•
Health dollars spent efficiently;
rate of growth slowed significantly
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Clinical and delivery system best
practices diffused rapidly
• CMS part of the
solution…
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Episode-based payments
Value-based purchasing
Accountable Care Organizations
Patient Centered Medical Homes
Resource Utilization Reporting
Innovation Center rapid
testing and diffusion
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A Future System
• Affordable
• Accessible – to care and to information
• Seamless and Coordinated
• High Quality – timely, equitable, safe
• Person and Family-Centered
• Supportive of Clinicians in serving their
patients needs
Transforming Health Care
• We can invent our way to success
• We can improve our way to a sustainable, proud,
and excellent American health care system
• We can make health care more affordable for our
country by making it better for the people who
depend on it
• Better care will be, overall, less costly care
Delivery Reform Continuum
ACO –
Medical Track 1
Homes
Bundling
Partnership
for Patients
ACO –
Track 2
Pioneer
ACOs
Global
Payment
Providers can choose from a range of care
delivery transformations and escalating
amounts of risk, while benefitting from
supports and resources designed to
spread best practices and improve care.
Meaningful
Use
Tools to Empower Learning and Redesign:
Data Sharing, Learning Networks, RECs, PCORI, Aligned Quality Standards
New Tools in the CMS Toolbox
• Medical Homes
• Hospital-Acquired Conditions (HAC) Payment Rules
• Value-Based Purchasing
• Reducing Fraud, Waste & Abuse
• Medicare and Medicaid Coordination Office
• CMS Innovation Center
• Medicare ACO Shared Saving Program
The Innovation Center
“The purpose of the Center is to test innovative payment and
service delivery models to reduce program expenditures
under Medicare, Medicaid and CHIP…while preserving or
enhancing the quality of care furnished…”
– “Preference to models that improve coordination, quality
and efficiency of health care services.”
• Resources - $10 Billion in funding for FY2011 through
2019
• Opportunity to “scale up”: HHS Secretary authority to
expand successful models to the national level
The Innovation Center
Mission Statement
“Be a constructive and trustworthy partner
in identifying, testing and spreading new
models of care and payment that
continuously improve health and
healthcare for all Americans.”
Our Work
Patient Care Models – The right care at the right time, in
the right setting – every time
Seamless Coordinated Care Models – Coordinating care
to improve health outcomes for patients
Community and Population Health Models – Keeping
families and communities healthy
Our Process
Solicit ideas for new models
Select the most promising models
Test and evaluate the models
Spread successful models
Initial Programs
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ACO Initiatives: Shared Savings Program, Pioneer, Advance Payment, Learning
Sessions
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Bundled Payments for Care Improvement
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Multi-Payer Advanced Primary Care Practice Demonstration
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Federally Qualified Health Center (FQHC) Advanced Primary Care Practice
Demonstration
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Medicaid Health Home State Plan Option
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State Demonstrations to Integrate Care for Dual Eligible Individuals
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Demonstration to Improve Quality of Care for Nursing Facility Residents
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Financial Models to Support State Efforts to Coordinate Care for MedicareMedicaid Enrollees
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Partnership for Patients
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Comprehensive Primary Care initiative
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Innovation Center Advisors
CMS ACO Initiatives
ACO Initiatives at CMS:
– Shared Savings Program
– Pioneer ACO Model
– Advance Payment Initiative
– ACO Accelerated Development Learning Sessions
Advance Payment Initiative
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The Innovation Center sought public comments on whether it should offer
an Advance Payment Initiative.
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The Advance Payment Initiative would give certain ACOs participating in
the Medicare Shared Savings Program access to part of their shared
savings up front.
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ACOs would need to provide a plan for using these funds to build care
coordination capabilities, and meet other organizational criteria.
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Advance payments would be recouped through the ACOs’ earned shared
savings.
Multi-payer Advanced Primary
Care Practice Model
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Evaluate the effectiveness of doctors and other health professionals
receiving a common payment method from Medicare, Medicaid, and
private health plans
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Medicare will participate in existing State multi-payer health reform
initiatives that currently include participation from both Medicaid and
private health plans.
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The demonstration program will pay a monthly care management fee
for beneficiaries receiving primary care from APC practices
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Eight states selected to participate: Maine, Vermont, Rhode Island, New
York, Pennsylvania, North Carolina, Michigan and Minnesota will
participate
Federally Qualified Health Center
Advanced Primary Care Demonstration
• Evaluate the impact of the advanced primary care practice
model on the accessibility, quality, and cost of care provided
to Medicare beneficiaries served by Federally Qualified
Health Centers (FQHCs).
• FQHC receives care management fee for each Medicare
beneficiary enrolled at the FQHC
• Applications were due September 9, 2011
• Up to 500 FQHCs will be selected
Medicaid Health Home State
Plan Option
• Option open to all states
• Allows Medicaid beneficiary with at least two chronic
conditions to designate a single provider as their “health
home”
• Participating states will receive enhanced financial
resources from the federal government to support “health
homes” (90-10 Federal-State match)
• The Innovation Center will be assisting with learning,
technical assistance and evaluation activities.
State Demonstrations to Integrate Care
for Dual Eligible Individuals
• CMS awards contracts to states for design of models
aimed at improving the quality, coordination, and cost
effectiveness of care for dual eligible individuals
• 15 states have received contracts of up to $1 million:
– California, Colorado, Connecticut, Massachusetts, Michigan,
Minnesota, New York, North Carolina, Oklahoma, Oregon, South
Carolina, Tennessee, Vermont, Washington and Wisconsin
Community-based Care
Transitions Program (CCTP)
• The CCTP, mandated by section 3026 of the Affordable Care Act,
provides the opportunity for community based organizations to partner
with hospitals to improve transitions between care settings
• $500 million available for community-based organizations
• Applications now being accepted and awarded on a rolling basis
• The goals of the Community-based Care Transitions Program are to:
• Improve transitions of beneficiaries from the inpatient hospital
setting to home or other care settings
• Reduce readmissions for high risk beneficiaries
• Document measurable savings to the Medicare program
• Learn more: www.healthcare.gov/partnershipforpatients
Comprehensive Primary Care initiative
Evidence Supporting
Comprehensive Primary Care
• Community Care of North Carolina
– Decreased preventable hospitalizations for asthma by 40 %
– Lowered visits to the Emergency Room by 16%
• Group Health Cooperative of Puget Sound
– Reduced emergent and urgent care visits by 29%
– Lowered hospital admissions by 6%
• Geisinger Health Plan
– Reduced admission rates by 18%
– Lowered hospital readmissions by 36% per year
Evidence Supporting Comprehensive
Primary Care: Employers
• Comprehensive Health Services
– Business is providing workforce health care
– Found increasing the use of primary care resulted in 17% reduction
in costs for established patients in one year
• Wisconsin-based QuadMed
– Operates five employee clinics on-site or nearby
– The company’s health costs/employee are approximately one
quarter the cost of the rest of community
• Increased quality indicators, including patient satisfaction
• Lower rates of emergency department visits and hospital admissions
Supportive Multipayer Environment
Practice and Payment Redesign
through the CPC initiative
Enhanced, accountable payment
Continuous improvement
driven by data
Comprehensive
primary care
Optimal use of health IT
Comprehensive primary care
functions:
 Risk-stratified care management
 Access and continuity
 Planned care for chronic conditions
and preventive care
 Patient and caregiver engagement
 Coordination of care across the
medical neighborhood
Aim:
Better health,
Better care,
Lower cost
Comprehensive Primary Care Functions:
What is CMS trying to support?
1. Risk-stratified care management
2. Access and continuity
3. Planned care for chronic conditions and
preventive care
4. Patient and caregiver engagement
5. Coordination of care across the medical
neighborhood
1. Risk-stratified care management
• Participating practices will deliver intensive care
management for the sickest patients with highest needs
• By engaging patients, providers can create a plan of care
that uniquely fits each patient’s individual circumstances and
values
• Markers of Success:
– Policies and procedures that describe routine risk assessment
– Presence of appropriate care plans informed by the risk assessment
2. Access and continuity
• Patient care team must be accessible to patients 24/7
• Use patient data tools to provide real-time, personal health
care information
• Provide care from the same provider or health team to build
trusted relationships
• Markers of Success:
– Continuity of visits with same provider
– Availability of EHR when office is closed
3. Planned care for chronic conditions
& preventive care
• Primary care practices will proactively assess patients to
determine need
• Provide appropriate and timely preventive care
• Use disease registries to track and appropriately treat
chronically ill patients
• Markers of Success:
– Provision of Medicare’s Annual Wellness Visit
– Documentation of medication reconciliation
4. Patient & caregiver engagement
• Primary care practices will engage patients and their
families in active participation in goal setting and decision
making.
• Patients will be full partners in truly patient-centered care
• Markers of Success:
– Policies and procedures designed to ensure that patient preferences
are sought and incorporated into treatment decisions
5. Coordination of care across the
medical neighborhood
• Primary care as first point of contact will take the lead in
coordinating care
• Primary care team will work together with broader health
team and the patient to make decisions
• Access to and meaningful use of electronic health records
will be used to support these efforts
• Markers of Success:
– Use of processes and documents for communicating key information
during care transitions or upon referral to other providers
Three Components of Medicare
Payment in the CPC initiative
• Medicare fee-for-service remains in place
• Average $20 PBPM fee (risk-adjusted) to support increased
infrastructure to provide CPC for first 2 years
– Reduced to an average of $15 PBPM in years 3 and 4
• Opportunity for Shared Savings in years 2, 3, and 4
– Calculated at the market level
– Practice share determined by size, acuity and quality metrics
Additional Support for Primary Care Practices
• Commitment to share data with practices on utilization and
the cost of care for aligned beneficiaries
• Shared learning to help practices effectively share their
experiences, track their progress and rapidly adopt new
ways of achieving improvements in quality, efficiency and
population health
Collaboration with Payers and Purchasers
• Individual health plans, covering only their
members, cannot provide enough resources to
transform primary care delivery
– Requires investment across multiple payers
• CMS is inviting public and private insurers to
collaborate in purchasing high value primary care in
communities they serve
Participating Payers and Purchasers
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Commercial Insurers
Medicare Advantage plans
States
Medicaid Managed Care plans
State/federal high risk pools
Self-insured businesses
Administrators of self-insured group (TPA/ASO)
CMS invites Payers and Purchasers to align
support strategies in a community
• Interested payers may describe in the application how they
would propose to align with CMS:
– What they are already doing to support CPC functions through
enhanced, non-visit based support
– What they would be prepared to do to support CPC functions
– Describe the geographic area in which they would be prepared to test
this model with CMS
• Payers may propose comprehensive primary support in one
or more markets, through one or more lines of business
What is a “market”?
• Interested payers will describe the contiguous geographic
area in which they would be prepared to test this model with
CMS
• Use a combination of Metropolitan Statistical Areas (MSAs),
counties, and/or zip codes as descriptors
– May span multiple MSAs and/or counties
• The final definition of a market will be based on the
overlapping, contiguous geographic services areas of
participating payers and will remain within one state
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States as Applicants
• May apply on behalf of state employees program or
encourage Medicaid manage care plans to apply
• May apply and propose support from the Innovation
Center for Medicaid fee-for-service beneficiaries
utilizing or assigned to participating practices
– Funding available for enhancements to primary care, such
as newly initiated or enhanced PCCM services
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Applying states need to
• Share data on cost and utilization
• Collaborate with CMS in conversations with their
states’ Medicaid managed care organizations to
encourage them to consider applying to
participate in this initiative
• Commit to working with CMS in its evaluation of
the initiative
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Evaluating Payer Applications
• Innovation Center will assess alignment of payer proposals:
– Method of enhanced, non-visit-based support for
comprehensive primary care functions
– Opportunity for practices to qualify for shared savings
– Attribution methodology for how a payer’s members will
be identified as being served by a participating practice
– Sharing data on cost and utilization with participating
practices
– Willingness to align quality, practice improvement and
patient experience measures
Market Selection
• Market selection is combination of:
– Scoring of individual payer proposals against eligibility
criteria
– Collective “market impact” of proposals
• Markets will be chosen based on where a preponderance of
health care payers:
– Apply, meet criteria, are selected, and agree to participate
• Goal is to have diverse geographic representation
Market Discussions
• Once markets are selected, CMS will invite all willing and
eligible payer applicants to participate in market-level
discussions involving payers, providers, consumers to
agree on:
– A common approach to data sharing
– Implementation milestones
– Alignment on quality measures
• No discussion of payment or pricing.
Result of Market Discussions
• Each payer will enter into a Memorandum of
Understanding (MOU) with CMS:
– The content of the MOU will be the same for all
payers in a market
– Through the MOU, payers will commit to the
common approach to data sharing, implementation
milestones and quality metrics
– The MOU will reference the payer’s proposal to CMS
of their support for comprehensive primary care
Practice Selection
• Occurs after the 5-7 markets are selected
• The goal is to enroll ~75 practices per market
• We expect to attract high-performing practices
• CMS and participating payers will enroll primary care
practices who agree to provide comprehensive primary care
• CMS will sign an agreement with practices
• Payers will sign separate agreements with practices
Resources
All application materials and more information can be found
on the website, http://innovations.cms.gov/
Letters of Intent are due November 15, 2011
Applications are due on January 17, 2012
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Questions?
For further questions, please email
[email protected]
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Partnership
• Join us on this journey to provide coordinated,
seamless, reliable, and patient-centered care that is
rooted in health, grounded in primary care, and
economically sustainable.
• CMS wants to support your transformation and work
with you to improve care and reduce costs.
Thank You
Questions?
Suggestions?
How can we work together?
[email protected]