Healthcare Reform: Improving the Healthcare World in Cleveland & Beyond

1. Healthcare Reform:Improving the Healthcare World in Cleveland & Beyond Barry M. Straube, M.D. Director, The Marwood Group Former Chief Medical Officer, Centers for Medicare & Medicaid Services October 27, 2012 University Hospitals: Case Medical Center Medical Quality Summit: Moving Forward

8. Life Expectancy at Birth vs.Spending by Country Source: OECD Health Data 2010

9. U.S. Healthcare Quality/Value Challenges • In the U.S. we spend more per capita on healthcare than any other country in the world • In spite of those expenditures, U.S. Healthcare quality is often inferior to that of other nations and often doesn’t meet expected evidence-based guidelines • There are significant variations in quality and costs across the nation with increasing evidence that there may be an inverse relationship between the two • Healthcare expenditures account for a larger section of the U.S. economy over the years and funding those expenditures is increasingly more difficult • Heretofore we have not addressed the problem of 45+ million uninsured Americans • Cost Effectiveness Analysis is resisted as a tool

10. U.S. HealthcareQuality/Value Challenges • Care is uncoordinated • Care is not patient-centered, it is more provider centered • Care is inefficient • There continues to be considerable waste (overuse) in the delivery of healthcare, as well as overt fraud & abuse • Insufficient emphasis is placed on major problems of: • Patient safety • Healthcare Acquired Conditions • Prevention • Unnecessary admissions and readmissions • Palliative & End-of-life Care • Health disparities • Health Information Technology has a critical & unfulfilled role in this

11. U.S. Healthcare Quality/Value Challenges • The private and public sectors collectively have failed to reform healthcare using conventional healthcare delivery and payment models • Traditional Fee-for-Service is a major reason: Pays for quantity, not quality • Managed care has intermittently controlled costs > quality • Regardless of payment system we haven’t publicly measured & compared cost or quality, and payers/providers are not held sufficiently accountable • “All healthcare is local” means integrated health systems have a significant role to play, Academic Centers special • The Affordable Care Act of 2010 has great potential to address the healthcare quality/value challenges

12. Ensuring Quality & Value:Tools/Drivers/Enablers • “Contemporary Quality Improvement” • Transparency: Public Reporting & Data Sharing • Incentives: Payment reform by All Payers • Regulatory vehicles: State & Federal • Payer Benefit Design and Coverage Decision Making • Demonstrations, pilots, research, innovation

13. “Contemporary” Quality Improvement • Need to set priorities, goals and objectives, strategic framework first • Evidence-Based goals, metrics, interventions, evaluations • Includes conformance with evidence-based guidelines, balanced with patient-centered considerations • Cost-effectiveness, let alone comparative effectiveness, has not yet been addressed adequately • Rapid-cycle development, implementation and change methodology • Leveraging of resources and efforts: Current and future models-collaboration, alignment, synergy, priorities • Many examples: Hospital Quality Initiative, Organ Donation Campaign, QIOs, ESRD Networks, IHI, Bridges to Excellence, NCQA, Nursing & Home Health Campaigns, many health plan collaboratives, local collaboratives, Partnership for Patients, etc.

14. Transparency:Public Reporting & Data Availability • CMS Compare Websites • Hospital Compare • Nursing Home Compare • Home Health Compare • Dialysis Facility Compare • MA Health Plan and Medi-Gap Compare • Prescription Drug Plan Compare • New under ACA • Physician Compare • VBP Programs: Above plus ASCs, LTCHs, IRHs, Hospices, others • Other comparative websites • www.WhyNotTheBest.org • MyMedicare.gov • HHS/CMS Data Dissemination Efforts: www.data.gov,www.healthcare.gov • Potential explosion of federal govt. & private sector data availability for private sector to drive data use innovation in previously unimaginable ways

15. Incentives • Pay for Reporting and Adoption Programs • P4R: Hospital Inpatient/Outpatient , PQRI, e-Prescribing, Home Health • ARRA /HITECH: EHR adoption and “meaningful use” • Value-based Purchasing (VBP) • ESRD Bundled Payment System January 1, 2011 • ESRD Quality Incentive Program (QIP) January 1, 2012 • Hospital VBP (ACA Section 3001) October 1, 2012 • VBP in many additional settings in pipeline • Competitive bidding, gain sharing, shared savings, bundled payment, ACOs, medical homes, salaries, integrated delivery, etc. • Will any of these be effective ?

16. VBP: Issues for Future • Alignment of multiple programs in existence or in pipeline • Goals and objectives, priorities • What do we want to accomplish other than plain measurement? • Public-Private alignment • Measures • Many not actionable or likely to lead to improvement • Process to develop and gain consensus too long, too contentious, too academic looking for the perfect • Financial Incentives • Balance of penalties, bonus/rewards, shared savings, etc. • How much? • Phase out P4R and adoption of outcomes-based VBP

17. Regulation • Conditions of Participation or Conditions for Coverage • COPs are minimum health and safety standards set by CMS for facilities that may receive Medicare payments • 17 separate provider/supplier settings have COPs • Survey & Certification • U.S. healthcare facilities certified must be in compliance with current Medicare regulations & applicable state laws • S&C process uses interpretive guidelines to assess compliance with regulations • In combination, a powerful tool for quality/value

18. Affordable Care Act (ACA) of 2010 • Title I: Quality, Affordable Health Care for all Americans • Title II: Role of Public Programs • Title III: Improving the Quality & Efficiency of Health Care • Title IV: Prevention of Chronic Disease & Improving Public Health • Title V: Health Care Work Force

19. Affordable Care Act (ACA) of 2010 • Title VI: Transparency and Public Reporting • Title VII: Improving Access to Innovative Medical Therapies • Title VIII: Community Living Assistance Services & Support (CLASS) Act • Title IX: Revenue Provisions • Title X: Strengthening Quality, Affordable Health Care for All Americans (Amendments)

21. High Profile ACA Topics • Greater Access to healthcare coverage • National Quality Priorities & Strategic Plan • National Prevention Priorities & Strategic Plan • Attention to not only Medicare & Commercial healthcare, but Medicaid and Dual-Eligibles • Prevention and Patient Safety • Numerous prevention initiatives • Population Health: Obesity, Smoking Cessation, etc. • Patient safety & medical errors reduction • Healthcare Acquired Conditions (HACs), Infections • Focus on better outcomes, greater efficiency

22. High Profile ACA Topics • Patient Centeredness • High-cost Chronic Disease Management • Care coordination & care transitions • Reduction of unnecessary admissions & readmissions • Accountable Care Organizations, Medical Homes • Integration of conventional providers with public health, community, and non-traditional sites of care • Innovation in payment, delivery systems, care • Rapid cycle change quality improvement • Best practices and learning environments • Attack on healthcare Fraud, Abuse, and waste/overuse

23. Center for Medicare & Medicaid Innovation:CMMI • CMMI establishment mandated by January 1, 2011 (Section 3021) • Consultation & input from broad healthcare sector in implementation • Develop patient-centered payment models • Rapid piloting/testing of new payment programs • Encourage evidence-based, coordinated care for Medicare, Medicaid, CHIP • Focuses on populations “for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures”

24. CMMI: Statutory Descriptors • “Risk-based comprehensive payment or salary-based payment” models • “Geriatric assessments and comprehensive care plans…interdisciplinary care teams…multiple chronic conditions…” • “transition health care providers away from fee-for-service-based reimbursement and towards salary-based” • “health information technology-enabled provider network that includes care coordinators, chronic disease registry, home telehealth technology”

25. CMMI: “The Innovation Center” • Other key characteristics in the statute for payment models • Varying payment for advanced diagnostic imaging services • Medication therapy management services • Community-based health teams to assist in care management • Patient decision-support tools • State flexibility for dual-eligibles and all-payer payment reform demonstrations • Collaboratives of high-quality, low-cost institutions • $10 billion over 10 years funding

26. Staging of Innovation Development, Demonstration, and Translation 2 To 3 years Design to Program Translation Cycle Time • Program trials and Demo development • Technology beta testing • Results evaluation • Findings and Recommendations • Publications • Trend Analysis • Prototype Design and Modeling • Collaborative Design Lab • Best Practice Analysis • Publication and Collaborative Learning • Program Policy Translation Analysis and Evaluation • Legislation/policy development • Regulation and Rule Development • Policy Execution and Implementation • Re Evaluation/ Publication Demonstration and Program Trial Stage Collaborative Innovation Laboratory Stage Program Policy Translation Evaluation and Diffusion Stage

27. Patient Centered Fee for Service Integrated Health • Patient Care Centered • Personalized Health Care • Productive and informed interactions between Patient and Provider • Cost and Quality Transparency • Accessible Health Care Choices • Aligned Incentives for wellness • Multiple integrated network and community resources • Aligned reimbursement/care management outcomes • Rapid deployment of best practices • Patient and provider interaction • Information focus • Aligned self care management • E-health capable Driving Healthcare SystemTransformation Un-managed Coordinated Care Accountable Care • Fee For Service • Inpatient focus • O/P clinic care • Low Reimbursement • Poor Access and Quality • Little oversight • No organized networks • Focus on paying claims • Little Medical Management • Organized care delivery • Aligned incentives • Linked by HIT • Integrated Provider Networks • Focus on cost avoidance • and quality performance • PC Medical Home • Care management • Transparent Performance Management

28. Driving Healthcare Delivery System Reform and Transformation 2011-2019 2014-2019 2012-2019 2011-2019

29. CMMI Programs • ACO Programs • Bundled Payment • Comprehensive Primary Care Initiative • Financial Alignment Initiative • FQHC Advanced Primary Practice Demonstration • Graduate Nurse Education Demonstration • Health Care Innovation Awards • Independence at Home Demonstration • Initiative to Reduce Avoidable Hospitalizations Among Nursing Home Residents • Innovations Advisors Program • Medicaid Emergency Psychiatric Demonstration • Medicaid Incentives for the Prevention of Chronic Diseases • Million Hearts • Partnership for Patients: Care Transitions: Community-based • State Innovations Models • Strong Start for Mothers & Newborns

30. Accountable Care Organizations (ACOs) • Medicare Shared Savings Program (Section 3022) • Implementation of the Medicare ACO Program mandated by January 1, 2012 • Encourages multiple providers of services and supplies to: • Join together and create ACOs • Be jointly accountable for health & experience of care for individuals over a period of time • Improve population health, overlap with community • Reduce rate of healthcare spending, improve quality

31. CMS ACO Proposed Rule • ACO Notice of Proposed Rulemaking (NPRM) issued March 31, 2011 • An ACO is an organization of healthcare providers that agrees to be accountable for the quality, cost, and overall care of assigned Medicare beneficiaries who are enrolled in Medicare FFS • Eligible organizations • Physicians in group practice arrangements • Physicians in networks of practices • Partnerships or joint venture arrangements between physicians and hospitals • Hospitals employing physicians • Other forms that the HHS Secretary deems appropriate

32. Reaction to ACO NPRM • Largely negative • Too complicated, too restrictive • Too much undefined risk • No specialty-focused ACOs • Negative comments about each criteria component • CMS responded in interim • Pioneer ACO Model • Advance Payment ACO Model • Accelerated Development Learning Sessions • Final rule issued November 2, 2011: Many revisions, less complicated, more options

33. What’s An Accountable Care Organization?

34. What’s An Accountable Care Organization?

35. CMS ACO Status Update • Medicare Shared Savings Program ACOs: 153 • 27 named in April, 2012 • 88 named in July, 2012 • 32 Pioneer ACOs • 6 Physician Group Practice Demo • Half are physician-driven groups serving < 10,000 patients • Serve 2.4 million Medicare beneficiaries • 33 Quality Measures • Care coordination and patient safety • Preventive health services • Improved care for at-risk populations • Patient and caregiver experience of care

36. Overall U.S. ACO Status Report • The number and types of ACOs are expanding • Growth is centered in larger population centers • Hospital systems appear to be the primary backers of ACOs, but physician groups are playing an increasingly larger role • Non-Medicare ACOs are experimenting with more diverse models than Medicare-backed ACOs • The success of any particular ACO model is still undetermined Source: Leavitt Partners report “Growth and Dispersion of Accountable Care Organizations, May 2012

37. Source: Leavitt Partners report “Growth and Dispersion of Accountable Care Organizations, May 2012

38. Source: Leavitt Partners report “Growth and Dispersion of Accountable Care Organizations, May 2012

39. Source: Leavitt Partners report “Growth and Dispersion of Accountable Care Organizations, May 2012

40. Source: Leavitt Partners report “Growth and Dispersion of Accountable Care Organizations, May 2012

41. ACA: Academic Health Systems • ACA Section 3025: Hospital Readmission Reduction Program • ACA Section 3026: Community Based Care Transition Program • Healthcare Delivery Research (Section 3501, AHRQ coordinating with CMS) • Identifies best practice institutions, organizations, etc. • Supports innovation in health care delivery system improvement • Quality Improvement Technical Assistance (Section 3501)

42. ACA: Academic Health Systems • Establishing Community Health Teams to Support the Patient-Centered Medical Home (Section 3502) • Medication Management Services in the Treatment of Chronic Diseases (Section 3503) • Emergency medicine regionalized systems and research, trauma care centers access & payment • Demonstration to integrate quality improvement and patient safety education into healthcare worker education (Section 3508) • National Health Care Workforce Commission (Section 5101) • Recruitment, education and training, retention

43. ACA: Academic Health Systems • National Center for Health Care Workforce Analysis (Section 5103) • Multiple student loan programs, various training & retention programs, & demonstration programs established • Primary care • Nurse-led care, advanced practice nursing, etc. • Allied health, public health, dental, pediatric, direct care professionals, geriatric, mental health, cultural competency in disabilities, mid-career, etc.

44. ACA: Academic Health Systems • United States Public Health Services Track (Part D, Section 271) • Centers of Excellence-additional funding • Medical Residency funding enhancements • Teaching grants and demonstrations in graduate medical education • The list goes on and on and on……. • But………, will ACA survive the legal, political and funding challenges in its entirety? • If not, which sections? • Whether or not, will savings estimates be achieved?

45. Conclusions • The Affordable Care Act provides innumerable opportunities to improve the quality, value and efficiency of healthcare in the United States • CMS/HHS is a major implementation center for this historic piece of legislation, but the private sector has an equally important role • Individual integrated health systems, particularly those with a focus on innovation and evidence, are essential to the success of healthcare reform • Implementation affects fee-for-service as well as managed care models, plus untested new models

46. Conclusions • There are numerous opportunities and needs for involvement of integrated/academic health systems in implementation of ACA and further health reform in the future: • Design of and leadership in contemporary quality improvement initiatives • Huge gap in comparative- & cost-effective analysis/improvement, let alone basic clinical knowledge • Ongoing input in review and improvement in clinical guidelines • Balancing evidence-based population RCT viewpoint with need for individual patient-centered concerns

47. Conclusions • Additional roles for integrated/academic health systems: • Education of multiple audiences in evidence-based medicine use: • Clinicians: Current/future, academic/community • Policy makers • Payers • Patients, consumers and their families • Development and use of quality and value metrics • Multiple perspectives: Clinicians, patients, payers, etc. • Relevance, actionability, accountability, attribution • Alignment/integration of traditional & community healthcare resources and models

48. Conclusions • Additional roles for integrated/academic health systems: • Collection, analysis, reporting and use of healthcare data • Health Information Technology development, adoption and “meaningful use” via EHRs • Other forms of data collection: Registries, claims, encounter data, telehealth, chart review, surveys, etc. • Balance of scientific rigor vs.. “information efficiency” • Minimization of burden • Privacy & security • Dissemination of data for widest possible appropriate use

49. Conclusions • Additional roles for integrated/academic health systems: • Development of and participation in new reimbursement and delivery systems • Higher quality leading to overall lower costs • Innovation, rapid change & adaptability • Care transitions and coordination • Integration of delivery systems • Patient-Centered, all of IOM Quality Aims • Public health focus, as well as individual health

50. Conclusions • We cannot continue to cover and pay for everything that’s available without considering: • Evidence-based coverage & payment decision making • Comparative effectiveness and cost effectiveness analysis • Overall costs involved, including global costs of lost productivity, quality of life, etc. • But are Academic Health Systems ready? • Rapid-cycle change, integrated systems (no departmental silos), authenticity & will to change (e.g., academic tenure?)