13 DPM_Health_Cost & Quality_19.pdf

Health Services Cost and Quality How the US Healthcare Payment Structure Has Influenced Care and Quality  1920s 1930s 1940s 1950s 1960s 1970s...

Health Services Cost and Quality How the US Healthcare Payment Structure Has Influenced Care and Quality  1920s 1930s 1940s 1950s 1960s 1970s 1980s 1990s 2000s Corporations begin to Health care costs integrate the hospital rise at double In the 1950s, the price system (previously a the rate of Consistent with the The Depression President Richard Nixon Penicillin comes into of hospital care decentralized structure), inflation. general mood of changes priorities, renames prepaid group health use. At the start of the decade, doubled. Now in the enter many other political with greater care plans as health Health care costs are. national health care early 1960s, those healthcare-related Expansion of complacency, there emphasis on outside the workplace, maintenance organizations on the rise again. is no strong effort unemployment Prepaid group expenditures are 4.5 percent of (HMOs), with legislation that businesses, and managed care healthcare begins, seen the Gross National Product. especially the elderly, consolidate control. helps to to change health insurance and "old provides federal endorsement, as radical. have difficulty affording Overall, there is a shift moderate insurance. age" benefits. certification, and assistance. insurance. toward privatization and increases in corporatization of health care healthcare. costs. Reformers now Healthcare costs are escalating emphasize the cost During the 2nd World rapidly, partially due to of medical care War, wage and price unexpectedly high Medicare Over 700 insurance instead of wages controls are placed on Attention turns to Korea and expenditures, rapid inflation in Federal health Medicare is viewed by companies selling Under President Reagan, lost to sickness - American employers. To away from health reform; the economy, expansion of care reform some as Social Security Act is health insurance. Medicare shifts to payment the relatively compete for workers, America will have a system of hospital expenses and profits, legislation fails unsustainable under passed, omitting. by diagnosis (DRG) instead higher cost of companies begin to offer private insurance for those who and changes in medical care again to pass in the present structure health insurance. Major medical of by treatment. Private medical care is a health benefits, giving can afford it and welfare including greater use of the U.S. and must be insurance endorses plans quickly follow suit. new and dramatic rise to the employer- services for the poor. technology, medications, and Congress. "rescued". based system in place high-cost medicine. development, conservative approaches to especially for the today. treatment. American medicine is middle class. now seen as in crisis. Push for health Concern about a Growing cultural insurance within the By the end of the Changing "doctor shortage" and Growing complaints by influence of the Roosevelt President Roosevelt asks President Nixon's plan for decade there are demographics of the the need for more insurance companies that medical profession Administration, but Congress for "economic national health insurance 44 million workplace lead many Federal responsibility for the "health manpower" the traditional fee-for- - physicians' politics begins to be bill of rights," including rejected by liberals & labor Americans, 16 % to believe the sick poor is firmly established. leads to federal service method of payment incomes are higher influenced by right to adequate unions, but his "War on Cancer" of the nation, employer-based measures to expand to doctors is being and prestige is internal government medical care. centralizes research at the NIH. with no health system of insurance education in the health exploited. established. conflicts over insurance at all. can't last. priorities. professions. Rural health Human Genome President Lyndon facilities are clearly Against the advice of Human Genome Project to identify all President Truman offers Johnson signs Medicare The number of women entering inadequate. insurance Project to of the more than national health program Many legislative proposals are and Medicaid into law. the medical profession rises professionals, Blue "Capitation" payments to identify all of the 100,000 genes in made for different approaches. General Motors plan, proposing a single dramatically. In 1970, 9% of human DNA is doctors become more. Cross begins offering more than private coverage for system that would to hospital insurance, but none "Compulsory Health medical students are women; by 100,000 genes in expected to be signs a contract common. include all of American succeed. Insurance" advocates the end of the decade, the with Metropolitan hospital care in human DNA gets completed a full two society. are no longer proportion exceeds 25%. Life to insure dozens of states. underway. years ahead of 180,000 workers. optimistic'. schedule, in 2003. Many more medications are available now to treat a range Penicillin is Truman's plan is By June 1990, of diseases, including The number of doctors Direct-to-consumer discovered, but it denounced by the 139,765 people infections, glaucoma, and reporting themselves advertising for will be twenty American Medical arthritis, and new vaccines World Health Organization in the United years before it is Association (AMA) , and as full-time specialists States have pharmaceuticals and become available that prevent declares smallpox eradicated. used to combat is called a Communist grows from 55% in HIV/AIDS, with medical devices is on dreaded childhood diseases, 1960 to 69%. the rise. infection and plot by a House a 60 percent including polio. The first disease. subcommittee. successful organ transplant is mortality rate. performed.. Adapted from: http://www.pbs.org/healthcarecrisis/history.htm Medicare Sets the Trend Private payers follow Cost base to fee for service and prospective payment DRG Bundling Diagnosis coding Prevention Coverage Medicare Conditions of Participation Title XVIII and Title XIX (Medicare and Medicaid respectively), included conditions of participation Shortly thereafter created Utilization Review Committees to enforce conditions of participation. Potential for Medicare and Medicaid (government) to effectively impact cost and quality it proved to be ineffective Chassin and Loeb, 2011 Early Attempts Medicare Conditions of Participation1 1965 Title XVIII and Title XIX (Medicare and Medicaid respectively) were passed and included conditions of participation Shortly thereafter created Utilization Review Committees to enforce conditions of participation Potential for Medicare and Medicaid (government) to effectively impact cost and quality but was ineffective Diagnosis Related Group or DRG Holding strong Set reimbursement based on diagnosis Forces hospitals to develop standards of care, limit ordering of procedures Drove growth in outpatient services (fee for service) Managed Care/HMOs Gatekeeper model Prior-authorizations, benefit denials Capitation and PMPMs (at the individual level) Resulted in consolidation of providers and rise of physician groups 1. Chassin and Loeb, 2011 Fee For Service Still Lingers (outpatient) Incites providers to order and use more services Typically rewards newer technologies and procedures with higher reimbursement Incremental – Incentives First Meaningful Use Source: cms.gov Incremental – Incentives First PQRS Began in 2007 2015 first penalty year based on 2013 reporting Value Based Modifier Based on cost of care for attributed patients, quality and meaningful use reporting. 2013 for large groups (>/=100) to affect 2015 reimbursement 2014 smaller groups (>/=10) to affect 2016 reimbursement Downward adjustments PQRS 2015 first penalty year based on 2013 reporting Value Based Modifier Based on cost of care for attributed patients, quality and meaningful use reporting. 2015 all provider to affect 2017 reimbursement – first year of downward adjustments 2016 – final reporting year affecting 2018 reimbursement Fee For Service Still Lingers With some modifications: Bundled payments LCDs Reduced payments Medicare Fiscal Intermediaries Affordable Care Act 2010 Alternative payment models ACOs PCMH 2012 first MSSP Preset spending levels for defined and attributed population Still pay on fee for service If care provider is under preset level then share in savings ACO moving to private/commercial insurance ACOs Intention Began as upside only Easing into capitation (at the population level) Moving to Shared Risk/shared downside Goal of high quality, low cost, and positive patient experience Population health management ACO Outcomes Big data and big data systems Building large network of primary care Greater patient population more opportunity to spread risk Has created Narrow Networks Internal referrals Manage the cost of care better with internal providers Own as much of the cost and care attribution as possible Providers owning the insurance Collect the premium dollar and keep cost down Rise of population health management (not only because of ACO) Services outside the patient encounter to manage the care and outcomes Health coaches MIPS – For those not playing at home Programs for those not participating in Medicare APM Combines MU, PQRS and Value Based Modifier Quality Measures - PQRS Advancing Care Information and Use of Certified EHR – MU Improvement Activities Resource Use/Cost BUDGET NEUTRAL Medicare Access and CHIP Reauthorization Act (MACRA) and Merit-based Incentive Payment System (MIPS) in One Slide Constant Thread – PQRS/MU through MIPS and Shared Savings Push for the triple aim AFFECT ON QUALITY AND HEALTHCARE DELIVERY? Payer Contracts Care Gaps HEDIS Measures Post-discharge follow-up Medical Condition Assessments Payer Contracts Measures Based on: National Committee for Quality Assurance (NCQA) United States Preventive Services Task Force (USPSTF) Centers for Disease Control and Prevention (CDC) Various other associations Workflow and Resources Quality Reporting Codes Quality management tools and built in logic Claims Rules Based on quality measures being reported Dashboards/Monitoring Improvement Activities Reporting Options EHR reporting Registry reporting Claims-based reporting Put It Into Practice CMS QPP