Transcript Pay for Performance Readiness (Julie Peskoe

Regional Care Collaborative
March 26, 2015
Pay for Performance
Slide 1
Objectives
• What is “Pay for Performance”?
• How will pay for performance impact my health center?
• Capabilities your organization already has that can be leveraged for
P4P performance success?
• Tools for P4P
• An example from the Mobile, AL County Health Department
• Q&A
Slide 2
Pay for Performance
• Early catalyst was the IOM Crossing the Quality Chasm 2001 Report
that recommended the federal government identify and test various
payment options that more closely align compensation methods
and quality improvement goals
• If Fee for Service encourages overuse and capitated payments
encourage under use, P4P creates the “right” incentives
• P4P is part of an overall quality and cost management strategy
Slide 3
What is Pay for Performance?
Catch all phrase that describes initiatives aimed at improving the
quality, efficiency and value of health care. Arrangements provide
financial incentives to providers/hospitals/health systems to improve
quality and outcomes for patients.
ACA expands P4P in Medicare with ACOs, hospital value-based
purchasing, physician quality reporting and Medicare Advantage bonus
plans
Slide 4
Pay for Performance
• Fee for Service medicine has not succeeded in controlling health
care costs
• ACA is one of several attempts to control cost of care by introducing
new payment models
– ACOs
– Quality incentives
– Medicaid Redesign – Advanced Primary Care
• The move is to incentivizing the triple aim
• FQHCs and CHCs already do that a lot of this work as part of their
Quality Assurance programs.
Slide 5
P4P Is Increasingly Important
CMS has announced that by 2016, 85% of FFS payment will be linked to
quality or value and 90% by 2018
CMS has also announced that by 2016, 30% of Medicare payments will
be tied to quality or value through alternative payment models and
50% by 2018.
In 2012 there were almost no payments made through these
alternative payment models.
Slide 6
CMS Categories of P4P
• Category 1—fee-for-service with no link of payment to quality
• Category 2—fee-for-service with a link of payment to quality
• Category 3—alternative payment models built on fee-for-service
architecture
• Category 4—population-based payment
Slide 7
Slide 8
Slide 9
Forms of P4P
• Bonuses – based on meeting minimum targets
• Withholds – a percentage of reimbursement is withheld based on a
provider meeting minimum target requirements
• Quality grants – health plan provides funding for specific quality
improvement projects (PCMH recogntion)
• Additional reimbursement for chronic care, care management and
investment in point-of care clinical information systems (creating
treatment plans for diabetic patients)
• ACO – shared savings
Slide 10
Examples from around the country
• FQHC – UDS Measures
• NYS Medicaid Redesign – Delivery System Reform Incentive
Payment
• California – IHA P4P program involves 200 physician organizations,
nongovernmental program. Was focused on quality measures in
2013 began to transition to Value Based Purchasing. Focus on
clinical and outcome measures
• Million Hearts Campaign – focus on ABCS to prevent heart disease
• ACOs – Medicare and Medicaid
• PCMH Incentives
• Others?
Slide 11
NACHC Payment Reform Readiness Assessment Tool
• Assesses three domains of competency for successful engagement
of health centers in payment reform.
1. Organizational Leadership – to pursue and guide efforts and
engage in partnerships
2. Change management and service delivery transformation – ability
to make robust use of data and information to support payment
reform efforts
3. Financial and operational analysis – Required for the successful
participation in reform initiatives.
Slide 12
Evaluating P4P - DATA
What do you need to evaluate for value based
payments?
1. Billing/Claims Data
2. Clinical data from EHR
3. Data on the cost of health services
4. Data on patient outcomes
5. Other information?
Slide 13
RWJF Steps to Make the Business Case for Payment
Reform
1. Define planned change in care
2. Estimate how the type and volume of service will change
3. Determine how payment/revenue will change under current
systm.
4. Determine how the costs of service will change
5. Calculate the changes in operating margins for providers
6. Identify changes in payment needed by providers to keep margins
7. Determine whether a business case exists for payers and providers
8. Refine the changes to improve the business case
9. Analyze the impact of potential deviations (variances)
10. Design a payment model that adequately pays for desires services
and assures desired outcomes and controls variation/risk.
Slide 14
Practice Transformation, quality management and
P4P require similar capabilities
• All require quality data and rapid cycle evaluation
• Requires operational, clinical, financial, and technology changes to
enhance data
• Require a focus on population health
• It is a multi-year journey
• Start now to be ready for P4P
– Example from Mobile, AL of how a clinical QA program focus can position your
health center for the future
Slide 15
The Challenge
Slide 16
Incremental steps toward pay for performance
• Developing a population management approach to drive
quality improvements and support clinical integration
• Managing the risk you already have
• Taking on quality-based risk contracts with payers
• Managing utilization risk
Slide 17
Focus on Rapid Cycle Evaluation and QA
• Continue to improve systematic approach to using data from and
about your practice to improve care.
• Monitor at the panel and provider level
• Understand how practice changes influence QA measures
• Use measures to improve quality
• Create a culture of improvement (train staff on QI methods, engage,
review data and plan improvements and share)
• Internally build the analytic capabilities to manage total cost of care
for the practice (reduce redundancy)
• Review payer feedback reports (aggregate and provider)
Slide 18
Mobile County Health
Department/Family Health
Susan Stiegler, B.S.N., M.P.H.
Assistant Health Officer
Slide 19
Fee For Service
Then
Before 2012
• Reimbursement and quality
had minimal correlation
(Category 1)
Slide 20
Fee For Service
Then
Before 2012
• Patients + Visits = $$$$
• Goal was to increase patients
and visits to increase
revenue
Slide 21
Quality Reporting
Now
2015
• UDS
• Meaningful Use
• Alabama Medicaid
• Alabama Medicaid Regional Care
Organization
• BCBS
• Alabama Medicare
Slide 22
Quality Reporting
I. Unified Data System
1. Table 6B - Quality of Care Indicators
a. Prenatal Care
b. Immunizations
c. Pap Tests
d. Weight Assess; Children and Adults
e. Tobacco Use
Slide 23
Quality Reporting
I. Unified Data System (Cont.)
1. f. Asthma
g. CAD
h. IVD
i. Colorectal Cancer Screening
j. HIV
k. Depression Screening
Slide 24
Quality Reporting
I. Unified Data System (Cont.)
2. Table 7 – Health Outcomes and Disparities
a. Prenatal Services
b. Hypertension
c. Diabetes
Slide 25
Quality Reporting
II. Meaningful Use
1. Diabetes
2.
3.
4.
5.
Asthma
Cancer Prevention
Immunizations
BMI
Slide 26
Quality Reporting
II. Meaningful Use (Cont.)
6. IVD
7.
8.
9.
10.
Tobacco Use
HBP
Weight Assessment – Children/Adult
Use of E-Prescriber
Slide 27
Quality Reporting
III. Alabama Medicaid
1.
2.
3.
4.
5.
6.
Use of Generics
Office Visits
ER Visits
EPSDT Screenings
Tests – Hgb – A1C
Asthma
Slide 28
Quality Reporting
IV. Alabama Medicaid RCO
1.
2.
3.
4.
5.
Diabetes Care
Asthma – Medical Management
Pap Smear
Prenatal Care
LBW
Slide 29
Quality Reporting
IV. Alabama Medicaid RCO (Cont.)
6.
7.
8.
9.
10.
Hospital Follow Up
Antidepressant Medications
EPSDT
Hospitalization
Hospital Transition
Slide 30
Quality = $
First UDS Bonus in 2014
a. PCMH
b. Quality
c. Data Collection
(Category 3)
Slide 31
Quality = $
In 2016, 85% of Fee for
Services Will Be Tied to
Quality/Value Measures
Slide 32
Step One – Define Your Quality
Improvement/Management Plan
A. Objectives
B. Responsibilities
C. Components
D.Tracking
E. Data Sources
F. Measurement
G.Process- PDSA
H.Review – At Least Annually
I. Mechanisms for Action
Slide 33
Step Two – Train to the Plan and Follow the
Plan
A. Assign a QI/QA Coordinator and Team
B. Have QI/PI Meetings with Agendas
C. Include Board Members
Slide 34
Federal Health IT Vision
Vision
Health Information is accessible when and where
it is needed to improve and protect people’s
health and well-being
Slide 35
Data Sources = EHR Design
Map for
Quality
Metrics
Redesign
Templates
and Clinic
Flow
Design
Templates
and Clinic
Flow
Evaluate
Train
Slide 36
Mechanisms for Action
Collect
Share
Use
Slide 37
Mechanism for Action - Results
Correction Action Plan - Adult
Question #
Baseline
Week 1
Week 2
Week 3
Week 4
Week 5
4.
4
23%
33%
0%
33%
67%
40%
10
66%
67%
75%
50%
100%
67%
11
14%
N/A
N/A
67%
N/A
100%
Immunizations up to date per MCHD protocols
10. Pap smear per MCHD protocols
11. Colorectal cancer screening per MCHD protocols
Slide 38
Mechanism for Action - Results
Correction Action Plan - Pediatric
Question #
4
8
12
Baseline
58%
40%
60%
Week 1
33%
100%
100%
Week 2
N/A
100%
100%
Week 3
N/A
100%
100%
Week 4
88%
100%
N/A
Week 5
100%
100%
100%
4. Immunizations up to date per MCHD/CDC protocols
8. Vision screenings per EPSDT guidelines: Subjective < 3, objective >/= 3
12. Dental referral – annually 1 yr. ‐ 21 yrs.
Slide 39
Mechanism for Action - Results
Corrective Action Plan – Family Planning
Question #
Baseline
Week 1
Week 2
Week 3
3
25%
0%
33%
67%
14
76%
100%
100%
50%
3. Immunizations: Assess and give if appropriate
14. Pap Smear
17. Physical Exam Performed Per Protocol
Slide 40
17
70%
100%
100%
100%
Contact:
Julie Peskoe
212 437-3954
[email protected]
www.pcdc.org
Slide 41