march 10, 2011. need to bend the cost curve increased attention to quality metrics reimbursement...
TRANSCRIPT
![Page 1: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/1.jpg)
Payers and Providers Collaborate for Success
In Age of Reform
March 10, 2011
![Page 2: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/2.jpg)
Need to bend the cost curve
Increased attention to quality metrics
Reimbursement models that incent patients and providers to move toward both lower cost and higher quality
The New Realty
![Page 3: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/3.jpg)
Reduced payment per service, reduced trend/annual rate increases
More efficient use of medically necessary services
Elimination of unnecessary services Fewer complications/higher cost services
due to improved quality and more coordinated care
Cost Curve – How do you Bend It?
![Page 4: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/4.jpg)
Shared savings Resources/support to initiate and maintain
Investment in the tools to accomplish Ongoing monitoring and sharing of data
Added value to provider, payer and employer/patient
Achievable? With Collaboration
![Page 5: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/5.jpg)
Payers -◦ Achieve a savings they can pass on to their
customers, investors, providers◦ Hit metrics they can market – utilization, quality,
and cost metrics Providers -
◦ Deliver the tools to better manage utilization◦ Demonstrate willingness to invest in changes that
will ultimately result in savings◦ Share in savings
Key Players – How to Engage?
![Page 6: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/6.jpg)
Win-Win Structures◦ Agreement on Goals that Benefit All
Lower cost BEFORE lower reimbursement Improve quality BEFORE increasing reimbursement Common set of metrics and attainable goals Data everyone can trust/rely on Meaningful shared savings – dollars significant
enough to generate/maintain interest
Coming Together – How?
![Page 7: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/7.jpg)
Pay for Performance/Gainsharing
Enhanced, data driven, primary care initiatives
Global risk, bundled payments and other alternative financial arrangements
Options for Collaboration
![Page 8: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/8.jpg)
Pay for Performance/Gainsharing Why?
Simple Method to Align and Achieve Physician and Hospital (and Payer) Goals
Engages physicians, payments to docs within the year, collaboration/improvements begin immediately
Not complicated - data is readily available & accepted as valid
Flexible - adapt to special needs of hospital
Perfect tool for any start up ACO and other “risk” entities
8
![Page 9: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/9.jpg)
Many efforts underway aimed at efficiency and quality improvements - BUT◦ Getting the attention and involvement needed from
physicians?◦ Physicians have a true understanding of their role in
achieving the goals – how to hit the benchmarks?◦ Providers getting the right kind of data, on a regular
basis, that give direction on behavior changes?
Usually Not…..
Pay for Performance/Gainsharing
![Page 10: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/10.jpg)
‣ 2006 Managed Care, 2008 Medicare demo‣ Designed to compensate Physicians who improve
quality and implement more efficient inpatient practice patterns
‣ Savings shared with physicians who move toward or hit benchmarks
‣ Upside bonus only, based on individual performance
‣ No change in current billing process or payment (and loss of income factor included in bonus)
Continuum Health PartnersPay for Performance Overview
![Page 11: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/11.jpg)
CHP Pay for Performance
Basic Framework
All cases severity adjusted to 4 levels using APR-DRGs to account for ‘sicker’ patients.
Benchmarks established using CHP actual experience – average cost of the top 25th percentile (lowest cost) performers.
Monies to pay bonus come from hospital savings generated by improvements in efficiency. No savings - no bonuses paid out.
Payments withheld from physicians who do not meet quality standards (Core Measures, Infection indicators, Readmission rates, medical record completion, patient complaints etc)
![Page 12: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/12.jpg)
12
![Page 13: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/13.jpg)
![Page 14: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/14.jpg)
Preliminary Results – Significant cost reductions and improved quality
Shrinking gap between bottom 75th percentile and top 25th percentile
Greater understanding of data and interest in clinical guidelines – moving toward standardization of care
Incentives more closely aligned
Successful Partnership Achieved
![Page 15: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/15.jpg)
AMI HF PN SCIP0
10
20
30
40
50
60
70
80
90
100
BIMC CORE MEASURE COMPLIANCE GRAPH 2006 - Present
2006 2007 2008 2009 1st half 2010
Core Measure Trends
![Page 16: March 10, 2011. Need to bend the cost curve Increased attention to quality metrics Reimbursement models that incent patients and providers to move](https://reader038.vdocuments.mx/reader038/viewer/2022110322/56649d0d5503460f949e1b4f/html5/thumbnails/16.jpg)
Enhanced, comprehensive data distribution among providers
Primary care/patient focused medical home Stratification of high risk patients with
directed case management Medical benefit redesign to incent greater
compliance Directing patients toward provider networks
sharing data/managing patients
Additional Initiatives