Healthcare Reform & Women in Surgery: Opportunities & Challenges

Transcription

1 Healthcare Reform & Women in Surgery: Opportunities & Challenges Barry M. Straube, M.D. Immediate Past (Retired) Chief Medical Officer, Centers for Medicare & Medicaid Services October 23, 2011 Association of Women Surgeons

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3 Shifting of the Poles

4 The Healthcare Quality/Value Challenges In the U.S. we spend more per capita on healthcare than any other country in the world In spite of those expenditures, U.S. Healthcare quality is often inferior to that of other nations and often doesn t meet expected evidence based guidelines There are significant variations in quality and costs across the nation with increasing evidence that there may be an inverse relationship between the two Healthcare expenditures account for a larger section of the U.S. economy over the years and funding those expenditures is increasingly more difficult 4

5 The Healthcare Quality/Value Challenges There continues to be considerable waste in the delivery of healthcare, as well as fraud & abuse CMS/HHS, and the executive branch is responsible for the healthcare of a growing number of persons in the public sector, and influences healthcare quality in the private sector CMS/HHS, in partnership/collaboration with other healthcare leaders, must address these issues Academic Medical Centers & Surgeons could provide great value Health Information Technology is indispensable in this The Affordable Care Act of 2010 is a major step forward to address the healthcare quality/value challenges 5

6 The Triple Aim Better Health for the Population Better Care for Individuals Lower Cost Through Improvement 6

7 IOM Aims for Quality Improvement Safety Effectiveness Patient centeredness Timeliness Efficiency Equity 7

8 Federal Stakeholders in the U.S. Healthcare System Department of Health & Human Services Veterans Affairs Department of Defense Department of Labor Department of Housing & Urban Development United States Coast Guard Office Personnel Management Federal Bureau of Prisons Federal Trade Commission Office of Management & Budget Department of Commerce National Highway Transportation & Safety Administration 8

9 Department of Health & Human Services: Agencies Secretary of HHS Administration for Children and Families Administration on Aging Agency for Healthcare Research & Quality Agency for Toxic Substances & Disease Registry Centers for Disease Control Centers for Medicare & Medicaid Services (CMS) Food & Drug Administration Health Resources & Services Administration Indian Health Service National Institute of Health Program Support Center Substance Abuse & Mental Health Services Administration Multiple other Assistant Secretaries 9

10 Centers for Medicare & Medicaid Services (CMS) Will provide health benefits for over 114 million Americans in FY 2011 PP Budget Medicare 48.1 million beneficiaries Medicaid 56.1 million beneficiaries CHIP 10 million beneficiaries Will spend $784 billion in FY 2011 PP Budget Medicare $476 billion Medicaid $297 billion CHIP $11 billion Effective January, 2011 incorporated the Office of Consumer Information and Insurance Oversight (OCIIO) as part of CMS 10

11 Ongoing CMS Core Medicare Work Provider payment focused activities Efficient, timely, accurate payment of claims Ongoing demonstrations and pilots of alternative payment methodologies and systems Addressing fraud & abuse Beneficiary focused activities Benefit education Health promotion and disease management education Beneficiary protection and advocacy Multiple tools to improve quality, efficiency and value Data collection & availability 11

12 Partners/Targets For Advocacy Federal Government Congress House: Ways & Means, Energy & Commerce Senate: Finance, HELP A variety of caucuses White House Many senior advisors Office of Management & Budget

13 Partners/Targets For Advocacy Executive Branch Agencies U.S. Department of Health & Human Services (HHS) Office of the Secretary, Office of the Assistant Secretary of Health Centers for Medicare & Medicaid Services (CMS) Agency for Health Research & Quality (AHRQ) Centers for Disease Control (CDC) Food & Drug Administration (FDA) Health Resources and Service Administration (HRSA) National Institutes of Health (NIH) Office of the National Coordinator (ONC) for HIT Many other HHS and other federal agencies have influence over surgical topics and issues

14 Partners/Targets For Advocacy Centers for Medicare & Medicaid Services Office of the Administrator Key Surgery Areas Office of Clinical Standards & Quality (OCSQ) Conditions of Participation, Conditions for Coverage Quality Improvement and Measurement Quality Improvement Organizations (QIOs) and ESRD Networks Information Services: Clinical Data systems Coverage decision making Center for Medicare Payment Center for Medicaid State Survey Agencies and regulatory oversight processes Regional Offices (10) Innovation Center

15 Partners/Targets For Advocacy State Governments Dialysis Providers/Organizations Professional Associations Renal Physicians Association American Society of Nephrology American Nephrology Nurses Association National Renal Administrators Association American Medical Association Kidney Care Partners Kidney Care Quality Alliance Private health plans Patient Advocacy Organizations: Should probably be #1 stop

16 Some Personal Notions & Experience Know the framework of the regulatory system that affects you, the people who run it, and work with them Congress passes laws (statutes) that direct federal agencies what to do and defines their authorities The President can sign or veto any law passed Agencies implement laws, following Congressional directives and intent, but if unclear have discretion to interpret the law as the agency (and executive branch leadership sees fit Regulations, through public rulemaking Administrative rulings, sometimes, with or without public comment Guidance and directives through manuals, letters, and other mechanisms There are multiple points at which advocates can effectively influence the above

17 Some Personal Notions & Experience Advocates can and do have major influence on the federal framework With regards to federal rulemaking Notice of Proposed Rule Making (NPRM) days of public comment Agency reviews comments, responds to all comments, and revises the proposed rule as indicated Final Rule is issued, published and implemented Cycles of rulemaking at CMS If final rules are unacceptable Influence subsequent laws and regulations Judicial challenges Elect new leaders

18 Ensuring Quality & Value: CMS Tools/Drivers/Enablers Contemporary Quality Improvement Transparency: Public Reporting & Data Sharing Incentives: Financial through payment reform Regulatory vehicles National & Local Coverage Decisions Demonstrations, pilots, research, innovation 18

19 Contemporary Quality Improvement Need to set priorities, goals and objectives, strategic framework first Evidence Based goals, metrics, interventions, evaluations Includes conformance with evidence based guidelines, balanced with patient centered considerations Cost effectiveness, let alone comparative effectiveness, has not yet been addressed adequately Rapid cycle development, implementation and change methodology Leveraging of resources and efforts: Current and future models collaboration, alignment, synergy, priorities Many examples: Hospital Quality Initiative, Organ Donation Campaign, QIOs, ESRD Networks, IHI, Bridges to Excellence, NCQA, Nursing & Home Health Campaigns, many health plan collaboratives, local collaboratives, etc. 19

20 Contemporary Quality Improvement : Collaboratives & Communities Quality Improvement Organization (QIO) 9 th SOW Care Transitions Theme Every Diabetic Counts Mississippi Health First (expanding to Texas) Links to: ACA Section 3025: Hospital Readmissions Reduction Program ACA Section 3026: Community Based Care Transitions Program 20

21 Transparency: Public Reporting & Data Availability CMS Compare Websites Hospital Compare Nursing Home Compare Home Health Compare Dialysis Facility Compare MA Health Plan and Medi Gap Compare Prescription Drug Plan Compare New under ACA Physician Compare VBP Programs: Above plus ASCs, LTCHs, IRHs, Hospices, others MyMedicare.gov HHS/CMS Data Dissemination Efforts: Potential explosion of federal government data availability for private sector to drive data use innovation in previously unimaginable ways 21

22 Surgical Care Improvement Project Process of Care Hospital Process of Care Measures Tables Average All U.S. Average All CA STANFORD UCSF UCD Antibiotic within one hour before surgery 92% 90% 93% 94% 89% Appropriate pre operative antibiotic 94% 92% 96% 92% 94% Patients taking beta blockers prior to the hospital kept on the beta blockers pre & postop 92% 91% 93% 99% 92% Patients given appropriate prophylactic antibiotics 97% 97% 99% 98% 97% Patients with prophylactic antibiotics stopped appropriately (within 24 hours after surgery) 94% 92% 97% 99% 95% Heart surgery patients with blood glucose kept under good control post op 93% 93% 91% 84% 88% Surgery patients with safe hair removal pre op 99% 99% 100% 100% 100% New Surgery patients whose urinary catheters were removed on the 1 st or 2 nd day post op 89% 89% 97% 83% 86% Surgery patients whose doctors ordered treatments to prevent blood clots 94% 91% 99% 95% 97% Patients treated (within 24 hours before or after their surgery) to help prevent blood clots 92% 90% 99% 92% 96% 22

23 Heart Attack Chest Pain Process of Care Hospital Process of Care Measures Tables Average number of minutes before transferred to another hospital (lower is better) Average number of minutes to an ECG (lower is better) Average All U.S. 62 Minutes 9 Minutes Average All CA STANFORD UCSF UC DAVIS 66 Minutes N/A N/A N/A 8 Minutes 8 Minutes 6 Minutes N/A Drugs to break up blood clots within 30 minutes of arrival (higher is better) 54% 55% N/A N/A N/A Aspirin within 24 hours of arrival (higher is better) 95% 96% 100% 100% N/A Aspirin at Arrival 98% 99% 100% 100% 98% Aspirin at Discharge 98% 98% 99% 99% 99% ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) 96% 96% 92% 88% 93% Smoking Cessation Advice/Counseling 99% 100% 100% 100% 100% Beta Blocker at Discharge 98% 98% 96% 97% 99% Fibrinolytic Medication Within 30 Minutes Of Arrival 54% 61% N/A N/A N/A PCI Within 90 Minutes Of Arrival 89% 90% 93% 95% 79% 23

24 Heart Failure Process of Care Hospital Process of Care Measures Tables Average All U.S. Average All CA STANFORD UCSF UC DAVIS Heart Failure Patients Given Discharge Instructions 87% 90% 93% 93% 54% Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function 98% 98% 99% 100% 100% Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) 94% 95% 92% 93% 93% Heart Failure Patients Given Smoking Cessation Advice/Counseling 98% 99% 100% 100% 100% 24

25 Pneumonia Process of Care Hospital Process of Care Measures Tables Average All U.S. Averag e All CA STANFORD UCSF UC DAVIS Pneumonia Patients Assessed and Given Pneumococcal Vaccination 92% 92% 91% 91% 64% Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics 95% 95% 95% 93% 88% Pneumonia Patients Given Smoking Cessation Advice/Counseling 97% 97% 98% 100% 100% Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival 95% 95% 96% 93% 90% Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s) 91% 92% 91% 92% 88% Pneumonia Patients Assessed and Given Influenza Vaccination 91% 91% 85% 96% 74% 25

26 Outcomes Measures: Mortality National Heart Failure Mortality: 11.2% Better Than No Different Worse Than STANFORD UCSF UC DAVIS Yes Yes Yes National Heart Attack Mortality: 16.2% Better Than No Different Worse Than STANFORD Yes UCSF UC DAVIS Yes Yes National Hospital Mortality: Pneumonia 11.6% Better Than No Different Worse Than STANFORD UCSF UC DAVIS Yes Yes Yes 26

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28 Outcome Measures: Readmission Rates National Heart Attack Readmission Rate: 19.9% Better Than No Different Worse Than STANFORD Yes UCSF UC DAVIS Yes Yes National Heart Failure Readmission Rate: 24.7% Better Than No Different Worse Than STANFORD Yes UCSF UC DAVIS Yes Yes National Pneumonia Readmission Rate: 18.3% Better Than No Different Worse Than STANFORD Yes UCSF Yes UC DAVIS Yes 28

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30 Medicare Payment & Volume Data Measure Description UC DAVIS UC DAVIS UCSF UCSF STANFORD STANFORD Median Medicare Payment Number of Medicare Patients Median Medicare Payment Number of Medicare Patients Median Medicare Payment Number of Medicare Patients to Hospital Treated to Hospital Treated to Hospital Treated Coronary bypass w/o cardiac cath w/o MCC MS DRG 236 $39,777 Coronary bypass w/o cardiac cath w MCC MS DRG 235 $54, Medicare Patients $25,547 (*)f $40, Medicare Patients $67, Medicare Patients $64, Medicare Patients 14 Medicare Patients 30

31 Medicare Payment & Volume Data Measure Description UC DAVIS UC DAVIS UCSF UCSF STANFORD STANFORD Median Medicare Payment Number of Medicare Patients Median Medicare Payment Number of Medicare Patients Median Medicare Payment Number of Medicare Patients to Hospital Treated to Hospital Treated to Hospital Treated Coronary bypass w/o cardiac cath w/o MCC MS DRG 236 $39,777 Coronary bypass w/o cardiac cath w MCC MS DRG 235 $54, Medicare Patients $25,547 (*)f $40, Medicare Patients $67, Medicare Patients $64, Medicare Patients 14 Medicare Patients 31

32 Incentives Current: Pay for Reporting and Adoption Programs P4R: Hospital Inpatient/Outpatient, PQRI, e Prescribing ARRA /HITECH: EHR adoption and meaningful use Value based Purchasing (VBP) Hospital VBP Report to Congress (Nov 2007) Physician VBP RTC (2010) ESRD Quality Incentive Program (QIP) January 1, 2012 Hospital VBP (ACA Section 3001) by October 1, 2012 ACA mandates VBP in many additional settings Competitive bidding, gain sharing, shared savings, bundled payment, ACOs, medical homes, salaries, integrated delivery, etc. 32

33 Incentives: CMS Hospital Quality Initiative National Voluntary Hospital Reporting Initiative (NVHRI) public private initiative Federation of American Hospitals AHA AAMC CMS, JCAHO, others Hospital Quality Alliance Medicare Modernization Act of 2003: Section 501b Financial incentive of 0.4% 33

34 Other Pay for Reporting Programs Hospital Inpatient Quality Reporting Program Hospital Outpatient Quality Reporting Program Physician Quality Reporting System (PQRS) E prescribing Program HITECH Meaningful Use Programs Home Health Reporting Program 34

35 PQRS 2011 Overview Toward Value Based Purchasing VBP TRHCA MMSEA MIPPA MIPPA ARRA and ACA 74 measures Claimsbased only 119 measures Claims 4 Measures Groups Registry 153 measures Claims 7 Measures Groups Registry EHR-testing erx 175 individual measures Claims 13 Measures Groups Registry EHRs erx Large Groups 190 individual measures Claims 14 Measures Groups Registry EHRs erx Large Groups Small Groups Maintenance of Certification Physician Compare Web Site 35

36 Goals for Value Based Purchasing Incentivize the best care and improve transparency for Beneficiaries Transform CMS from a passive payer to an active purchaser of care Link payment to quality outcomes and stimulate efficiencies in care Recognize and address potential unintended consequences for Beneficiaries 36

37 Hospital Value Based Purchasing : Background Hospital Value Based Purchasing Report to Congress 2007 Premier Demonstration and other Demos Experience with other reporting programs Hospital Inpatient and Outpatient Quality Reporting Programs Physician Quality Reporting System ESRD Quality Incentive Program beginning January 1,

38 Hospital Value Based Purchasing Program (HVBP) Affordable Care Act (ACA), Section 3001 Effective date: FY2013 payment for discharges on or after October 1, 2012 Criteria: Must be a Hospital Inpatient Quality Reporting Program participant Meets quality metrics by demonstrating improvement or high levels of achievement 38

39 Hospital Value Based Purchasing FY2013 Medicare payment based on quality measure performance 5 Clinical topics Acute Myocardial Infarction Heart Failure Pneumonia Surgeries and Hospital Acquired Infections (HAIs) HCAHPS patient survey 39

40 Hospital Value Based Purchasing Replace current 2% with HVBP in a 5 year phased in approach between FY 2013 and FY Payment Year RHQDAPU* HVBP** FY13 1% 1% FY % 1.25% FY % 1.50% FY % 1.75% FY17 0% 2.0% *Annual Payment Update **Reduction from the Base DRG payment for all hospitals 40

41 Regulation Conditions of Participation or Conditions for Coverage COPs are minimum health and safety standards set by CMS for facilities that may receive Medicare payments 17 separate provider/supplier settings have COPs Survey & Certification U.S. healthcare facilities certified must be in compliance with current Medicare regulations & applicable state laws S&C process uses interpretive guidelines to assess compliance with regulations 41 In combination, a powerful tool for quality/value

42 Other Tools National Coverage Decisions, Payment Policy, Benefit Design Deciding whether a device, service or therapy is paid for (or not) can influence quality of care E.g., Non payment for Hospital Acquired Conditions (HACs) E.g., Non coverage of Never Events for both hospitals or physicians E.g., limitation of services to qualified facilities or providers, such as ICD implantation, etc. CED and use of registries collects further quality information Patient incentives: Waiver of co pays Demonstrations, pilots, research Numerous CMS Demonstrations in past and going forward with the ACA 42

43 Conclusions CMS Statutory Authority provides powerful tools to focus on improving quality, value & patient safety QI by providers, payers, collaboratives, others Transparency: Public Reporting and Data Dissemination Incentives Regulatory compliance Coverage, benefit, and utilization purposes Research and Demonstrations Health Information Technology essential to above Opportunities for input & alignment abound 43

44 Conclusions CMS Statutory Authority provides powerful tools to focus on improving quality, value & patient safety QI by providers, payers, collaboratives, others Transparency: Public Reporting and Data Dissemination Incentives Regulatory compliance Coverage, benefit, and utilization purposes Research and Demonstrations Health Information Technology essential to above Opportunities for input & alignment abound Academic Medical Centers have a potential major leadership role 44

45 Affordable Care Act (ACA) of 2010 Patient Protection & Affordable Care Act (PPACA) Health Care & Reconciliation Act of 2010 (HCERA) Affordable Care Act of 2010 (ACA) 45

46 Affordable Care Act (ACA) of 2010 Title I: Quality, Affordable Health Care for all Americans Title II: Role of Public Programs Title III: Improving the Quality & Efficiency of Health Care Title IV: Prevention of Chronic Disease & Improving Public Health Title V: Health Care Work Force 46

47 Affordable Care Act (ACA) of 2010 Title VI: Transparency and Public Reporting Title VII: Improving Access to Innovative Medical Therapies Title VIII: Community Living Assistance Services & Support (CLASS) Act Title IX: Revenue Provisions Title X: Strengthening Quality, Affordable Health Care for All Americans (Amendments) 47

48 ACA & Women Search term women 145 instances Mostly relate to women s health and women as patients Frequent linkage to pregnant or young modifiers Search term surgeon 41 instances, most Surgeon General 2 instances: American College of Surgeons trauma center accreditation and guidelines 5 Instances: General surgeons rural, committees 48

49 ACA & Surgeons Search term surgery 10 total instances 4 instances: Cosmetic surgery 5% tax 3 instances: General Surgery services Search term surgical Ambulatory Surgical Centers (8): VBP plan mandated to Congress by 1/1/2011 Surgical specialties 49

50 High Profile ACA Topics Greater Access to healthcare coverage National Priorities & Strategic Plan HHS Interagency Quality Work Group Quality Measurement comment by NQF Data collection and national work plan Focus on outcomes, efficiency Patient Centeredness High cost Chronic Disease Management Care coordination & care transitions 50

51 High Profile ACA Topics Healthcare Acquired Conditions (HACs) Healthcare Acquired Infections Patient safety & medical errors reduction Prevention and Patient Safety Population Health: Obesity, Smoking Cessation, etc. Reduction of unnecessary admissions & readmissions Accountable Care Organizations, Medical Homes Innovation in payment, delivery systems, care Rapid cycle change quality improvement Best practices and learning environments 51

52 Center for Medicare & Medicaid Innovation: CMMI CMMI establishment mandated by January 1, 2011 (Section 3021) Consultation & input from broad healthcare sector in implementation The Innovation Center Develop patient centered payment models Rapid piloting/testing of new payment programs Encourage evidence based, coordinated care for Medicare, Medicaid, CHIP Focuses on populations for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures 52

53 CMMI: Statutory Descriptors Risk based comprehensive payment or salary based payment models Geriatric assessments and comprehensive care plans interdisciplinary care teams multiple chronic conditions transition health care providers away from fee forservice based reimbursement and towards salary based health information technology enabled provider network that includes care coordinators, chronic disease registry, home telehealth technology 53

54 CMMI: The Innovation Center Other key characteristics in the statute for payment models Varying payment for advanced diagnostic imaging services Medication therapy management services Community based health teams to assist in care management Patient decision support tools State flexibility for dual eligibles and all payer payment reform demonstrations Collaboratives of high quality, low cost institutions $10 billion over 10 years funding 54

55 Staging of Innovation Development, Demonstration, and Translation 2 To 3 years Design to Program Translation Cycle Time Trend Analysis Prototype Design and Modeling Collaborative Design Lab Best Practice Analysis Publication and Collaborative Learning Collaborative Innovation Laboratory Stage Demonstration and Program Trial Stage Program trials and Demo development Technology beta testing Results evaluation Findings and Recommendations Publications Program Policy Translation Analysis and Evaluation Legislation/policy development Regulation and Rule Development Policy Execution and Implementation Re Evaluation/ Publication Program Policy Translation Evaluation and Diffusion Stage 55

56 Driving Healthcare System Transformation Un managed Fee for Service Fee For Service Inpatient focus O/P clinic care Low Reimbursement Poor Access and Quality Little oversight No organized networks Focus on paying claims Little Medical Management Coordinated Care Accountable Care Organized care delivery Aligned incentives Linked by HIT Integrated Provider Networks Focus on cost avoidance and quality performance PC Medical Home Care management Transparent Performance Management Patient Centered Integrated Health Patient Care Centered Personalized Health Care Productive and informed interactions between Patient and Provider Cost and Quality Transparency Accessible Health Care Choices Aligned Incentives for wellness Multiple integrated network and community resources Aligned reimbursement/care management outcomes Rapid deployment of best practices Patient and provider interaction Information focus Aligned self care management E health capable 56

57 Driving Healthcare Delivery System Reform and Transformation

58 Innovation Fellowship Details (still pending) at conference 58

59 Accountable Care Organizations (ACOs) Medicare Shared Savings Program (Section 3022) ACO Program must be implemented by January 1, 2012 ACO Notice of Proposed Rulemaking (NPRM) issued March 31, 2011 Public comment ended June 6, 2011 Final rule publication date not determined (publicly) Encourages providers of services and supplies to: Create ACOs Be accountable for health & experience of care for individuals Improve population health Reduce rate of healthcare spending 59

60 ACO Proposed Rule Provisions Providers must notify beneficiary of participation Includes description of program, quality/cost focus Beneficiary can opt out & seek non ACO care Beneficiary to be notified of data sharing Purpose: Coordinate care better Beneficiary can t be required to see ACO providers Beneficiary may opt out of data sharing arrangements For those opting in, data sharing has limitations Patient selection controls to avoid cherry picking 60

61 ACO Proposed Rule Provisions Types of providers & suppliers Professionals (physicians, hospitals) in group practice arrangements Networks of individual practices of professionals Partnerships or joint ventures of hospitals & physicians Hospitals employing ACO professionals Others, as determined by the Secretary Governing body of ACO professionals and beneficiaries Application with detailed submission requirements Minimum responsibility for 5,000 beneficiaries 61

62 ACO Proposed Rule Provisions Rigorous (& complicated) monitoring plan In order to qualify for financial shared savings, must meet specified quality standards (65 proposed in NPRM) Quality reports to CMS, feedback to providers 50% of PCPs must meet meaningful use standards by year 2 Pubic reporting requirements Termination by CMS if: Avoidance of at risk patients Failure to meet quality standards 62

63 ACO Proposed Rule Provisions 3 year agreement at minimum Primary care driven model for organization Specialty driven ACO founders not proposed in NPRM Two shared savings risk models original proposal One sided Risk: ACO shares in any savings in first 2/3 years; Third year can lose money if costs >Medicare norm. Two sided Risk: ACO at risk all three years; can have greater % of savings share, however. Waivers allowed FTC of DOJ and IRS issues 63

64 Reaction to ACO NPRM Largely negative Too complicated, too restrictive Too much undefined risk No specialty focused ACOs Negative comments about each criteria component CMS responded in interim Pioneer ACO Model: Applications being accepted Advance Payment ACO Model: Public comments Accelerated Development Learning Sessions Final rule pending review of comments & policy decisions 64

65 ACO Final Rule Pending: Details (if available) at conference 65

66 Will ACOs be the Answer? Probably not, in the short to intermediate term The concept is intriguing, but whether it is translational is in doubt Can you replicate existing likely ACOs in other communities without requisite infrastructure? The model is untested, will it achieve the goals of better quality at lower costs? ACO program under ACA is a voluntary program that is essentially a demonstration Financial risk may not be assumable for many Consolidation, reduced competition? 2 nd Generation Managed Care? 66

67 ACA: Academic Medical Centers ACA Section 3025: Hospital Readmission Reduction Program ACA Section 3026: Community Based Care Transition Program Healthcare Delivery Research (Section 3501, AHRQ coordinating with CMS) Identifies best practice institutions, organizations, etc. Supports innovation in health care delivery system improvement Quality Improvement Technical Assistance (Section 3501) 67

68 ACA: Academic Medical Centers Establishing Community Health Teams to Support the Patient Centered Medical Home (Section 3502) Medication Management Services in the Treatment of Chronic Diseases (Section 3503) Emergency medicine regionalized systems and research, trauma care centers access & payment Demonstration to integrate quality improvement and patient safety education into healthcare worker education (Section 3508) National Health Care Workforce Commission (Section 5101) Recruitment, education and training, retention 68

69 ACA: Academic Medical Centers National Center for Health Care Workforce Analysis (Section 5103) Multiple student loan programs, various training & retention programs, & demonstration programs established Primary care Nurse led care, advanced practice nursing, etc. Allied health, public health, dental, pediatric, direct care professionals, geriatric, mental health, cultural competency in disabilities, mid career, etc. 69

70 ACA: Academic Medical Centers United States Public Health Services Track (Part D, Section 271) Centers of Excellence additional funding Medical Residency funding enhancements Teaching grants and demonstrations in graduate medical education The list goes on and on and on. But, will ACA survive the legal, political and funding challenges in its entirety? If not, which sections? Whether or not, will savings estimates be achieved? 70

71 Conclusions The Affordable Care Act provides innumerable opportunities to improve the quality, value and efficiency of healthcare in the United States CMS is a major implementation center for this historic piece of legislation Implementation crosses Medicare, Medicaid, CHIP and the entire health care sector, including the private sector Implementation affects fee for service as well as managed care models, plus untested new models 71

72 Conclusions There are numerous opportunities and needs for involvement of academic medical centers in implementation of ACA and further health reform in the future: Design of and leadership in contemporary quality improvement initiatives Huge gap in comparative & cost effective analysis/improvement, let alone basic clinical knowledge Ongoing input in review and improvement in clinical guidelines Balancing evidence based population RCT viewpoint with need for individual patient centered concerns 72

73 Conclusions Education of multiple audiences in evidencebased medicine use: Clinicians: Current/future, academic/community Policy makers Payers Patients, consumers and their families Development and use of quality and value metrics Multiple perspectives: Clinicians, patients, payers, etc. Relevance, actionability, accountability, attribution 73

74 Conclusions Collection, analysis, reporting and use of healthcare data Health Information Technology development, adoption and meaningful use via EHRs Other forms of data collection: Registries, claims, encounter data, telehealth, chart review, surveys, etc. Balance of scientific rigor vs.. information efficiency Minimization of burden Privacy & security Dissemination of data for widest possible appropriate use 74

75 Conclusions Development of and participation in new reimbursement and delivery systems Achieve the Triple Aim Higher quality leading to overall lower costs Innovation, rapid change & adaptability Care transitions and coordination Integration of delivery systems Patient Centered, all of IOM Quality Aims Public health focus, as well as individual health 75

76 Conclusions We cannot continue to cover and pay for everything that s available without considering: Evidence based coverage & payment decision making Comparative effectiveness and cost effectiveness analysis Overall costs involved, including global costs of lost productivity, quality of life, etc. But are Academic Medical Centers ready? Rapid cycle change, integrated systems (no departmental silos), authenticity & will to change (e.g., academic tenure?) 76

77 Conclusions The under emphasized topics (?ignored): End of life care & Palliative Care Health disparities reduction, not talk Racial/ethnic Geographic Age Gender Socioeconomic LGBT Medical Conditions 77

78 Healthcare Reform, Politics & Surgery Healthcare Reform in context of budget deficit ACA originally estimated by CBO to generate Joint Steering Committee must come up with $1.2 trillion in savings If not, reverts to sequestration process Current projections are that JSC may come up with $ billion of savings Shortfall of same amount will lead to additional sequestration cuts of $ billion from Medicare, Medicaid, CHIP 78

79 Healthcare Reform, Politics & Surgery Likely targets for further cuts: Post acute care setting: Long term care (SNFs), Home Health, Hospitals (especially GME) DME Sustainable Growth Rate (SGR) Tort Reform 2012 Election 79

80 Thank you for your contributions in improving the American healthcare system! Questions? Discussion & Dialogue 80