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The Importance of Quality Measurement in a Bundled Payment Environment
Woody Eisenberg, MD
Senior Vice President, PQA
BUNDLED PAYMENTS FOR CARE IMPROVEMENT INITIATIVES
Model 1 Model 2 Model 3 Model 4
Episode All acute patients, all
DRGsSelected DRGs, hospital plus post-
acute period
Selected DRGs, post-acute period only
Selected DRGs, hospital plus readmissions
Services included in the bundle
All Part A services paid as part of the MS-DRG payment
All non-hospice Part A and B services during the initial inpatient stay, post-acute period and readmissions
All non-hospice Part A and B servicesduring the post-
acute period and readmissions
All Part non-
hospice A and B services (including the hospital and physician) during initial inpatient stay and readmissions
Payment Retrospective Retrospective Retrospective Prospective
Quality Measures
? ? ? ?
Implementing Quality Measurement
The bundled care approaches to improving value do not currently work by providing payments based on assessed value using performance measurements.
Bundled payment methods require robust quality measurement both to guard against potential adverse effects of bundled payment, such as stinting on care or avoiding sicker patients, and to provide tools for quality improvement and pay-for-performance.7
Medicare’s Payment Strategy For ESRD
Embraces Bundled Payment and
P4P To Cut Costs
Date Payment Initiative Result
1972 Medicare institutes FFS coverage for dialysis, drugs, labs, ancillary services
Volume, intensity and cost of services spiral spectacularly over 2 decades
1983 -
1989
Composite rate services: nursing, dietary, clinical, equipment and supplies, social services, and certain laboratory tests and drugs
Continued increases in costs
1991 FFS extended to erythropoietins Use increases dramatically $3.1B in 2007
2007 FDA issues warning regarding health risks for use of erythropoietins
Use declines 2009-2011
2011 Composite rate services�•
Separately billable (Part B) injectables•
ESRD-related laboratory tests�•
Selected ESRD Part D drugs�(erythropoietins)•
Self-dialysis
training
services
2012 bundled payment rate reduced by up to 2 percent for facilities that do not achieve or make progress toward specified quality
measures.
Performance Measures in the Final ESRD Pay-for-Performance rule
Percentage of Medicare patients with: average hemoglobin levels of less than 10 grams per deciliter;
average hemoglobin levels of greater than 12 grams per deciliter;
and average post-dialysis urea reduction ratios of greater than 65 percent.
Result: most dialysis units today meet these quality measures and the use of erythropoietin has declined
Challenges to the Successful Diffusion of the ACO Model and Approaches to Overcoming Them (Fisher, NEJM 2011)
Challenge ApproachProviding timely and useful data
Payers provide ACOs with patient-level data to support care management.Quality measures used for accountability are also useful for care improvement.
Overcoming transition costs
Use quality-related payments to support needed ACO investments.Provide up-front funding options for provider groups that need them.
Gaining consumer support
Adopt performance measures that are more meaningful to consumers.Support consumer choice and allow consumers to share savings as well.
Learning what works; using that knowledgeto inform policy and practice
Develop and test multipayer or all-payer ACOs where possible.Track and evaluate both public and private ACO implementation.
Clarifying the path forward
Create meaningful alternatives to FFSMeasure effect on overall quality and cost in all payment reforms
NQF Evaluation Criteria
•Importance•
High impact•
Opportunity for improvement / gap in care•
Evidence to support measure focus•Scientific Acceptability
•
Reliability•
Validity•Usability
•
Meaningful and understandable•
Public reporting/quality improvement•Feasibility
•
Data are available and retrievable without undue burden•
Unintended consequences•Related or competing measures
•
Harmonization
How do you build quality measures?
Measure Set for evolving models of care
Complimentary Medication Use Measures
Three condition-level framework questions for measure development
1.
Is the condition chronic in nature, or is it an acute hospital-based condition?
2.
Are there medical care quality measures relating to this condition that are likely to be impacted by pharmaceutical use, and are these quality measures being mandated by payers?
3.
How large a role do pharmaceuticals play in the cost of treating
the condition? What is their share of the overall costs, and to what
extent are medical cost offsets possible from appropriate pharmaceutical use?
Two Chronic Condition Examples
Condition Conditi
on Type
Rx Focus Rx Impact on Quality?
Quality measure in CMS bundle?
Rx Share of cost?
Cost offset from Rxs?
Heart failure
Chronic
, Hospital
Outpatient Receiving B-blocker Rx; % of patients requiring re-hosp
Yes; Rx written
Low Impact re-
hospitaliz
ation
Rheuma-
toid
Arthritis
Chronic Outpatient Receiving Rx; Functional Status
No High Unknown
•Most bundled care products involve medications for chronic conditions•Assessment of medication effectiveness and efficiency is key
Pharmacists are the key professionals for:•Performing comprehensive therapy reviews of prescribed and
self-care medications•Resolving medication-related problems•optimizing complex regimens•Monitoring adherence•recommending cost-effective therapies•Fulfilling medication use performance measures
1. Smith, et. al. HEALTH AFFAIRS 29, NO. 5 (2010): 906–913
Why Pharmacists Should be included in bundled care quality measurement
PROMETHEUS*: a performance-based bundled payment programs
Assigns evidence-based case reimbursement rates (ECRs) to common conditions
A single ECR covers all inpatient and outpatient care associated
with a given condition
A quality score ties outcomes, treatment complications, and patient satisfaction to bundled reimbursement
-
ensures that providers are held financially accountable for inappropriate care and patient dissatisfaction
-
results may be reported back to providers for use in quality improvement and may be used to add performance-based bonuses or penalties to the bundled payment amounts.
-
incentives can account for as much as 10% to 20% of the total bundled payment -
publicly reported provider rankings based on quality and patient
satisfaction scores
*Provider payment Reform for Outcomes Margins Evidence Transparency Hassle-reduction Excellence Understandability and Sustainability
Challenges Implementing the PROMETHEUS Bundle Model
Implementation Challenge
Pilot Site Experience
Defining Bundles ECR defined based on own experienceDefining payment model “Chicken (care re-engineer and quality measures) or
egg (payment)”
first?Implementing Quality Measurement
EHR crucial, but implementation of electronic measures is time and resource intensive
Determining Accountability How to determine accountability and payment; leakage of patients beyond their system
Engaging Providers Frontline Physicians still skepticalDelivery Redesign Where do bundles fit in with FFS, ACOs, PCMH?
Geisinger’s
ProvenCare�
Physicians agree to follow 40 preoperative, perioperative, and postoperative treatment guidelines in exchange for a flat rate of reimbursement
Quality Improvement Indicators (as opposed to Performance Measures) monitor guideline adherence-
Process measures-
Internal quality improvement indicators for rapid cycle improvement-
Not publicly reported
Performance Measure tied to reimbursement
ProvenCare
Components
Patient-centricity
Appropriate care
Evidence/consensus-based best practices
Highly reliable care
Optimized work flows
Explicit accountabilities
Packaged pricing
Performance-based reimbursement
"Warranty” (patient satisfaction)
Proven Care Benchmarks (selected benchmarks for CV surgery)
Preadmission documentation
Operative documentation
Post-Operative patient documentation
Discharge documentation-
Discharge medications (e.g., beta-blocker)-
Discharge medication: aspirin-
Discharge medication: statin
Post-Discharge documentation-
Patient correctly taking beta-blocker?-
Patient correctly taking aspirin?-
Patient correctly taking statin?-
Patient correctly administering anticoagulant?
•
With the rapidly changing health care environment, payers and policy makers are increasingly interested in payment models that reward
quality and patient safety
•
In order to achieve quality and cost goals, accountable systems of care need to consider medication management and might formally include Pharmacists on the care team
•
Pharmacists will need to demonstrate the value they add to accountable care systems
•
A core set of pharmacy quality measures can be built to compliment existing clinical quality measures, with an eye toward expanding
this as gaps are identified
Conclusions
BUNDLED PAYMENTS FOR CARE IMPROVEMENT INITIATIVE
Model
1 Model
2 Model
3 Model
4
Episode All acute patients, all
DRGsSelected DRGs, hospital plus post-
acute period
Selected DRGs, post-acute period only
Selected DRGs, hospital plus readmissions
Services included in the bundle
All Part A services paid as part of the MS-DRG payment
All non-hospice Part A and B services during the initial inpatient stay, post-acute period and readmissions
All non-hospice Part A and B servicesduring the post-
acute period and readmissions
All Part non-
hospice A and B services (including the hospital and physician) during initial inpatient stay and readmissions
Payment Retrospective Retrospective Retrospective Prospective
Quality Measures
TBD TBD TBD TBD
