The Ever Shifting Sands: - PowerPoint Presentation

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The Ever Shifting Sands:Health Policy Influencing Readmissions

Eric A. Coleman, MD, MPH, AGSF, FACPProfessor of Medicine, Head, Division of Health Care Policy and Research

(c) Eric A. Coleman, MD, MPH

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RoadmapShifting sands of national health policies

Key theme—physician fee scheduleKey theme—pay for valueKey theme—population health(c) Eric A. Coleman, MD, MPHSlide3

Shifting National Health Policies

(c) Eric A. Coleman, MD, MPH3Slide4

Triple Aim

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New Payment Policies Signal a Shift from Encounter to Episode to Population Care

Penalties for hospitals with excessive readmissionsCodes to pay physicians for post-hospital discharge care coordination provided to Medicare beneficiariesPayment mechanism for community organizations to bill Medicare for transitional careBundled payment for episodes of careAccountable care organizations

(c) Eric A. Coleman, MD, MPH

(c) Eric A. Coleman, MD, MPH

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Transitional Care Management CodesDesigned to promote greater support through both face-to-face and non face-to-face encountersNew CPT codes (99495 and 99496) to pay physicians (and NPs & PAs) for post-hospital discharge (30 days) care coordination provided to FFS Medicare beneficiaries

$163.88 or $230.86, for combined face-to-face and non face-to-face (depending on E&M level 3 or 4 and whether face-to-face visit is <14 days or <7 days)(c) Eric A. Coleman, MD, MPH6Slide7

Care Coordination Services Include:Non-Face-to-FaceCommunication with patient and/or caregiver w/in 2 days of D/C Communication with home health or other community services

Patient/family caregiver education to support self-management Support for treatment adherence and medication management Review of discharge information and follow-up on diagnostic tests Face-to-Face Office or home visit within 14 or 7 days of discharge

(c) Eric A. Coleman, MD, MPH

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(c) Eric A. Coleman, MD, MPHSlide8

CMS Is Likely to Implement a New Complex Care Code for Ambulatory CarePublic comment just completedWould share many of the common elements found in the newly released Transition Care Management codes

(c) Eric A. Coleman, MD, MPH

(c) Eric A. Coleman, MD, MPH

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Patient Centered Medical HomesModel of comprehensive primary care

Strong orientation towards care integration/coordinationGreater emphasis on supporting self-managementBetter communication with specialists and facilitiesMajor emphasis on incorporating technologyFocus on achieving quality and safety benchmarks

(c) Eric A. Coleman, MD, MPH

(c) Eric A. Coleman, MD, MPH

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Enter the Retail ClinicsConcept--embed a NP run clinic into a retail chain store1400 nationwide—in lead CVS (650) and Walgreens (372)

Attractive to consumers with high deductible plans, with difficulty accessing PCP, and who want convenienceInitially included immunizations & school physicals, now moving into disease management (HTN, DM, Asthma)Insurers and ACOs are increasingly embracing

(c) Eric A. Coleman, MD, MPH

(c) Eric A. Coleman, MD, MPH

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Proposed MedPAC Recommendation:Readmission Penalties for SNFs

Medicare Payment Advisory Commission’s (MedPAC) 2014 budget proposal recommendations to CongressProposal reduces payments by up to 3% for SNFs with high rates of care-sensitive, preventable readmissionsProposed start date in 2017

(c) Eric A. Coleman, MD, MPH

(c) Eric A. Coleman, MD, MPHSlide12

Medicare Two Midnight RuleIf a physician expects a beneficiary’s treatment to require a stay in the hospital lasting at least two midnights, and admits the beneficiary to the hospital based on that expectation, it is presumed to be appropriate that the hospital receive Medicare Part A payment (rather than Observation Part B)Began October 1, 2013

(c) Eric A. Coleman, MD, MPHSlide13

Moving from Encounters to Episodes: Bundling of Services for Episodes of CareCould include inpatient hospital services combined with post-acute care services or post-acute care services

onlyBundle could be 30 days or 90 days(c) Eric A. Coleman, MD, MPH13

(c) Eric A. Coleman, MD, MPHSlide14

MedPAC Bundling Approaches

(c) Eric A. Coleman, MD, MPH14Slide15

PAC Services By Condition

(c) Eric A. Coleman, MD, MPH15Slide16

Moving from Episodes to Populations: Accountable Care OrganizationsMove from several select providers sharing a bundled payment to organizing care across a community or regionMultiple providers are organized to the needs of a population of patients (minimum = 5000)

Patients are attributed to the ACO based on prior care seeking patterns; they are strongly encouraged to receive care from providers in the ACO but are not restricted(c) Eric A. Coleman, MD, MPH

(c) Eric A. Coleman, MD, MPH

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Accountable Care OrganizationsFollow the MoneyACO can be organized by physician group, hospital or otherACO accepts varying levels of risk for costs of attributed population (variant Medicare Shared Savings Plan)

In return, the ACO is rewarded for meeting quality metrics and cost containment goalsInformation exchange, risk identification, and cross continuum collaboration are keys to success

(c) Eric A. Coleman, MD, MPH(c) Eric A. Coleman, MD, MPH

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And of Course—Many Newly Insured Americans Seeking CareLack capacity to incorporate into existing primary careMassachusetts experienceNew options

(c) Eric A. Coleman, MD, MPH(c) Eric A. Coleman, MD, MPH

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Physician Fee Schedule

(c) Eric A. Coleman, MD, MPH19Slide20

Where We Have BeenThe SGR or Sustainable Growth RatePassed in 1997 Medicare

physician payment rates set through a formula based on economic growth (the SGR) For the first few years, physicians received modest pay increases In 2002 physicians were outraged by a proposed 5% cutEvery year since Congress has postponed the cuts2013

proposed cut is 24%

Deferrals increase price of a fix (estimated at $139 billion/10

yrs

)

The

current fix expires on Dec.

31, 2013

(c) Eric A. Coleman, MD, MPH

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Where We Are GoingLot of uncertainty and anxietyThe SGR is widely viewed as a failure

As we speak, the Senate Finance and House Ways and Means Committee is entertaining a proposal with significant bipartisan support

(c) Eric A. Coleman, MD, MPH(c) Eric A. Coleman, MD, MPH

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Summary of Current Plan on Table Repeals the SGRTransitions

Medicare away from a volume-based system towards one based on value Specifically—the proposed plan freezes any physician payment updates for at least 10 yearsInstead, physicians will be eligible for payment increases if we participate in Alternate Payment Models--PCMH, Bundled Payment, or ACO

(c) Eric A. Coleman, MD, MPH

(c) Eric A. Coleman, MD, MPH

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Tell Me MoreThe proposal explicitly encourages participation in APM(s) (PCMH, Bundled Payment, or

ACO)Professionals who receive a significant portion of their revenue from an APM(s) that involves financial risk and quality measurement will receive a bonus payment The proposal would encourage care management services for individuals with complex chronic care needs through the development of new payment codes

(c) Eric A. Coleman, MD, MPH

(c) Eric A. Coleman, MD, MPH

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Keep Talking…A Value Based Performance (VBP) would begin in 2017Professionals who

receive a significant portion of their revenues from an APM(s) would be excluded The VBP program would assess performance: 1) Quality 2) Resource Use 3) Clinical Practice Improvement Activities

4) EHR Meaningful Use.

(c) Eric A. Coleman, MD, MPH

(c) Eric A. Coleman, MD, MPH

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Pay for Value

(c) Eric A. Coleman, MD, MPH25Slide26

Value Based Performance (VBP)Buyers should hold providers of health care accountable for both cost and quality of care VBP brings together info on quality of health care

, including patient outcomes and health status, with data on the dollar outlays going towards health VBP focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Meyer, Rybowski, and Eichler, 199726Slide27

Replacing Volume with ValuePhysicians have largely been rewarded for doing more Payers are adopting reimbursement that puts the provider at risk for

delivering high quality and cost effective care Physicians have been reporting on quality measures for years through Medicare’s PQRSUntil now, physicians paid for simply reporting data Future payments

based on meeting quality metrics

(c) Eric A. Coleman, MD, MPH

(c) Eric A. Coleman, MD, MPH

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Population Health

(c) Eric A. Coleman, MD, MPH28Slide29

Principles of Population HealthEmploy principles of population-based careSegment population—healthy, chronically ill, frail, end of life and customize approach to each group

More explicit focus on prevention and wellnessRisk stratify populationEmploy disease registriesContact extends beyond face-to-face encounters(c) Eric A. Coleman, MD, MPH29Slide30

Thank You30