Des Moines University Health Care Delivery PDF

A Distinctive System of Health Care Delivery III Presenter: Joshua Pearson, EdD, MHA, CPHQ, CHFP Lecture overview Shift from volume to value-based care Volume to value transformation Quintuple Aim and the Risk Enterprise Increased focus on cost containment/risk sharing...

A Distinctive System of Health Care Delivery III Presenter: Joshua Pearson, EdD, MHA, CPHQ, CHFP Lecture overview Shift from volume to value-based care Volume to value transformation Quintuple Aim and the Risk Enterprise Increased focus on cost containment/risk sharing Resistance to change and reform: Underlying causes Looking ahead: What will the future look like? CMS Innovation Center Strategic Objectives 2 Learning outcome covered in this lecture Recognize the key forces that are likely to shape the future of health care delivery in the 21st century and why the system has been resistant to reform 3 Shift from Volume to Value-Based Care 4 Cost containment challenges in the U.S. Annual per capita health expenditures in the United States far exceed other countries, with costs growing between 4.2% and 5.8% annually. From a cost containment perspective, private insurers have mechanisms in place to control spending. Federal and state governments have limited abilities to control spending. This greatly differs from other international health systems – which leverage strategies like universal fee schedules, global budgets and resource rationing. Commonwealth Fund (2020). How are costs contained? https://www.commonwealthfund.org/international-health-policy-center/system-features/how-are-costs-contained 5 Shift from fee-for-service (FFS) to value-based care To address rising costs and suboptimal health outcomes, we’ve seen a growth in value-based care models in recent years. Models typically focus on moving away from FFS towards a more cost-controlled and effective system of reimbursement: Capitated per-member-per-month (PMPM) models with fixed reimbursement per beneficiary Alternative payment models (APMs) focused on aligning reimbursement with outcomes Shared savings arrangements where accountable care organizations (ACOs) can “share” in savings with the government when certain standards are met, generally focused on reducing costs while improving outcomes 6  Quintuple Aim – guiding health care transformation Risk Categories Strategic Improving Health population Equity Operational health Quality and Human Workforce Enhancing process Capital the care well-being experience improvement Technology Reducing costs Financial Nundy, S., Cooper, L. A., & Mate, K. S. (2022). The quintuple aim for health care improvement: A new imperative to advance health equity. JAMA, 327(6), 521-522. https://doi.org/10.1001/jama.2021.25181 7 Mental model transition from volume to value Volume Value Patient satisfaction Persons as partners in their care Increase top-line revenue Decrease per unit cost and waste Complex all-purpose hospitals and Lower cost, focused care delivery sites facilities Quality departments and experts Quality improvement in daily work for all Swensen, S., Pugh, M., McMullan, C., & Kabcenell, A. (2013). High-impact leadership: Improve care, improve the health of populations, and reduce costs. http://www.ihi.org/resources/Pages/IHIWhitePapers/HighImpactLeadership.aspx 8 The “why” - value-based care benefits NEJM Catalyst (2017). What is value-based healthcare? https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0558 9 Looking ahead: Continued growth of risk enterprise In addition to shifting away from fee-for-service care – many payers are now embracing shared risk models, where providers/organizations are subject to both upside and downside risk. These new models ensure providers have “skin in the game” – strong performance nets incentives, while poor performance can result in penalties. “For these reasons, hospitals and other healthcare systems are expanding their risk management programs from ones that are primarily reactive and promote patient safety and prevent legal exposure, to ones that are increasingly proactive and view risk through a much broader lens of the entire ecosystem.” - New England Journal of Medicine, 2018 New England Journal of Medicine (2018). What is risk management in healthcare? https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0197 10 Resistance to change and reform: Underlying causes 11 Underlying factors for resistance to change Even though we’ve witnessed great strides towards improving our healthcare delivery system, resistance to change has resulted from a variety of underlying causes. While it is not possible to highlight all of these underlying issues, a few prominent challenges exist which result in resistance: Health reform tends to “nudge” for change rather than require it Misalignment in payer models creates administrative hurdles Reimbursement barriers for innovative models of care Logistical issues due to complex nature of system 12 Using “nudges” for reform Challenges: “Nudges” tend to result in suboptimal outcomes – early adopters are willing to change, whereas the late majority/laggards may resist. Physicians/providers are oftentimes not included in decision-making for clinical changes – requirements are passed down from payers without provider involvement. There is a need for balance between evidence-based medicine and provider autonomy. 13 Misalignment of various value-based care models Challenges: Requirements for value-based care contracts can vary by payer. This means managing many different contracts with differing payment methodologies. There is great administrative burden in reporting quality measures/outcomes for many different value-based care arrangements. Models are constantly evolving and changing over time – moving targets for success. 14 Reimbursement barriers for innovative care models Challenges: Insurance plans are at different stages of value-based care – some payers are still locked into fee-for- service contracts dependent on traditional provider-led visits. Lack of reimbursement consistency for innovations like care coordination and community health workers. For value-based care model incentives – oftentimes these are paid out on the backend, thus requiring significant upfront investment for an opportunity (not guarantee) to receive incentives. 15 Logistical issues resulting from system complexity Challenges: There are many stakeholders with a financial interest in the system. Incremental changes can result in drastic effects on stakeholders. Health care is a very politicized issue due to its representation as the largest sector of the U.S. economy. Meaningful change requires coordination of many systems within the larger healthcare environment – disagreements about issues such as role of government. Harvard T.H. Chan School of Public Health (2013). What’s so hard about health care reform? https://www.hsph.harvard.edu/news/magazine/centennial-health-care-reform-hard/ 16 Looking Ahead: What will the future look like? 17 What are the priorities for future years? Healthcare reform can be unpredictable due to the overly complex nature of our system and the many interacting parts. One of the best resources we can look to for a general idea of what to expect would be guidance released by the Centers for Medicare and Medicaid Services (CMS). In late 2021, the CMS Innovation Center released a refresh on its Innovation Center Strategies white paper, which highlighted five key strategic objectives for future system transformation… 18 CMS Innovation Center Strategic Objectives Centers for Medicare and Medicaid Services (2021). Innovation Center strategy refresh. https://innovation.cms.gov/strategic-direction-whitepaper 19 SO #1: Drive Accountable Care What we can expect: Aim: Heightened push for participation in Increase the number of people in a care relationship accountable care models. with accountability for quality and total cost of care. Continued evolution of payment models to support accountable care Measuring Progress: (e.g. shared risk arrangements, All Part A and B beneficiaries will be in a care capitated payment models, advanced relationship with accountability for quality and total payment models). cost of care by 2030. Further system redesign to encourage The vast majority of Medicaid beneficiaries will be in and support ACOs in providing high- a care relationship with accountability for quality and cost patients and episodic care. total cost of care by 2030. Centers for Medicare and Medicaid Services (2021). Innovation Center strategy refresh. https://innovation.cms.gov/strategic-direction-whitepaper 20 SO #2: Advance Health Equity What we can expect: Aim: Healthcare organizations will need to Embed health equity in every aspect of CMS develop comprehensive health equity Innovation Center models and increase focus on plans. underserved populations. Social determinants of health will be established as a core function of treatment. Measuring Progress: All new models will require participants to collect Further advancements in reimbursement and report the demographic data of their reform to better support care models beneficiaries and, as appropriate, data on social addressing SDOH. needs and social determinants of health. Value-based care arrangements will All new models will include patients from historically include health equity in quality strategies. underserved populations and safety net providers. Centers for Medicare and Medicaid Services (2021). Innovation Center strategy refresh. https://innovation.cms.gov/strategic-direction-whitepaper 21 SO #3: Support Care Innovations Aim: What we can expect: Leverage a range of supports that enable integrated, person-centered care such as actionable, practice- Patient preference and choice will specific data, technology, dissemination of best represent a guiding force in the design practices, peer-to-peer learning collaboratives, and of innovative delivery models. payment flexibilities. Efforts to bridge patient preferences and low-cost treatment options (e.g. Measuring Progress: home- and community-based care). Set targets to improve performance of models on patient experience measures. Increased emphasis on the provider’s ability to meaningfully engage patients All models will consider or include patient-reported in care. outcomes as part of the performance measurement strategy. Centers for Medicare and Medicaid Services (2021). Innovation Center strategy refresh. https://innovation.cms.gov/strategic-direction-whitepaper 22 SO #4: Improve Access by Addressing Affordability What we can expect: Aim: Pursue strategies to address health care prices, Further emphasis on total cost of affordability, and reduce unnecessary or duplicative care models – incentivization to be care. innovative and reduce spending. Further reimbursement reform to Measuring Progress: reduce dependence on high-cost Set targets to reduce the percentage of beneficiaries providers for billable visits. that forgo care due to cost by 2030. Health insurance reform – new All models will consider and include opportunities to models to support high-value care improve affordability of high-value care by beneficiaries. decision-making. Centers for Medicare and Medicaid Services (2021). Innovation Center strategy refresh. https://innovation.cms.gov/strategic-direction-whitepaper 23 SO #5: Partner to Achieve System Transformation What we can expect: Aim: Align priorities and policies across CMS and aggressively engage payers, purchasers, providers, Increased emphasis at the federal states and beneficiaries to improve quality, to achieve level to encourage multi-payer equitable outcomes, and to reduce health care costs. alignment for value-based care. Program requirements for partnering with external entities to Measuring Progress: support the infusion of health Where applicable, all new models will make multi- equity into value-based care. payer alignment available by 2030. Additional efforts for information All new models will collect and integrate patient and data transparency to support perspectives across the life cycle. alignment. Centers for Medicare and Medicaid Services (2021). Innovation Center strategy refresh. https://innovation.cms.gov/strategic-direction-whitepaper 24 Other considerations for the future Expanded use of AI for both administrative and clinical efficiencies. Growing presence of large corporations involved in the delivery of health care services (e.g. Amazon, Walmart) Political interest in a universal health care model (e.g. Medicare for All) or expanded public insurance programs to expand coverage. Further development of cost containment methodologies – resource rationing, global budgets, etc. 25 Questions? Feel free to reach out! Thank you! Dr. Joshua Pearson, EdD, MHA, CPHQ, CHFP [email protected] References Centers for Medicare and Medicaid Services (2021). Innovation Center strategy refresh. https://innovation.cms.gov/strategic-direction- whitepaper Commonwealth Fund (2020). How are costs contained? https://www.commonwealthfund.org/international-health-policy-center/system- features/how-are-costs-contained Harvard T.H. Chan School of Public Health (2013). What’s so hard about health care reform? https://www.hsph.harvard.edu/news/magazine/centennial-health-care-reform-hard/ NEJM Catalyst (2017). What is value-based healthcare? https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0558 New England Journal of Medicine (2018). What is risk management in healthcare? https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0197 Nundy, S., Cooper, L. A., & Mate, K. S. (2022). The quintuple aim for health care improvement: A new imperative to advance health equity. JAMA, 327(6), 521-522. https://doi.org/10.1001/jama.2021.25181 Swensen, S., Pugh, M., McMullan, C., & Kabcenell, A. (2013). High-impact leadership: Improve care, improve the health of populations, and reduce costs. http://www.ihi.org/resources/Pages/IHIWhitePapers/HighImpactLeadership.aspx 27