Transcript Slide 1

THE
COMMONWEALTH
FUND
Developing Innovative Payment
Approaches: Finding the Path to High
Performance
Stuart Guterman
Assistant Vice President and
Director, Program on Payment System Reform
Council of State Governments/Eastern Region
Webinar/Conference Call
November 30, 2009
Outcome
measures; large
% of total
payment
Global
Payment
Global Case
Rates
Less
Feasible
More
Feasible
Blended
FFS/Care
Management fee
Fee-forService
Care
coordination and
intermediate
outcome
measures;
moderate % of
total payment
Continuum of P4P Design
Continuum of Payment Bundling
The Relationship Between
Payment Methods and Organizational Models
Simple process and
structure measures;
small % of total
payment
Small practices;
unrelated
hospitals
Independent Practice
Associations; Physician
Hospital Organizations
Fully integrated
delivery system
Continuum of Organization
THE
COMMONWEALTH
FUND
Source: Adapted from A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. McCarthy, Organizing the U.S. Health Care Delivery System for High
Performance, The Commonwealth Fund, August 2008.
Current Public and Private Sector
Initiatives I
• Medicare
– Collecting and reporting data on quality in nursing
homes, home health agencies, hospitals, dialysis
facilities; preliminary process for physician
reporting
– Testing value-based purchasing models for
hospitals, physicians; nursing homes and home
health agencies
– Testing models for improving coordination of care
among different types of providers (mainly hospitals
and physicians)
– Testing models of broader system redesign
THE
COMMONWEALTH
FUND
Current Public and Private Sector
Initiatives II
• Medicaid
– Pay for performance mechanisms in place in more than
half the states
– Medical home models being tested in more than 30
states
– New initiative to align incentives in Medicare and
Medicaid around the establishment of medical homes
• Private Sector
– Initiatives by individual payers aimed at improving
quality and efficiency
– Collaborative initiatives by groups of payers (e.g.,
Institute for Clinical Systems Improvement, Patient
Choice Healthcare) or purchasers (e.g., Bridges to
Excellence)
– Development of alternative payment models (e.g.,
PROMETHEUS) or organizational models (e.g.,
Accountable Care Organizations or ACOs)
THE
COMMONWEALTH
FUND
How Can the (Medicare) Process Be
Improved?
• Ensuring transparency in selecting
demonstration projects and conducting
demonstrations
• Eliminating barriers to Medicare’s ability to
participate in multi-payer initiatives
• Streamlining the long and burdensome process
required to identify sites and to approve
demonstrations
• Addressing limitations in the methodology and
data available to conduct comprehensive
evaluations of demonstration projects
• Establishing an explicit mechanism for
translating initiatives into policy change
• Providing sufficient resources for developing,
implementing, monitoring, and evaluating
demonstration projects
THE
COMMONWEALTH
FUND
Health Reform Legislation
• House bill mandates Medical Home pilot
program (with 10 percent participation goal)
• Senate Finance bill allows states to designate
health homes for chronically ill Medicaid
beneficiaries
• House and Senate Finance bills call for ACO
pilots (House bill includes 10 percent
participation goal)
• House and Senate Finance bills include pilots
bundling Medicare payments for acute and
post-acute care
• Senate Finance bill establishes value-based
purchasing programs for hospitals and
physicians
THE
COMMONWEALTH
FUND
Center for Medicare and Medicaid Innovation:
Selection, Evaluation, and Expansion of Pilots
• Beginning January 1, 2011, Center in CMS 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; current demonstration authority
expanded
• Models to be selected based on evidence that they
address a defined population for which there are
deficits in care leading to poor clinical outcomes or
potentially avoidable expenditures
• Emphasis on care coordination, patient-centeredness
• Can’t require budget neutrality initially, but over time
must improve quality without increasing spending,
reduce spending without reducing quality, or both
• Evaluation should include quality of care, including
patient-level outcomes, and changes in spending;
could consider cross-program impact
• Secretary could expand duration and scope if model
reduces spending without reducing quality
THE
COMMONWEALTH
FUND
Center for Medicare and Medicaid Innovation:
Structure, Funding, and Reporting
• Director reports to Administrator of CMS
• $10 billion for 2011-2019 funding remains
until expended; $25 million of this to design,
implement and evaluate models
• Beginning in 2012, a report to Congress not
less than every other year, describing models
tested, models expanded, and results of
evaluations
THE
COMMONWEALTH
FUND
Expanding the Power of the Secretary of Health and Human Services to
Put Medicare Payment Pilots on “Fast Track”
“How strongly would you favor or oppose expansion of the Secretary of Health and Human Services’
authority to put Medicare payment pilots that meet appropriate requirements on a ‘fast track’, with the
ability to extend their duration and scope if they appear to be successful?”
Strongly
Oppose
2%
Somewhat
Oppose
2%
Somewhat
Favor
21%
Strongly
Favor
74%
THE
COMMONWEALTH
FUND
Source: Commonwealth Fund Health Care Opinion Leaders Survey, October 2009.
Expanding the Power of the Secretary of Health and Human Services to
Work with Other Parties to Implement Multipayer Payment Initiatives
“How strongly would you favor or oppose expansion of the Secretary of Health and Human Services’
authority to work with private payers, providers, and other interested parties to develop and implement
multipayer payment initiatives (including Medicare, Medicaid, and private payers) in selected areas?”
Neither Favor Strongly
nor Oppose Oppose
2%
3%
Somewhat
Favor
26%
Strongly
Favor
68%
THE
COMMONWEALTH
FUND
Source: Commonwealth Fund Health Care Opinion Leaders Survey, October 2009.
Requiring Medicare recipients to participate in an all-payer database for
research, policy development, and monitoring and evaluation purposes
“How strongly would you favor or oppose requiring Medicare to participate in the development of
state/regional/national all-payer data bases, including Medicare, Medicaid, and private insurance data, to
provide a foundation for research, policy development, and monitoring and evaluation?”
Somewhat Strongly
Oppose
Oppose
2%
Neither Favor 4%
nor Oppose
3%
Somewhat
Favor
18%
Strongly
Favor
73%
THE
COMMONWEALTH
FUND
Source: Commonwealth Fund Health Care Opinion Leaders Survey, October 2009.