Value Driven Health Care

43 %
57 %
Information about Value Driven Health Care

Published on October 19, 2007

Author: nashp

Source: slideshare.net

Description

Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Jean Moody Williams

Value Driven Health Care Jean D. Moody-Williams, RN, MPP Division of Quality, Evaluation, and Health Outcomes Center for Medicaid and State Operations Centers for Medicare & Medicaid Services

Medicaid/SCHIP Quality Strategy Vision: The right care for every person every time Aims: Make care safe, effective, efficient, person-centered, timely; and equitable The pillars of the Medicaid/SCHIP framework are: Evidenced-Based Care and Quality Measurement Supporting Value Based Payment methodologies Health Information Technology Partnerships Information Dissemination and Technical Assistance

Vision: The right care for every person every time

Aims: Make care safe, effective, efficient, person-centered, timely; and equitable

The pillars of the Medicaid/SCHIP framework are:

Evidenced-Based Care and Quality Measurement

Supporting Value Based Payment methodologies

Health Information Technology

Partnerships

Information Dissemination and Technical Assistance

Secretary Leavitt challenged State Medicaid programs to partner in a value driven health-care initiatives centering around four cornerstones: Intraoperatable health information technology Measuring and publishing quality information Measuring and publishing price information Creating positive incentives for high quality health care purchasers

Secretary Leavitt challenged State Medicaid programs to partner in a value driven health-care initiatives centering around four cornerstones:

Intraoperatable health information technology

Measuring and publishing quality information

Measuring and publishing price information

Creating positive incentives for high quality health care purchasers

Transparency of Quality Request that health plans use and publicly report measures adopted by AQA, HQA, PQA, NQF and other national bodies. Request that plans and EQROs participate in AQA, HQA, PQA, NQF or another national quality transparency collaborative. Participate in national public-private collaborative committees or workgroups to establish and support standards in measuring or reporting quality. Become a member of NQF Collaborate with other state Medicaid agencies and CMS to share your success and challenges

Request that health plans use and publicly report measures adopted by AQA, HQA, PQA, NQF and other national bodies.

Request that plans and EQROs participate in AQA, HQA, PQA, NQF or another national quality transparency collaborative.

Participate in national public-private collaborative committees or workgroups to establish and support standards in measuring or reporting quality.

Become a member of NQF

Collaborate with other state Medicaid agencies and CMS to share your success and challenges

 

 

Evidenced-Based Coverage Decisions Medicaid Medical Director Learning Network – Collaborative to discuss the evidence and share promising practices (sponsored by AHRQ) Many States have accelerated efforts to review the evidence in making decisions CMS developed a promising practices website to share efforts in states CMS sponsors Quality Conference Series to discuss evidenced based treatment practices

Medicaid Medical Director Learning Network – Collaborative to discuss the evidence and share promising practices (sponsored by AHRQ)

Many States have accelerated efforts to review the evidence in making decisions

CMS developed a promising practices website to share efforts in states

CMS sponsors Quality Conference Series to discuss evidenced based treatment practices

Incentives for High-Value Health Care Encourage beneficiaries to use providers with the highest quality and lowest cost. Offer providers incentives and rewards for delivering high-value care Provide direct financial incentives and/or public recognition to providers who demonstrate superior performance Implement incentive programs to encourage provider adoption on electronic health records and health information exchange Provide beneficiaries with incentives for prevention and wellness Provide beneficiaries with incentives for self-management of chronic illness

Encourage beneficiaries to use providers with the highest quality and lowest cost.

Offer providers incentives and rewards for delivering high-value care

Provide direct financial incentives and/or public recognition to providers who demonstrate superior performance

Implement incentive programs to encourage provider adoption on electronic health records and health information exchange

Provide beneficiaries with incentives for prevention and wellness

Provide beneficiaries with incentives for self-management of chronic illness

Supporting Medicaid Efforts in Value Based Purchasing A quality improvement and reimbursement methodology which is aimed at moving towards payments that create much stronger financial support for person focused, high value care. At least 28 States have 35 Medicaid value-based purchasing initiatives In the next two years, at least 34 states are planning 47 new activities Important that evolving programs include an evaluation component to answer the question of effectiveness Considerations related to the approach a State uses to implement program (e.g. State Plan, Waiver, etc.)

A quality improvement and reimbursement methodology which is aimed at moving towards payments that create much stronger financial support for person focused, high value care.

At least 28 States have 35 Medicaid value-based purchasing initiatives

In the next two years, at least 34 states are planning 47 new activities

Important that evolving programs include an evaluation component to answer the question of effectiveness

Considerations related to the approach a State uses to implement program (e.g. State Plan, Waiver, etc.)

IOM: Rewarding Provider Performance Payment incentives to reward quality “can serve as a powerful stimulus to drive institutional and provider behavior toward better quality” Incentives alone would be insufficient without certain conditions such as public reporting, beneficiary incentives, and education of boards of directors.”

Payment incentives to reward quality “can serve as a powerful stimulus to drive institutional and provider behavior toward better quality”

Incentives alone would be insufficient without certain conditions such as public reporting, beneficiary incentives, and education of boards of directors.”

Overarching Principles: Medicaid P4P programs should be: Data driven Beneficiary-centered Transparent Developed through partnerships Administratively flexible

Data driven

Beneficiary-centered

Transparent

Developed through partnerships

Administratively flexible

Incentive Structure: P4P incentives consideration: Equitable and fair to program participants including the beneficiary Timely Sufficient to motivate improvement Flexible enough to provide payment for innovative care processes Structured to avoid unintended consequences

Equitable and fair to program participants including the beneficiary

Timely

Sufficient to motivate improvement

Flexible enough to provide payment for innovative care processes

Structured to avoid unintended consequences

Incentives Currently Used in the Industry Public reporting of quality information Performance based rate adjustments Performance based bonuses Competitive payment schedule Tiered payment levels Performance based fee schedules Performance based payment withholds Quality Grants Autoassignments

Public reporting of quality information

Performance based rate adjustments

Performance based bonuses

Competitive payment schedule

Tiered payment levels

Performance based fee schedules

Performance based payment withholds

Quality Grants

Autoassignments

Pennsylvania P4P Value-based purchasing programs in three delivery settings HealthChoices and Access Plus HealthChoices is the State’s mandatory managed care program covering approximately one million lives The incentive program began in 2005 Performance requirements are included in state contracts with MCOs Based on ten clinical HEDIS measures

Value-based purchasing programs in three delivery settings

HealthChoices and Access Plus

HealthChoices is the State’s mandatory managed care program covering approximately one million lives

The incentive program began in 2005

Performance requirements are included in state contracts with MCOs

Based on ten clinical HEDIS measures

Pennsylvania P4P HealthChoices Payments $4.4 Million in incentive payments to date Beginning January 2008, PA will add $1.00 PMPM to fund a provider level P4P program Plans must submit proposals to the state for approval The additional funding must be passed to providers and must not cover administrative costs

HealthChoices Payments

$4.4 Million in incentive payments to date

Beginning January 2008, PA will add $1.00 PMPM to fund a provider level P4P program

Plans must submit proposals to the state for approval

The additional funding must be passed to providers and must not cover administrative costs

Pennsylvania P4P Access Plus is PA’s Enhanced Primary Care Case Management (EPCCM) and Disease Management Program for Medicaid recipients outside of HealthChoices operating area (primarily rural) Performance Measures EPSDT screening rates Four clinical HEDIS measures Access Plus Payments $200, 000 in incentive payments in first phase

Access Plus is PA’s Enhanced Primary Care Case Management (EPCCM) and Disease Management Program for Medicaid recipients outside of HealthChoices operating area (primarily rural)

Performance Measures

EPSDT screening rates

Four clinical HEDIS measures

Access Plus Payments

$200, 000 in incentive payments in first phase

Arkansas P4P State operates a Primary Care Case Management Delivery System Inpatient Quality Incentive Program Uses information from the QIO data warehouse for acute PPS Hospitals but excludes critical access hospitals, University of Arkansas Medical Sciences and Arkansas Children’s Hospital Hospital must pass validation on 5 Medicaid charts Hospital earn up to 5.8% of Per diem rate Excludes dual eligibles and discharges for children under 1 year age

State operates a Primary Care Case Management Delivery System

Inpatient Quality Incentive Program

Uses information from the QIO data warehouse for acute PPS Hospitals but excludes critical access hospitals, University of Arkansas Medical Sciences and Arkansas Children’s Hospital

Hospital must pass validation on 5 Medicaid charts

Hospital earn up to 5.8% of Per diem rate

Excludes dual eligibles and discharges for children under 1 year age

Arkansas P4P Clinical Performance Thresholds Must pass 5 of 7 quality measures by threshold 1 or 2 Threshold performance 1 : performance at or above the statewide 75 th percentile or a rate ≥ 95% Threshold performance 2: A 25% reduction in failure rate Heart Failure and Pneumonia measures

Clinical Performance Thresholds

Must pass 5 of 7 quality measures by threshold 1 or 2

Threshold performance 1 : performance at or above the statewide 75 th percentile or a rate ≥ 95%

Threshold performance 2: A 25% reduction in failure rate

Heart Failure and Pneumonia measures

Arkansas P4P Outcomes: $3.9 Million in incentive payments in year 1 Minimum payment of $12, 500 Maximum payment of $595,650 Qualifying Hospitals 17% Average Relative Improvement All seven quality measures are above national averages Non-qualifying Hospitals 6% Average Relative Improvement Only four quality measures are above national averages OB and pediatric measures will be added

Outcomes:

$3.9 Million in incentive payments in year 1

Minimum payment of $12, 500

Maximum payment of $595,650

Qualifying Hospitals

17% Average Relative Improvement

All seven quality measures are above national averages

Non-qualifying Hospitals

6% Average Relative Improvement

Only four quality measures are above national averages

OB and pediatric measures will be added

New York State P4P State contracts with 28 fully capitated plans (2.6 million enrollees) 1115 Waiver (began 1997) Began P4P in the fall of 2002 to begin to make the business case for investing in quality, to accelerate improvement, and to align with other P4P initiatives (health plan initiated or private payor initiated) Methodology includes awarding 2/3 points for meeting goals in the HEDIS/QARR measures and 1/3 for meeting CAHPS goals. Over $13 million distributed to high performing plans in the first two years (02/03 and 03/04) of the program

State contracts with 28 fully capitated plans (2.6 million enrollees)

1115 Waiver (began 1997)

Began P4P in the fall of 2002 to begin to make the business case for investing in quality, to accelerate improvement, and to align with other P4P initiatives (health plan initiated or private payor initiated)

Methodology includes awarding 2/3 points for meeting goals in the HEDIS/QARR measures and 1/3 for meeting CAHPS goals.

Over $13 million distributed to high performing plans in the first two years (02/03 and 03/04) of the program

Medicare Demonstrations Premier Demo Nursing Home VBP Home Health P4P ESRD Disease Management

Premier Demo

Nursing Home VBP

Home Health P4P

ESRD Disease Management

Medicare VBP Section 5001(c) of Pub. L. 109-171 requires the Secretary to select, by October 1, 2007, at least two conditions that are (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines . For discharges occurring on or after October 1, 2008, hospitals will not receive additional Medicare payment for cases in which one of the selected conditions was not present on admission.

Section 5001(c) of Pub. L. 109-171 requires the Secretary to select, by October 1, 2007, at least two conditions that are

(a) high cost or high volume or both,

(b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and

(c) could reasonably have been prevented through the application of evidence-based guidelines .

For discharges occurring on or after October 1, 2008, hospitals will not receive additional Medicare payment for cases in which one of the selected conditions was not present on admission.

Transparency of Price Make available to beneficiaries the cost or price of care. Assure that cost or price information is made available with quality information to the maximum extent possible. Participate in broad-based public-private collaborative efforts to develop strategies to measure the overall cost of services. Participate in regional or national public-private collaborative committees or workgroups to establish and support uniform standards for measuring or reporting quality information.

Make available to beneficiaries the cost or price of care.

Assure that cost or price information is made available with quality information to the maximum extent possible.

Participate in broad-based public-private collaborative efforts to develop strategies to measure the overall cost of services.

Participate in regional or national public-private collaborative committees or workgroups to establish and support uniform standards for measuring or reporting quality information.

Linking Quality and Cost: Pay for Performance and Efficiency Efficiency Is One of the Institute of Medicine's Key Dimensions of Quality Safety Effectiveness Patient-Centeredness Timeliness Efficiency: absence of waste, overuse, misuse, and errors Equity Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century, March, 2001.

Efficiency Is One of the Institute of Medicine's Key Dimensions of Quality

Safety

Effectiveness

Patient-Centeredness

Timeliness

Efficiency: absence of waste, overuse, misuse, and errors

Equity

Institute of Medicine: Crossing the Quality Chasm:

A New Health System for the 21st Century, March, 2001.

Interoperable Health Information Technology Request health insurance plans, TPAs, and others involved with HIT monitor activities of national standard setting bodies Encourage providers to utilize EHRs that have been certified by national certification bodies Encourage participation in HIE Utilize the national RFI to measure health plan performance. Self-assess the PCCM program Develop expertise regarding MITA

Request health insurance plans, TPAs, and others involved with HIT monitor activities of national standard setting bodies

Encourage providers to utilize EHRs that have been certified by national certification bodies

Encourage participation in HIE

Utilize the national RFI to measure health plan performance.

Self-assess the PCCM program

Develop expertise regarding MITA

IT and Quality Supports Strategies for achieving Quality in a transformed health care system Changing organizational culture Developing systems that support clinical processes as well as payment processes Using information technology more effectively to improve safety, outcomes, and health care policy Transforming data into information for providers and consumers

Supports Strategies for achieving Quality in a transformed health care system

Changing organizational culture

Developing systems that support clinical processes as well as payment processes

Using information technology more effectively to improve safety, outcomes, and health care policy

Transforming data into information for providers and consumers

Medicaid Transformation Grants In FY07, grants totaling over $155 million were awarded to states to support innovation and modernization of Medicaid operations, including adoption of health information technology platforms, such as electronic medical records, health information exchanges and e-prescribing platforms. Grant focus areas also include quality and value-drive health care, reduction of Medicaid fraud and abuse, and enhanced risk management and clinical decision support systems. Expected results include a reduction in adverse medical events, expanded consumer choice through system transparency, and streamlined, efficient healthcare services.

In FY07, grants totaling over $155 million were awarded to states to support innovation and modernization of Medicaid operations, including adoption of health information technology platforms, such as electronic medical records, health information exchanges and e-prescribing platforms.

Grant focus areas also include quality and value-drive health care, reduction of Medicaid fraud and abuse, and enhanced risk management and clinical decision support systems.

Expected results include a reduction in adverse medical events, expanded consumer choice through system transparency, and streamlined, efficient healthcare services.

FY07 and Beyond in Medicaid Quality : White House Releases Medicaid PART Information on ExpectMore.Gov. Quality Goal is highlighted We are taking the following actions to improve the performance of the program: Working with the States to measure, track, and improve quality of care in Medicaid and moving toward a national framework for Medicaid quality.

Progress to Date Published a compendium of measures available on the CMS website AHRQ and CMS are collaborating to develop performance indicators for HCBS 18 states and the District of Columbia have committed in writing to the VDHC initiative 12 State Medicaid agencies have implemented a total of 16 HIT initiatives (five of the states are currently receive some support from Medicaid Transformation Grants) 25 State Medicaid agencies are involved in planning and developing statewide HIE networks. 13 State Medicaid agencies include MITA as a part of their HIT and HIE planning.

Published a compendium of measures available on the CMS website

AHRQ and CMS are collaborating to develop performance indicators for HCBS

18 states and the District of Columbia have committed in writing to the VDHC initiative

12 State Medicaid agencies have implemented a total of 16 HIT initiatives (five of the states are currently receive some support from Medicaid Transformation Grants)

25 State Medicaid agencies are involved in planning and developing statewide HIE networks.

13 State Medicaid agencies include MITA as a part of their HIT and HIE planning.

Progress to Date 28 States have 35 value-based purchasing programs 12 States with transformation grants have formed a coalition on HIT coordination, standards harmonization and joint planning At least 2 States plan to apply to serve as a CVE 2 States are pursing the relationship of consumer incentives and personal responsibility which has a similar correlation to the goals of the price transparency or getting consumers engaged based on the value of care.

28 States have 35 value-based purchasing programs

12 States with transformation grants have formed a coalition on HIT coordination, standards harmonization and joint planning

At least 2 States plan to apply to serve as a CVE

2 States are pursing the relationship of consumer incentives and personal responsibility which has a similar correlation to the goals of the price transparency or getting consumers engaged based on the value of care.

The Right Care for Every Person Every Time

The Right Care for Every

Person Every Time

Add a comment

Related pages

Value-Driven Health Care Home - HHS Archive Home Page

Value-Driven Health Care Home. Consumers deserve to know the quality and cost of their health care. Health care transparency provides consumers with the ...
Read more

Value-Driven Health Care Initiative - HHS Archive Home Page

Value-Driven Health Care Initiative “At a Glance” WHAT: The goal of the Value-Driven Health Care Initiative is to provide public information about the ...
Read more

Value-driven health care: implications for hospitals and ...

1. J Hosp Med. 2009 Oct;4(8):507-11. doi: 10.1002/jhm.535. Value-driven health care: implications for hospitals and hospitalists. Conway PH(1).
Read more

Value-Driven Health Care - Cornerstone Health Care

Value-Driven Health Care. At Cornerstone Health Care, we believe that putting the patient first is the best way to deliver high quality of care.
Read more

VALUE-DRIVEN HEALTH CARE - The Leapfrog Group

THE PURCHASER GUIDE TO VALUE-DRIVEN HEALTH CARE MEETING THE COMMITMENT I. Introduction page 3 II. Quick Reference Guide page 5
Read more

Value in Health Care - NCBI Bookshelf - National Center ...

Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes, and Innovation summarizes a two-day workshop held in November 2008, convened by the ...
Read more

Values-Driven Healthcare: Freedom of Conscience for the ...

Conclusion. Health care reform should give individuals and families the freedom to make values-driven decisions about their care. Personal decisions about ...
Read more

Roadmap for Implementing Value Driven Healthcare in the ...

Roadmap for Implementing Value . Driven Healthcare in the Traditional Medicare Fee-for-Service Program. ... Improve Quality and Value of Health Care .
Read more

What Is Value in Health Care? — NEJM - The New England ...

Two framework papers that develop the concepts outlined in this article, “Value in Health Care” and “Measuring Health Outcomes,” are available as ...
Read more

Value-Driven Health Care Purchasing: Four States that Are ...

Four State Initiatives to Improve Value in Health Care Purchasing: Value-Driven Initiative: Model: Scale: Massachusetts Group Insurance Commission (GIC)
Read more