health care reform perspectives and implications
DESCRIPTION
Health Care Reform Perspectives and Implications. Grand Rounds New England Baptist Hospital April 13, 2011 Bob Gibbons [email protected] Alex Calcagno [email protected]. Health Care Reform Perspectives and Implications. Politics and Government - Potent Mix - PowerPoint PPT PresentationTRANSCRIPT
Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Grand RoundsGrand Rounds
New England Baptist HospitalNew England Baptist Hospital
April 13, 2011April 13, 2011
Bob Gibbons Bob Gibbons [email protected]
Alex Calcagno Alex Calcagno [email protected]
Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Politics and Government - Potent MixPolitics and Government - Potent Mix• Elections/AppointmentsElections/Appointments• Policy MakingPolicy Making• EngagementEngagement
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Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Political ClimatePolitical Climate• State Environmental AssessmentState Environmental Assessment
- Elections- Elections
- Economy- Economy
- State Revenues- State Revenues
- Health Care Costs- Health Care Costs
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Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Political ClimatePolitical Climate• Policy ConsiderationsPolicy Considerations
- Payment Reform- Payment Reform
- Cost Control - Cost Control
- State Budget- State Budget
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Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Payment ReformPayment Reform• Special CommissionSpecial Commission
- Established on heels of coverage reform- Established on heels of coverage reform
- Examination of payment methodologies- Examination of payment methodologies
- Global Payment w/ACOs recommended- Global Payment w/ACOs recommended
- New Independent Board Recommended- New Independent Board Recommended
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Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Source: MHASource: MHA
Payment Reform (cont.)Payment Reform (cont.)
Fixed risk adj. amountFixed risk adj. amount
““The ACO”The ACO”
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Current Fee-for-Service Payment System
GlobalPayment System
SpecialistPrimaryCare
Post Acute
Provider
Hospital
$
Primary CareHospital
SpecialistPost Acute
$ $ $ $
Consumer/PatientPremium Dollar
Health Insurance Co.
Consumer/PatientPremium Dollar
Health Insurance Co.
Consumer/PatientPremium Dollar
Health Insurance Co.
Consumer/PatientPremium Dollar
Health Insurance Co.
Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Payment Reform - ReportPayment Reform - Report• MHA Position – “Support w/Caveats” MHA Position – “Support w/Caveats”
www.mhalink.org
- Risk- Risk
- Benefit design; Patient choice; Employer role- Benefit design; Patient choice; Employer role
- ACO Formation- ACO Formation
- Societal Needs- Societal Needs
- Oversight- Oversight 77
Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Cost ControlCost Control• Ch. 288Ch. 288
- Small group reforms (- Small group reforms (AHPs, Coops, Rate/Enroll 1 yrAHPs, Coops, Rate/Enroll 1 yr., ., rate shockrate shock) )
- Limited/Tiered Networks (- Limited/Tiered Networks (small groupsmall group))
- Wellness Pilot (- Wellness Pilot (small groupsmall group))
- Inpatient/outpatient costs ,health status adjusted TME- Inpatient/outpatient costs ,health status adjusted TME
- Relative Prices, contract price tying prohibition- Relative Prices, contract price tying prohibition
- DOI Approval of Premiums (- DOI Approval of Premiums (CPI, MLR, ReservesCPI, MLR, Reserves))
- Administrative Simplification - Administrative Simplification
- Bundled Payments Pilot- Bundled Payments Pilot
- Special Commission on Provider Price Reform- Special Commission on Provider Price Reform
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Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Patrick Administration Bill Patrick Administration Bill • Payment & Delivery ReformPayment & Delivery Reform• Immediate Cost Control: Price RegulationImmediate Cost Control: Price Regulation• Game Changer!Game Changer!
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Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Policy ObjectivesPolicy Objectives• ACOs by 2015ACOs by 2015• Alternative Payment MethodologiesAlternative Payment Methodologies• ““Med Mal Reform”Med Mal Reform”
Regulatory OversightRegulatory Oversight• Enhanced Powers: AG, DOI, DHCFPEnhanced Powers: AG, DOI, DHCFP• Payment Reform Coordinating CouncilPayment Reform Coordinating Council• DPH Division of Health PlanningDPH Division of Health Planning
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Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Cost Control & Payment ReformCost Control & Payment Reform• Provider ImpactProvider Impact
- Payment Squeeze- Payment Squeeze
- Realignment (Redistribution?)- Realignment (Redistribution?)
- Accountability: Costs/Outcomes- Accountability: Costs/Outcomes
- PCP Focus- PCP Focus
- HIT investments- HIT investments
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Health Care ReformHealth Care ReformPerspectives and ImplicationsPerspectives and Implications
Cost Control & Payment ReformCost Control & Payment Reform• Next StepsNext Steps
- Advocacy- Advocacy
- Engagement- Engagement
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Federal Health Care Reform & Physician Federal Health Care Reform & Physician Payment Reform:Payment Reform:
A Physician PerspectiveA Physician Perspective
Grand RoundsGrand RoundsNew England Baptist Hospital New England Baptist Hospital
April 13, 2011April 13, 2011
Alex. Alex. CalcagnoCalcagno
Director, Federal RelationsDirector, Federal RelationsMassachusetts Medical SocietyMassachusetts Medical Society
112112thth Congress CongressThe Political BackdropThe Political Backdrop
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Key Delivery System Reforms in the ACA Key Delivery System Reforms in the ACA
Medicare Shared Savings (ACOs) - January 2012Medicare Shared Savings (ACOs) - January 2012
Center for Medicare and Medicaid Innovation - January Center for Medicare and Medicaid Innovation - January 20112011
National Pilot on Payment Bundling - January 2013National Pilot on Payment Bundling - January 2013
Medical HomesMedical Homes
CBO estimates $13 billion savings/10 yearsCBO estimates $13 billion savings/10 years1515
Medicare Shared Savings DemosMedicare Shared Savings DemosACOsACOs
January 1, 2012January 1, 2012
Voluntary organization of health care providers who agree to be Voluntary organization of health care providers who agree to be accountable for the overall care, quality and cost of care for their Medicare accountable for the overall care, quality and cost of care for their Medicare patients. CMS and ACO share savings if the ACO meets quality standardspatients. CMS and ACO share savings if the ACO meets quality standards
and the cost of care is less than traditional FFS.and the cost of care is less than traditional FFS.
General Statutory RequirementsGeneral Statutory Requirements Formal legal structure to receive & distribute savingsFormal legal structure to receive & distribute savings Sufficient # of primary care professionalsSufficient # of primary care professionals 5,000 minimum beneficiaries5,000 minimum beneficiaries Contract for 3 years (minimum)Contract for 3 years (minimum) Leadership and management includes clinical and administrative Leadership and management includes clinical and administrative Defined process to 1)promote evidence based medicine 2) report data to evaluate Defined process to 1)promote evidence based medicine 2) report data to evaluate
quality and cost and 3) coordinate carequality and cost and 3) coordinate care Demonstrate patient centered care Demonstrate patient centered care
Proposed Rules & Regulatory NoticesProposed Rules & Regulatory Notices
4 Regulatory Notices released on March 31, 2011: Comments due June 6, 20114 Regulatory Notices released on March 31, 2011: Comments due June 6, 2011
CMS:CMS: EligibilityEligibilityLeadershipLeadershipGovernanceGovernancePayment Models & Payment Models & RiskRiskQualityQualityBeneficiariesBeneficiariesCMS: OIGCMS: OIG Waives re Fraud issues (CMP, Anti-kickback, Stark)Waives re Fraud issues (CMP, Anti-kickback, Stark)FTC- DOJFTC- DOJ Antitrust IssuesAntitrust IssuesIRSIRS Tax implication for tax exempt organizationsTax implication for tax exempt organizations
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Medicare Shared Savings ModelMedicare Shared Savings Model
EligibilityEligibilityACO professionals ( MDs, physician assistants, nurse practitioners and ACO professionals ( MDs, physician assistants, nurse practitioners and clinical nurse specialists) clinical nurse specialists) in group practice arrangementsin group practice arrangements;;Networks of individual ACO professionalsNetworks of individual ACO professionalsPartnerships or joint venture arrangements between hospitals, acute care Partnerships or joint venture arrangements between hospitals, acute care hospitals and ACO professionalshospitals and ACO professionalsAcute care hospitals paid under IPPS, Acute care hospitals paid under IPPS, Critical Access hospitalsCritical Access hospitals
In combination with the above, can include Federally Qualified Health In combination with the above, can include Federally Qualified Health Centers, Rural Health Centers, post acute facilities and Medicare enrolledCenters, Rural Health Centers, post acute facilities and Medicare enrolledproviders and suppliersproviders and suppliers
Legal and Governance StructureLegal and Governance Structure
Legal and Governance StructureLegal and Governance Structure ACO must have a “formal legal structure to receive and distribute payments for ACO must have a “formal legal structure to receive and distribute payments for
shared savings” and the authority to conduct business under state lawshared savings” and the authority to conduct business under state law ““Provides all ACO participants with appropriate proportional control over Provides all ACO participants with appropriate proportional control over
decision-making” decision-making” Board must be 75% ACO Participants and include beneficiariesBoard must be 75% ACO Participants and include beneficiaries
Leadership and ManagementLeadership and Management Detailed requirements to demonstrate clinical and administrative alignment re Detailed requirements to demonstrate clinical and administrative alignment re
quality, cost efficiencies and patient centered carequality, cost efficiencies and patient centered care
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Payment Models & RiskPayment Models & Risk
2 models: All ACO contracts are for 3 years2 models: All ACO contracts are for 3 years One sided risk model (Track 1): Shared savings for first two years with One sided risk model (Track 1): Shared savings for first two years with
shared savings of risk and losses in the third year ( limited risk) “on ramp”shared savings of risk and losses in the third year ( limited risk) “on ramp”
Two sided risk model ( Track 2):Shared savings and losses for all three Two sided risk model ( Track 2):Shared savings and losses for all three yearsyears
All ACO participants are paid under FFSAll ACO participants are paid under FFS
Formula based on last 3 years of Part A and Part B to develop benchmarks and Formula based on last 3 years of Part A and Part B to develop benchmarks and minimum savings, shared savings and lossesminimum savings, shared savings and losses
Primary care belong to one ACO; hospitals and specialists, severalPrimary care belong to one ACO; hospitals and specialists, several
2020
Quality MeasurementsQuality Measurements
Five DomainsFive DomainsPatient/Caregiver Experience of CarePatient/Caregiver Experience of CareCare CoordinationCare CoordinationPatient SafetyPatient SafetyPreventative HealthPreventative HealthAt risk populations/Frail ElderlyAt risk populations/Frail Elderly
65 quality measurements for 2012 – only report on, following years report and 65 quality measurements for 2012 – only report on, following years report and achieveachieve50% of primary care must be “meaningful EHR users”50% of primary care must be “meaningful EHR users”Must meet quality measurementsMust meet quality measurements
..
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BeneficiariesBeneficiariesEach ACO must have at least 5,000 beneficiariesEach ACO must have at least 5,000 beneficiaries
Beneficiaries will be assigned to the ACO based on primary care usage ( internal Beneficiaries will be assigned to the ACO based on primary care usage ( internal medicine, general, family, geriatric) CMS requesting commentmedicine, general, family, geriatric) CMS requesting comment
Beneficiaries will be assignedBeneficiaries will be assigned to an ACO based on the primary care physician from to an ACO based on the primary care physician from whom they receive the plurality of their primary carewhom they receive the plurality of their primary care
Beneficiaries will be assigned Beneficiaries will be assigned retrospectively retrospectively to an ACO.to an ACO.
Beneficiary choice – opt outBeneficiary choice – opt out
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Threshold IssuesThreshold IssuesInfrastructure SupportInfrastructure SupportRisk ManagementRisk ManagementRisk AdjustmentsRisk AdjustmentsPatient Choice – “leakage”Patient Choice – “leakage”Profitability - % of “shared savings”Profitability - % of “shared savings”Retrospective assignmentRetrospective assignmentFinancingFinancingTime frame – 3 years too limited?Time frame – 3 years too limited?Quality measurements – metric does not existQuality measurements – metric does not exist
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MMS: Key ACO IssuesMMS: Key ACO IssuesSeries of focus groups, working meetings across MASeries of focus groups, working meetings across MA
One size doesn’t fit allOne size doesn’t fit allAdoption must be voluntaryAdoption must be voluntaryFoster and promote innovationFoster and promote innovation– Multiple organizational modelsMultiple organizational models– Multiple payment methodologiesMultiple payment methodologies
Oversight body: 2/3rds should be providersOversight body: 2/3rds should be providersACOs must be physician-ledACOs must be physician-led
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ACOs : Key MMS Issues, ACOs : Key MMS Issues, contcont..
Quality measures must be scientifically validQuality measures must be scientifically validIndependent development of risk adjustersIndependent development of risk adjustersProfessional liability reform/Defensive medicineProfessional liability reform/Defensive medicineExpand peer review protectionsExpand peer review protectionsEase self-referral and anti-trust rulesEase self-referral and anti-trust rulesLiability of the ACO as an entityLiability of the ACO as an entity
AMA “How To” :AMA “How To” : www.ama-assn.org/go/ACO www.ama-assn.org/go/ACO
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IPAB – Independent Payment Advisory BoardIPAB – Independent Payment Advisory Board15 member Commission 15 member Commission Similar to base close commission – authorized to find $13.3 billion starting Similar to base close commission – authorized to find $13.3 billion starting in 2014 if overall Medicare spending exceeds targets. in 2014 if overall Medicare spending exceeds targets. Initial focus on insurers, pharmacy and physicians. In 2019 other providers Initial focus on insurers, pharmacy and physicians. In 2019 other providers are includedare included
Value Index Modifier Value Index Modifier Similar to MA GIC: Authorizes CMS to develop profiles on individual Similar to MA GIC: Authorizes CMS to develop profiles on individual physicians, based on Medicare and private payer data that could be physicians, based on Medicare and private payer data that could be posted on a “Physician Compare” web site. posted on a “Physician Compare” web site. CMS “to the extent practicable,” should make sure the information is CMS “to the extent practicable,” should make sure the information is statistically valid and reliable”statistically valid and reliable”Geographic variation: practice costs vs. utilization Geographic variation: practice costs vs. utilization
Cost Containment ProvisionsCost Containment Provisions
Physician Payment ReformPhysician Payment Reform
Medicare Physician Payment Reform (SGR)Medicare Physician Payment Reform (SGR)29% cut January 1, 201229% cut January 1, 2012
MedPac Recommendations – October 2011MedPac Recommendations – October 2011
In Ma, cost of medical practice up over 30%, Medicare up 1%In Ma, cost of medical practice up over 30%, Medicare up 1%
AMA Task Force: AMA Task Force: – 7 national medical specialty groups and 7 state medical societies7 national medical specialty groups and 7 state medical societies
3 phases : short term stability, interim transitional payment, permanent solution3 phases : short term stability, interim transitional payment, permanent solution
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Defensive Medicine – Medical Malpractice Defensive Medicine – Medical Malpractice ReformReform
112112thth Congress – renewed interest post ACA Congress – renewed interest post ACA
MMS supports University of Michigan Model initiated in 2001MMS supports University of Michigan Model initiated in 2001Culture of patient safety, apology, investigatory period, access to court if Culture of patient safety, apology, investigatory period, access to court if necessarynecessaryOpen cases fell from 300 to fewer than 60Open cases fell from 300 to fewer than 60Premiums have dropped dramatically; for example, annual OB/GYN Premiums have dropped dramatically; for example, annual OB/GYN premiums are $30,000 compared to approximately $100,000 outside of premiums are $30,000 compared to approximately $100,000 outside of the system. the system. The Culture has changed, less pressure to practice defensive medicineThe Culture has changed, less pressure to practice defensive medicine
Solution must be bipartisan to succeedSolution must be bipartisan to succeed
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Doctors Day at the State HouseDoctors Day at the State HouseMay 9, 2011May 9, 2011
Let Your Voice Be HeardLet Your Voice Be Heard……
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For More InformationFor More Information
www. massmed.orgwww. massmed.org
Alex. CalcagnoAlex. Calcagno