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Emad Rizk, MD - Navigating the Complexity of New Value-Based Reimbursement Models
1. Navigating the Complexity of
New Value-Based
Reimbursement Models
Emad Rizk, MD
President
McKesson Health Solutions
2. Agenda/ Outline
ā¢ Healthcare Economic Trends
ā¢
ā¢
ā¢
ā¢
ā¢
ā¢
Funding sources over time
Types of employer benefit plans over time
Medicare reimbursement cut projections by provider type
Medicare piloting value reimbursement methods
Prevalence of value-based reimbursement
Resulting industry consolidation
ā¢ Value Based Reimbursement: A way to survive
ā¢ What is it?
ā¢ How do you prove value?
ā¢ What do you need to be successful
3. Healthcare has changed significantly in its
funding since the 1960s
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the
Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health
Expenditures by type of service and source of funds, CY 1960-2010; file nhe2010.zip).
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4. We are increasingly becoming a government
funded healthcare industry
Government
Private
1987 (Total = $519.1 billion)
Government
Private
2000 (Total = $1,377.2 billion)
Government
2010 (Total = $2,593.6 billion)
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group
https://www.cms.gov/NationalHealthExpendData/ (see Historical; NHE Web tables, Table 5).
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Private
6. Employer plans have changed dramatically
Distribution of Health Plan Enrollment, by Plan Type, 1988-2012
Conventional
1988
PPO
POS
HDHP/SO
73%
1993
16%
46%
1996
27%
1999
2000
8%
2001
21%
31%
10%
7%
2002
HMO
7%
14%
39%
29%
24%
42%
24%
21%
46%
23%
27%
52%
18%
54%
17%
2003
5%
24%
2004
5%
25%
2005 3%
2006 3%
55%
21%
20%
2007
3%
2008
2%
2009
1%
2010
1%
1%
21%
16%
8%
12%
60%
8%
10%
58%
56%
5%
13%
58%
55%
4%
13%
57%
20%
17%
15%
60%
19%
2011
15%
61%
20%
2012 <1%
26%
28%
28%
4%
11%
8%
10%
9%
13%
17%
19%
NOTE: Information was not obtained for POS plans in 1988. A portion of the change in plan type enrollment for 2005 is likely attributable to
incorporating more recent Census Bureau estimates of the number of state and local government workers and removing federal workers
from the weights. See the Survey Design and Methods section from the 2005 Kaiser/HRET Survey of Employer-Sponsored Health Benefits
for additional information.
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2012; KPMG Survey of Employer-Sponsored Health
Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988.
14. The delivery system adapts to new payment models, often
through consolidation- in 2012 consolidation hits a high
Physicians becoming employees of
Hospitals
ā¢ 40% of PCPs are now employed by hospitalsā
this has more than doubled in the last decade1
ā¢ In 2000, 1 in 20 specialists were employed by
hospitals, today itās 1 in 41
ā¢ 73% of surgical specialists recently reported
consolidation between physicians & hospitals
as ālikelyā or very likelyā in the near future2
Hospitals Consolidating &
Collaborating
ā¢ 2012 consolidation activity was highest since
20003 (94 deals4) & consolidation is projected to
continue
ā¢ But, the FDC is taking a watchful eye and blocked
4 deals in 20125
ā¢ In 2011, 92 deals were doneābut they were
much larger in dollar value4
ā¢ 52% of hospitals plan to acquire physician
practices in 20133
ā¢ Baylor and Scott & White plan to merge, includes
health plan
ā¢ 70% of hospital Execs say providers are
approaching them first3
ā¢ Cleveland Clinic announced collaboration with
Community Health Systems, TN (March 2013)
ā¢ Beth Israel Deaconess & Lahey Clinic are
āThe great consolidation is coming. It will
considering an affiliation, this would rival the
remake healthcare in coming years and
size of Partners in the Boston area (April 2013)
change itā¦for the betterā Delos
Cosgrove, CEO, Cleveland Clinic, March
2013
Sources: 1=As hospitals take over doctors' practices, fees rise, September 15, 2012, By Marni Jameson, Orlando Sentinel (stats from Southwind, an Advisory Board
Company); 2= 2013 Deloitte Survey of US Physicians; 3=Trend Watch: Physician Practice Acquisitions, Jackson Healthcare, March 2003; 3=Fitch: U.S. Hospital
Consolidation Activity Hits High in 2012 Spurred By Healthcare Reform, Jan. 2013; 4=Irving Lewis Associates, Jan 2013; 5=4 FTC-challenged hospital mergers of 2012,
FierceHealthcare, Dec. 2012.
15. Physician Practice
Acquisitions
Physician Consolidation Has Been Underway for the
Last Decade, and it is Now a Two-Sided Trend
1993 ā 95: Number of
hospital-owned practices
tripled
Direct
Employment
Health care reform
response
M&A
1995 ā 2002: Hospitalowned physician practices
suffered significant losses
Securing profitable FFS
procedures & surgeries
Physician Practice
Divestitures
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020
The āGreat Reconsolidationā
PhyCor
Collapses
ā¢ A number of market trends and expert consensus support
continued consolidation of physicians
ā¢ Consolidation will affect our businesses in different ways, as
technology and services decisions move to aggregators, where
supplies decisions may remain at the practice level
Source: Accenture; MGMA; Merritt Hawkins; Investment Banks
Wave 1 ā Specialist
Revenue
ā¢ Surgical specialists
ā¢ Proceduralists
ā¢ Internal Medicine /
Primary Care
Wave 2 (current)
ā¢ Direct employment
ā¢ Cardiology
ā¢ IM/Primary care
ā¢ Oncology
ā¢ Radiology
Wave 3
ā¢ Direct
employment
ā¢ CIN to
employment
ā¢ Multi-specialty to
corporate &
health system
18. Reimbursement Model Comparison
Model
Definition
Incentive
Fee-For-Service
Provider is paid for services previously rendered at
cost plus profit
No incentive. Although, itās been argued that
there is an incentiveā¦to provide more than
needed
Capitation
Provider is at risk for care delivered. Provider
receives a lump sum of $$ per member monthlyā
no matter how much or how little care is delivered.
Prevention & Efficiency. Provide the care that
is needed with an emphasis on keeping
patients well. Although, some feel this model
can incent providers not to provide care
Pay-forPerformance
Providers receive bonuses based on quality and
efficiency performance or other predetermined
metrics
Quality & Efficiency. Replacing some of the
other incentive driven programs. Large focus
on quality metrics.
Episodes of
Care/ Bundled
Payments
A group of providers receive a single payment for
care delivered to a patient for a defined bundle of
services related to an episode, such as a knee
replacement. Providers are at risk for that episode
of care.
Quality & Efficiency. Providers are incented
to improve care coordination and find more
efficient ways to deliver care
Global Payment
Providers are at risk for care delivered. Providers
receive a fixed-dollar payment for care delivered
during a given time period. Global payments are risk
adjusted, include incentives for quality and access,
and require more sophisticated systems to manage
care.
Prevention & Efficiency. Providers have an
incentive to constrain costs so as not to
exceed the global payment amount and to
integrate services in order to manage risk,
especially when payment covers services in
multiple settings.
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21. Provider concerns about value-based
reimbursement
Forbes Insights, Getting from volume to value in health care,
2012. www.forbes.com/forbesinsights
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