Healthcare Reform: Implications for the Trustee- Audit and Compliance Committee Conference
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Healthcare Reform: Implications for the Trustee- Audit and Compliance Committee Conference



This presentation will explore fundamental ...

This presentation will explore fundamental
strategies including: the passage of health reform legislation will require new skills and competencies for
trustees, anticipated change in the delivery system will
shift the focus of board work from competition
to collaboration and from maximizing revenue
to increasing value, payment reform will require trustees to
better understand quality data, performance
improvement and the impact of quality on
revenue production,physician partnership in delivering healthcare value for patients will become an increasingly
important strategic approach for governance.



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Healthcare Reform: Implications for the Trustee- Audit and Compliance Committee Conference Healthcare Reform: Implications for the Trustee- Audit and Compliance Committee Conference Presentation Transcript

  • Healthcare Reform: Implications for the Trustee Health Care Compliance Association Audit and Compliance Committee Conference February 7, 2011
  • Overview • Elements of Reform – Coverage – Payment Reforms – Delivery System Reforms – Quality and Patient Safety • Physician Relationships
  • Elements of Reform
  • It’s the law - March 23, 2010
  • 5 Hospitals will be: • More Integrated • More Accountable • More At-Risk
  • Elements of Reform • Coverage • Payment Reforms • Delivery System Reforms • Quality and Safety
  • Coverage
  • Coverage • Expands access to coverage to 32 million individuals by 2019 • A combination of public program expansions and private section health insurance reforms. • Beginning in January 1, 2014, all U.S. citizens and legal residents would have to obtain coverage or face a tax penalty. • Those without employer plans can obtain coverage through newly formed "health insurance exchanges." • Subsides are available to assist low-income individuals with the purchase of health insurance premiums and Medicaid would be expanded to provide coverage for the poor. • While employers are not required to provide coverage, large employers will be charged a "free rider" assessment if their employees purchase health care coverage through the exchange with federal premium subsidies.
  • • Number of uninsured has fallen – Lowest in nation (2.5 percent) • Cost of plan higher than expected – More individuals receiving subsidies – Prescription drugs covered as a benefit – Health care costs rising faster than expected • Employer penalty fund generating less revenue than expected • Provider concerns – Lack of primary care in some areas – Safety net provider viability – Promised Medicaid payment increases did not result The Massachusetts Experience
  • Implications for Trustees • Planning for New Volume • ER Overcrowding • Hospital Flow • Lower Rates of Reimbursements • Matching Costs to Revenue Levels
  • Payment Reform
  • Payment Reform • Readmission Penalties – Hospitals will be penalized for “excessive readmissions;” reducing readmissions requires better management of patient post-discharge • Bundling – national, voluntary pilot program for acute care hospitals, LTCHs, IRFs, doctors, SNF, and HHA to receive bundled Medicare payments in selected conditions. • Chronic Disease Management
  • Readmissions • Beginning in FY 2013, imposes financial penalties on hospitals for so-called "excess" readmissions when compared to "expected" levels of readmissions based on the 30-day readmission measures for heart attack, heart failure and pneumonia that are currently part of the Medicare pay-for reporting program. • Excludes critical access hospitals and post-acute care providers.
  • Readmissions • Synthesizes the underlying strategies from the interventions that have been successful in reducing unplanned readmissions • Organized by the three stages of the care continuum: during hospitalization, at discharge, and in the period immediately following discharge • An evaluation of the level of effort required for their implementation
  • Bundling Beginning in 2013, requires the Secretary to establish a national, voluntary, five-year pilot program on bundling payments to hospitals, doctors and post-acute care around 10 conditions. If successful, the Secretary may expand the pilots after 2015.
  • Primary Care Physicia ns Specialty Care Physicia ns Outpatien t Hospital Care and ASCs Inpatient Hospital Acute Care Long Term Acute Hospital Care Inpatient Rehab Hospital Care Skilled Nursing Facility Care Home Health Care Medical Home Acute Care Bundling Acute Care Episode with PAC Bundling PAC Episode Bundling Models of Service DeliveryAccountable Care Organizations
  • AHA Research Synthesis Report Bundled Payment • May 2010 • Sample bundled payment programs • Results / Outcomes • Key issues for consideration 17
  • Implications for Trustees • At Risk Payments • Partnering – Physicians – Other Providers • System Redesign – Improved Outcomes – Infrastructure Support
  • Delivery System Reform
  • Delivery System Reform… • Accountable Care Organizations – beginning 2012, allows physicians, hospitals and others to participate in a “shared savings” program with Medicare. Allows partial capitation. • Center for Medicare & Medicaid Innovation – Beginning January 2011, allows testing of innovative payment and service delivery models.
  • …Delivery System Reform • Patient-Centered Medical Home – grants to create community-based interdisciplinary health teams to support primary care, and capitated payments primary care providers. • Independence at Home – beginning January 2012, crates demonstrations targeting physicians and nurse practitioner home-based primary care teams for high risk patients.
  • Delivery System Reform • Achieving Integration –Accepting Risk –Continuum of Care –Quality Management and System Improvement –Chronic Care Management
  • Implications for Trustees • New Governance Structures – Shared Governance – Trustee Skills and Competencies – New Information • Strategic Initiatives – Wellness vs. Sick Care – Community Involvement • Redesigned Outcomes – Measures of Success
  • Quality and Patient Safety
  • Quality and Patient Safety • Increase Transparency • Value-based Purchasing • Readmissions • Hospital-acquired Conditions • Minimizing Disparities • Comparative Effectiveness Research
  • Value-Based Purchasing (VBP) • Establishes a VBP program for hospital payments beginning in FY 2013 based on hospitals' performance in 2012 on measures that are part of the hospital quality reporting program. • The program is budget neutral. • Redistributes 1 percent of hospital payments in FY 2013, growing over time to 2 percent in 2017 and beyond.
  • Current CMS Reporting Heart Attack (Acute Myocardial Infarction) • Aspirin at arrival • Aspirin prescribed at discharge • ACE inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction • Beta blocker at arrival • Beta blocker prescribed at discharge • Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival • Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI) • Adult smoking cessation advice/counseling Heart Failure (HF) • Left ventricular function assessment • ACE inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction • Discharge instructions • Adult smoking cessation advice/counseling Pneumonia (PNE) • Timing of receipt of initial antibiotic following hospital arrival • Pneumococcal vaccination status • Blood culture performed before first antibiotic received in hospital • Adult smoking cessation advice/counseling • Appropriate initial antibiotic selection • Influenza vaccination status Surgical Care Improvement Project (SCIP) Prophylactic antibiotic received within 1 hour prior to surgical incision • Prophylactic antibiotics discontinued within 24 hours after surgery end time • SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patients • SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery • SCIP Infection 2: Prophylactic antibiotic selection for surgical patients • SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose • SCIP Infection 6: Surgery Patients with Appropriate Hair Removal Mortality Measures • Acute Myocardial Infarction 30-day mortality Medicare patients) • Heart Failure 30-day mortality (Medicare patients) • Pneumonia 30-day mortality (Medicare patients) Patients' Experience of Care • HCAHPS Patient Survey
  • New CMS Measures for 2010 Surgical Care Improvement Project (SCIP) Measure: • SCIP Cardiovascular 2, surgery patients on a beta blocker prior to arrival who received a beta blocker during the peri-operative period Re-admission Measure: • Heart failure (HF) 30-day risk standardized re-admission measure (Medicare patients) Nursing Sensitive Measure: • Failure to rescue (Medicare patients) AHRQ Patient Safety and Inpatient Quality Indicator Measures (9): • Patient Safety Indicators (PSIs) • Death among surgical patients with treatable serious complications • Iatrogenic pneumothorax, adult • Postoperative wound dehiscence • Accidental puncture or laceration • Inpatient Quality Indicator Measures • Abdominal aortic aneurysm (AAA) mortality rate (with or without volume) • Hip fracture mortality rate • Mortality for selected medical conditions (composite) • Mortality for selected surgical procedures (composite) • Complication/patient safety for selected indicators (composite) Cardiac Surgery Measure: • Participation in a systematic database for cardiac surgery
  • Hospital-Acquired Conditions (HACs) Beginning in FY 2015, adds a 1 percent penalty to hospitals in the top quartile of rates of HACs, resulting in reductions of $1.5 billion over 10 years
  • Implications for Trustees • Understanding Quality Data – Performance Quartiles – Readmission Rates – At Risk Payments • Programs to Reduce Avoidable HAC • Partnering – Physicians
  • Physician Relations
  • Health Care Reform Opportunities New structures to encourage physician-hospital collaboration … – Bundling – Accountable Care Organizations – Center for Medicare & Medicaid Innovation New policies to encourage hospitals to reach out to physicians … – Hospital Value-Based Purchasing – Hospital Readmissions. – Hospital-Acquired Conditions New opportunities to encourage physicians to reach out to other providers … – Patient-Centered Medical Home – Independence at Home
  • Where Are We Heading? • Accountable Care Organizations – MedPAC analysts define an ACO as an integrated health care delivery system that relies on a network of primary care physicians, one or more hospitals, and subspecialists to provide care to a defined patient population. • Don Berwick’s Triple Aim – Improve the health of the population – Enhance the patient experience of care (including quality, access, and reliability) – Reduce, or at least control, the per capita cost of care • Alternative Quality Payment Mechanism – BC/BS of MA AQC
  • Year1 Year2 Year3 Year4 Year5 Key Components of the Alternative Quality Contract Expanded Margin Opportunity INITIAL GLOBAL PAYMENT LEVEL Efficiency Opportunity Inflation Performance • Initial global payment level based on health status adjusted regional network averages • Inflation factor derived from CPI • Providers benefit from this model by a) achieving high performance on quality and safety metrics and b) driving efficiencies while managing to a global payment level • Customers benefit from this model due to more predictable and controlled trend • Full payment of the incentive is based on achieving “Gate 5” performance on all measures in a given year • Partial payment will be based on achieving performance levels along a continuum
  • Physician-Hospital Relationships… • Physicians and hospitals are reexamining their respective strategic and operating roles in light of a changing landscape… – improving quality and safety of care while achieving cost containment, – new patient care models, – on call coverage – local competition, and – regulatory environment, including specialty services, reporting and payment
  • …Physician-Hospital Relationships • Pay for performance, requiring greater measurement and disclosure, will create new dynamics relative to—achieving quality and cost objectives and the relationship between physicians and hospitals, including governance of the “medical franchise”
  • Shared Interests Physician ViewTraditional Hospital View Interdependent Independent Associated
  • Reframing the Discussion Structure and Control Accountability and Performance
  • Engaging Physicians 1. Discover Common Purpose 2. Reframe Values and Beliefs 3. Segment the Engagement Plan 4. Use “Engaging” Methods 5. Demonstrate Constancy of Purpose 6. Adopt an Engaging Style Adapted from: Engaging Physicians in a Shared Quality Agenda, IHI, Innovation Series 2007
  • Discover Common Purpose • Improve patient outcomes • Reduce hassles and wasted time • Create the organization’s desired culture • Respect the legal opportunities and barrier
  • Reframe Values and Beliefs • Make physicians partners, not customers • Promote both system and individual responsibility for quality
  • Segment the Engagement Plan • Use the 20/80 Rule • Identify and activate champions • Educate and inform structural leaders • Develop project management skills • Identify and work with “laggards”
  • Use “Engaging” Methods • Standardize what’s standardizable, and no more • Generate light, not heat, with data • Make the right thing easy to try • Make the right thing easy to do
  • Demonstrate a Constancy of Purpose • Provide consistent expectations and accountability at all levels of the organization including the Board
  • Adopt an Engaging Style • Involve physicians from the beginning • Work with the real leaders • Work with early adopters • Make physician involvement visible • Build trust within each initiative • Communicate candidly, often • Value physicians time with your time
  • New Social Contract • Traditional Physician Compact –Autonomy –Protection –Entitlement • New Physician Compact –Partner/Patient Focus –Interdependence –Delegated Authority
  • Planning a New Social Contract • Set Aside the Time • Make It an Explicit Statement of Mutual Expectations • Needs of Patients First • Front-line Physicians • Invest in Communications • Develop Physician Leaders • Define the Purpose of the MSO • Provide Adequate Resources
  • Redefinition Process • Yearlong Process • Committee of Physicians, Board Members and Human Resource Personnel • Included –Code of Conduct –Responsibilities –Accountabilities
  • Moving Forward • Establish a Steering Group –Board, Medical Staff, Administration –Focus on Mutual Goals and Improved Medical Staff Cohesiveness –Develop a Physician-Hospital Strategic Plan –Develop Timeline and Mileposts
  • Elements of a Plan • Define the Problem –Market Analysis –Consumer Awareness • Medical Staff Development –Inventory –Projected Physician Needs • Medical Staff Relations –Survey Service Needs –Establish Expectations –Measure Results
  • Recommendations How to develop true partnership with the support of your Medical Staff: – Educate all parties – Address the silos – Focus on improvement of patient care – Integrate evidence-based best practices – Provide financial support for leadership development, quality and clinical management activities – Celebrate success
  • Summary
  • Core Competency: Manage quality, patient safety, costs, and patient experience during more of the episode Reach: Connections to other care givers, patients pre- and post- Sharing: Share information on patients, quality, costs; share incentives Integration: Accepting Risk, Managing Care Integration Least Greatest Make Collaborate Buy
  • Summary • Understand quality and safety data • Tie between quality and safety performance and financial performance • Understanding clinical care risk • Collaborating vs. Competing • Moving from maximizing revenues and utilization to controlling costs and utilization