William Shrank: Payment reform activities at CMS
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William Shrank: Payment reform activities at CMS






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    William Shrank: Payment reform activities at CMS William Shrank: Payment reform activities at CMS Presentation Transcript

    • William Shrank, MD MSHS Division of Pharmacoepidemiology and Pharmacoeconomics Harvard Medical School Brigham and Women’s Hospital An Update on Payment Reform Activities at CMS and How Data Analytics and Rapid-Cycle Evaluation Support Transformation
    • The Innovation Center The charge: Identify, Test, Evaluate, Scale “The purpose of the Center is to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP…while preserving or enhancing the quality of care furnished.” “preference to models that improve the coordination, quality, and efficiency of health care services.” Resources: $10 billion funding for FY2011 through 2019 Opportunity to “scale up”: The HHS Secretary has the authority to expand successful models to the national level
    • Innovation Center Initiatives Coordinated Care: Accountable Care Organizations  Pioneer ACO Model  Advance Payment ACO Model Primary Care/Medical Homes  Comprehensive Primary Care Initiative (CPCI)  Federally Qualified Health Center Advanced Primary Care Practice Demonstration  Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Right Care: • Partnership for Patients • Community-Based Care Transitions • Bundled Payment for Care Improvement Innovation Infrastructure: • Healthcare Innovation Challenge • Innovation Advisors Program State/Medicaid/Duals: • State Demonstration to Integrate care for Dual Eligible Individuals • Financial Alignment to Support State Efforts to Integrate Care • Demonstration to Reduce Avoidable Hospitalizations of Nursing Facility Residents • Medicaid Health Home State Plan Option • State Innovation Models Preventive Care: • Million Hearts Campaign • Strong Start 3 INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
    • Partnershi p for Patients Bundled Payment Pioneer ACOs Global Payment for Dual- Eligibles ACOs -Advance Payment Comprehensive Primary Care Innovation Challenge Providers can choose from a range of care delivery transformations and escalating amounts of risk, while benefitting from supports and resources designed to spread best practices and improve care.
    • Coordinated Care Initiatives Accountable Care Organizations • Pioneer ACO Model • Advance Payment ACO Model Primary Care/Medical Homes • Comprehensive Primary Care Initiative (CPCI) • Federally Qualified Health Center Advanced Primary Care Practice Demonstration • Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration
    • The Pioneer ACO Model GOAL: Test the transition from a shared-savings payment model to a population-based payment. Designed for health care organizations and providers that are already experienced in coordinating care. Focused on improving the health and experience of care for individuals, improving population health, and reducing the rate of growth in health care spending. CMS will publicly report the performance of Pioneer ACOs on quality metrics. Awardees announced, programs have begun
    • Advance Payment Model GOAL: Test whether pre-paying a portion of future shared savings will increase participation and success of physician-based and rural ACO’s in the Medicare Shared Savings Program. Three ways in which participating ACOs may receive payment: 1. Upfront fixed payment 2. Upfront payment based on number of Medicare patients served 3. Monthly payment based on number of Medicare patients Application deadlines were consistent with Medicare Share Savings Program.
    • GOAL: Test a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. • Requires investment across multiple payers, because individual health plans, covering only their members, cannot provide enough resources to transform primary care delivery. CMS has invited public and private insurers to collaborate in purchasing high value primary care in communities they serve. • Medicare will pay approximately $20 per beneficiary per month (PBPM) then move towards smaller PBPM to be combined with shared savings opportunity. • 7 markets selected where majority of payers commit to investing in comprehensive primary care; approximately 75 practices per market. Comprehensive Primary Care initiative (CPCi)
    • Multi-payer Advanced Primary Care Practice Model GOAL: Test the effectiveness of offering providers a common payment method from Medicare, Medicaid, and private health plans. Medicare will participate in existing State multi-payer health reform initiatives. • Must include participation from Medicaid and private health plans. Monthly care management fee for beneficiaries receiving primary care from Advanced Primary Care practices. Eight states selected: Maine, Vermont, Rhode Island, New York, Pennsylvania, North Carolina, Michigan and Minnesota.
    • Federally Qualified Health Center Advanced Primary Care Demonstration GOAL: Evaluate impact of the advanced primary care practice model in the Federally Qualified Health Center (FQHC) setting. Open to FQHCs that have provided medical services to at least 200 Medicare beneficiaries in previous 12-month period. FQHC receives care management fee for each Medicare beneficiary enrolled. Striving to meet NCQA level 3 medical home status. 500 FQHCs were selected. Performance year started Nov 1st 2011.
    • Right Care Initiatives • Partnership for Patients • Community Based Care Transitions Program • Bundled Payment for Care Improvement
    • Improving Patient Safety GOAL: Testing intensive programs of support hospitals as they make care safer. • Provide training, support, and technical assistance for hospitals and other care providers. • Establish and implement a system to track and monitor hospital progress towards attaining quality improvement goals. • Engage patients and families in the process of improving patient safety. • Establish a network of “Vanguard Hospitals” to work on new ways to reduce all-cause harm in hospitals. $500 million for hospitals and other providers to improve patient safety. Awards given in the late 2011.
    • Partnership for Patients: Better Care, Lower Costs New nationwide public-private partnership to tackle all forms of harm to patients. GOALS: 40% Reduction in Preventable Hospital Acquired Conditions over three years.  1.8 Million Fewer Injuries  60,000 Lives Saved 20% Reduction in 30-Day Readmissions in Three Years.  1.6 Million Patients Recover Without Readmission  $35 Billion Dollars Saved in Three Years Over 3,800 hospitals have signed pledge.
    • Community-based Care Transitions Program (CCTP) $500 million available for community-based organizations partnered with hospitals to reduce 30-day hospital readmissions. GOALS: • Improve transitions of beneficiaries from inpatient hospitals to home or other care settings. • Reduce readmissions for high risk beneficiaries. • Document measurable savings to the Medicare program.
    • Bundled Payments for Care Improvement • • • •
    • Innovation Infrastructure • Healthcare Innovation Challenge • Innovation Advisors Program
    • Health Care Innovation Awards To identify and support a broad range of innovative service delivery and payment models that achieve better care, better health and lower costs through improvement in communities across the nation. Round 1: Around $900 million committed, with individual awards ranging from approximately $1M to $30M.
    • Innovation Advisors Program GOAL: Support the Innovation Center’s development and testing of new models of payment and care delivery in their home organizations and communities. •Opportunity to deepen key skill sets in: o Health care economics and finance o Population health o Systems analysis o Operations research and quality improvement  1 year commitment; 6 months of intensive training.  Up to $20K Stipend available to home organizations.  Up to 200 individuals will be selected within the first year.  For further information, see: www.orise.orau.gov/IAP 18
    • State/Medicaid/Duals Initiatives • State Demonstration to Integrate Care for Dual Eligible Individuals • Financial Alignment to Support State Efforts to Integrate Care • Demonstration to Reduce Avoidable Hospitalizations of Nursing Facility Residents • Medicaid Health Home State Plan Option
    • Financial Models to Support State Efforts to Coordinate Care for Medicare-Medicaid Enrollees GOAL: Align financing and improve care for dual eligible populations Two models: Capitated Model • State, CMS, and a health plan enter into three-way contract. • Health plan receives a prospective blended payment. Managed Fee-for-Service Model • State and CMS enter into an agreement. • State could benefit from savings resulting from initiatives designed to improve care for dual eligible beneficiaries.  All states that meet program standards and conditions will have the option to pursue either or both of these models.
    • CMS State Innovation Models  Purpose : To test whether new payment and service delivery models will produce greater results when implemented in the context of a state-sponsored Comprehensive Health System Transformation Plan.  States are expected to:  Apply all state policy levers, including things such as scope of practice credentialing, provider licensing, public health activities;  Ensure multi-payer participation in new integrated payment and service delivery models;  Drive transformation of state hospitals and medical schools;  Coordinate multiple ACA-supported activities, including insurance exchanges, CMMI models, and Medicaid waiver activities; and,  Promote prevention and integrate community health services to address the determinants of poor health.
    • Preventive Health: Strong Start  Strong Start I  A nationwide public awareness effort working to improve the health of moms and babies by encouraging mothers and practitioners to let labor begin on its own: CMMI based initiative Goal: Reduce incidence of early elective deliveries (scheduled induction or cesarean without medical indication before 39 weeks)  Strong Start II  MIHOPE-SS (home visiting through Nurse Family Partnership and Healthy Families America)  HRSA project with ACA mandate; evaluation funds from CMMI  Three approaches to enhanced prenatal care: CMMI based initiative Goal: Reduce incidence of preterm birth among high risk Medicaid beneficiaries
    • Preventive Care Initiatives • Million Hearts Campaign
    • Rapid-Cycle Evaluation  “Be part of the solution”: Gather information and leverage our claims data to promote and support continuous quality improvement in the marketplace.  Speed: Improve our data systems and our ability to use data so that we can frequently and rapidly assess effectiveness and provide feedback to providers.  Rigor: Use advanced epidemiologic methods to measure effectiveness to meet a high standard of evidence and allow for certification.
    • No “Turnkey” Solutions  The models require fundamental changes in the structure of healthcare delivery  Realigning incentives for health systems, primary care, hospitals, home-care  Substantial learning and adaptation will be necessary before achieving the greatest efficiencies  Healthcare delivery in these models will be maturing once implemented  RCTs not feasible in most cases
    • Blurring the Lines Between Formative and Summative Evaluation  Feedback to clinicians includes comparisons against controls and other participants  Impact assessments early after implementation in hopes of identifying and scaling successful programs as soon as possible
    • Key Features of Formative Evaluation and Feedback  Understand the context: Gather qualitative data from providers and health systems to assess perceptions/barriers/enablers of success  Study the process: We will ask providers to report how they implement different models  Regularly measure performance: Frequently apply automated measurements of effectiveness using claims data  Developing capacity to perform these analyses faster in-house
    • Key Features of Formative Evaluation and Feedback  Provide frequent feedback and reports to providers/systems:  Collaborate with Learning and Diffusion team to deliver data to providers in ways that can be easily interpreted  Deliver data to promote more helpful self-evaluation  Develop learning collaboratives to spread effective strategies for each model as well as to identify failing approaches
    • Summative Evaluation – Speed without Sacrificing Rigor  Program Design: Evaluation team participates in all phases of design  Sample selection for intervention (generalizability)  Availability of control groups  Sample size (power)  Measurement:  Standardized priority outcome metrics across models  Unique metrics for each intervention  Patient and provider experience metrics  Develop population-based metrics; equity; access  Specific metrics unintended consequences
    • Summative Evaluation – Speed without Sacrificing Rigor  Methods: Time-series analyses that allow us to assess both changes in level and slope of improvement  Includes transition phase to account for time to “learn”  Partnership: Communicate early and often with the actuaries  Consider how soon we can expect changes and when a model can be deemed certifiable
    • New Methods  Automating and improving performance reporting  Selecting comparison groups  Aligning, improving and harmonizing measures  Establishing clear thresholds for evidence standards needed to scale models  Developing a “kill switch” for failing programs  Disentangling multiple program effects  Adjusting for multiple sources of selection bias
    • Primary Goal: To Promote Value in Healthcare  At the core of our models a fundamental realignment of incentives to promote:  Improved Quality  Greater Efficiency  Less Waste and Variability  And NOT Greater Volume