Embed Size (px)
Citation preview
No Outcome, No IncomeThe Role of Primary Care in the
Healthcare Value Revolution
Lawrence Ward, MD, MPH, FACPAssociate Professor of Medicine
Thomas Jefferson University
Incoming Governor, Pennsylvania SE, American College of Physicians
November 15, 2017
1
Mandatory Slide For Talks Like This
2
Source: Bipartisan Policy Center,
“F” as in Fat: How Obesity Threatens
America’s Future (TFAH/RWJF, Aug.
2013)
5
Payers moving towards risk
Global Risk/Shared
Savings Models
Care Continuum
Deg
ree o
f S
hare
d R
isk
Episodic
Bundling
Network P4P
Pay-for-
Performance
Providers need
data, analytics,
tools and new care
models to succeed
in risk models.
Healthcare in transition…
You
are
here
Required Capabilities for Risk-Bearing Under Each Payment Model
Science of Prevention
2018-2025
Patient Engagement
2015-2020
Phases of Change
14
Patient-Centered Care
2010-2017
Provider-centric &Focused on sickness
Team-based careAlign resourcesTarget high utilizersWellness
Reduced use of hospitals & EDAppropriate specialty and radiologyTransparency based on performance
Compete on valueEngage with non-health
Science-based preventionPersonal genomicsTechnology innovation
Oliver Wyman: The Volume to Value revolution
Health kiosks
Personal genomics
Mobile apps
Home-based monitoring
= Real-time access to services
The Value of Primary Care
The Value of Primary Care
• Key to patient attribution
• Lower cost care
• Appropriate referrals to subspecialists and imaging
• “downstream”
• Fulfill quality measures
• Patient satisfier
Primary Care at a Crossroads
48% plan to reduce hours or
take other steps to cut back
on the number of patients
they see.
Physicians Foundation, 2016
Direct
Primary Care
Retainer/Concierge
Medicine
Retire
Leave
Clinical Care
Plow Ahead
Reduced Hours
Fully Embrace the Quadruple Aim
19
Primary Care at a Crossroads
Value based care starting to make impact
• Increasing financial risks in contracts
• MIPS/APM/MACRA impact
• Risk stratification of patients
• Movement beyond the PCMH (i.e. CPC+)
• Team based care
• Every hour spent clinically = 2 hours administrative
• Increasing quality metrics and other responsibilities
Ann Intern Med. 2016;165(11):753-760.
Value-Based Reimbursement:
It’s Complex: Hospital & Ambulatory Quality Master Grid
Requires Strategic Focus
CMS Stars
Measures CPC+ Aetna Aetna
IBC
PPIP IBC IPPIP
IBC
QIPS/PCAM
HMO
IBC
QIPS/PCAM
PPO
United Health
Care
United
Health Care Humana
Cigna
HealthSpring
"POD
Performance
Bonus
Program
Agreement"
incl. Cigna
HealthSpring
Partnership
for Quality
(P4Q)
Measures
Health
Partners Plus
Medicare
Health
Partners Plus
Medicaid
Keystone First
Keystone
First: "The
Primary Care
Provider
Quality
Enhancement
Program"
Keystone
First: OB/GYN
Quality
Enhancement
Program"
Vantage
Cancer Care
Measure
Identifier #1
Measure
Identifier #2
Measure
Identifier #3
Measure
Identifier #4
Contract Level DVACO Aria JUP
(Amb. Quality
Measures
ONLY)
Enhanced FFS Enhanced FFS DVACO JUP DVACOJeffCare (JUP
& Abington)Aria Aria
JeffCare (JUP
& Abington)Enhanced FFS Enhanced FFS
JeffCare (JUP
& Abington)ACO NQF PQRS
HEDIS
Measure
Contains Gated Component 100% 50%?? 100% 100% 100%
Line of Business Medicare Medicare Commercial Commercial
Medicare
Advantage
and
Commercial
Commercial Commercial Commercial CommercialMedicare
Advantage
Medicare
AdvantageCommercial Commercial Medicaid Medicaid Medicaid
Contract Term 2017 2017 4/1/20161/1/2016-
12/31/20172013-2017 2016 2016 1/1/2016
Ends
September
2017
1/1/2014 6/1/2015 2016 2016 2016
2016
(Awaiting DHS
approval)
2016
(Awaiting DHS
approval)
10/1/2015
Measurement Timeframe 1/1/2017- 1/1-12/31 1/1-12/31 9/1-8/31 1/1-12/31 1/1-12/31Varies by
metric1/1-12/31 1/1-12/31 7/1 - 6/30 1/1-12/31 1/1-12/31 10/1-9/30
Quality Measures
Screening Measures
Care for Older Adults - Pain Assessment C11 ✓
Screening for Future Fall Risk ✓ ✓ P ACO-13 NQF-0101
Adult BMI assessment C07 ✓ ✓
Adult BMI assessment and education (for BMI >=30) ✓
BMI Screening and Follow-Up Plan ✓ P ACO-16 NQF-0421
Tobacco Use Screening and Cessation Intervention ✓ ✓ P ACO-17 NQF-0028
Depression Screening and Follow-Up Plan ✓ P ✓ ACO-18 NQF-0418
Cervical cancer screening ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NQF-0032 ✓
Annual cervical cancer screening or follow-up in high-risk women NQF-0579
Non-recommended cervical cancer screening in adolescent females N/A
Chlamydia screening ✓ ✓ NQF-0033
Chlamydia screening and follow-up NQF-1395
Colorectal Cancer Screening C02 ✓ ✓ P ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ACO-19 NQF-0034 ✓
Appropriate follow-up interval for normal colonoscopy in average risk patients NQF-0658
Colonoscopy interval for patients with a history of adenomatous polyps - avoidance of inappropriate use NQF-0659
Screening colonoscopy adenoma detection rate measure N/A 343
Age appropriate screening colonoscopy (85+; lower rate is better) N/A 439
Screening for hepatocellular carcinoma in patients with Hep C cirrhosis N/A 401
Hepatitis C: One-time screening for Hep C virus for patients at risk N/A 400
Breast Cancer Screening C01 ✓ ✓ P ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ACO-20 NQF-2372 ✓
HIV/AIDS: Sexually transmitted diseases - screening for Chlamydia, Gonorrhea, and Syphilis NQF-0409 205
HIV screening of STI patients: Percentage of patients diagnoses with an acute STI who were tested for HIV P22
Lead Screening in children under 2 y/o ✓
Immunization Measures
Influenza Immunization ✓ P ACO-14
Annual Flu Vaccine C03 ✓
Pneumonia Vaccination DMC11 ?? ✓ P ✓ ACO-15 NQF-0043 ✓
Childhood Immunization ✓ ✓ ✓
Adolescent Immunization- Meningococcal ✓ ✓ ✓
Adolescent Immunization- Tdap ✓ ✓ ✓
Adolescent Immunization- HPV ✓ ✓
Diabetes Measures
Diabetes: HbA1c testing ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NQF-0057 ✓
Diabetes: HbA1c Control (< 7 %; (<8% for select commercial populations)) ✓ ✓
Diabetes: HbA1c < 8% ✓ ✓ ✓ ✓ ✓ ✓ NQF-0575 ✓
Diabetes: HbA1c < 9% C15 ✓ ✓ ✓
Diabetes: HbA1c Poor Control (>9 %) ✓ ✓ P ✓ ✓ ACO-27 NQF-0059
Diabetes: Retinal Eye Exam C13 ✓ ✓ P ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ACO-41 NQF-0055 ✓
Diabetes: Medical attention for nephropathy C14 ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NQF-0062 ✓
Diabetes: Medication Adherence: % Patients adherent to oral diabetic agents ✓
Diabetes: Foot exam NQF-0056
Diabetes: Controlling hypertension ✓
Medication Management Measures
Antidepressant medication management (Remaining on meds at least 12 weeks after diagnosis) ✓
Chronic stable CAD: Antiplatelet therapy NQF-0067
Chronic stable CAD: Beta-blocker therapy - Prior MI or LVSD (<40%) NQF-0070
Ischemic Vascular Disease (IVD): Use of aspirin or another antithrombotic ✓ P ACO-30 NQF-0068
Chronic anticoagulation therapy NQF-1525
Persistence of beta-blocker therapy after MI ✓ ✓ ✓ NQF-0071
ACE Inhibitor or ARB therapy for LVSD ✓ NQF-0081
Statin therapy for the prevention and treatment of CV disease ✓ R PREV-13
Cholesterol Medication Adherence: % Patients adherent to statins ✓
Monitoring for patients on persistent medications: ACEIs/ARBs ✓ ✓
Monitoring for patients on persistent medications: Digoxin ✓
Monitoring for patients on persistent medications: Diuretics ✓ ✓
Monitoring for patients on persistent medications: Digox, ACEI/ARB, or Diuretics (Composite) ✓ NQF-2781
Avoidance of antibiotic therapy in adults with acute bronchitis ✓ ✓ ✓ NQF-0058
Medication management for people with asthma ✓ ✓ ✓ ✓ ✓ ✓ ✓ NQF-1799
Asthma: Controller medication for 75% of Tx period ✓
Osteoporosis management after (non-pathological) fracture C12 ✓ ✓ ? ✓
Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) C17 ✓ ✓ ? ✓
Follow-up care for children prescribed ADHD medication - initiation phase ✓
Generic prescribing rate ✓ ✓ ✓
Medication Reconciliation Post Discharge (NOT on CMS 2017 Stars list) ? NEW ✓ P ✓ ACO-12 NQF-0097
Use of High Risk Medications in the Elderly D11 ✓ ✓ ✓ NQF-0022
Care for Older Adults - Medication Review C09 ✓
Medication Adherence - Hypertension D13 ✓ ✓ ✓
Medication Adherence - Cholesterol D14 ✓ ✓ ✓
Medication Adherence - Diabetes D12 ✓ ✓ ✓
HIV/AIDS: Pneumocystitis jiroveci pneumonia (PCP) prophylaxis NQF-0405
OB/GYN Measures
Prenatal care ✓ ✓ ✓
Frequency of ongoing prenatal care ✓ ✓
Postpartum care ✓ ✓ ✓ ✓
Medical & Radiation Oncology Measures
Combination chemotherapy is considered or administered within 4 months (120 days) of dx for women <70 w/
AJCC T1c or Stage II or III hormone receptor negative breast cancerNQF-0559
Pts w/ breast cancer and negative or undocumented human epidermal growth factor receptor 2 (HER2) status who
are spared treatment with trastuzumabNQF-1857
Trastuzumab administered to patientsw/ AJCC state 1 (T1c) - III abd human epidermal growth factor receptor 2
(HER 2) pos breast cancer who receive adjuvant chemotherapyNQF-1858
Adjuvant chemotherapy is considered or administered within 4 months (120 days) of dx to pts <80 with AJCC III
(lymph node pos) colon cancerNQF-0223
KRAS gene mutation testing performed for patients with metastatic colorectal cancer who receive anti-epidermal
growth factor receptor monoclonal antibody therapyNQF-1859
Percentage of pts w/ a post-discharge f/u visit (face-to-face or telemedicine) w/i 3 days ✓
Percentage of pts w/ a (modified)IOM care plan documented w/I 2 weeks of diagnosis ✓
Percentage reduction from the baseline in the number of ED visits per patient during the measurement period ✓
Satisfactory practice overall performance in the CAHPS or other oncology-specific patient survey ✓
Percentage of pts w/ treatment interventions in accordance w/ evidence-based guidelines (where applicable) ✓
Percentage of pts w/ a clinical trials consultation when no evidence-based guidelin exists ✓
Percentage of pts where standardized symptom management pathways were employed ✓
Orthopedic Measures
Hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA)
and/or total knee arthroplasty (TKA)NQF-1550
Hospital-level 30-day, all-cause risk-standardized readmission rate (RSRR) following elective primary THA and/or
TKANQF-1551
Patient expereince w/ surgical care based on the CAHPS Surgical Care Survey NQF-1741
Other Quality Measures
Hypertension: Controlling high blood pressure (HEDIS 2016) C16 ✓ ✓ ✓ N/A ✓
Hypertension: Controlling high blood pressure ✓ ✓ P ✓ ACO-28 NQF-0018
Depression remission at twelve months ✓ ✓ R ACO-40 NQF-0710
Depression remission at twelve months -progress towards remission NQF-1885
Use of spirometry testing in the assessement and dx of COPD ✓ ✓ ✓
Use of imaging studies for Low back pain ✓ ✓ R ✓ ACO-44 NQF-0052
Annual dental visit (2-20 y/o) ✓ ✓ ✓
Appropriate testing for children with pharyngitis ✓ ✓ ✓
Appropriate treatment for children with URI ✓ ✓
Well-Child Visit (< 15 months) ✓ ✓ ✓
Well-Child Visit (Ages 3-6) ✓ ✓ ✓
Adolescent Well-Care Visit ✓ ✓ ✓ ✓ ✓ ✓
Annual Wellness Visit ✓
Welcome to Medicare Visit ✓
IBD: Preventive care: Corticosteroid related iatrogenic injury - bone loss assessment N/A 271
IBD: Assessment of Hep B Virus status before initiating anti- TNF therapy N/A 275
HIV viral load suppression NQF-2082 338
Care for Older Adults - Functional Status C10 ✓
Dementia: Cognitive Assessment ✓ N/A
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment ✓ NQF-0004
Adult access to preventive/ambulatory care ✓
Child/adolescent access to care ✓
Utilization Measures
All Condition Readmissions, 30 daysC19 ✓ P ✓ ✓ ✓ ACO-8
NQF-1789-
Adapted
Amb Care Sensitive Conditon Acute composite (AHRQ PQI # 91) ✓ P ACO-43 AHRQ
SNF 30-Day All-Cause Readmission Measures✓ P ACO-35
NQF-2510-
Adapted
All-Cause Unplanned Admissions for Patients with Diabetes ✓ P ACO-36
All-Cause Unplanned Admissions for Patients with Heart Failure ✓ P ACO-37
All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions ✓ P ACO-38
Potentially Avoidable Admissions ✓
Potentially Preventable Readmission Rate, 30 days ✓ ✓
Reducing potentially preventable readmissions ✓
Hospital 30-day, all cause risk-standardized readmission rate following HF hospitalization NQF-0330
Hospital 30-day, all-cause risk-standardized readmission rate following GABG NQF-2515
Hospital 30-day all-cause risk-standardized readmission rate following AMI hospitalization NQF-0505
Non-Participating Labs % ✓
Medical Cost Management ✓
Cost efficiency management ✓
ED Utilization per 1000 members ✓
Non-Emergent ED utilization ✓
Ratio Risk Adjusted LOS to Expected LOS ✓
Total Cost Efficiency ✓ ✓
Care Efficiency Management ✓
HIV medical visit frequency NQF-2079
Patient Experience/Satisfaction
CAHPS: Getting Timely Care, Appointments, and Information ✓ P ACO-1 NQF-0005
CAHPS: How Well Your Providers Communicate ✓ P ACO-2 NQF-0006
CAHPS: Patients’ Rating of Provider ✓ P ACO-3 NQF-0007
CAHPS: Access to Specialists ✓ P ACO-4 NQF-0008
CAHPS: Health Promotion and Education ✓ P ACO-5 NQF-0009
CAHPS: Shared Decision Making ✓ P ACO-6 NQF-0010
CAHPS: Health Status/Functional Status ✓ R ACO-7
CAHPS: Stewardship of Patient Resources (providers ask patients if they can afford meds) ✓ P ACO-34
Patient Experience Rating ✓
Structural/Other Measures
Use of certified EHR technology ✓ P ACO-11
Patient Centered Medical Home Recognition ✓
Maintain Dx list in Patient's EMR ✓
Cigna HealthSpring Enhanced Encounters ✓
Annual bonus - PCP visits: Attributed patients w/ at least 2 PCP visits during the CY ✓
Closing the Referral Loop: Receipt of Specialist Report ✓
CMS ACO MSSP GPRO
Measures
DVACO
2017
1/1-12/31
Medicare
100%
Value Based Purchasing Federal FFY2017 FFY18
Oct 2015 - Sept 2016 Oct 2017 - Sept 2018
Clinical Care - Outcomes wt 25% 25%
MORT-30-AMI ✓ ✓
MORT-30-HF ✓ ✓
MORT-30-PN ✓ ✓
Clinical Care - Process 5% 0%
AMI-7A Fibronolytic therapy w/in 30 mins ✓
IMM-2 Flu Immunization ✓
PC-01 Elective Delivery prior to 39wks ✓
Patient Experience of Care - HCAHPS 25% 25%
Nurse communication ✓ ✓
Doctor communication ✓ ✓
Staff responsiveness ✓ ✓
Pain Mgt ✓ ✓
Facility quietness/cleanliness ✓ ✓
Information @ discharge ✓ ✓
Overall hospital rating ✓ ✓
Safety 20% 25%
CAUTI ✓ ✓
CLABSI ✓ ✓
CDI ✓ ✓
MRSA ✓ ✓
AHRQ PSI-90 composite ✓ ✓
SSI Colon ✓ ✓
SSI Abdominal Hysterectomy ✓ ✓
PC-01 Elective Delivery prior to 39wks ✓
Efficiency - Medicare Spend per Beneficiary (25%) ✓ ✓
Readmissions Reduction Federal
Acute Myocardial Infarction ✓ ✓
Heart Failure ✓ ✓
Pneumonia ✓ ✓
COPD ✓ ✓
Total Knee/Total Hip ✓ ✓
CABG ✓
CMS Stars Updated Quarterly Updated semiannually (June/Dec)
Mortality 22%
MORT-3-AMI
MORT-30-CABG
MORT-30-COPD
MORT-30-HF
MORT-30-PN
MORT-30-STK
PSI-4-Surg-Comp
Safety of Care Measures 22%
HAI-1 CLABSI
HAI-2 CAUTI
HAI-3 SSI-colon
HAI-4 SSI -abdomen
HAI-5 MRSA
HAI-6 CDI
COMP-HIP-KNEE
PSI-90-Safety
Readmission Measures 22%
READM-30-AMI
REDAM-30-CABG
READM-30-COPD
READM-30-HF
READM-30-Hip-Knee
READM-30-PN
READM-30-STK
READM-30-HOSP-WIDE all cause unplanned
Patient Experience Measures 22%
H-CLEAN-HSP Cleanliness (Q8)
H-COMP-1 Nurse Communication (Q1,Q2,Q3)
H-COMP-2 Doctor Communication (Q5,Q6,Q7)
H-COMP-3 Responsiveness of Staff (Q4, Q11)
H-COMP-4 Pain Mgt (Q13, Q14)
H-COMP-5 Communication about medicines (Q16, Q17)
H-COMP-6 Discharge Information (Q19,Q20)
HCOMP-7 HCAHPS 3 Item Care Transition (CTM-3)
H-HSP-RATING Overall Hosp Rating (Q21)
H-QUIET-HSP Quietness of Hospital (Q9)
H-RECMND Willingness to Recommend Hospital (Q22)
Effectiveness of Care Measures 4%
CAC-3 Home Management Plan of Care document
IMM-2 Influenza Immunization
IMM-3/OP-27 Healthcare Personnel Influenza Vaccination
OP-4 Aspirin at Arrival
OP-22 ED- Patient Left without being Seen
OP-23 ED Head CT/MRI w/in 45 mins
OP-29 Endoscopy/ Polyp Surveillance
OP-30 Endoscopy/Polyp Surveillance Inappropriate use
PC-01 Elective Delivery
STK-1 VTE
STK-4 Throbolytic Therapy
STK-6 Discharged on Statins
STK-8 Stroke Education
VTE-1 VTE Prophylaxis
VTE-2 ICU VTE Prophylaxis
VTE-3 VTE Anticoag
VTE-5 VTE Warfarin
VTE-6 HAC PPVTE
Timeliness of Care Measures 4%
ED-1b Median time from arriaval to admit
ED-2b Admit decsion time
OP-3 Median transfer time
OP-5 Median time to ECG
OP18b/ED3 Median time to ED Discharge
OP-20 Door to Dignostic eval
OP-21 ED Median time to pain mgt for fracture
Medical Imagery Measures 4%
OP-8 MRI Lumbar
OP-10 Abdomen CT use
OP-11 Thorax CT
OP-13 Use of Cardiac Imaging
OP-14 Simultaneous use of CT/Sinus CT
Embrace Team-Based Care
Physician Leader
Advanced Practice Provider
Advanced Practice Provider
Advanced Practice Provider
Medical Assistant
Medical Assistant
Medical Assistant
Medical Assistant
Registered Nurse
Care Coordinator
Support Staff
Medical Assistant
CPC+: Program Overview5-year CMMI/CMS program.“Payment redesign by payers, both public and private, will offer the ability for greater cash flow and flexibility for primary care practices to deliver high quality, whole-person, patient-centered care and lower the use of unnecessary services that drive total costs of care.”
Began on January 1, 2017
- 2,983 primary care practices accepted with 13,090 clinicians
- serving 1.76 Million Medicare beneficiaries
- individual practices apply
- must have 150 Medicare beneficiaries
Both CMS and private insurers participating
Practices split into 2 Tracks (Basic and Advanced)
$10M+/year program at Jefferson Health
Not at RiskNot at Risk At Risk
0.117-0.503 1.248 and over0.766-1.2470.504-0.727
0.117-0.503 0.504-0.765 0.766-1.247 1.248-1.991
1.992+ and Dementia
CPCP Payment Explained
+10% 10%25%
40% or
65%
by 2019
2015
Medicare
Billings
2017
Medicare
Billings
FFS reduced
compared
to prior rate
10% up front
Non Face-to-Face
&
Less reliance on volume
Much aligns
with PCMH
Much aligns
with PCMH
Keys For Success in CPC+
29
1. Embedded Mental Health
2. Time to review data and meet with Teams
3. Patient-Family Advisory Council
4. Care Coordination
• Develop care plans
• Acute and long term care management
• Referral to community resources
5. Risk Stratification
6. Non-traditional office visits
• Minimum 40% non-face-to-face by 2019
Population Health Risk Stratification
80% “Low” Risk 15% 5%
• Loyalty
• Access, Access,
Access, Access
• Wellness Benefits
• Preventive Care
• Touch points
• Needs Assessment
• Chronic conditions
• Gaps in Care
• Outreach
• Patient Education
• Care Coordination
• Self management
plan
• 40% of Spend
• Risk Assessment:
• Clinical
• Socio-economic
• Environmental
• Behavioral Health
• Care coordination
• End of Life
planning
• Focus on top 1%, then top 5% then top 10%
Succeeding on Value
• Early Interventions (ie Home-based monitoring)
• Easier Access
• Embrace Informatics
• Engage patients
31
Oliver Wyman: The Volume to Value revolution
What Does This All Mean?
Major Themes Moving Forward
1. Using data to strategically deploy resources
2. Accountability/Feedback
3. Team-based care
4. No outcome, No income
How Might We Get There?
Change the Culture in Primary Care
1. Make practices patient-focused and across the
continuum of care
2. Practice based on evidence
3. Reduce unexplained clinical variation
4. Embrace team-based care
5. Continuously measure and improve
