9/23/2015

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Anthony Dawson, RN, MSN

Senior Vice President, Chief Operating Officer

Milstein Hospital

NewYork-Presbyterian Hospital

HEALTH CARE IN 2015:IT’S ALL ABOUT THE PATIENT

Disclosures

No Disclosures

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Objectives

• Describe the impact of health care reform on transplant services

• Understand the implications of health care reform on transplant services

• Describe pay for performance related to transplant services

HEALTH CARE REFORM

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Unknowns in Health Care

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• Pace of change

• Population Health

• High Deductibles/ Defined Contribution Plans

• Future market size

• Political environment

• What is quality?

• No proven interventions

• Social and environmental factors

The US Healthcare System in Context

Source: CIA World Fact Book 2012

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2012 Nominal GDP

USA $15.7 Trillion

CHINA $8.3 Trillion

JAPAN $6.0 Trillion

GERMANY $3.4 Trillion

US Healthcare System $2.9 Trillion

FRANCE $2.6 Trillion

UK $2.4 Trillion

BRAZIL $2.4 Trillion

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Healthcare Trends for 2015

• Physicians start to feel the financial pinch from CMS’s

regulations:

• VBP programs are solidly in place

• Starting to feel the pinch – penalty phase quality reporting

and Meaningful use

• 257,000 providers will loose 1% this year

• May also see reductions for noncompliance with

Electronic Prescribing (eRx) and Physician Quality

Reporting Systems (PQRS)

• Positive news (CPT) code 99490 MD bill CMS $41.92 per

month for providing remote chronic care management to

qualifying pts

Healthcare Costs Are Concentrated

23 Million Beneficiaries•Spending $1,130 each•Total Spending = 5%

($26 B)

16.1 Million Beneficiaries•Spending $6,150 each•Total Spending = 20%

($104 B)

7 Million Beneficiaries•Spending $55,000 each•Total Spending = 75%

($391 B)

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Medicaid DSRIP

$7.4B Delivery System Reform Incentive Program

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* Population Health Measures are pay-for-reporting

Process

Measures

Outcome Metrics

Population Health Measures*

Time

Paym

ent

Goals

1. Reduce avoidable

hospitalizations and

emergency department

visits by 25% over 5 years

2. Transform the Medicaid

delivery system with 80-

90% of total payments

value-based by 2019.

3. Achieve Triple Aim (better

health, better healthcare,

lower costs)

Quality Reports: Prevention, Satisfaction,

Safety, Outcomes, Care Coordination

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Vertical Acquisition Strategies Have Led to Consolidation

Across Healthcare Services

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Acquire

Health Plan

Start Up New

Health Plan

Merge With An Integrated

Delivery System

Partner With A Managed

Care Organization

Purchase Expertise from

Managed Care Solution

Providers

Providers Are Pursuing Managed Care Capabilities

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The Very Competitive Landscape

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For Profit and Not-for-Profit New Market Entrants

Joint Venture to Form New System

Joint Venture to Acquire Catholic Hospitals

acquires

acquires

acquires

becomes

acquires

forms an affiliation with

acquires

acquires

New Entrants in Healthcare Delivery

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The (R)evolution of Precision Medicine

Past Present Future

Human Genome

Project - first human

genome sequenced in

2003

Targeted therapy

around:

$2.7 billion

• Breast, lung & colon

cancer

• BMT

• Rare diseases

• Warfarin

Genomes done

infrequently

$1,000+ /test

$2,500+ /genome $1,000 /genome

“Inexpensive”

sequencing means:

• More discovery

• Earlier diagnosis

• More targeted therapy

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Technology Advancement

• Proliferation of new technology in healthcare is exploding

PWC – Top health industry issues 2105|PWC Health Research Institute

Technology Advancement

• Public craving for convenience

• Intuitive mobile apps that monitor vital signs, analyze

blood and urine, track medications adherence and more

PWC – Top health industry issues 2105|PWC Health Research Institute

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Technology Advancement

• Wearable technology some 70 million people in the US

are wearing mobile devices to track activity, sleep

patterns, calorie consumption, blood sugar etc.

• How can we adapt and transform that technology to care

for acute and chronic transplant patients

High Cost Savings

• 1% of all patients in the US consume 20% of the nations healthcare spending. In 2015, these high-cost patients-including the aging baby boomers and the chronically ill will be the focus of US healthcare

• Among the most costly are the “dual eligibles” approx 9.6 million individuals who qualify for both Medicare and Medicaid. In 2010 the average cost was $19,418 on each of these patients- compared to $8789 on other beneficaries

• Health systems and insurers can identify high-cost patients and coordinate their care

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The Newly Insured

• 2015 will be a bumper year for insurance as we begin to

learn about the new 10 million enrollees

PWC – Top health industry issues 2105|PWC Health Research Institute

PAY FOR PERFORMANCE

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Financial Performance

Domain ScoreFiscal

Year

Process

of Care HCAHPS Outcomes Efficiency

Process

of Care HCAHPS Outcomes Efficiency TPS $

FY2013 70% 30% 0% 0% 51.82% 30.00% - - 45.27 ($594,120)

FY2014 45% 30% 25% 0% 70.00% 28.00% 100% - 64.90 $1.8M

FY2015 20% 30% 30% 20%

FY2015

• New domain (Efficiency, 1 measure - Medicare spending per beneficiary)

• Additional measures (Outcomes domain, 2 measures - Patient Safety Composite,

CLABSI)

FY2016

• CMS proposing to remove 3 measures: AMI-8a (PCI timing), PN-3b (Blood culture),

HF-1 (Discharge Instructions)

• CMS proposing to add 4 measures: Influenza vaccination, CAUTI, Surgical Site

Infections (Colon, Abdominal Hysterectomy)

The Patient Experience is the sum of all interactions that influence patient perceptions across the continuum of

care

What is The Patient Experience?

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Patient Centered Care

• HCAHPS is an acronym for Hospital Consumer Assessments of Healthcare

Providers and Systems

• The HCAHPS survey measures patients’ perceptions of how often they felt

they received high quality clinical care and customer service

• This survey is mandatory for adult inpatient populations, excluding primary

psych diagnosis or patients who discharge to skilled nursing facilities,

rehabilitation facilities, etc.

• CMS shares the survey results publicly to help consumers make informed

decisions about where to seek healthcare

• CMS also uses the HCAHPS data to determine the Value Based Purchasing

Reimbursement

• Many administering the HCAHPS survey through Press Ganey via mail

How do we measure the Patient Experience?

Press Ganey HCAHPSPrivate survey Government survey

Voluntary Mandatory

Reported internally Reported publicly

How well we do it How often we do it

Very poor to very good Never/sometimes/usually/always

Score 1 – 5 (0-100 points) % always

All patients eligible Adult Inpatient (non-Behavioral Health)

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HCAHPS Domains

Overall Rating of Hospital 9-10

Would Recommend

Communication with Nurses

Communication with Doctors

Responsiveness of Staff

Pain Management

Communication about Medications

Hospital Environment – Cleanliness & Quietness

Discharge Information

Care Transitions (NEW)

HCAHPS Publicly Reported Data

Background

• CMS announced “Star” ratings for hospitalcompare.com

• Per Press-Ganey, the Stars are scheduled to appear on website April 2015 (Discharges Q2, 2013 – Q1, 2014)

• Twelve Stars one per Domain and one Overall rating based on the average number of stars received across all domains

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How The Stars Are Calculated

CMS scrubs the data to remove inappropriate responses

The Patient Mix Adjustment is applied

Black Box Adjustment is applied

A Linear score (0-100) is calculated for each domain

–Linear score is calculated: (% Always * 1) + (% Usually * .66) + (% Sometimes * .33) + (% Never * 0) = adjusted Linear Score

CMS applies a “clustering algorithm” to the scores to calculate star ratings

The star rating for each HCAHPS domains are averaged to determine a hospital overall star rating

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Your Focus Should Be On…..

TRANSITION TO ICD-10

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Introduction to ICD-10

• ICD stands for International Classification of Diseases. It is the set of diagnosis and

procedure codes developed by the World Health Organization (WHO).

• These codes capture patients’ conditions and the things we do to diagnose and treat

them. They are used to determine reimbursement and also to inform quality

research.

• ICD-9 is the current version of this code set. ICD-10 is the next version. It is more

than a simple expansion of ICD-9. It is an entire new set of codes and a significantly

revised classification system.

• The United States is going live with ICD-10 on October 1st, 2015, as mandated by

CMS.

The Transition from ICD-9 to ICD-10

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Why the Change?New Documentation

RequirementsEffect on Codes

• ICD-9 is close to 40

years old and does not

reflect new and

emerging technologies

• ICD-9 codes are not

detailed/descriptive

enough

• Inaccurate & vague

codes compromise

integrity of research data

and public health

reporting

• It’s ultimately about

QUALITY

• Acuity

• Anatomic site

• Laterality (right, left or

bilateral)

• Related conditions

• Staging of disease

• Association with

medication or drug use

• Causative agents

• Significance of abnormal

lab values

• Number of diagnosis codes

increasing by a factor of 5

• Number of procedure codes

increasing by a factor of 24

• Codes are longer and have a

different format

Diagnosis

codes

Procedure

codes

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Differences between ICD-9 and ICD-10 Diagnosis Codes

ICD-9 ICD-10

3-5 characters in length 3-7 characters in length

Approximately 13,000 codes Approximately 68,000 available codes

First digit may be alpha (E or V) or numeric;

digits 2-5 are numbers

Digit 1 is alpha; digits 2 and 3 are numeric;

digits 4-7 are alpha or numeric

Limited space for adding new codes Flexible for adding new codes

X X X XXX X

Category Etiology, anatomic site,

severityExtension

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Differences between ICD-9 and ICD-10 Procedure Codes

ICD-9 ICD-10

3-4 characters in length 3-7 characters in length

Approximately 3,000 available codes Approximately 87,000 available codes

Numeric characters only Alphanumeric

Limited multiaxial structure Multiaxial structure – each code character has the same

meaning within the specific procedure section & across

procedure sections where possible

47.01 – Laparoscopic appendectomy ODTJ4ZZ – Laparoscopic appendectomy

X X X XXX X

Section

Body System

Root

operation

Body part

Approach

Device

Qualifier

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Service Specific Conversion Examples

ICD-9

Diagnosis

Code

ICD-10

Diagnosis

Code(s)

ICD-10

Descriptor

Cardiac

Rehab

V45.82 Z98.61 Coronary angioplasty status

413.9I2Ø.8 Other forms of angina pectoris

I2Ø.9 Angina pectoris, unspecified

Adult Chemo

174.9 C5Ø.919 Malignant neoplasm of unspecified site of unspecified female breast

V68.9 ZØ2.9 Encounter for administrative examinations, unspecified

157.9 C25.9 Malignant neoplasm for pancreas, unspecified

Hemo-

dialysis

282.60 D57.1 Sickle-cell disease without crisis

204.00 C91.ØØ Acute lymphoblastic leukemia not having achieved remission

585.6 N18.6 End stage renal disease

Radiology

Oncology

185 C61 Malignant neoplasm of prostate

174.4 C5Ø.419Malignant neoplasm of upper-outer quadrant of unspecified female

breast

ICD-9 code conversion to ICD-10 can be 1:1 mapping up to 1:2530 mapping

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And the Future Will Look Like

Limitations to the Field of Transplantation

• Drug treatment-related complications

• Chronic rejection

• Availability of organs

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What’s Next for Organ Transplant

• Xenografting

• Tolerance work with bone marrow

• Deep sequencing of t-cell responses

• Living donor liver transplantation

• Paired exchange kidneys

• Lung in a box and regeneration therapies.

• Integration of device development and heart failure

• Immunologic studies of intestinal transplantation and

chimerism

Allograft:

A transplant from another individual of the

same species

Xenograft:

A transplant from another species

Xenotransplantation: A Solution to the

Organ Shortage

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Xenotransplantation Advantages

• Consistent quality of organs

• Healthy donors without comorbidities

• May be resistant to recurrent autoimmunity

• Amenable to genetic manipulation

• Addition of protective genes

• Elimination of deleterious antigens

• Scheduled transplants permit recipient preconditioning

• Donor-specific unresponsiveness or TOLERANCE

Koulmanda M, Qipo A, Smith RN, Auchincloss Jr H. Pig islet xenografts are resistant to autoimmune destruction by non-

obese diabetic recipients after anti-CD4 treatment. Xenotransplantation 2003;10(2):178–84

Building a Smarter Immune System to Overcome

Current Limitations to Transplantation

• Drug treatment-related complications: Avoid long-term

drugs via IMMUNE TOLERANCE

• Chronic rejection: avoid via IMMUNE TOLERANCE

• Availability of organs: XENOTRANSPLANTATION-

NEED TOLERANCE

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Immune Tolerance

• The immune system treats the donor antigens like “self”.

The donor graft is therefore accepted without

immunosuppressive drugs

• Bone marrow transplantation can induce immune

tolerance by re-educating the immune system to see the

donor as “self”

We Have Only Just Begun

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Questions