connecting the dots: macra and payment reform – the...

ConnectingtheDots:MACRAandPaymentReform–TheImpactonPediatricPractices

ColoradoChildren’sHealthcareAccessNovember15,2016

PamelaBallou-Nelson,RN,MSPH,PhD,PCMHCCESeniorConsultant

MGMAHealthCareConsultingGroup630.294.1072cell

877.275.6462,[email protected]

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Objectives• MACRA’simpactonvalue-basedpaymentreform• Alternativepaymentmodelsforpediatricoutpatientpractices• DefinehowpediatricssetsthetoneforPopulationHealthManagement• Howtoprepareyourpracticeforalternative-basedmodelsofpayment• Identifyruralhealthchallengesandvalue-basedpayments• Collectingthedata

Copyright 2016. Medical Group Management Association® (MGMA®) . All rights reserved..

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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.

Copyright 2016. Medical Group Management Association® (MGMA®) . All rights reserved.

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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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,[email protected] 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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DiscussionQuestions


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