Healthcare Reform & Women in Surgery: Opportunities & Challenges Barry M. Straube, M.D. Immediate...
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Healthcare Reform & Women in Surgery: Opportunities & Challenges Barry M. Straube, M.D. Immediate Past (Retired) Chief Medical Officer, Centers for Medicare
Healthcare Reform & Women in Surgery: Opportunities &
Challenges Barry M. Straube, M.D. Immediate Past (Retired) Chief
Medical Officer, Centers for Medicare & Medicaid Services
October 23, 2011 Association of Women Surgeons
Slide 2
Slide 3
Shifting of the Poles
Slide 4
The 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 doesnt 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 4
Slide 5
The Healthcare Quality/Value Challenges There continues to be
considerable waste in the delivery of healthcare, as well as fraud
& abuse CMS/HHS, and the executive branch is responsible for
the healthcare of a growing number of persons in the public sector,
and influences healthcare quality in the private sector CMS/HHS, in
partnership/collaboration with other healthcare leaders, must
address these issues Academic Medical Centers & Surgeons could
provide great value Health Information Technology is indispensable
in this The Affordable Care Act of 2010 is a major step forward to
address the healthcare quality/value challenges 5
Slide 6
Better Health for the Population Better Care for Individuals
Lower Cost Through Improvement The Triple Aim 6
Slide 7
IOM Aims for Quality Improvement Safety Effectiveness
Patient-centeredness Timeliness Efficiency Equity 7
Slide 8
8 Federal Stakeholders in the U.S. Healthcare System Department
of Health & Human Services Veterans Affairs Department of
Defense Department of Labor Department of Housing & Urban
Development United States Coast Guard Office Personnel Management
Federal Bureau of Prisons Federal Trade Commission Office of
Management & Budget Department of Commerce National Highway
Transportation & Safety Administration
Slide 9
9 Department of Health & Human Services: Agencies Secretary
of HHS Administration for Children and Families Administration on
Aging Agency for Healthcare Research & Quality Agency for Toxic
Substances & Disease Registry Centers for Disease Control
Centers for Medicare & Medicaid Services (CMS) Food & Drug
Administration Health Resources & Services Administration
Indian Health Service National Institute of Health Program Support
Center Substance Abuse & Mental Health Services Administration
Multiple other Assistant Secretaries
Slide 10
Centers for Medicare & Medicaid Services (CMS) Will provide
health benefits for over 114 million Americans in FY 2011 PP Budget
Medicare 48.1 million beneficiaries Medicaid 56.1 million
beneficiaries CHIP 10 million beneficiaries Will spend $784 billion
in FY 2011 PP Budget Medicare - $476 billion Medicaid - $297
billion CHIP - $11 billion Effective January, 2011 incorporated the
Office of Consumer Information and Insurance Oversight (OCIIO) as
part of CMS 10
Slide 11
11 Ongoing CMS Core Medicare Work Provider payment-focused
activities Efficient, timely, accurate payment of claims Ongoing
demonstrations and pilots of alternative payment methodologies and
systems Addressing fraud & abuse Beneficiary focused activities
Benefit education Health promotion and disease management education
Beneficiary protection and advocacy Multiple tools to improve
quality, efficiency and value Data collection & availability
11
Slide 12
Partners/Targets For Advocacy Federal Government Congress
House: Ways & Means, Energy & Commerce Senate: Finance,
HELP A variety of caucuses White House Many senior advisors Office
of Management & Budget
Slide 13
Partners/Targets For Advocacy Executive Branch Agencies U.S.
Department of Health & Human Services (HHS) Office of the
Secretary, Office of the Assistant Secretary of Health Centers for
Medicare & Medicaid Services (CMS) Agency for Health Research
& Quality (AHRQ) Centers for Disease Control (CDC) Food &
Drug Administration (FDA) Health Resources and Service
Administration (HRSA) National Institutes of Health (NIH) Office of
the National Coordinator (ONC) for HIT Many other HHS and other
federal agencies have influence over surgical topics and
issues
Slide 14
Partners/Targets For Advocacy Centers for Medicare &
Medicaid Services Office of the Administrator Key Surgery Areas
Office of Clinical Standards & Quality (OCSQ) Conditions of
Participation, Conditions for Coverage Quality Improvement and
Measurement Quality Improvement Organizations (QIOs) and ESRD
Networks Information Services: Clinical Data systems Coverage
decision making Center for Medicare Payment Center for Medicaid
State Survey Agencies and regulatory oversight processes Regional
Offices (10) Innovation Center
Slide 15
Partners/Targets For Advocacy State Governments Dialysis
Providers/Organizations Professional Associations Renal Physicians
Association American Society of Nephrology American Nephrology
Nurses Association National Renal Administrators Association
American Medical Association Kidney Care Partners Kidney Care
Quality Alliance Private health plans Patient Advocacy
Organizations: Should probably be #1 stop
Slide 16
Some Personal Notions & Experience Know the framework of
the regulatory system that affects you, the people who run it, and
work with them Congress passes laws (statutes) that direct federal
agencies what to do and defines their authorities The President can
sign or veto any law passed Agencies implement laws, following
Congressional directives and intent, but if unclear have discretion
to interpret the law as the agency (and executive branch leadership
sees fit Regulations, through public rulemaking Administrative
rulings, sometimes, with or without public comment Guidance and
directives through manuals, letters, and other mechanisms There are
multiple points at which advocates can effectively influence the
above
Slide 17
Some Personal Notions & Experience Advocates can and do
have major influence on the federal framework With regards to
federal rulemaking Notice of Proposed Rule Making (NPRM) 30-90 days
of public comment Agency reviews comments, responds to all
comments, and revises the proposed rule as indicated Final Rule is
issued, published and implemented Cycles of rulemaking at CMS If
final rules are unacceptable Influence subsequent laws and
regulations Judicial challenges Elect new leaders
Slide 18
Ensuring Quality & Value: CMS Tools/Drivers/Enablers
Contemporary Quality Improvement Transparency: Public Reporting
& Data Sharing Incentives: Financial through payment reform
Regulatory vehicles National & Local Coverage Decisions
Demonstrations, pilots, research, innovation 18
Slide 19
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, etc. 19
Slide 20
Contemporary Quality Improvement: Collaboratives &
Communities Quality Improvement Organization (QIO) 9 th SOW Care
Transitions Theme Every Diabetic Counts Mississippi Health First
(expanding to Texas) Links to: ACA Section 3025: Hospital
Readmissions Reduction Program ACA Section 3026: Community-Based
Care Transitions Program 20
Slide 21
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 MyMedicare.gov HHS/CMS Data Dissemination Efforts:
www.data.gov, www.healthcare.gov www.data.gov www.healthcare.gov
Potential explosion of federal government data availability for
private sector to drive data use innovation in previously
unimaginable ways 21
Slide 22
Surgical Care Improvement Project Process of Care 22 Hospital
Process of Care Measures Tables Average All U.S. Average All
CASTANFORDUCSFUCD Antibiotic within one hour before
surgery92%90%93%94%89% Appropriate pre-operative
antibiotic94%92%96%92%94% Patients taking beta blockers prior to
the hospital kept on the beta blockers pre- & post-
op92%91%93%99%92% Patients given appropriate prophylactic
antibiotics97% 99%98%97% Patients with prophylactic antibiotics
stopped appropriately (within 24 hours after
surgery)94%92%97%99%95% Heart surgery patients with blood glucose
kept under good control post-op93% 91%84%88% Surgery patients with
safe hair removal pre-op99% 100% New Surgery patients whose urinary
catheters were removed on the 1 st or 2 nd day post-op89% 97%83%86%
Surgery patients whose doctors ordered treatments to prevent blood
clots94%91%99%95%97% Patients treated (within 24 hours before or
after their surgery) to help prevent blood
clots92%90%99%92%96%
Slide 23
Heart Attack-Chest Pain Process of Care 23 Hospital Process of
Care Measures Tables Average All U.S. Average All CASTANFORDUCSFUC
DAVIS Average number of minutes before transferred to another
hospital (lower is better) 62 Minutes 66 MinutesN/A Average number
of minutes to an ECG (lower is better) 9 Minutes 8 Minutes 6
MinutesN/A Drugs to break up blood clots within 30 minutes of
arrival (higher is better)54%55%N/A Aspirin within 24 hours of
arrival (higher is better)95%96%100% N/A Aspirin at
Arrival98%99%100% 98% Aspirin at Discharge98% 99% ACE Inhibitor or
ARB for Left Ventricular Systolic Dysfunction (LVSD)96% 92%88%93%
Smoking Cessation Advice/Counseling99%100% Beta Blocker at
Discharge98% 96%97%99% Fibrinolytic Medication Within 30 Minutes Of
Arrival54%61%N/A PCI Within 90 Minutes Of
Arrival89%90%93%95%79%
Slide 24
Heart Failure Process of Care 24 Hospital Process of Care
Measures Tables Average All U.S. Average All CASTANFORDUCSFUC DAVIS
Heart Failure Patients Given Discharge Instructions87%90%93% 54%
Heart Failure Patients Given an Evaluation of Left Ventricular
Systolic (LVS) Function98% 99%100% Heart Failure Patients Given ACE
Inhibitor or ARB for Left Ventricular Systolic Dysfunction
(LVSD)94%95%92%93% Heart Failure Patients Given Smoking Cessation
Advice/Counseling98%99%100%
Slide 25
Pneumonia Process of Care 25 Hospital Process of Care Measures
Tables Average All U.S. Average All CASTANFORDUCSFUC DAVIS
Pneumonia Patients Assessed and Given Pneumococcal Vaccination92%
91% 64% Pneumonia Patients Whose Initial Emergency Room Blood
Culture Was Performed Prior To The Administration Of The First
Hospital Dose Of Antibiotics95% 93%88% Pneumonia Patients Given
Smoking Cessation Advice/Counseling97% 98%100% Pneumonia Patients
Given Initial Antibiotic(s) within 6 Hours After Arrival95%
96%93%90% Pneumonia Patients Given the Most Appropriate Initial
Antibiotic(s)91%92%91%92%88% Pneumonia Patients Assessed and Given
Influenza Vaccination91% 85%96%74%
Slide 26
Outcomes Measures: Mortality 26 National Heart Failure
Mortality: 11.2%Better ThanNo DifferentWorse Than STANFORDYes
UCSFYes UC DAVISYes National Hospital Mortality: Pneumonia -
11.6%Better ThanNo DifferentWorse Than STANFORDYes UCSFYes UC
DAVISYes National Heart Attack Mortality: 16.2%Better ThanNo
DifferentWorse Than STANFORDYes UCSFYes UC DAVISYes
Slide 27
27
Slide 28
Outcome Measures: Readmission Rates 28 National Heart Attack
Readmission Rate: 19.9%Better ThanNo DifferentWorse Than
STANFORDYes UCSFYes UC DAVISYes National Heart Failure Readmission
Rate: 24.7%Better ThanNo DifferentWorse Than STANFORDYes UCSFYes UC
DAVISYes National Pneumonia Readmission Rate: 18.3%Better ThanNo
DifferentWorse Than STANFORDYes UCSFYes UC DAVISYes
Slide 29
29
Slide 30
Medicare Payment & Volume Data 30 Measure DescriptionUC
DAVIS UCSF STANFORD Median Medicare Payment to Hospital Number of
Medicare Patients Treated Median Medicare Payment to Hospital
Number of Medicare Patients Treated Median Medicare Payment to
Hospital Number of Medicare Patients Treated Coronary bypass w/o
cardiac cath w/o MCC MS-DRG 236$39,777 18 Medicare
Patients$25,547(*)f$40,994 22 Medicare Patients Coronary bypass w/o
cardiac cath w MCC MS-DRG 235$54,000 11 Medicare Patients$67,469 11
Medicare Patients$64,678 14 Medicare Patients
Slide 31
Medicare Payment & Volume Data 31 Measure DescriptionUC
DAVIS UCSF STANFORD Median Medicare Payment to Hospital Number of
Medicare Patients Treated Median Medicare Payment to Hospital
Number of Medicare Patients Treated Median Medicare Payment to
Hospital Number of Medicare Patients Treated Coronary bypass w/o
cardiac cath w/o MCC MS-DRG 236$39,777 18 Medicare
Patients$25,547(*)f$40,994 22 Medicare Patients Coronary bypass w/o
cardiac cath w MCC MS-DRG 235$54,000 11 Medicare Patients$67,469 11
Medicare Patients$64,678 14 Medicare Patients
Slide 32
Incentives Current: Pay for Reporting and Adoption Programs
P4R: Hospital Inpatient/Outpatient, PQRI, e-Prescribing ARRA
/HITECH: EHR adoption and meaningful use Value-based Purchasing
(VBP) Hospital VBP Report to Congress (Nov 2007) Physician VBP RTC
(2010) ESRD Quality Incentive Program (QIP) January 1, 2012
Hospital VBP (ACA Section 3001) by October 1, 2012 ACA mandates VBP
in many additional settings Competitive bidding, gain sharing,
shared savings, bundled payment, ACOs, medical homes, salaries,
integrated delivery, etc. 32
Slide 33
33 Incentives: CMS Hospital Quality Initiative National
Voluntary Hospital Reporting Initiative (NVHRI) public-private
initiative Federation of American Hospitals AHA AAMC CMS, JCAHO,
others Hospital Quality Alliance Medicare Modernization Act of
2003: Section 501b Financial incentive of 0.4%
Slide 34
Other Pay for Reporting Programs Hospital Inpatient Quality
Reporting Program Hospital Outpatient Quality Reporting Program
Physician Quality Reporting System (PQRS) E-prescribing Program
HITECH Meaningful Use Programs Home Health Reporting Program
34
Slide 35
PQRS 2011 Overview 35 Toward Value-Based Purchasing VBP 2007
TRHCA 74 measures Claims- based only 2008 MMSEA 119 measures Claims
4 Measures Groups Registry 2009 MIPPA 153 measures Claims 7
Measures Groups Registry EHR-testing eRx 2010 MIPPA 175 individual
measures Claims 13 Measures Groups Registry EHRs eRx Large Groups
2011 ARRA and ACA 190 individual measures Claims 14 Measures Groups
Registry EHRs eRx Large Groups Small Groups Maintenance of
Certification Physician Compare Web Site
Slide 36
Goals for Value Based Purchasing Incentivize the best care and
improve transparency for Beneficiaries Transform CMS from a passive
payer to an active purchaser of care Link payment to quality
outcomes and stimulate efficiencies in care Recognize and address
potential unintended consequences for Beneficiaries 36
Slide 37
Hospital Value Based Purchasing : Background Hospital Value
Based Purchasing Report to Congress 2007 Premier Demonstration and
other Demos Experience with other reporting programs Hospital
Inpatient and Outpatient Quality Reporting Programs Physician
Quality Reporting System ESRD Quality Incentive Program beginning
January 1, 2012 37
Slide 38
Hospital Value Based Purchasing Program (HVBP) Affordable Care
Act (ACA), Section 3001 Effective date: FY2013 payment for
discharges on or after October 1, 2012 Criteria: Must be a Hospital
Inpatient Quality Reporting Program participant Meets quality
metrics by demonstrating improvement or high levels of achievement
38
Slide 39
Hospital Value Based Purchasing FY2013 Medicare payment based
on quality measure performance 5 Clinical topics Acute Myocardial
Infarction Heart Failure Pneumonia Surgeries and Hospital Acquired
Infections (HAIs) HCAHPS patient survey 39
Slide 40
Hospital Value Based Purchasing Replace current 2% with HVBP in
a 5-year phased in approach between FY 2013 and FY 2017. 40 Payment
YearRHQDAPU*HVBP** FY13 1% FY140.75%1.25% FY150.50%1.50%
FY160.25%1.75% FY17 0%2.0% *Annual Payment Update **Reduction from
the Base DRG payment for all hospitals
Slide 41
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
41
Slide 42
Other Tools National Coverage Decisions, Payment Policy,
Benefit Design Deciding whether a device, service or therapy is
paid for (or not) can influence quality of care E.g., Non-payment
for Hospital Acquired Conditions (HACs) E.g., Non-coverage of Never
Events for both hospitals or physicians E.g., limitation of
services to qualified facilities or providers, such as ICD
implantation, etc. CED and use of registries collects further
quality information Patient incentives: Waiver of co-pays
Demonstrations, pilots, research Numerous CMS Demonstrations in
past and going forward with the ACA 42
Slide 43
Conclusions CMS Statutory Authority provides powerful tools to
focus on improving quality, value & patient safety QI by
providers, payers, collaboratives, others Transparency: Public
Reporting and Data Dissemination Incentives Regulatory compliance
Coverage, benefit, and utilization purposes Research and
Demonstrations Health Information Technology essential to above
Opportunities for input & alignment abound 43
Slide 44
Conclusions CMS Statutory Authority provides powerful tools to
focus on improving quality, value & patient safety QI by
providers, payers, collaboratives, others Transparency: Public
Reporting and Data Dissemination Incentives Regulatory compliance
Coverage, benefit, and utilization purposes Research and
Demonstrations Health Information Technology essential to above
Opportunities for input & alignment abound Academic Medical
Centers have a potential major leadership role 44
Slide 45
Affordable Care Act (ACA) of 2010 Patient Protection &
Affordable Care Act (PPACA) Health Care & Reconciliation Act of
2010 (HCERA) Affordable Care Act of 2010 (ACA) 45
Slide 46
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 46
Slide 47
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) 47
Slide 48
ACA & Women Search term women 145 instances Mostly relate
to womens health and women as patients Frequent linkage to pregnant
or young modifiers Search term surgeon 41 instances, most Surgeon
General 2 instances: American College of Surgeons-trauma center
accreditation and guidelines 5 Instances: General surgeons-rural,
committees 48
Slide 49
ACA & Surgeons Search term surgery 10 total instances 4
instances: Cosmetic surgery-5% tax 3 instances: General Surgery
services Search term surgical Ambulatory Surgical Centers (8): VBP
plan mandated to Congress by 1/1/2011 Surgical specialties 49
Slide 50
High Profile ACA Topics Greater Access to healthcare coverage
National Priorities & Strategic Plan HHS Interagency Quality
Work Group Quality Measurement comment by NQF Data collection and
national work plan Focus on outcomes, efficiency Patient
Centeredness High-cost Chronic Disease Management Care coordination
& care transitions 50
Slide 51
High Profile ACA Topics Healthcare Acquired Conditions (HACs)
Healthcare Acquired Infections Patient safety & medical errors
reduction Prevention and Patient Safety Population Health: Obesity,
Smoking Cessation, etc. Reduction of unnecessary admissions &
readmissions Accountable Care Organizations, Medical Homes
Innovation in payment, delivery systems, care Rapid cycle change
quality improvement Best practices and learning environments
51
Slide 52
Center for Medicare & Medicaid Innovation: CMMI CMMI
establishment mandated by January 1, 2011 (Section 3021)
Consultation & input from broad healthcare sector in
implementation The Innovation Center 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 52
Slide 53
CMMI: Statutory Descriptors Risk-based comprehensive payment or
salary-based payment models Geriatric assessments and comprehensive
care plansinterdisciplinary care teamsmultiple 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
53
Slide 54
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 54
Slide 55
Staging of Innovation Development, Demonstration, and
Translation 55 Trend Analysis Prototype Design and Modeling
Collaborative Design Lab Best Practice Analysis Publication and
Collaborative Learning Trend Analysis Prototype Design and Modeling
Collaborative Design Lab Best Practice Analysis Publication and
Collaborative Learning Collaborative Innovation Laboratory Stage
Collaborative Innovation Laboratory Stage Program trials and Demo
development Technology beta testing Results evaluation Findings and
Recommendations Publications Program trials and Demo development
Technology beta testing Results evaluation Findings and
Recommendations Publications Demonstration and Program Trial Stage
Program Policy Translation Analysis and Evaluation
Legislation/policy development Regulation and Rule Development
Policy Execution and Implementation Re Evaluation/ Publication
Program Policy Translation Analysis and Evaluation
Legislation/policy development Regulation and Rule Development
Policy Execution and Implementation Re Evaluation/ Publication
Program Policy Translation Evaluation and Diffusion Stage Program
Policy Translation Evaluation and Diffusion Stage 2 To 3 years
Design to Program Translation Cycle Time
Slide 56
Accountable Care Coordinated Care 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 Integrated Health
Patient Centered 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 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 Un-managed Driving
Healthcare System Transformation 56 Fee for Service
Slide 57
Driving Healthcare Delivery System Reform and Transformation
2011-2019 Successful Payment and Service Model Innovation Program
and Policy Redesign Healthcare Delivery System Reform and
Transformation 57 2011-2019 2012-2019 2014-2019
Slide 58
Innovation Fellowship Details (still pending) at conference
58
Slide 59
Accountable Care Organizations (ACOs) Medicare Shared Savings
Program (Section 3022) ACO Program must be implemented by January
1, 2012 ACO Notice of Proposed Rulemaking (NPRM) issued March 31,
2011 Public comment ended June 6, 2011 Final rule publication date
not determined (publicly) Encourages providers of services and
supplies to: Create ACOs Be accountable for health & experience
of care for individuals Improve population health Reduce rate of
healthcare spending 59
Slide 60
ACO Proposed Rule Provisions Providers must notify beneficiary
of participation Includes description of program, quality/cost
focus Beneficiary can opt-out & seek non-ACO care Beneficiary
to be notified of data sharing Purpose: Coordinate care better
Beneficiary cant be required to see ACO providers Beneficiary may
opt-out of data sharing arrangements For those opting in, data
sharing has limitations Patient selection controls to avoid cherry
picking 60
Slide 61
ACO Proposed Rule Provisions Types of providers & suppliers
Professionals (physicians, hospitals) in group practice
arrangements Networks of individual practices of professionals
Partnerships or joint ventures of hospitals & physicians
Hospitals employing ACO professionals Others, as determined by the
Secretary Governing body of ACO professionals and beneficiaries
Application with detailed submission requirements Minimum
responsibility for 5,000 beneficiaries 61
Slide 62
ACO Proposed Rule Provisions Rigorous (& complicated)
monitoring plan In order to qualify for financial shared savings,
must meet specified quality standards (65 proposed in NPRM) Quality
reports to CMS, feedback to providers 50% of PCPs must meet
meaningful use standards by year 2 Pubic reporting requirements
Termination by CMS if: Avoidance of at-risk patients Failure to
meet quality standards 62
Slide 63
ACO Proposed Rule Provisions 3 year agreement at minimum
Primary care-driven model for organization Specialty-driven ACO
founders not proposed in NPRM Two shared savings risk models -
original proposal One-sided Risk: ACO shares in any savings in
first 2/3 years; Third year can lose money if costs >Medicare
norm. Two-sided Risk: ACO at risk all three years; can have greater
% of savings share, however. Waivers allowed FTC of DOJ and IRS
issues 63
Slide 64
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: Applications being accepted Advance
Payment ACO Model: Public comments Accelerated Development Learning
Sessions Final rule pending review of comments & policy
decisions 64
Slide 65
ACO Final Rule Pending: Details (if available) at conference
65
Slide 66
Will ACOs be the Answer? Probably not, in the
short-to-intermediate term The concept is intriguing, but whether
it is translational is in doubt Can you replicate existing likely
ACOs in other communities without requisite infrastructure? The
model is untested, will it achieve the goals of better quality at
lower costs? ACO program under ACA is a voluntary program that is
essentially a demonstration Financial risk may not be assumable for
many Consolidation, reduced competition? 2 nd Generation Managed
Care? 66
Slide 67
ACA: Academic Medical Centers 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) 67
Slide 68
ACA: Academic Medical Centers 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 68
Slide 69
ACA: Academic Medical Centers 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. 69
Slide 70
ACA: Academic Medical Centers 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?
70
Slide 71
Conclusions The Affordable Care Act provides innumerable
opportunities to improve the quality, value and efficiency of
healthcare in the United States CMS is a major implementation
center for this historic piece of legislation Implementation
crosses Medicare, Medicaid, CHIP and the entire health care sector,
including the private sector Implementation affects fee-for-service
as well as managed care models, plus untested new models 71
Slide 72
Conclusions There are numerous opportunities and needs for
involvement of academic medical centers 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
72
Slide 73
Conclusions 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 73
Slide 74
Conclusions 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 74
Slide 75
Conclusions Development of and participation in new
reimbursement and delivery systems Achieve the Triple Aim 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 75
Slide 76
Conclusions We cannot continue to cover and pay for everything
thats 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
Medical Centers ready? Rapid-cycle change, integrated systems (no
departmental silos), authenticity & will to change (e.g.,
academic tenure?) 76
Slide 77
Conclusions The under-emphasized topics (?ignored): End-of-life
care & Palliative Care Health disparities reduction, not talk
Racial/ethnic Geographic Age Gender Socioeconomic LGBT Medical
Conditions 77
Slide 78
Healthcare Reform, Politics & Surgery Healthcare Reform in
context of budget deficit ACA originally estimated by CBO to
generate Joint Steering Committee must come up with $1.2 trillion
in savings If not, reverts to sequestration process Current
projections are that JSC may come up with $500-700 billion of
savings Shortfall of same amount will lead to additional
sequestration cuts of $100-200 billion from Medicare, Medicaid,
CHIP 78
Slide 79
Healthcare Reform, Politics & Surgery Likely targets for
further cuts: Post-acute care setting: Long-term care (SNFs), Home
Health, Hospitals (especially GME) DME Sustainable Growth Rate
(SGR) Tort Reform 2012 Election 79
Slide 80
Thank you for your contributions in improving the American
healthcare system! Questions? Discussion & Dialogue Email:
[email protected] 80