Transcript THE COMMONWEALTH FUND Developing Innovative Payment Approaches: Finding the Path to High Performance Stuart Guterman Vice President, Payment and System Reform Executive Director, Commission on a High Performance.

THE
COMMONWEALTH
FUND
Developing Innovative Payment Approaches:
Finding the Path to High Performance
Stuart Guterman
Vice President, Payment and System Reform
Executive Director, Commission on a
High Performance Health System
The Commonwealth Fund
Alliance for Health Reform Briefing on
“The Innovation Center: How Much Can It
Improve Quality and Reduce Costs – and How Quickly?
Washington, DC
July 18, 2011
“The country needs, and unless I mistake its
temper, the country demands, bold,
persistent experimentation. It is common
sense to take a method and try it. If it fails,
admit it frankly and try another. But above
all, try something.”
Franklin D. Roosevelt, 1932
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Problems with the Current Payment System and
Goals of Reform
• Problems:
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Fragmented care
Lack of coordination
Variable quality
High and rapidly-growing costs
• Goals:
– Create incentives for providers to take broader accountability for
patient care, outcomes, and resource use
– Provide rewards for improved care coordination among
providers
– Slow growth in health spending
– Put in place an infrastructure to support providers in improving
quality and efficiency
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Center for Medicare and Medicaid Innovation
• Innovation Center 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
• Could increase spending initially, but over time must improve
quality without increasing spending, reduce spending without
reducing quality, or both
• Evaluation should include quality of care, including patientlevel outcomes, and changes in spending; could consider
cross-program impact
• Secretary could expand duration and scope if model reduces
spending without reducing quality
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Models to be Tried by the Innovation Center
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Patient-centered medical homes for high-need individuals,
women’s health care needs, and comprehensive or salary-based
payment
Promotion of innovative care delivery models with providers
such as risk-based comprehensive payment or salary-based
payment
Using geriatric assessments and comprehensive care plans to
coordinate care
Promote care coordination through salary-based payment
Support care coordination for chronically-ill through the use of
health information technology
Vary payment to physicians ordering diagnostic imaging
services based on appropriateness criteria of the order
Use medication therapy management services
Establish community-based health teams to support small
practice medical homes
Support individuals in making health care decisions through the
use of patient decision support tools
(cont.)
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Models to be Tried by the Innovation Center
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Allow states to test and evaluate care for dual eligibles
Allow states to test and evaluate all-payer payment reform
Align nationally recognized, evidence-based guidelines of cancer
care with payment incentives
Improve post-acute care through continuing care hospitals
Fund home health providers offering chronic care management
Develop a collaborative of high-quality, low-cost health care
institutions to develop, disseminate, and implement best
practices and provide assistance to other institutions
Use electronic monitoring to facilitate inpatient care of
hospitalized individuals at their local hospital
Promote efficiency and timely access to outpatient services
through models not requiring a physician or other health
professional to make a referral
Establish comprehensive payments to Healthcare Innovation
Zones
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Key Considerations for Successful Pilots
• Multi-payer involvement
• ‘Ground-up’ as well as ‘top-down’ development
• Array of potential models
• Flexibility in design and implementation
• “Innovation with Evidence Development”
• Establish infrastructure to support success
• Work with MedPAC, MACPAC/feed into IPAB
deliberations
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Improving the Process
• Transparency
• Site selection and approval
• Evaluation
• Translating pilots into policy
• Resource availability
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“At this point, we can’t afford any illusions: the
system won’t fix itself, and there’s no piece of
legislation that will have all the answers, either. The
task will require dedicated and talented people in
government agencies and in communities who
recognize that the country’s future depends on their
sidestepping the ideological battles, encouraging
local change, and following the results. But if we’re
willing to accept an arduous, messy, and continuous
process we can come to grips with a problem even
of this immensity. We’ve done it before.”
Atul Gawande, 2010
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