Improving Health Care Quality and Outcomes: Transition to Value Based Care
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1 Improving Health Care Quality and Outcomes: Transition to Value Based Care
2 Why the Focus on Healthcare Quality and Outcomes? Health care spending in the U.S. is out of control Pay for volume, regardless of outcome High variance in care for like conditions Aging population Marked increase in chronic disease Problem: there is no correlation between high cost and high quality in the US health care system 2
3 Healthcare s Value Proposition Quality Outcomes Access/ Satisfied Customers Lower Costs Driving Value in Health Care: Health Plans: Star Ratings (CMS, NCQA) Health Providers: Value Based Purchasing (CMS, Private Insurers)
4 Driving Value in Health Care Value is driving a fundamental reorientation of the health care system around the quality and cost effectiveness of care Source: Value in Health Care: Current State and Future Directions,
5 How do we drive better value in health care? Creating value in health care will require bringing payment and quality the two factors of the value equation to the fore and, as in other industries, defining them around the purchaser s needs Embrace strategies, tactics, and tools that healthcare organizations can use to build, enhance, and communicate their value capabilities Use payment incentives and penalties selectively, emphasizing performance on metrics that have been proven or stakeholders agree are most likely to drive the most desirable quality or cost outcomes Source: healthcare financial management association, 2015, The Healthcare Value Sourcebook, ). 5
6 Driving Value Historical vs. Future Health Delivery Health Delivery 1.0 Health Delivery 2.0 Broad Network/ Higher Volume Select Network (Cost, Quality) Responsive Member Service/ Reactive Sick Care Health Plans: Managed Benefit Utilization Affordable, Accessible Care Targeted Outreach, Proactive, Preventive Care Shared Accountability: Outcomes/Cost Affordable, Accessible Care
7 CMS Measures of Hospital Performance Source: CMS, Hospital Value Based Purchasing Program, available at: and Education/Medicare Learning Network MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN pdf The Hospital Value Based Purchasing (VBP) Program is a Centers for Medicare & Medicaid Services (CMS) initiative that rewards acute care hospitals with incentive payments for the quality of care they provide to people with Medicare. From 2013 to 2015, emphasis moved away from process and toward Outcomes and Efficiency
8 CMS Physician Quality Reporting System (PQRS) A reporting program that promotes reporting of Medicare quality information by eligible professionals (EP) Not a substitute for quality improvement efforts! EPs and group practices that do not participate or satisfactorily report PQRS will be subject to a negative payment adjustment ( 2.0% for adjustment periods ) on covered Medicare Part B professional services Program enables EPs to quantify how often targeted care metrics are met, assessing quality of care delivered Program goals are to promote effective, safe, efficient, patient centered, equitable, and timely care 2016 PQRS Measures by Domain Domain Number Communication and Care Coordination 42 Community/Population Health 15 Effective Clinical Care 145 Efficiency and Cost Reduction 20 Patient Safety 43 Person and Caregiver Centered Experience and Outcomes 16 Total 281
9 Growing Importance of HEDIS to NCQA NCQA has shifted to focus more on HEDIS and less on Standards Since 2008, NCQA has taken 11.3 available accreditation points away from Standards and moved to HEDIS In 2015, 70.86% of the weighting in NCQA s STAR program was assigned to HEDIS
10 What is BlueCross BlueShield of Tennessee Doing to Drive Value in Health Care? Every day we embark upon the mission to improve our members health. We will continue working for their peace of mind to ensure they receive the best health care available at the best value. Dr. J.B. Sobel, vice president and chief medical officer for senior products
11 Our Mission: indicates Quality Initiatives 11
12 Our Focus: Every Member Every Day (EMED) Progression 2014: Proof of Concept Created workgroups to support Member, Provider and Technology strategies Created ad hoc solutions to support consolidated concepts across the enterprise 2015 : Projects/Pilots Provider and Member strategies go to market Implement enterprise technical solution to automated consolidated efforts Train and Communicate internally and externally 2016: Operationalize Operationalize enterprise quality efforts Create and Collaborate with new innovation models Align with Total Population Health efforts 12
13 EMED Workgroups and Projects EMED Quality Executive Committee Quality Care Partnership Initiative Total Cost of Care EMED Combined Strategies Team Enterprise Quality Oversight Committee Provider Strategy Workgroups and Sub Workgroups Member Strategy Workgroups and Sub Workgroups Technical Strategy Workgroups Clinical Strategy Workgroups Pay 4 Gaps Comm, BlueCare Inpatient P4Q PCMH Expansion Total Cost of Care Nonfinancial Implementation Provider Payment Automation Field Team Strategy Member Rewards Investment BiAnnual Member Score Card CAHPS Strategy Committee Clinical Data Exchange Supplemental Data Repository Automated gaps and performance reporting HEDIS TAG Committee Provider Perf. Module HEDIS Dashboard STARS Dashboard Immunization Taskforce Pharmacy Measures/Strategy Operation Bottom Dweller: 25 th or less Plan All Cause Readmission Committee Medicare Advantage Programs Embedded
14 BlueCross Focus on Primary Care Use of evidence based preventive services and primary care keeps individuals healthy, improves population health, and avoids adverse outcomes. Source: Fact Sheet CMS Strategy: The Road Forward , CMS/Agency Information/CMS Strategy/Downloads/CMS Strategy.pdf Overall, HHS seeks to have 85 percent of Medicare payments tied to quality or value by 2016 and 90 percent by Source: Fact Sheet: Health Care Payment Learning and Action Network sheets/2015 fact sheetsitems/ html
15 Current BlueCross PCMH Landscape Implemented in 2009 with 2 pilot practices, initial focus was NCQA Recognition and targeted members with chronic conditions Today, 30 physician groups, 750 providers, 213K total member participants (attributed members) and 90K chronic members Shelby 46 Tipton 4 Lake Dyer Obion Gibson 5 Crockett Hardeman Weakley 2 Madison 2 5 Chester 1 Fayette McNairy 1 11 Henry Carroll 24 Decatur Hardin Stewart Houston Perry Wayne Dickson Hickman Lewis Lawrence Maury Giles Robertson Macon Sumner 8 12 Trousdale Davidson 85 Williamson 16 Marshall Bedford Wilson 4 Rutherford 37 Coffee Smith DeKalb Warren Grundy Clay Lincoln Franklin Marion 8 Putnam 2 White Van Buren Pickett Scott Fentress Morgan Cumberland Roane 3 Rhea McMinn 1 Polk 23 Monroe 13 Claiborne 2 Union 5 Knox 124 Sevier 15 Blount 9 Hawkins 3 11 Greene Cocke 1 Sullivan 57 Carter 12 15
16 Transition to Value Based Care 1 6
17 BlueCross Collaboration with the Provider Community: Patient Centered Medical Home Advisory Council Regional Advisory Panels Tennessee Hospital Association Quality Committee Payer Simplification Panel
18 The BCBST Primary Care Reimbursement Evolution Fee for Service: PCPs are reimbursed for each service rendered Pay for Gaps: PCPs are rewarded for ensuring identified gaps in care are closed Pay for Quality: PCP reimbursement based on set of measures Total Cost of Care: PCP rewarded for managing costs while maintaining quality contracting Commercial BlueCare 40 Practices 8 QCPI Contracts 2016 Goal: 20 total contracts Medicare Advantage 39 Practices 2016 Goal: 9 contracts TennCare s THCII GOAL: All Lines of Business >95% PCPs in Quality Care Contracts 2 Gain Share Arrangements, 2016 Goal: 7 additional contracts Select providers are those who deliver quality at cost. 18 QCPI Overview Presentation v2
19 Reimbursement Evolution Timeframes/Goals 100% Fee for Service Pay for Gaps % of Providers*** Pay for Performance Total Cost of Care 0% ***% Providers figures are for demonstration purposes only and do not reflect actual performance expectations. 19
20 Data is Key! Health care is an industry awash in data, but the industry is just beginning to unlock the potential of that data to drive the changes in the quality and cost of care that a value based healthcare system will require. Source: healthcare financial management association, 2015, The Healthcare Value Sourcebook,
21 Clinical Data Exchange Providers working with BlueCross can demonstrate performance is through a clinical data exchange (CDE) Allows providers to share securely integrated clinical information Supports collaboration initiatives Reduces administrative burden Identifies new opportunities to drive patients to providers practice Enhances reporting tools so providers can access actionable information at the point of care CDE enables BlueCross to report back to providers via: The BlueAccess provider module (phase one launched, phase 2 July 2016); or The Rise/Stratus application for practices contracted as PCMH QCPI Overview Presentation v2
22 Provider Performance Module Available on BlueAccess. Automation for current Quality Care Partnership Initiative reporting and provider scorecard through a dashboard. 22
23 Provider Performance Module A Member Roster reports BlueCross patients attributed to the provider. Reports the % gap closures completed and source (e.g., claims). 23
24 Provider Performance Module An Attestation Statement is required if the gap is closed or excluded by the provider or licensed clinical staff member. 24
25 The Tennessee Health Care Innovation Initiative (THCII) Partnership with the State of Tennessee to transition the healthcare payment system to better reward patient centered, high quality, highvalue healthcare outcomes for all Tennesseans. The State of Tennessee under the Tennessee Health Care Innovation Initiative is pursuing two complementary payment strategies in tandem with select MCOs; A retrospective Episode of Care program rewarding providers who provide high quality and efficient care, and Patient Center Medical Home and Health Home Programs rewarding providers who care for their patients on an ongoing basis, promote prevention, treat chronic conditions and coordinate care over time. The State and BlueCross are working together to ensure consistency and transparency of the programs to the provider community.
26 Example: The Tennessee Health Care Innovation Initiative (THCII) Wave Episodes of Care Perinatal, Asthma Acute Exacerbation, Total Joint Replacement COPD acute exacerbation, Colonoscopy, Cholecystectomy, PCI acute, PCI non acute GI Hemorrhage, Upper GI Endoscopy, Respiratory Infection, Pneumonia, UTI outpatient, UTI inpatient ADHD, CHF Acute Exacerbation, ODD, CABG, Valve Repair and Replacement, Bariatric Surgery Anxiety, Depression Chronic, Breast biopsy and/or mammography, Breast Cancer Mastectomy, Breast Cancer Chemotherapy, Tonsillectomy, Otitis First Performance Period Jan to Dec 2015 Jan to Dec 2016 Jan to Dec 2017 Jan to Dec 2017 TBD First Gain Share Payout August 2016 August 2017 August 2018 August 2018 TBD
27 THCII Reporting BCBST has dedicated significant resources to THCII program monitoring and reporting, critical to successful execution of THCII Initial reporting demonstrating the effectiveness of payment bundling are expected in May
28 For additional questions or comments, please reach out to: Lisa Slattery, VP Quality Management BlueCross BlueShield of Tennessee
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