Transcript Payment Reform for Substance Use Disorder Treatment

TREATMENT RESEARCH INSTITUTE
Applying Science to Transform Lives
Payment Reform for Substance
Use Disorder Treatment
Mid-Atlantic CTN
Regional Dissemination Workshop
June 3-4, 2010
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Overview
• Addiction is a Health Care issue
• Chronic not acute condition
• Health care financing/payment reform
• Some new models
• Implications for Addiction Treatment
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Core Foundation
• Health Care Arena – Addiction is a
HEALTH problem:
• Part of mainstream healthcare
• Chronic not acute condition:
• Purchasers will need to change contracts, funding
mechanisms and expectations
• Treatment programs will need to change from acute to
chronic care design and service delivery
(more)
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Core Foundation
• Medication Assisted Treatment (MAT)
• New medications for addiction
• Psychotropic meds for co-occurring MH disorders
• Recovery is the goal
• Treatment prepares for recovery
• Continuing care
• Disease & self management not program completion
• Recovery Support
• Recovery Coaches/Linkage Coordinators
• Family and other “community strengths” support
• Return to treatment program for “tune ups”, etc.
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Acute Care Assumptions
•
Some fixed amount or duration of treatment will
resolve the problem
•
Treatment Completion is a goal and expected
outcome
•
Evaluation of effectiveness should occur following
completion
• Poor outcome means failure
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In Chronic Care
• The effects of treatment do not last very
long after care stops
• Patients who are out of contact are at
elevated risk for relapse
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New Expectations
• Programs are responsible for results during
treatment
• Treatment offers choices – patient
centered/adaptive care
• Easy transition between levels of care and
treatment programs
•Collaboration vs. competition among
programs
• Recovery Oriented Systems of Care:
•Continuing care and self-management
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Health Care Payment/Financing
Reform
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Congressional Research Service
Healthcare Payment Reform
• Institute of Medicine issued several
reports recommending differential
payments based on quality in 1999, 2001
and 2006.
• Medicare Payment Advisory Committee
has recommended paying providers
different rates based on differences in
quality in 2004, 2005 and 2006.
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Disruptive Innovation
(NY Times 2/1/09)
• Concept pioneered by Clayton Christensen from
Harvard Business School
• Old business models based on treating illness
not promoting wellness
– Hospitals benefit from full beds and repeat visits
– No financial incentive to keep patients healthy
• Acute disease drove the costs
(more)
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Disruptive Innovation
• Disruptive innovation will shape healthcare
systems to provide a continuum of care focused
on each individual’s needs, instead of focusing
on the crises.
• Fixed fee, integrated systems
• Routine cases handled through lower cost
facilities
• Follow patients wherever they go within an
integrated system
• Integrated systems are the disruptive innovation
needed to be turned loose on healthcare
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Health CEO’s for Health Reform
• 30% of resources spent on health care in US are a
result of too few efforts to coordinate care and
not enough attention to quality.
• Realign current incentives to create new
payment structures that reward high-quality,
patient centered, efficient care, while
discouraging the fragmented and low –value
care that drives health care cost today.
(more)
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Health CEO’s for Health Reform
• Improve the way we deliver care by
moving toward more integrated,
coordinated delivery models.
• Align incentives across multiple providers
to give efficient, high-quality care both
medical and business value.
• Link payment to value not volume.
(more)
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Health CEO’s for Health Reform
“VISION”
• System should deliver the right care, at the
right time, at the right place, with the right
outcome.
• Payment policy should be refocused to
reward:
• Clinical quality of care
• Patient satisfaction
• Better health
• Efficient resource use.
(more)
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Health CEO’s for Health Reform
“Specific Proposals”
• Fee for service is unsustainable:
• Transition the entire delivery system away from
fee for service payment and toward outcome
driven, bundled payments that encourage
provider accountability.
• Payment will be dependent on compliance with
standards related to quality of care, patient
outcomes and satisfaction, and patientcenteredness.
(more)
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Health CEO’s for Health Reform
“Specific Proposals”
• Develop and transition toward bundled
payment models:
• Linking payment to quality and patient outcomes
within an episode or continuum of care delivery
and allowing clinicians to share in the potential
savings will encourage care coordination, increase
quality and efficiency, and refocus health care on
the patient.
• Bundled payments can be used to set “efficient”
payment rates for groups of services that should
be delivered to specific types of patients.
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Build Systems of Care Through
Partnerships
• Providers must act in concert:
– Handoffs: adequate communication, sharing of
patient information (transparency), clear lines of
accountability
– Transitions: carefully planned and executed with
adequate patient and family caregiver involvement
– Referrals to specialists: informed by complete
information on services performed and the benefits of
additional services
(more)
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Build Systems of Care Through
Partnerships
– Adherence to practice guidelines: the
responsibility of all providers of the complete
bundle of services
– Provision of ongoing support: to patients for
self-management and maintenance of healthy
lifestyles
(more)
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Build Systems of Care Through
Partnerships
• Providers must look beyond walls of their own
institutions or practices
• Providers will likely pursue various types of
“partnership’ arrangements to work more
closely and effectively, and to share financial
rewards
• Some of the greatest gains will come from the
collective efforts of the multiple stakeholders in
the system
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Payment Reform Models
• Pay for Performance
• Prometheus Payment
• Accountable Care Organizations (ACO’s)
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Pay For Performance
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Theory and Conceptual Foundation
• Economic theory holds that individual
purchasers compare their implicit
assessment of value against the explicit
price to make optimal purchasing
decisions.
• In health care, this relationship has been
almost non-existent because buyers and
payers are not typically the patients who
receive the care.
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Theory and Conceptual Foundation
• Insurers and payers have not made any
distinctions in payments to providers who
exhibit differences in quality.
• P4P programs are an attempt to bring this
relationship between prices and value, as
reflected in quality care, into a closer
balance.
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A P4P Research Report
Med-Vantage
• Fee for service payments encourage
overuse, while capitated payments
encourage under-use.
• Neither systematically rewards excellence
in quality.
• P4P incentive programs are designed to
overcome these limitations by aligning
financial reward with improved
outcomes.
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Congressional Research Service
Report for Congress
P4P Defined
• A pay for performance system is a remuneration
arrangement in which a portion of the payments
is based on performance assessed against a
defined measure.
• Typically, there is another component of the
remuneration that is independent of the amount
at risk.
• The terms merit and bonus pay are also used to
describe similar systems.
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Elements Common to P4P Programs
• A set of targets or objectives that define what
will be evaluated
• Performance standards for establishing the
target criteria
• Measures to determine whether the targets have
been achieved
• Rewards – typically financial incentives – that
are at risk, including the amount and the
method for allocating payments among those
who meet or exceed the reward threshold.
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Impact of Private Sector P4P Programs
• Rewarding Results grant program funded
by RWJF and California Healthcare
Foundation, and administered by the
Leapfrog Group
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Impact of Private Sector P4P Programs
• Financial incentives motivate change – provided
they are large enough to make a difference.
• Non-financial incentives also can make a
difference.
• Engaging physicians is a critical activity – they
must be brought in early as collaborators to
ensure that the goals are clinically meaningful.
• There is no clear picture yet of return on
investment.
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Impact of Private Sector P4P Programs
• P4P is not a magic bullet – it is one of a
number of activities that can work to
improve healthcare quality and change
the way it is delivered and financed.
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MedVantage P4P Survey (2008)
N = 62 P4P Program Responses
• What Results do you attribute to P4P?
• 84% - Performance on clinical measures improved
• 66% - Improvement was statistically significant
• What changes do you anticipate making?
• 65% - Expand scope or number of measures used
• 53% - Change performance domains or relative
weighting of measures
• 0% - Discontinue the program
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Prometheus Payment
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PROMETHEUS Payment
• Taking up IOM’s challenge, a group of
experts from healthcare financing, law,
medicine, quality improvement, research
and economics, convened in 2004 to
develop a new provider payment model.
• Seeks to transform health care payment by
moving away from unit of service
payment to episode of care payment.
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PROMETHEUS Payment
• Tests paying for individual, patient
centered treatment that fairly rewards
providers for coordinating and providing
high quality care.
• Centers on packaging payment around a
comprehensive episode of care that covers
all patient services related to a single
illness.
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PROMETHEUS Payment
• Covered services are determined by
commonly accepted clinical guidelines or
expert opinion that lay out tested,
medically accepted methods for best
treating the condition from beginning to
end.
• The services are calculated into
“Evidence-informed Case Rates” (ECR’s),
which creates a specific budget for the
entire care episode.
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PROMETHEUS Payment
• ECR’s include all the covered services
related to the care of a single condition,
bundled across all the providers who
would treat a given patient for a given
condition.
• What makes PROMETHEUS different is
its strong incentive for clinical
collaboration to ensure positive patient
outcomes.
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PROMETHEUS Payment
• Provider is paid monthly for the duration
of the ECR an amount which reflects 90%
of the agreed upon rate.
• 10% holdback is paid based on the results
of the Scorecard:
• Quantifies whether the salient elements of the
Clinical Practice Guideline (CPG) were provided,
the patient’s experience of the care, and the
patient’s outcomes.
• 70% of the score based on what the provider
himself does; 30% reflects what other providers
treating the patient does.
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PROMETHEUS Practice Nexus
• Intended to foster clinical collaboration
and flexibility in how care is provided, so
long as the salient elements of the CPG are
present.
• Because all providers in the ECR do better
financially when they improve quality,
PROMETHEUS encourages collaboration
among providers, especially those who
score highly on the scorecards.
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Accountable Care Organizations
(ACO’s)
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Accountable Care Organizations
MedPac Report to Congress – 2009
• Basic concept – holding a set of providers
responsible for the health care of a
population
• This set of providers is an Accountable
Care Organization
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ACO’s
• Includes at least primary care physicians,
specialists and hospitals
• Defining characteristic – the ACO
members agree to accept joint
responsibility for the quality and cost of
care received by their ACO patients.
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ACO’s
• Goal – to create an incentive for providers
to constrain growth in volume while
improving quality of care
• ACO member providers are held jointly
responsible for quality and cost metrics
• Expected to improve coordination of care
and reduce duplication of services
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ACO’s
• If the ACO meets both quality and cost
targets, members receive a bonus
• If the ACO fails to meet both, no bonus
and possible withholds
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ACO’s
• Idea is to create a set of incentives strong
enough to overcome the incentives in feefor-service system for increased volume
without improving quality
• ACO’s are being envisioned as one tool to
induce change in the health care delivery
system
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Concluding Thoughts
• Why do people who know the least know
it the loudest?
• If you’re going to try cross-country skiing,
start with a small country.
• Health is merely the slowest possible rate
at which one can die.
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Contact Information
Jack Kemp
Treatment Research Institute
[email protected]
215-399-0980
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