Thriving in the New Health Care Landscape: Payment Reform, Data and Engagement Sarah Woolsey, Medical Director, HealthInsight Utah

HealthInsight’s Annual Quality Conference October 18, 2016

What You’ll Learn Today

By attending this session, participants will be able to: • Discover how new and ongoing health care

initiatives across the nation impact health care providers and patients

• Identify opportunities for change and a plan for action

• Identify resources for learning more along with colleagues and the HealthInsight team

Key Topics for Today

• Payment reform and the alternative payment movement

• The data imperative • Patient engagement

– a must

PAYMENT REFORM AND THE ALTERNATIVE PAYMENT MOVEMENT

What is the Problem?

• Our health care costs keep going up and are a much greater percentage of gross domestic product (GDP) than other countries

• Wage increases are being eaten up by insurance cost

• Even spending all that money, our quality outcomes are mediocre at best

• This decreases our global competitiveness

Average Annual Worker and Employer Contributions to

Premiums and Total Premiums for Family Coverage, 1999-2016

Cumulative Increases in Health Insurance Premiums, Workers’ Contributions to Premiums, Inflation and Workers’ Earnings,

1999-2016

“Value” Reform: The Vision

Value-Based Purchasing

• Federal – Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

• Medicare Incentive Payment System (MIPS) • Advanced Payment Models (APMs)

– Comprehensive Care for Joint Replacement (CCJR) – Centers for Medicare and Medicaid Innovation (CMMI)

• Employers – Private Accountable Care Organizations (ACOs) – Bundled or Tiered Payments – Direct Primary Care

• States – State Innovation Models – Public Employer Retirement Systems – Medicaid Managed Care

Who it Really Impacts

Payers Providers

Patients Purchasers

Federal Program: MACRA

• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

• Focuses on Part B Medicare • Intent is three-fold:

– Sustainable growth rate repeal – Improve care for Medicare beneficiaries – Change our payment system from focus on

volume to value

CMS Framework

CMS Target Percentage of Payments in Fee for Service Linked to Quality and Alternative Payment Models

A Step: Medicare Incentive Payment System (MIPS)

Clinicians will be scored under MIPS using a single composite score that will factor in performance in four weighted categories for Year 1:

Advanced APMs

Based on the proposed criteria, which current APMs will be Advanced APMs in 2017? • Shared Savings Program: Tracks 2 and 3 • Next Generation ACO Model • Comprehensive End Stage Renal Disease Care

(CEC): Large dialysis organization arrangement • Comprehensive Primary Care Plus (CPC+) • Oncology Care Model (OCM): Two-sided risk

track available in 2018

Where Does MACRA Fit in the Big Picture?

• Where CMS goes others will follow • Track/report quality on care and understand

and act on information about the cost of care • Use technology to support internal

improvement efforts as well as to coordinate across the continuum of care

• Very likely leading to changes in patient engagement and experience

The Systems Vision: Transforming the Care of Complex Patients

Acr

oss

Car

e Se

tting

s

Essential Services System Requirements

Care Mgt

Clinical Pharmacy

Health IT

QI Training

Performance Incentives

Collaboration and

Integration Medication

Reconciliation

Informed, Activated, Discerning

Consumers, esp. End-of-

Life

Data to Treat,

Measure, Evaluate

Perfect Patient Care

Rewards for

Collaboration

Hospice/Palliative Long-Term Care

Rehab Hospital

Emergency Services Specialty Care

Primary Care

Screening and Tx

Behavioral Health

Engaged Patient

U.S. ACO Participation: Contract Growth

U.S. ACO-Covered Lives to Date

Source: Leavitt Partners Center for Accountable Care Intelligence

Utah Alternative Payment Model Participation

• Utah State Innovation Model review of 7/12 large health plans reported (spring 2016) – All have patients in shared savings arrangements, (4-

26%) of their panels – 5/7 only bonus for hitting targets, no penalty – 2/7 have up and downside targets – 1/7 has bundled payment arrangements

• Medicaid ACOs (capitated payment, aligned quality) spread to all major population centers

• Significant Medicare Advantage participation • Many direct care employer opportunities

Utah Participation in Alternative CMS Payment

• Medicare Shared Savings Program ACOs – Granger Medical, Revere Health,

Aledade Mountain West , and Utah Physicians' Quality Care

• Medicare Care Choices Model – Intermountain Homecare and

Hospice • Oncology Care Model

– Utah Cancer Specialists • Cardiovascular Disease Risk

Reduction Model – University of Utah Department

of Family and Preventive Medicine

• Bundled Payments for Care Improvement – Encompass Home Health and

Hospice – Sandy Health and Rehab – Copper Ridge Health Care – St. Joseph Villa – HealthSouth Rehabilitation

Hospital – University of Utah Health Care – Salt Lake Regional Medical

Center

So, Where Are You?

THE DATA IMPERATIVE

Data Reports

• Audiences • Purposes • See your organization • See other organizations • Target areas for

improvement • Determine additional data

needs • Public/private data

collection • Availability/transparency • Sources

Sources • CMS

– Medicare Compare – Value-Based Purchasing Reports – Material Data Safety Reports (MDS) – OASIS OBQI/Outcome-Based Quality Improvement Reports – Quality and Resource Utilization Reports (QRUR) – Program for Evaluating Payment Patterns Electronic Report

(PEPPER) – HealthInsight prepared reports on CMS data

• CDC – National Healthcare Safety Network (NHSN)

• Agency for Healthcare Research and Quality (AHRQ) – Quality and safety indicators – Healthcare Cost and Utilization Project (HCUP) – Consumer Assessment of Healthcare Providers and Systems

(CAHPS®)

Sources (continued)

• State/County – Office of Healthcare Statistics

• All Payer Claims Database • Health Care Facilities Data • Health Plan Quality and Satisfaction Data

– IBIS Public Health Indicator System – My HealthCare in Utah – County Health Rankings Report

• HealthInsight – National rankings by setting – UtahHealthScape

Home Health Agencies

• CMS – Home Health Compare and Star Ratings – Outcome and Assessment Information Set (OASIS) – Medicare provider utilization and payment data – Home Health Quality Improvement (HHQI) data

access reports • HealthInsight

– National rankings – Performance feedback reports – UtahHealthScape

Skilled Nursing Facilities

• CMS – Nursing Home Compare and Star Ratings – Certification and Survey Provider Enhanced Reporting

system (CASPER) – Cost Report Data

• HealthInsight – National rankings – HealthInsight website – Composite scores provided to participating facilities – UtahHealthScape

Hospitals

• CMS – Hospital Compare – Utilization and payment data reports

• State-based reports – Inpatient – Ambulatory surgical – Emergency department

• HealthInsight – National rankings – Performance feedback reports – UtahHealthScape

Clinical Practices

• State-based reports – Clinic Quality Comparisons on Open Data – Total Cost of Care reports (primary care) – UtahHealthScape

• CMS

– Physician Compare – Physician Quality Reporting System (PQRS) feedback

reports – Medicare provider utilization and payment data – Quality and Resource Use Report (QRUR)

Quality and Resource Use Report (QRUR)

• Shows how a group or solo practice performed on quality and cost measures used to calculate the Value Modifier

• Based on care provided to Medicare fee-for-service (FFS) beneficiaries attributed to the practice

• Composite scores: Compares practice’s average score to national mean on – Quality across six domains of care – Cost attributed to care of key conditions

QRUR Scatter Plot

QRUR Utility

The QRUR provides information to PCP regarding: • Care coordination efforts • Areas where care is more costly than peers (DM,

CAD, COPD, CHF) • Referral patterns • Worklist of high-risk patients that need more

attention • Post-acute care partners

Clinical Health Information Exchange (cHIE)

• A resource to enhance individual patient and organizational decision making

• Real time clinical data • View a patient’s history and encounters with

the health care system • Alerts can be set up to notify on your patient’s

access of health care

Health Information Exchange

• May reduce (costly) duplication of lab and radiology tests

• Improves – Decision-making – Timeliness, effectiveness and quality of care

• Meets reporting requirements – meaningful use

Utah Statewide Immunization Information System (USIIS)

• Information exchange for vaccinations • Reduces duplication • Improves workflow • Useful to assess gaps in population health

Data to Ensure Success

PATIENT ENGAGEMENT – A MUST

Source: Health Affairs 32, no.2 (2013):223-231 Patient And Family Engagement: A Framework For Understanding The Elements Adams, Christine Bechtel and Jennifer Sweeney Kristin L. Carman, Pam Dardess, Maureen Maurer, Shoshanna Sofaer, Karen doi: 10.1377/hlthaff.2012.1133

The Continuum of Engagement

Effectiveness of Patient Engagement: What Do We Know?

• Systematic review to assess strategies for informing, educating and involving patients – 129 systematic reviews, 2007

• Key findings – Health literacy – Acute and chronic health problems

• Clinical benefit at home and clinical settings • Better use of resources

– Shared decision-making and self-management • Mutually supportive approaches, use together

– Health information materials, decision aids, self-management action plans, technologies supplement or augment not replace, personal interactions

– Develop health professionals skills, provide resources for them to assist patients

Source: Coulter A and J Ellins. Effectiveness of strategies for informing, educating, and involving patients. BMJ. July 2007. 335: 24-27

Evidence for Patient and Family Centered Care

Patient and Family Centered Care Pediatric Literature • Study outcomes included patient experience, patient knowledge, attitudes to

care, provider behavior and health status – Assessed

• Education from provider to family • Information sharing from family to provider • Social-emotional support • Adapting care to match family background • Shared decision-making

• Results – Addition of social emotional support was single factor impacting knowledge, attitudes to

care, and experience of care – Best outcomes when targeting patient and family, provider and patient/family

• Not provider-only interventions

– Impact on health status hard to show (less than 50% showed benefit) but impact on improving patient experience of care may be precursor of eventual health-related outcomes

Source: A Narrative Synthesis of the Components of and Evidence for Patient- and Family-Centered Care. Clin Pediatr. April 2016 55: 333-346, first published on June 26, 2015 doi:10.1177/0009922815591883

NATIONAL CMS TRENDS

MACRA Proposal and Patient Engagement

• Care coordination and communication among health team members, including patients and families

• Managing transitions of care in partnership with community-based entities and services

• Developing and updating individual care plans with patients

• Fostering linkages with neighborhood/community-based resources to support patient health goals

• Use of evidence-based decision aids to support shared decision-making

• Support for patient self-management using techniques such as teach back, action planning or motivational interviewing

• Expanded access to care • Beneficiary engagement activity

(assessment, surveys, advisory councils)

• PCMH elements of – Collecting and reporting patient

experience of care – Meaningful engagement of

patients and families – Shared decision-making

• Consumer Assessment of Healthcare Providers and Systems (CAHPS) as a priority not mandate

Comprehensive Primary Care Plus (CPC+)

• CMS Alternative Payment Program • One of five key components of CPC+ is

convening and engaging a Patient and Family Advisory Committee

• Requires supporting patients’ self management of high-risk conditions

• Requires psychosocial needs assessment and inventory resources and supports

Survey of ACOs and Patient Activation and Engagement Practices

Process % of ACOs Surveyed Using this Practice

Patient Reminders (EHR, phone, mail) 100

Patients may access EHR (Portal) 71

Patients may access own EHR notes (i.e. Open Notes) 24

Health Coaching 45

PCP with training in Pt Activation and Engagement 48

Decision Aids for Patients 45

Formal Health Literacy Assessment 23

Patients may participate in ACO governing Board 63 (low pt. participation)

Patients may participate in ACO QI 50

Provide Patient experience data provided to PCPs 87

Source: Shortell, SM et.al An Early Assessment of Accountable Care Organizations’ Efforts to Engage Patients and Their Families. Medical Care Research and Review 2015, Vol. 72(5) : 580–604.

ACO Continued

• Of ACOs calculating ROI of patient activation and engagement – Report 2:1 to 4:1 – Emergency department and hospital use reductions

• Commonly reported strategies – Heavy use of coordinators and care managers – Developing patient communication and IT

infrastructure – Training staff in Motivational Interviewing Source: Shortell, SM et.al An Early Assessment of Accountable Care

Organizations’ Efforts to Engage Patients and Their Families. Medical Care Research and Review 2015, Vol. 72(5) : 580–604.

EXPANDING ENGAGEMENT

Key Themes

• Assess and move patient along a continuum of engagement or activation

• Use decision aids for shared decision-making • Advocate for patient held records • Add patients to leadership and QI teams,

meaningfully • Imbed self-management opportunities for

patients

Train and support your workforce

Patient Activation Measure

• Commercial tool (owned by Insignia Health) – Assesses an individual’s knowledge, skill, and

confidence for managing one’s health and care – Measures patients on a 0-100 scale – Predictive of success with most health behaviors – Extensive evidence that it is possible to increase

activation levels in patients

Source: Hibbard, Judith; Stockard, J; Mahoney, ER; Tusler, M (August 2004). "Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers". Health Services Research. 39 (4): 1005–10026. doi:10.1111/j.1475-6773.2004.00269.

Strategies Used by Clinicians with High and Low Change on Patient Activation Scores

The Ottawa Hospital Patient Decision Aid Site

Source: The Ottawa Hospital

Shared Decision-Making Tools

Source: The Ottawa Hospital

Shared Decision-Making Support From Payer

• United Healthcare • Shared Decision-Making Support for members

with preference sensitive conditions – Targeted RN counseling on individual options for

care – 2009 analysis of 4225 “engaged members” from

151 employers – $11,000 savings/procedure as patients chose

evidence based conservative treatment options

Source: G. Sandy, Reed V. Tuckson and Simon L. Stevens. UnitedHealthcare Experience Illustrates How Payers Can Enable Patient Engagement. Health Affairs 32, no.8 (2013):1440-1445. doi: 10.1377/hlthaff.2012.1082

Patient Held Records

• Patient held records can enhance patients’ knowledge and sense of control

• Self monitoring of blood pressure, blood glucose, and oral anticoagulation

• Remote tele-monitoring, can be both effective and cost effective

• Open Notes

Open Notes Movement

• Initiative to give patients access to their medical providers’ notes via secure patient portals – Not a specific vendor product or software – Epic, Cerner, Allscripts, Meditech can support

implementation at this time – Currently implemented in 50+ organizations reaching

more than 10 million patients in 35 states – Same model in place at VA since 2010

Source: Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting Patients to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead. Ann Intern Med. 2012;157:461-470. doi:10.7326/0003-4819-157-7-201210020-00002

Open Notes Movement (Continued)

Study in 2010, trial of PCPs and patient volunteers over one year Patient results:

– 80% read a note initially, 50-60% long term – 75% reported benefits (replicated multiple times) in Engagement,

Adherence, Planning, Control, Understanding – 99% wanted to continue (replicated multiple times) – 85% would use OpenNotes as criterion for selecting providers

PCP results:

– Little impact on workflow, email volume unchanged – Worries about negative patient effects didn’t materialize – After study, no provider stopped – Providers do need to improve notes

Source: Delbanco T, Walker J, Bell SK, Darer JD, Elmore JG, Farag N, et al. Inviting Patients to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead. Ann Intern Med. 2012;157:461-470. doi:10.7326/0003-4819-157-7-201210020-00002

Benefits of Patient and Family Advisory Councils

For Health Care Organizations • Provide an effective mechanism for

receiving and responding to consumer input

• Result in more efficient planning to ensure that services really meet consumer needs and priorities

• Transform the culture toward patient-centered care

• Strengthen community relations • Recognize that collaboration leads

to better self-management of chronic conditions and improved adherence to medication regimens

For Patients and Families • Gain a better understanding of the

health care system • Appreciate being listened to and

having their opinions valued • Become advocates for the patient

and family-centered healthcare in their community

• Understand how to become an active participant in their own health care

• Provide an opportunity to learn new skills (facilitating groups, listening skills, telling their story)

Laurie West et. al Patient and Family Advisory Council Getting Started Tool Kit accessed at http://c.ymcdn.com/sites/www.theberylinstitute.org/resource/resmgr/webinar_pdf/pfac_toolkit_shared_version.pdf

HealthInsight Initiative: Development of Patient and Family Advisor Councils

• Patient and Family Advisory Council Development – St. Mark’s Hospital – Uintah Basin Medical Center/Hospital – Exodus Healthcare – Eastern Utah Women’s Health Clinic – Provo Care Center (nursing home) – University of Utah PA Program Satellite in St. George – Socorro General Hospital – Albuquerque – Gerald Champion Regional Medical Center – Alamogordo

• Five training modules over the next six months • Technical assistance from HealthInsight facilitators • Councils live by March 2017

Process Mapping Quality Improvement Initiative with Patients and Staff

Impact go-zone diagram: The green quadrant contains statements rated as having high impact by both patients and providers.

Lanoue M, Mills G, Cunningham A, Sharbaugh A. Concept mapping as a method to engage patients in clinical quality improvement. Ann Fam Med. 2016;14(4):370-376.

Patient Engagement with Chronic Disease

• Educational and self-help programs that are actively supported by clinicians improve health outcomes for patients chronic disease

• Chronic Disease Self-Management Program – Stanford Model, evidence-based – Self management focused – Six weeks of workshops, 2 ½ hours, led by trained

peer leaders who have chronic disease or diabetes

Outcomes

• 2009 randomized, controlled, trial, at six and 12 months after workshop completion – 345 participants with DM2 had significant

improvements in depression symptoms – Fewer symptoms of hypoglycemia – Better communication with physicians – Reported increased healthy eating, and reading food

labels – Increased patient activation and self-efficacy

Source: Lorig K, Ritter PL, Villa FJ, Armas J, Community-based peer-led diabetes self-management , a randomized trial. Diabetes Educator, 35(4):641-651, 2009.

Diabetes Prevention Plan (DPP) Prevention of Diabetes

• Diabetes Prevention Plan (DPP) will add to Medicare plan as of January 2017

• Core curriculum consisting of 16 sessions delivered by lifestyle coaches weekly – Sixteen sessions delivered approximately monthly that

promote healthy lifestyle changes and weight loss – Maintenance sessions following one year – Payment based on attendance and percent weight lost

• Extensive evidence to show better results than placebo, particularly in > 61 years old, reducing risk of DM 2 by (71%) across diverse patient groups

Source: https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp/Pages/default.aspx

Access to Classes in Utah

• Livingwell.utah.gov – Links to state classes available

• Contact HealthInsight if you want to train your staff to deliver chronic disease sessions on your setting – Uptake is higher with on site classes and provider

support of patient attendance throughout

Action!

• Re-look at the Inventory • What are you going to focus on today? • Listen for opportunities in all these areas to

augment of expand your capacity to thrive • Share with the person next to you one thing

you will focus on today

Questions

Thank You

Sarah Woolsey, M.D. HealthInsight Utah Medical Director

swoolsey@healthinsight.org 801-892-6622

This material was prepared by HealthInsight, the Medicare Quality Innovation Network -Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.11SOW-CORP-16-118-UT