0 multi-stakeholder payment reform and system redesign: working together to improve healthcare value...
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Multi-stakeholder Payment Reform and System Redesign: Working Together to Improve
Healthcare Value
Elizabeth MitchellCEO
Maine Health Management Coalition
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Maine Health Management Coalition
www.mhmc.info
The Maine Health Management Coalition Foundation is a public charity whose mission is to bring the purchaser, consumer and provider communities together in a partnership to measure and report to the people of Maine on the value of healthcare services and to educate the public to use information on cost and quality to make informed decisions.
The Maine Health Management Coalition Foundation is a public charity whose mission is to bring the purchaser, consumer and provider communities together in a partnership to measure and report to the people of Maine on the value of healthcare services and to educate the public to use information on cost and quality to make informed decisions.
16 Private Employers5 Public Purchasers
21 Hospitals14 Physician Groups
5 Health Plans
Employers
Health Plans
Providers
Collectively 35% of Comm. Market
The MHMC is a purchaser-led partnership among multiple stakeholders working collaboratively to maximize improvement in the value of healthcare services delivered to MHMC members’ employees and dependents.
The MHMC is a purchaser-led partnership among multiple stakeholders working collaboratively to maximize improvement in the value of healthcare services delivered to MHMC members’ employees and dependents.
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quality / outcomes + Value = improved health +
employee satisfactioncost
• Best quality health care• Best outcomes and quality of life• Most satisfaction • For the most affordable cost• For all Maine citizens
MHMC Value Equation
Maine’s Economy Has Moved From Manufacturing to Healthcare
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Maine Jobs in Manufacturing and Health Care, 1990-2010
Manufacturing
Health Care
Manufacturing
Manufacturing
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Health Care
Maine Has 5th Highest Insurance Premiums in U.S. For Singles
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Average Single Employee Insurance Premiums, 2010Employer Contribution Employee Contribution
Maine
20-25% of Chronic Disease Admits Return Within 30 Days
0% 5% 10% 15% 20% 25% 30%
PARKVIEW ADVENTIST MEDICAL CENTERST MARYS REGIONAL MEDICAL CENTER
HOULTON REGIONAL HOSPITALAROOSTOOK MEDICAL CENTER,THE
ST JOSEPH HOSPITALHENRIETTA D GOODALL HOSPITAL
CENTRAL MAINE MEDICAL CENTEREASTERN MAINE MEDICAL CENTERMILLINOCKET REGIONAL HOSPITAL
PENOBSCOT VALLEY HOSPITALMAINE MEDICAL CENTER
BLUE HILL MEMORIAL HOSPITALSOUTHERN MAINE MEDICAL CENTER
MAYO REGIONAL HOSPITALMERCY HOSPITAL
MID COAST HOSPITALSTEPHENS MEMORIAL HOSPITAL
INLAND HOSPITALNORTHERN MAINE MEDICAL CENTER
FRANKLIN MEMORIAL HOSPITALMAINE GENERAL MEDICAL CENTER
MILES MEMORIAL HOSPITALRUMFORD HOSPITAL
CALAIS REGIONAL HOSPITALYORK HOSPITAL
CARY MEDICAL CENTERST ANDREWS HOSPITAL
DOWN EAST COMMUNITY HOSPITALREDINGTON FAIRVIEW GENERAL HOSPITAL
WALDO COUNTY GENERAL HOSPITALBRIDGTON HOSPITAL
MAINE COAST MEMORIAL HOSPITALSEBASTICOOK VALLEY HOSPITAL
PENOBSCOT BAY MEDICAL CENTERMOUNT DESERT ISLAND HOSPITAL
Hospital 30-Day Readmission Rates from Heart Failure
Maine Has 3rd Highest Rate of Surgeries in U.S.
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Surgeries Per 1,000 Population, 2008
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But Inpatient Utilization Is Low, Meaning Cost/Day is Higher
Source:CommercialCostVariationbyHospitalReferralRegion,MillimanAugust 2010
Portland
Spending on Physicians is Below Average
Source:CommercialCostVariationbyHospitalReferralRegion,MillimanAugust 2010
Portland
Multiple Cost Drivers Require Multiple Strategies
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1) Performance Measurement and Public Reporting
2) Consumer Engagement
3) Value Based Purchasing
4) Reformed Payment/Effective Incentives
4 Steps to Improving Health Care Value
Meaningful system performance measurement and public reporting is necessary for accountability to purchasers, patients and community.
•Transparency of cost, resource use and appropriateness
•Transparency of utilization rates and patterns
•Transparency of patient outcomes and experience
•Transparency of quality and safety
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Employer Use
• State of Maine Tiered Networks– Hospital based on PTE Metrics - 2006
• Added cost of care w/ quality Aug 2011
– PCPs based on PTE Metrics - July 2007
• Other Employers/Plan Sponsors– Jackson Lab and Barber Foods – January 2011– U Maine System – January 2012– MMEHT – January 2012
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Employer Use
• Employer members choose if/how to use performance measures
• Consistency across employers preferred by providers
• Gradual ‘raising of the bar’ on performance
• Transparent, multi-stakeholder process important to employees and providers
• Threshold: Achieving minimum of ‘Good’ in every category (only quality/safety for 5 years)
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Employer Use
• Exceptions made for ACO pilots: ‘Higher value initiatives’– MaineGeneral - Cary– PenBay - SMMC
• Drove provider and employer engagement on delivery system and payment reform
• RFP for direct contracts: JAX
• Network Design: MaineSense
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Cost Variation
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Publishing Hospital Costs
How the data is used is what matters:
•Without tiering: Low cost hospitals negotiated higher rates
•With tiering: High cost hospitals renegotiating lower rates to be included in network (4.7%)
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If food prices had risen at medical inflation rates since the 1930’s.
*Source: American Institute for Preventive medicine
2009
1 dozen eggs $85.08
1 pound apples $12.97
1 pound sugar $14.53
1 roll toilet paper $25.67
1 dozen oranges $114.47
1 pound butter $108.29
1 pound bananas $17.02
1 pound bacon $129.94
1 pound beef shoulder $46.22
1 pound coffee $68.08
10 Item Total $622.27
Employee engagement curriculum to develop optimal incentives and engage patients in their role to improve their health and healthcare:•Module 1: Examining What You Have, Determining What You Want •Module 2: Bright Spotting: Best Practice Locally, Regionally and Nationally•Module 3: Securing High Quality Healthcare Services•Module 4: Preventing Poor Health•Module 5: Monitoring Your Benefits Package to Assure the Best Value for Benefit Dollars
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‘I am part of labor representing about 360 members. My members can not afford a healthcare plan that does not give them the best possible outcome or quality of care. The classes have taught me the buying power of our group. We should not pay for bad results or poor quality of service. As consumers, we need to be more pro-active in our healthcare.’
- City of Portland Employee
‘Before I learned about the work of the Coalition, I thought the only thing I could do about healthcare was complain.’
- Prof. Arthur Hill, UMaine Employee
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Accountable Benefit Design
Option Explanation/Rationale
Incent Selection of PCP provider in ACO
If primary care is to be foundation of ACO, plan must encourage use of selected practices
Incent PCP visits v. ER visits Establish significant differential to obtain care at PCP or network urgent care
Incent compliance with preventive care
100% coverage or preventive services and age-sensitive screenings linked to health credit
Incent participation in practice based care management
Waive all co-pays for participation in practice based care management for members with chronic conditions
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Employers Pay For:TestsVisits
ProceduresPrescriptions
Errors & Complications
Employers Want:Informed Employees
Improved Outcomes
Care Coordination
Prevention
Functional Status
Return to Work
You Get What You Pay For
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Dr. Steele: The Way YOU Pay is Major Part of Problem!
Rests on the head…
of a pin
ERLOSE
??
LOSE
LOSE
LOSE
$$
$$
$$$
Example: Maine’s Transition to Global Payments & ACOs
PURCHASERS PROVIDERSFACILITATORState
EmployeesHealth
Commission and UMS
MaineGeneralHealth
MaineHealth
ManagementCoalition
Bath Iron Works
MidCoastHealthSystem
DataTechnical
Assistance
BestOpportunities forShort-TermSignificantSuccess
Choosing a Starting Point in Moving to Higher-Value Care
ConditionsAffectingMany Patients
ServicesWith Evidence of Over-Utilization
Low-CostInterventionsWith SignificantShort-Term Impact
Willingand AbleClinicalLeadership
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• It’s not about “risk” or “incentives,” it’s about giving healthcare providers the ability/flexibility to improve outcomes and reduce costs in a way that is financially feasible
• Desired changes in care should drive payment reforms that support them, not the other way around
• Principal Tools:– Episode-of-Care Payment– Risk-Adjusted Global Payment
Payment Reforms Needed that Support Care Changes
Payers Need to Truly Align to Allow Focus on Better Care
Payer
Provider
Payer Payer
PatientPatientPatient
Better Payment System A
BetterPaymentSystem B
Better PaymentSystem C
Even if every payer’s system is better than it was, if they’re all different, providers will spend too much time
and money on administration rather than care improvement
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Many Changes in Care Needed to Achieve Significant Savings
Category of SpendingProjectedSpending
Change in Utilization Savings
Advanced Imaging $971,879 -20% ($194,376)ER Utilization $755,969 -15% ($113,395)ACSC Hospitalizations $2,380,536 -40% ($952,214)Back Surgeries $506,451 -10% ($50,645)CABGs $546,673 -10% ($54,667)Other Hospitalizations & SNF $22,052,815 -3% ($661,584)Other Physician Services $13,320,298 0% $0 Other Outpatient Services $4,527,880 0% $0 Home Health, Hospice, & DME $6,437,500 0% 0
$51,500,000 -3.9% ($2,026,882)
Identifying Opportunities and Strategies for Win-Win Savings
• Questions to Address:– Is this a desirable opportunity to pursue?– Does the opportunity vary among regions or among employers?– What are the barriers and how could they be overcome?– What does each stakeholder need to do differently to support
success?
• Employers/Medicaid• Health Plans• Hospitals• Physicians• Consumers/Patients/Families
– What additional information is needed to develop the business case for a win-win-win approach and implement the changes?
Who, What and How? Employers
– Patient Incentives through Benefit Design/Wellness– Informed purchasing with performance data – reward high performance– Payment reform – pay for what we value (PCMH)
Providers – High-value, coordinated, patient centered care– Shared Decision Making– Increase primary and effective care/Decrease services of limited value– Transparent cost and quality information
Health Plans – New roles, products and reimbursement systems
Patients – Informed choice and engagement to seek appropriate care– Awareness of risks/benefits with reliable information– Personal health responsibility
Key Next Steps
1. Access and use your data1. Identify key cost drivers
2. Quantify and prioritize opportunities
2. Build partnerships with providers1. Set clear goals with physician leaders to change
care delivery and lower cost
3. Do your part- benefit design/reimbursement changes to support accountable care
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Key Next Steps
4. Expect Accountability1. Review transparent data - monitor impact
2. Reward success
3. If progress is not made, act
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