connecting the dots: macra and payment reform – the...
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ConnectingtheDots:MACRAandPaymentReform–TheImpactonPediatricPractices
ColoradoChildren’sHealthcareAccessNovember15,2016
PamelaBallou-Nelson,RN,MSPH,PhD,PCMHCCESeniorConsultant
MGMAHealthCareConsultingGroup630.294.1072cell
877.275.6462,ext.1877officepballounelson@mgma.org
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Objectives• MACRA’simpactonvalue-basedpaymentreform• Alternativepaymentmodelsforpediatricoutpatientpractices• DefinehowpediatricssetsthetoneforPopulationHealthManagement• Howtoprepareyourpracticeforalternative-basedmodelsofpayment• Identifyruralhealthchallengesandvalue-basedpayments• Collectingthedata
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VALUE-BASED PAYMENT REFORMMACRA’s Impact
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MACRA’s Impact Payment Reform
• CongressintendedMACRAtobeatransformativelawthatconstructsanew,fast-speedhighwaytotransportthehealthcaresystemfromitstraditionalfee-for-service(FFS)paymentmodeltonewrisk-bearing,coordinatedcaremodels.
• Ithasthepotentialtobeagame-changeratalllevelsofourhealthcaresystemandforallstakeholders.
• Already,thelawisignitingstrategicdiscussionsaroundnewcare,paymentanddeliverymodels,andcreatingnewsourcesofriskforhealthcareorganizations.
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Impact Payment Reform - Commercial Plans
• 75%ofbusinessinvalue-basedpaymentarrangementsby2020–HealthTransformationAlliance
• Unitedwilldoublevalue-basedcontractsby2018—thisincludesself-fundedplans
• Aetnacurrentlyhas22%ofspendrunningthroughcontractswithavalue-basedcomponent
• Inarecentconference,AetnastatedtheywerefollowingCMSgoalsfortransitiontovalue-basedpayments
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MACRA’s Impact - Payment Reform
• BasedonCMSrequirements,theroadmapenvisions80-90%ofallMedicaretraditionalpaymentstoprovidersbeingvalue-basedby2020.(CMSmetthe2016goalof30%,11monthsaheadofschedule.)
• Becauseservicesforchildrenmakeupasmallpercentageofoverallspending,discussionaboutVBPmodelshastodateprimarilyaddressedtheadultpopulation.
• Adultcarepaymentmodelstendtofocusonreducingunnecessaryinpatientandemergencydepartmentutilizationtosavecosts,andprovidingmorecoordinatedandintegratedcaretobothimprovethequalityofcareandtohelpreducegrowthintotalcostofcare.
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FOR PEDIATRICSAlternative Payment Models
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AlternativePaymentModelsforPediatricsFourkeychallengestoapediatricvalue-basedpaymentmodel:• Mostchildrengeneratelittlemedicalexpense.• Childrenwithhighmedicalneedsareaheterogeneouspopulation.• Presentandfuturehealthstatusislargelydefinedbyfactorsnotunder
thecontrolofclinicians.• Manypediatricprovidersarenotpreparedforvalue-basedpayment.
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Current Child Healthcare Value-Based Payment Models• SupplementalPaymentandPay-for-Performance
o RhodeIsland
• Episode-basedpaymentso Arkansas&Massachusetts
Ø High-riskAsthmaBundledPayment,whichwasrecentlypilotedwith200patients.TheArkansasbundlecoversinpatientandoutpatientcostsfor30daysfromthetriggerdate.Servicesarepaidonafee-for-servicebasiswithanopportunityforcostsavingsifcostscomeinbelowthe75thpercentileofcosts.
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Current Child Healthcare Value-Based Payment Models• Sharedsavingsontotalcostofcare
o OhioExample:ThereareanumberofpediatricACOsinthecountrythathavebeenformedbychildren’shospitalswhichserveconsiderablenumbersofchildrencoveredbyMedicaid.PartnersforKidsisanACOinColumbus,OH,organizedbyNationwideChildren’sHospital.ItoperatesundercontractswithOhioMedicaid,managedcareplansinalargeurbanandruralregionofthestate,andisserving325,000MedicaidchildrenthroughitsACOasof2015.
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Recommendation from Research:
• Payersneedtodesignmodelsthatrecognizesavingsfrompediatriccarecomeprincipallyfrompreventingadultchronicconditions.
• Concurrently,apaymentmodelmustalsorecognizethattherearevulnerablepediatricsubpopulationsthatrequirehigherspendingduringchildhoodformedicalservices.
• Also,paymentmodelsneedtoaddressmentalhealthconditions,preventionandsocialdeterminants.
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Recommendation from Research:• Controllingcostsrequirestheengagementofspecialists,aswellasa
pediatrician.• Aligningpaymentincentivesaroundsharedaccountabilityfor
outcomeandcost.• Othershaveadvocatedforsocioeconomicriskadjustmenttoensure
adequatepaymentlevelstoproviders,provisionoffundingflexibilityandincentivesformoredirectcollaborationwithsocialserviceagencies.
• Parentactivationmeasurescoresevaluateforbehavioraloutcomesimpactingwellnessandillness.
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Recommendation from Research:• CapitatedPrimaryCarePayment:
• Coversmostchildhealthservices
• Carecoordinationpayment• Risk-adjustedper-patient-per-monthpaymenttofundcarecoordination
forchildrenwithinthepracticewithmedicalandsocialriskfactors
• PerformanceIncentiveBonus
• Totalcostofcareforthosecaringforthe1-5%ofthepediatricpopulationwithmedicalcomplexity
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PEDIATRICS: POPULATION HEALTH MANAGEMENT
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Population Health Is an Outcome
Populationhealthisdefinedasthehealthoutcomesofagroupofindividuals,includingthedistributionofsuchoutcomeswithinthegroup.
Thesegroupsareoftengeographicpopulationssuchasnationsorcommunities,butcanalsobeothergroupssuchasinsuranceattributions,employees,ethnicgroups,disabledpersons,prisoners,oranyotherdefinedgroup.
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Kindig,DA,StoddartG.(2003).Whatispopulationhealth?AmericanJournalofPublicHealth,93,366-369.
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Pediatric Population Health • PopulationscanbecategoriesofpopulationssuchasAsthma
population:
o Portland,OR
Ø BasedChildren’sHealthAlliance(CHA),anot-for-profitassociationof100-plusindependentprimarycarepediatriciansinOregonandsouthwestWashington,thecommongoalofimprovingqualityinpediatriccare.
Ø Beganaqualityimprovementprogramforasthmacaremanagementimprovement,includingthedevelopmentofapediatricasthmaregistry.
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ALTERNATIVE BASED MODELS OF PAYMENT
Howtoprepareyourpracticefor:
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How to Prepare Your Practice• Knowyourpractice:
o Whoaremypatients?o Whatmedicalconditionsdotheyhave?o Whatgapsincaredotheyhave?o HowcanI/thecommunityhelpthemfillthosegaps?
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How to Prepare Your Practice• Reconcileyourpatient’sdiseaseentity
o ClaimsdataandEHRdX data,problemlist
• Servicereconciliation
o Lookatpatientsandwhatservicesvisitstheyshouldhavehadandifithasbeendone
• InvestinyourstaffandeducatetheminExcelandotherapplications
• Considercollaborativearrangementswithotherpediatricgroups/hospital
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RURAL HEALTH CHALLENGES AND VALUE-BASED PAYMENTS
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Rural Health Challenge
GeographicIsolationLow Income
LowEducationLevel
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EducationLevel
Rural Health Challenge
Income GeographicIsolation
MoreMedicaid
LessInsurance
HealthLiteracy Shallowlaborpool
FewerPhysicians
Longertraveltocare
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Rural Health Challenges
Shallowlaborpool
MoreMedicaid
Lessinsurance
Fewerpracticeresources
Decreasedpayment
DecreasedCompliance
Pooraccess
Missedappointments
Poorself-careability
Fewerphysicians
Longertraveltomedicalcare
Lowhealthliteracy
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VB Models Can Increase Rural Disparity
Cherrypicking
Fewerpracticeresources
Fewerin-networkproviders
Pooroutcomemetrics
Decreasedpayments
SuppressedActivationLevels
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Key Points in Rural Health
• Ruralhealthisdifferent• Thereisfreehelpandlow-costhelpavailableforruralhealthpractice
transformation• Culturechangeiscore• Datamanagementstartswithreconciliationofyourdata• InvestinyourstafftolearnhowtouseOfficeApplications• Collectivecollaborationwithotherpediatricgroups
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DATA CRITICAL FOR BENCHMARKING
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IMPERATIVE TO COLLECT THE DATA TO MEASURE IMPACT OF CHANGE
MGMA DataDive
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MGMA DataDiveMGMADataDive providesrobustdatainstantly
• Quicklyaccessdataonyourphone,tabletorcomputer• Accessdatainjustthreesimple-to-followsteps
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Compensation Survey Data
MGMADataDive ProviderCompensationincludesdataon:• Physicians,nonphysicianproviders,academicproviders• Providersthattakecall• Providerspaidformedicaldirectorshipduties• Newlyhiredproviders
Usethisdatato:• Evaluatefactorsthataffectcompensationtosetrealisticgoals• Targetareasofimprovementinproviderperformance• Determinetherightmixofcompensation,benefits,incentivesand
opportunitiestooffernewproviders
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Compensation Survey DataMGMADataDive ManagementandStaffCompensationincludesdataon:
• Managementandstaffcompensation• Administrativeandclinicalstaffsalaries
Usethisdatato:• Understandhowdifferentpaymentmethods,experience,educationand
credentialsaffectcompensation• Negotiatefaircompensationcommensuratewithindividual
qualificationsandpracticegoals• Compareyourmanagerandstaffsalariestosimilarpracticesinyour
regiontoensurethatyourcompensationiscompetitive
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Cost and Revenue Survey DataMGMADataDive CostandRevenueincludesdataon:
• Singleandmultispecialtypracticesbrokenoutbyspecialty• Datafiltersincludingorganizationownership,geographicregion,
demographicclassificationandsizeofpractice• DatacutsincludingperFTEphysician,asapercentageoftotalmedical
revenue,perRVU,perpatient
Usethisdatato:• Analyzeyourstaffinglevelsviakeyperformanceindicators• Performcost-reductionanalysis• Determinehowpayermixcanaffectyourorganization’sbottomline• Benchmarkaccountsreceivabletoidentifyareasforimprovement• Recognizepracticetraitsthatenhancecostefficiencyandprofitability
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Visithttp://data.mgma.com/DataDive/rdPage.aspx• IfnotalreadyloggedinwithyourMGMAusernameandpassword,login
whenprompted.o Ifthisisthefirsttimeloggingin,click“didyouforgetyourpassword?”
andfollowpromptstoresetthepassword.o MGMAsetupaccountsusingemailaddressesprovidedbySIM.
• Onceloggedinandathttp://data.mgma.com/DataDive/rdPage.aspx,clickonthe“MGMADataDive”icon.Thisdirectsyourightintotheproduct.
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• ForquestionsonusingDataDive,ourDataSolutionsteamisavailableM-F,8am-5pmMSTatsurvey@mgma.org or877.275.6462,ext.1895,toansweranyquestions.ItmaybehelpfultomentionSIMwhencontactingwithquestions.
• WealsoconductmonthlywebinarsonusingDataDive.Recordedwebinarscanbefoundhere: http://online.mgma.org/data-dive-monthly-webinars.Thesearefreetoviewandanyonewhowantstoreceivenotificationsaboutupcomingwebinarscanentertheirinformationonthispage.
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Collaboration
- HenryFord
Comingtogetherisabeginning
Keepingtogetherisprogress
Workingtogetherissuccess
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