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Semelhante a Session 4 - American Healthcare
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Session 4 - American Healthcare
- 1. June 2005 Gregg S. Meyer, MD, MSc Senior Vice President Edward P. Lawrence Center for Quality and Safety, MGH/MGPO gmeyer@partners.org The Evolution of Healthcare Quality and the Marketplace
- 2. Why Should You Care? • The federal health systems do not operate in a vacuum • Trends in civilian healthcare will have increasing impact on the MHS (including healthcare reform efforts) • Civilian healthcare will be the lens through which MHS care is viewed under the microscope of oversight • Federal health programs are seen as test beds and demonstration sites for innovations in care (IOM Report – Leadership by Example) • The MHS is no longer stand alone and requires increasing interaction, interoperability, and in some cases interdependence, with civilian healthcare programs • It is unlikely that you will be working in the MHS for your entire career • Transitioning leadership in the MHS arena to the civilian sector is a well worn path but it requires contextual awareness • You have some important advantages in terms of experience but you need to know them well
- 3. What type of evolutionary era are we in? • Gradualism versus punctuated equilibrium • Environmental assessment as the key to what we will look like • Technical Revolution and Cultural Revolution • Globalization of healthcare, ongoing global financial crisis and the elections of 2008 and 2010 are punctuators
- 4. IOM 2: Crossing the Quality Chasm “The Rest of the Iceberg” There are serious problems in quality Between the health care we have and the care we could have lies not just a gap but a chasm. The problems come from poor systems…not bad people In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves. We can fix it… but it will require changes
- 5. VARIATIONS ARE WIDESPREAD – Intensity of Care The Cost Conundrum What a Texas town can teach us about health care. Atul Gawande June 1, 2009
- 6. The Cost Landscape • Per capita health care costs have grown steadily for 40 years • Private insurance payers subsidize underpayments by Medicare, Medicaid and the uninsured • Chronic disease and technology are the primary drivers of cost • Proposals to extend health insurance coverage magnify cost pressures 0 500 1000 1500 2000 2500 3000 3500 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 PerCapitaNHEin$ Per Capita Growth In Health Expenditures Has Increased at 2.5% Above Inflation For 40 Years (adjusted for inflation)
- 7. Two Competing View of Healthcare Costs….. Both are correct* Medicare cost trends are unsustainably high and threaten to bankrupt the Federal Government (along with a few other things) Inadequate payment rates from government payers threaten the viability of hospitals, access of elderly patients to needed care and are driving unprecedented cost shifting to the private sector •BTW the healthcare sector is a driver of local economies
- 8. Two Views on Quality v. Cost Source: Baicker, K and Chandra, M : Medicare spending, the Physician Workforce and Beneficiary Quality of Care, Health Affairs, April 7, 2004
- 9. The Purchaser’s dilemma • The cost of health benefits for employees > the cost of steel in American cars for 2 decades • Starbucks spends more on health insurance for employees than on coffee for 4 years • We are not immune! • Partners Healthcare pays nearly $700 million for healthcare for our employees • Most large health care providers are trying payment/delivery innovations with their own employees • For other inputs purchasers are used to getting more when they pay more (value added) • Not transparent in healthcare • BUT, Levers for demanding “added value” have not existed • Purchasers (including CMS) are asking and now demanding payers to develop such levers • Citing healthcare as a driver of global non-competitiveness Optimal Quality Effective and Efficient Utilization Value Added
- 10. One Model of the Evolution of Healthcare The Long View Performance comparisons for hospitals, MDs & Tx Market sensitivity to hospital/MD quality & TCO Clinical re- engineering by MDs, hospitals & suppliers Q 50 ppts $ 40 ppts Value of Health Benefits Key Evolutionary Steps High Low 2002 2012 Performance Disclosure Consumerism & P4P Chasm Crossing Q = compliance with guidelines $ = annual health benefits cost Reproduced with permission of Arnold Milstein, MD (Mercer)
- 11. The “5 Stages” of Getting Involved in Quality Measurement • Denial • Anger • Bargaining • Depression • Acceptance • We need help getting through the stages
- 12. • 7 HealthGrades awards • Ranked as the 9th best hospital in Boston • One of the lowest rated hospitals in Boston Massachusetts General Hospital • Ranked #2 in the nation overall • Only other Massachusetts Hospital in the top 10 is our partners institution, the Brigham and Women’s Hospital. • “There are wide disparities in hospital payments but no real difference in cost.” Clear Information for Decisionmaking?
- 13. Being Careful About What You Measure (and wish for) Quality Measurement in Aortic Valvuloplasty • To palliate congenital aortic stenosis, the valve is dilated with a balloon • Therapeutic success is achieved by maximizing the amount of dilation/gradient relief -- use a bigger balloon • Safety is achieved by avoiding rupture/damage to the valve -- use a smaller balloon • Do not measure quality of aortic valvuloplasty purely by procedural morbidity/mortality, need a measure of efficacy and long term benefit as well, otherwise the incentive is purely to use a smaller balloon Lee TH. Torchiana DF. Lock JE. Is zero the ideal death rate?. New England Journal of Medicine. 357(2):111-3, 2007 Jul 12.
- 14. Consumer effects of public reporting • Is information available at the right time? • Is information readily understandable? • Is information presented in a manner which is statistically appropriate? Kaiser Family Foundatin, 2008 Public reporting of quality alone may not do it and now cost reporting ($, $$, $$$, $$$$) is getting greater attention…
- 15. The new face of transparency
- 16. Adjusted in-hospital mortality rates by center 1987-2000 N=37,599 0 1 2 3 4 5 6 7 8 1988 1990 1992 1994 1996 1998 MortalityRate(%) 2000 Year The Realities of Reporting
- 17. UsesofQuality Measurement Results (Performance) Goals Purpose Improvement Motivation Consumers Purchasers Regulators Patients Contractors Referring Clinicians Etc. Knowledge About Performance Measurement for Selection & Accountability Selection Knowledge About Processes and Results • Process Improvement • New Design • Process Control Care Deliver Teams and Practitioners Change Organizations THE NEW YORK STATE EXPERIENCE MOTIVATION
- 18. The Long View Performance comparison s for hospitals, MDs & Tx Market sensitivity to hospital/MD quality & TCO Clinical re- engineering by MDs, hospitals & suppliers Q 50 ppts $ 40 ppts Value of Health Benefits Key Evolutionary Steps High Low 2002 2012 Performance Disclosure P4P & Consumerism Chasm Crossing Q = compliance with guidelines $ = annual health benefits cost Reproduced with permission of Arnold Milstein, MD (Mercer)
- 19. Why Payment for Performance Is So Important • There is a “quality chasm” between what is and what ought to be in healthcare • We have programs that we know work to improve quality • Patients have improved outcomes and quality of life (win) • The savings accrue to the payers (win) • The costs of the program are borne by the providers (lose) • Payment for performance could make it a win – win – win • This is a key additional motivator for improvement • CMS sees this as its key tactic (becoming a “value based purchaser”) • Payment for reporting • Payment for performance (or withholding payment updates – e.g. SREs and readmission rates)
- 20. What is Payment for Performance? Payment for Performance = Concrete financial incentives (either “bonuses” or “return of withholds”) for meeting negotiated targets on quality and efficiency Goals include: 1. Efficiency (managing utilization and costs) • Inpatient days or admissions or readmissions • High cost imaging utilization • Pharmacy costs • Emergency Room utilization • Management of High Risk Patients 2. Quality (improving patient safety and quality care) • Pediatric asthmatic use of controller medications • Adult diabetes population HbA1c testing and control • Chlamydia testing in young adult women • Cardiac Care • Reporting of healthcare acquired infections 3. Infrastructure • Electronic Medical Record (EMR) implementation by PCPs and Specialists (accelerated by HITECH and ARRA) • Computerized Physician Order Entry (CPOE) implementation • Safety system implementation
- 21. No decision is a decision: Impact of pay for value programs: once fully implemented (FY ’17) for one unnamed New England Hospital CMS Program Start Year Payment mechanism Annual risk* $M Cum risk thru FY 17 $M Inpatient Quality Reporting 2010 MB penalty for failure to report $9 M $63 M Value Based Purchasing 2013 MB reduction with option to earn back based on performance $4 M $15 M Hospital Acquired Conditions 2015 MB penalty for bottom quartile performance $3 M $9 M Reducing Readmissions 2013 MB penalty for performance (stratified) $9 M $34 M Meaningful Use 2015 MB penalty if failure to meet MU requirements $6 M $24 M Total Financial Risk $31 M $145 M * Annual risk when fully implemented CMS Is Getting Serious
- 22. P4P for Patients: Minnesota Experiment With Tiering
- 23. Tiered Co-Pays as a Lever
- 24. Turning Up the Heat: Selective Contracting Example: Aetna Aexcel “If a doctor has opened with a bronze lancet an abscess of the eye of a gentleman and has cured the eye, he shall take ten shekels of silver” “If a doctor has opened with a bronze lancet an abscess of the eye of a gentleman and has caused the loss of the eye, the doctor’s hands shall be cut off” Projected savings vary from 1.6 % to 4.5% depending on the region, specialties involved and other factors. This product has grown rapidly
- 25. The Long View Performance comparison s for hospitals, MDs & Tx Market sensitivity to hospital/MD quality & TCO Clinical re- engineering by MDs, hospitals & suppliers Q 50 ppts $ 40 ppts Value of Health Benefits Key Evolutionary Steps High Low 2002 2012 Performance Disclosure P4P & Consumerism Chasm Crossing Q = compliance with guidelines $ = annual health benefits cost Reproduced with permission of Arnold Milstein, MD (Mercer)
- 26. THE HEALTH CARE & EDUCATION AFFORDABILITY RECONCILIATION ACT of 2010 •Coverage • Payment • Delivery (including I. T.) • Financing Health Reform 1.0 v. v.
- 28. There is a lot about quality in Health Reform 1.0* IMPLEMENTATION TIMELINE • 2010 • Improving Consumer Information through the Web. • Strengthening the Quality Infrastructure. • Establishing a Patient Centered Outcomes Research Institute. • 2011 • Improving Health Care Quality and Efficiency. • 2012 • Encouraging Integrated Health Systems. • Linking Payment to Quality Outcomes. • Reducing Avoidable Hospital Readmissions. • 2013 • Fee for patient centered outcomes research. • 2014 • Quality Reporting for Certain Providers. • 2015 • Paying Physicians Based on Value Not Volume. *that does not depend upon the individual mandate or the Supreme Court
- 29. Payment Reform In the States (the rest of the story) • Bundled payment pilots • National pilots/demonstrations in key areas such as CHF, arthroplasty, pneumonia • Capitation/global payment • Massachusetts Payment Reform Commission • BCBS Alternative Quality Contract (AQC) • ? All payer rate setting • No payment for excess readmissions • Medicare: starting with 30-day readmissions for heart attack, heart failure and pneumonia • Accountable care organizations/medical home/CMS demonstrations with shared savings • 31 Pioneer ACOs launched on 1 January 2012
- 30. The Myth of a “Right” Way to Pay for Healthcare Type of Care Example Goals of a payment method Possible optimal method Simple self limiting disease Recurrent UTI in sexually active woman > 18 1.Rationalization of utilization 2.Ease of access Fee for service with self pay (Retail Health) Minor trauma Fractured forearm 1.Rationalization of utilization 2.Ease of access Fee for service with co- pay Stable chronic disease Congestive heart failure 1.Rationalization of utilization 2.Reduction of hospitalization 3.Investment in infrastructure Capitation Major single illness Breast cancer 1.Coordination of multiple providers within a team 2.Investment in infrastructure including staff Episode of care Emergency, major trauma Motor vehicle accident 1.Universal access 2.Maintenance of surge capacity Public Utility Key Capability: Provide high quality patient centered care efficiently (i.e. High Value)
- 32. Provide high quality patient centered care efficiently Goals • Demonstrably higher quality • Decreased unit cost • Savings to purchasers Approach • Improve quality (patient outcomes) • Reduce unit costs • Redesign care (fewer units/patient) • Improve access (more patients) Episodes of Illness Inpatient and Outpatient Encounters Inpatient and Outpatient Encounters Episodes of Illness Population Management Population Management Imperative* * This is what you do!
- 33. Key Capabilities Required to Provide High Value Longitudinal Care Episodic Care Primary Care Specialty Care Hospital Care Access to care Patient portal/physician portal Hospital Access Center Extended hours/same day appointments Reduced low acuity admissionsExpand virtual visit options Design of care Defined process standards in priority conditions (multidisciplinary teams) High risk care management Shared decision making Re-admissions Hospital Acquired Conditions 100% preventive services Appropriateness Hand-off standards Continuity visit EHR with decision support and order entry Incentive programs Measurement Variance reporting/performance dashboards Quality metrics: clinical outcomes, satisfaction Costs/population Costs/episode
- 34. Process for Defining Episode Process Standards Themes in Care Redesign Recommendations • Implement scheduling and navigation functions • Reduce unwarranted variation in resource use • Ensure reliable implementation of planned processes • Develop capacity to monitor patients prospectively, longitudinally Document current state process map Identify opportunities for improvement Activities Hand-Offs/ transitions Phases of care Timing Assess implications Quality improvement Cost savings 1 2 3 Population mix Quality Cost (internal and market) Define recommended care innovations System-level recommendations Implementation options Performance metrics to monitor implementation
- 35. 36 36 36 Distribution of Diabetes Costs IP Stay ED Visits Ambulatory Care (Hospital) Prof services OP Other Pharmacy Based on Actual Payments for One Insurer, N = 3,824 bundles PACs Top Potential Avoidable Complications (PACs) • Diabetic emergency, hypo-hyper glycemia • Preventative, rehab, and after care • Skin and wound care • CHF, carditis, cardiomyopathy • Cardiac dysrhthmias • Labs • Diagnostic radiology • Colonoscopy and biopsy • Diagnostic cath • Radioisotope scan • Anesthesia • Lens and cataract procs • MRI • Decompression peripheral nerve • Debridement of wound • Excision of skin lesions Hospital-billed dollars • DME//supplies • Labs • Transportation • Home health • Medications (injections, infs, etc.) Diabetes Episode Timeframe • 365 days from the date of service of visit with a Diabetes diagnosis • Coronary atherosclerosis • Complications of medical care Overall PACs rate for Diabetes is 27% with PACs distributed across these groupings of care • Consultation • Labs • Ophthalmologic and Otologic diag and treatment • Electrocardiogram • Excision of skin lesions • Destruction of lesion of retina and choroid • MRI
- 36. Key Capabilities Required to Provide High Value Longitudinal Care Episodic Care Primary Care Specialty Care Hospital Care Access to care Patient portal/physician portal Hospital Access Center Extended hours/same day appointments Reduced low acuity admissionsExpand virtual visit options Design of care Defined process standards in priority conditions (multidisciplinary teams) High risk care management Shared decision making Re-admissions Hospital Acquired Conditions 100% preventive services Appropriateness Hand-off standards Continuity visit EHR with decision support and order entry Incentive programs Measurement Variance reporting/performance dashboards Quality metrics: clinical outcomes, satisfaction Costs/population Costs/episode
- 37. MGH Medicare Demo Opportunity • 10% of Medicare patients account for nearly 70% of spending • 20% of Medicare patients have 5 or more chronic conditions • Congestive heart failure • Chronic pulmonary disease • Coronary disease • Diabetes • Depression MGH Demo • Medicare selected MGH to participate in a 3-year demonstration focusing on high- cost beneficiaries in 2006 • Success validated in 2010 • Contract renewed (3 more years) • Expanded to new sites • Brigham and Women’s Hospital • North Shore Medical Center
- 38. MGH Medicare Demo Results from Independent Evaluator (RTI) Successful Enrollment • 87% of eligible beneficiaries enrolled Successful Targeting of Interventions • Interventions focused on the enrolled patients with the greatest opportunity Successful Communication • Improved communication between patients and health care team • High patient and physician satisfaction Successful Outcomes • Hospitalization rate among enrolled patients was 20% lower than comparison* • ED visit rates were 25% lower for enrolled patients* • Annual mortality 16% among enrolled and 20% among comparison Successful Savings • 7.1% annual net savings (12.1% gross) for enrolled patients • Approximately 4% annual savings for total population • For every $1 spent, the program saved at least $2.65 *Based on difference in differences analysis
- 39. Key Capabilities Required to Provide High Value Longitudinal Care Episodic Care Primary Care Specialty Care Hospital Care Access to care Patient portal/physician portal Hospital Access Center Extended hours/same day appointments Reduced low acuity admissionsExpand virtual visit options Design of care Defined process standards in priority conditions (multidisciplinary teams) High risk care management Shared decision making Re-admissions Hospital Acquired Conditions 100% preventive services Appropriateness Hand-off standards Continuity visit EHR with decision support and order entry Incentive programs Measurement Variance reporting/performance dashboards Quality metrics: clinical outcomes, satisfaction Costs/population Costs/episode
- 40. Consumerism - Shared Decision Making • Concept developed by MGH and Dartmouth physicians in 1990s • • Research suggests that Shared Decision Making (SDM) results in a 20% decrease in the use of elective services • Partners disseminates access to SDM videos to all physicians and patients • Physicians send SDM videos to patients with a single click of an icon in EHR • In 2008, more than 2,200 SDM videos were ordered for Mass General adult primary care patients
- 41. Prostate cancer care pathway Proton beam Cross- over therapies + Biopsy Interventional Radiologist Urologist Hormone Brachy Surgery PSA test IMRT Digital rectal exam Watch and wait Symptoms Current patient experience: PCP Med. - Oncologist Rad. - Oncologist Urologist PCP Clinician: 3 5 Phase of care Diagnosis Treatment Analysis of practice variation 6 Feedback to PCP’s Input to Multi-disciplinary process or overall guidelines Discussion of therapies 4 2 1 PSA pre- screening education Pre-biopsy education Informed decision – making with better aids Multi- disciplinary input Standardized informed consent * Possible Intervention Points
- 42. The New “Good Doctor” • “ In the past, a stereotypical good doctor was independent and always available, had encyclopedic knowledge, and was a master of rescue care. Today, a good doctor must have a solid fund of knowledge and sound decision-making skills but also must be emotionally intelligent, a team player, able to obtain information from colleagues and technological sources, embrace quality improvement as well as public reporting, and reliably deliver evidence-based care, using scientifically informed guidelines in a personal, compassionate, patient-centered manner.”
- 43. Conclusions • Quality reporting to date has had modest effects on selection, but clearly focuses attention and fosters improvement • Focus on reporting has shifted from quality to value • Payment for performance had transformed into value-based purchasing but taking on greater financial risk is likely to emerge as dominant mode of market reform • Increased out of pocket costs with tiering • Selective contracting • Shared savings plans • Re-emergence of forms of capitation • Health reform (national, state, and local) will be seen as a value re-engineering opportunity • Providing high quality patient centered care efficiently (i.e. High Value) will be the key differentiator of successful healthcare organizations in the civilian marketplace • Focusing on key capabilities (health IT implementation, care redesign, high risk patient management, shared decision-making, etc) and shifting from an individual to a population based focus are the imperatives in the civilian marketplace • Some of these have been a longstanding focus in the MHS • We are likely to experience a continuing period of punctuated equilibrium in the evolution of the healthcare marketplace in the next few years – can further incremental healthcare reform (focused on payment, delivery and financing) continue to wait?