Workforce Implications of Payment Reform: Renewed Opportunities for Nursing - PowerPoint Presentation

1. Workforce Implications of Payment Reform: Renewed Opportunities for Nursing Betty Rambur, PhD, RN

2. Faculty DisclosuresBetty Rambur, PhD, RN has no relevant relationships with a commercial interest to report.She is a member of the State of Vermont’s Green Mountain Care Board, an independent, quasi-judicial body with regulatory, innovation, and evaluation responsibilities.

3. January 2015—Historic Sea Change!HHS makes historic announcementClear goals and timeline for shifting Medicare reimbursements from volume to value30% of current traditional FFS to value-based (like ACOs or bundled payments) by end of 2016; 50% by 2018In addition, 85% of all traditional FFS tied to quality/value by end of 2016; 90% by 2018In current system poor quality care often receives the same reimbursement, or even higher reimbursement

4. Why So Important?Will change what is paid for, and how, for all those over 65 on MedicareMedicare is often default template for Medicaid and Commercial InsuranceThus, Medicare reimbursement policies and procedures shape all of health care reimbursementWhat is reimbursed grows…what is not withers!

5. Part of A History of MedicareFDR and Original Social Security ActPassage of universal publicly funded single payer for those over 65 (payroll tax)GME Rules set in place, still in place, that are arcaneAddition of prospective payment in 1982(DRGs)Now, value based payment

6. How Does This Relate to the Affordable Care Act of 2010Financing ReformInsurance OnrampsPayment ReformDelivery ReformIn other words, everything has changed but the way we think!

7. To Understand What’s Happening and Why, you need to Understand the Past

8. How Did Health Care Become the Way it Is? A Spin Through History

9. Baylor and Teachers, 1929Pre-Paid Hospital Insurance 21 Days/Year $6/Year Employer based

10. Great Depression DeepenedPrivate hospital occupancy fell to 62%Similar plans grewAHA built on this prepayed movement and established free choice of hospitalsRather anticipated HMOs by limiting to a particular hospitalBy 1940, 39 Blue Cross plans enrolled over 6 million people

11. Great DepressionAlso reduced what patients could pay physiciansCalifornia Medical Association—first Blue Shield in 1939Followed Blue Cross in spreading across the nation

12. What Does this Mean? Reimbursement Provider Driven—to insure incomeEurope—Consumer DrivenUS-Provider Driven—(Starr, 1982)

13. A Radical (at the time) Idea!

14. How Does Insurance Work?The “well carry the sick”Risk is spread among the insurance pool

15. How to Keep Insurance Rates Low?Don’t let anyone sick in the pool!Both experience rating and community rating involve redistribution from well to sick, just in different ways.

16. Flexner Report—Another ForceCommissioned by Carnegie Foundation at the urging of the AMA in response to quality concernsFlexner influenced by biomedical model he saw at Johns HopkinsUsing Johns Hopkins as his model he concluded that ”… The situation can improve only as weaker and superfluous schools are extinguished” (Flexner, 1910).

17. Flexner EffectResulting criteria for medical education forced the closure of most of the schools serving black and female medical studentsIn the years following the Flexner report there was an increase in both the numbers and proportions of white male medical students and a decrease in othersNear elimination of women in the physician workforce between the years 1920 and 1970 (Barkin, S., Fuentes-Afflick, Brosco, & Tuchman, 2010).

18. Post-FlexnerMedical education following the Johns Hopkins also became longer and more expensive (Harley, 2006).

19. Flexner’s Era Flexner’s model was biological and physiological focused--reductionalisticCreated a shift away from and eventual closure of what we now call “complementary and alternative medicine” oriented hospitals, colleges, and teaching programs 80% of the programs in homeopathy, naturopathy, eclectic therapy, physical theory, osteopathy, and chiropractic closed. (Stahnisch & Verhoef, 2012).

20. ConsequenceStandard education for medicine became the template for standard education for other professionsMicrobiology, allopathic anatomy/physiologyDisease model rooted in mind/body splitManagement with pharmaceuticals/surgeryLittle to no attention to care coordination, chronicity, end of life support, antecedents to illness etc.

21. Conceptualization of Care Deserving PaymentReductionalisticBiomedical modelPhysician and hospital centricThus supported evolution of episodic, acute and emergent MEDICAL servicesNot a fit with the needs of an aging societyChronicitySupport servicesCare-centric rather than cure-centric needed

22. Who is left out with employer based Insurance?

23. Social Climate of the 1960EdMedicaicSolutions to unintended consequences of employer based insurance --Medicare --MedicaidWithin the milieu of “The Great Society”

24. Unintended ConsequencesGuaranteed revenue stream for those “guaranteed” to be ill or in need of health servicesAll within fee-for-serviceWhat are the incentives?Per diem for hospitalsDRGs shifted risk for length of stay to the hospitalMedicare retained risk for number of hospitalizations

25. FFS FueledUnbundling of servicesIncreased income for physicians, particularly invasive, high tech specialization (the more is better approach)Corollary growth of health professionsGrowth in nursing specialties/ICUsAn insatiable appetite for treatmentAmericans, in general, value high tech interventionist approaches

26. Impetus for Change: Growing understanding of the difference between health and health careSocial determinants of health

27. What are best ways to influence the 90% non-clinical determinants of health?Socioeconomic FactorsChanging the Contextto make individuals’ default decisions healthyLong-lasting Protective InterventionsClinicalInterventionsCounseling & EducationLargestImpactSmallestImpactExamplesPoverty, education, housing, inequalityImmunizations, brief intervention, cessation treatment, colonoscopyFluoridation, trans fat, smoke-free laws, tobacco tax Rx for high blood pressure, high cholesterol, diabetesEat healthy, be physically activeCDC Health Impact Pyramid

28. High Degree of Waste—21-47% of Total Health Care SpendingTypes of WasteFailures of coordinationFailures of care deliveryOvertreatmentAdministrative complexityPricing failuresFraud and abuse(Berwick & Hackbarth, 2012)

29. ""Health Policy Brief: Reducing Waste in Health Care," Health Affairs, December 13, 2012.http://www.healthaffairs.org/healthpolicybriefs/

30. Ethics/EthinomicsEthics of cost containmentPonder impact of $8,500/year in medical costs in three income levels$30,000/year$95,000/year$200,000/yearFair equality of opportunity (Saloner & Danials, 2011)

31. Health Care Financed ByTaxpayersMedicareMedicaidEmployees, as a reduction in real wagesEmployers, in the start up phase of a companyPeople, out of pocket at time of service

32. The Cost Shift

33.

34. Thus, Employer based insurance offers a hidden tax on the employees of the employers who offer health insurance (Reinhardt)

35. Financing Federal Level US health care currently funded via hybrid approachEmployee/employer contributionEmployer-based insurance is bourn by the employee as a reduction in real wagesUS “real wages” flat for a decadeTax funded—nearly 50% of US health care is publically fundedMedicareMedicaidTri-care

36. Affordable Care Act—Rooted in “the Triple Aim”Universal Coverage via hybrid modelPublicly fundedEmployer mandatesIndividual mandatesEliminates pre-existing condition and lifetime cap clausesEnables “shopping” via the “exchange”Essential benefits packagesWhat varies is the amount of cost sharingMetals—Actuarial Value

37. Federal Financing Reform: ACAMuch of ACA is insurance reform to enable access to coverage--Retains hybrid approach but includes employer and individual mandatesChildren on parent’s policy until age 26Individual Health Insurance Mandate with Subsidized Health ExchangesEmployers with 50 or more employees must provide health coverage or pay a penaltyElimination of pre-existing condition and life time cap exemptions

38. Emerging ACA Issues“Cadillac tax”—excise tax on high AV plans (2018)Challenges to ACAFederal subsidies of states who opted into Federal exchange

39. The Real Game ChangerPayment reformOffers one of the greatest area for clinician influenceMany providers largely unawareFunded via State Innovation Model funding in the ACA

40. Current Fee-for-Service FuelsA more is better approachPayment –and therefor treatment--silosFragmented careDisincentives for coordination and integration An inability to control costs

41. Emerging Payment Model

42. Conceptual Payment Models Along a Range of Most to Least Like FFSFFSP4PPCMHACOsBundled Payment Global BudgetsOutcomesCost & OutcomesAccountable forVALUECOST

43. Pay for Performance (P4P)Complementary health care reimbursement Offers financial rewards to providers who achieve or exceed specified quality benchmarks Most approaches adjust aggregate payments to physicians and hospitals on the basis of performance on a number of different quality measures. Payments may be made at individual,group, or institutional level

44. Advanced Primary Care/Patient Centered Medical Homes/Person Centered Health HomesAdvanced Primary Care Practices (Patient Centered Medical Homes)Practice Facilitators (assist with preparation for NCQA scoring and ongoing quality improvement)Community Health Teams (core teams and extenders)Self-Management Programs (Healthier Living, Tobacco Cessation, Diabetes Prevention, Wellness Recovery)Multi-Insurer Payment ReformsHealth Information Technology InfrastructureEvaluation and Reporting SystemsLearning Health System Activities44

45. Health IT FrameworkEvaluation FrameworkAdvanced Primary CareHospitalsPublic Health Programs & ServicesCore Community Health TeamNurse CoordinatorsSocial WorkersNutrition SpecialistsCommunity Health WorkersPublic Health SpecialistsExtended Community Health TeamMedicaid Care CoordinatorsMedicare SASH Teams in Housing HubsAddiction (“Spoke”) TeamsSpecialty Care & Disease Management ProgramsA foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of servicesMulti-insurer payment reform that supports this foundation of medical homes and community health teamsA health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registryAn evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impactMental Health & Substance Abuse ProgramsSocial, Economic, & Community ServicesHealthier Living WorkshopsAdvanced Primary CareAdvanced Primary CareAdvanced Primary CareMulti-Insurer Payment Reform Framework45HVVoVNAs/HHAsBLUEPRINT STRUCTURE WITHIN A SINGLE HEALTH SERVICE AREA

46. 46464646HigherAcuity &ComplexityLowerAcuity &ComplexityLocus of Service & SupportLevel of NeedHealth MaintenancePreventionAccessCommunicationSelf Management SupportGuideline Based CareCoordinate ReferralsCoordinate AssessmentsPanel ManagementSpecialty CareAdvanced AssessmentsAdvanced TreatmentsAdvanced Case ManagementSocial ServicesEconomic ServicesCommunity ProgramsSelf Management SupportPublic Health ProgramsAdvanced PrimaryCare PracticeCommunity HealthTeamsSpecialized & TargetedServicesContinuum of Health Services Support Patients & FamiliesSupport PracticesCoordinate CareCoordinate ServicesReferrals & TransitionsCase ManagementMedicaid Care CoordinatorsSenior Services CoordinatorsAddictions Care CoordinatorsSelf Management SupportCounselingPopulation Management

47. Examples of CHT Team Members474747 Care Coordinators CHT Managers Registered Nurses Social Workers Mental Health/Substance Abuse CliniciansPharmacists Nutrition Specialists and Registered Dietitians Health Educators and Health Coaches Certified Diabetes Educators and Asthma Educators Tobacco Cessation Counselors Community Health Workers Panel Managers Medical AssistantsAnd of course, physicians, nurse practitioners, and PAs

48. Xcenda Slide Presentation. 201248What is an ACO? Accountable Care Organizations (ACOs) are comprised of and led by health care providers who have agreed to be accountable for the cost and quality of care for a defined population. These providers work together to manage and coordinate care for their patients and have established mechanisms for shared governance. *SIM Payment Standards Work Group Definition 2013

49. http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2012/Aug/1618_Forster_accountable_care_strategies_premier.pdf49What is an ACO Shared Savings Program (SSP)? A performance-based contract between a payer and provider organization that sets forth a value-based program to govern the determination of sharing of savings between the parties.

50. 50Patient AttributionACOIf their PCP belongs to an ACO, the ACO accepts responsibility for the cost and quality of care provided to that personPeople see their PCP as they usually doProviders bill FFS as they usually do

51. 51Calculating Shared SavingsProjected ExpendituresActual ExpendituresShared SavingsAccountable Care OrganizationsMatched Federal $$Quality TargetsRisk AdjustmentPayer

52. Three Iterations of ACOsPioneerMany dropped outSaved Medicare nearly $400 million over 2 years per independent actuaries (Beck, WSJ, May 4, 2015)Shared Savings Programs (SSP)In year two of three“Next Gen”At least one lay member on governing bodyRisk sharing inclusive of fully capitated PMPMAddresses significant limitations of SSP

53. Limitations Next Gen AddressingACO accountability for a patients with whom they have had little contact. Incentives patients to seek care within the ACO by—potentially—up to $50 per covered lives.Modifies existing provisions that lead to unnecessary gaps in care. Claims from home visits for non-homebound beneficiariesWaives 3 day hospitalization before SNFTelehealth outside of rural areas etc. (Finkelberg Bortniker, Geilfuss, & Rosen, 2015).

54. Bundled Payments--GOALSTo remove FFS incentives and replace with those which reward collaboration and evidence-based practices across specialties and primary care providers for targeted episodes or types of care which represent opportunities for high return on investment. (SIM Narrative)Note: Nursing care has always been bundled in hospital chargesEpisodes of care

55. Congestive Heart Failure-Bundled Payment ExampleGoal: Improve care for patients with CHF inpatient admission via integrated care delivery—nurse ledParticipants: Hospital, VNA, SNF, Pulmonologist, Cardiologists, FQHCScope: 120 patients DX/yearexpenditures of $1.9 MPreliminary results: 30 day readmission now averaging 12-13%down from historic rates of 24-25%

56. Another Example—Super-utilizersSuper utilizers—1% of pop/22% annual costsMedicaid even more dramatic—5%/55% of costsUnder FFS, no disincentive for hospitals/providers to see and treat, even if it the ED.But remember, society paying, through taxes and insurance premiums

57. What are the population relative costs of the seriously ill?5/30/201557

58. Vermont Chronic Care InitiativeTeam of nurses and social workers for individual and population managementNeed data, so local and centralized data analytic staffField based care managers and care coordinatorsCARE BASED, not CURE BASED model

59. 59Examples of VCCI Services  RNs and MSWs: Encourage and support healthy behaviors Help with related issues such as housing, food security, and transportation to medical appointments Assist beneficiaries in talking with their health care providers Meet with beneficiaries and providers to develop and support a plan of care5959

60. 60VCCI’s Tiered Approach Beneficiaries with complex health problems receive face-to-face case management from an RN or MSW to coordinate care among providers and connect with other resources in communities and from the state.  Beneficiaries at lower risk receive health education and coaching from RNs by phone.  The goal is for all VCCI participants to learn to better manage their own health conditions and to work with their health care providers. 6060

61. Outcomes: Base and FY 13-14 changesSaving After Expenses$11.5 FY 12; $30.5 M FY 14Reduction in inpatient utilization8% FY 12; 30% FY14Decrease in ED utilization4% FY 12; 15% FY 14Decrease in 30 day readmission 11% FY 12; 31% FY 14Source: Eileen Girling, RNVermont Dept of Health Access

62. Global BudgetsHospitals currently exploring—Why?Need to move away from fee for service to more comprehensive cost control mechanismWay to link payment system to goals of population based health careHospital—service area matchOver time represent the total amount community willing to spend on hospital careGive providers flexibility to allocate resources in community responsive wayLike a household budget, hospital has strong incentive to reduce unnecessary care and coordinate servicesPMPM

63. How Big of A Change is This?“Major changes in culture, business strategy, and relationships would be required if hospitals were to shift from celebrating full beds to celebrating empty ones. The greatest technical challenge in removing waste from US health care will be to construct sound and respectful pathways of transition from business models addicted to doing more and more to ones that do only what really helps.” (Berwick & Hackbarth, 2012)

64. Now, again, back to the REALLY Big News!January 2015, HHS makes historic announcementClear goals and timeline for shifting Medicare reimbursements from volume to value30% of current traditional FFS to value-based (like ACOs or bundled payments) by end of 2016; 50% by 2018In addition, 85% of all traditional FFS tied to quality/value by 2016 and 90% by 2018In current system poor quality care often receives the same reimbursement, or even higher reimbursement

65. Skills Needed in the Era of Health ReformCare coordinationCare process reengineeringDissemination of best practicesTeam-based careContinuous quality improvementUse of data (Fraher, Ricketts, Lefebvre, and Newton, Academic Medicine, 2013)Understanding the underlying financing and quality metricsQuality science still in evolution

66. Everything Has Changed But Way We ThinkLimited by “physician-centric models with unimaginative use of NPs and PAs” (Nutting, Crabtree & McDaniel, (Health Affairs, 2012) & nurses and other providers (Rambur)Places enormously heavy burden on physicians that can be alleviated by having those with care coordination expertise at the tableClinician Use of DataHITECH and meaningful use Personal Use of DataBIG DATA

67. Rethinking our socializationProviders have been socialized in an episodic, fee-for service milieu“Sim labs” and high tech practiceLittle to no practice in “watchful waiting”Have not been held accountable for the cost of care or quality beyond immediate errors (MD and NP accountable for revenues)Accountability horizon narrow and short-termNo population based or temporal accountabilityLittle questioning of underlying assumptions of care

68. Nurses Pivotal“Because of sheer numbers—the U.S. health care system employs 2.7 million registered nurses—it is nurses who are arguably in the most pivotal position to drive system change. …More attention needs to be given, first, to identifying the competencies nurses need in these new roles and, then, to providing continuing professional development opportunities for nurses who wish to undertake the new functions.”(Fraher, Ricketts, Lefebrve, & Newton, 2013)

69. Actually…all disciplines pivotal…each has a special lensPTsExercise ScientistsSocial WorkersNursesPharmacistsCommunicative DisordersAudiologySpeech TherapyMental Health PractitionersAddiction SpecialistsPrimacy Care ProvidersSpecialists…but the disciplines will evolve and look different in 5-10 years

70. Team Based CareA strategy toward the Triple Aim, not a goal in and of itselfInterprofessional care has interaction cost and transaction costsSOMETIMES…Need most appropriate individual providerOften… Need well configured teamTEAMNESS.. a concept in evolution

71. Teams…Because aging adults in transitions have lives…We have disciplinesMedical CareHealth CareHealthHuman FlourishingSteven Levin reminds us that we can die “healed”…not cured, but healed. How do we create the world we want to age in…and eventually die in?

72. Post Flexner, Post FFS PlanningWe can’t solve problems by using the same kind of thinking we used when we created them.