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Dr. Mark McClellan Presentation on Health Reform and Long-Term Care


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Dr. Mark McClellan spoke at the 2010 AAHSA House of Delegates meeting in Los Angeles about how health reform will affect long-term care providers.

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Dr. Mark McClellan Presentation on Health Reform and Long-Term Care

  1. 1. Long Term Services and Supports and Health Care Reform Mark McClellan, MD, PhD Engelberg Center for Health Care Reform The Brookings Institution 10/30/2010
  2. 2. 2 Overview • Health Care Reform and Long-Term Services and Supports: Goals vs Reality • Key Issues for Real Health Care Reform – Identify key opportunities to improve care – Measure – Align payments – Align benefits – Better evidence • Accountable Care • Next Steps
  3. 3. 3 Long Term Services and Supports: Essential Element of Health Care Reform • Large and growing part of health care expenditures • Over $200 billion annually (10% of total) • Expected to rise, along with doubling of older population in next 30 years • Disproportionately affects patients who account for most health care costs and spending growth • 80 percent Medicare spending from the 20 percent of beneficiaries with multiple chronic conditions • Disproportionate share of admissions, institutional costs, and other health care costs • Potential for “medical home” vs home
  4. 4. 4 Opportunities for Innovative LTSS • Promise: Reductions in overall health care costs and improvements in health, quality of life through… – Supportive care – Living arrangements – Technology – Other opportunities? • Reality: Uneven quality and availability, variations in quality, limited funding in traditional payment systems • Example: Preventing admissions and readmissions
  5. 5. 5 Traditional Health Care Reform • Expand coverage – More populations – Incremental coverage of enumerated services • Reduce payment rates, delay coverage of innovative services • Affordable Care Act: – Medicaid expansions and credits for insurance through health information exchanges – Incremental Medicare benefit expansions – Medicare payment reductions (and additional tax revenues) • Future outlook: rising cost pressures
  6. 6. 6 Achieving Real Health Care Reform: Aligning Policies and Care Goals • Health care reform • Measurement • Payment reform • Benefit reform • Better evidence
  7. 7. 7
  8. 8. 8 • Robust health IT infrastructure can greatly improve care delivery – VNSNY uses EHRs to exchange real-time information and care instructions, and telehealth to avoid visits – Care Management Plus provides special geriatric training to providers and tracks patient-provider conversations • Integration of medical services and social supports is essential – Guided Care uses highly skilled nurses to create an evidence-based care plan that helps integrate medical services and social supports • Sustain effective care delivery reforms through simultaneous payment and benefit reforms – PACE coordinates all medical services and social supports by combining various funding streams – ACOs/Shared Savings Programs: Support actual or virtual integration – PCMH: Carilion Clinic, TMC, Indianapolis, CCNC, Vermont pilots – Bundled payments • Better performance measurement should also be used to support and rigorously evaluate care delivery reforms – Long-Term Quality Alliance created to develop and implement quality measures reflecting care continuum, to achieve improvements in care Key Themes
  9. 9. 9 Accountable Care and Health Care Reform Absent or poor data leaves practice unexamined and presumption that more is better Better information that engages providers, supports improvement; informs consumers for best care Non-aligned payments reinforce problems, reward fragmentation, induce preventable complications and inefficient care Pay more for better, more efficient care: Align financial incentives with professional aims Principles Unclear aims creates conflicts about what we’re trying to produce Clarify aims: Better health, better care lower costs – for patients and communities Fragmented delivery system, without accountability for capacity, quality or costs Foster provider accountability for the full continuum of care – and for the capacity of the local health system Barrier
  10. 10. 10 1 2 3 Important Caveats • ACOs are not gatekeepers • ACOs do not require changes to benefit structures • ACOs do not require exclusive patient enrollment Key Elements of an ACO
  11. 11. 11 Improving Care through ACOs Challenges Need for More Effective Measures …promote more holistic care and effective care transitions through saved savings and performance measurement. …pay more to providers who use social supports effectively (e.g., providing care in lower cost settings, like the home, through integrating funding streams). …require robust performance measurement, which can help identify the most effective care strategies for those with multiple chronic conditions or functional impairments. Fragmentation of Financing and Care Lack of Integration between Medical Services and Social Supports ACOs…
  12. 12. 12 ACOs in the Affordable Care Act • Part of Medicare – Not Pilot Program – Wide range of provider groups meeting certain criteria can implement an ACO outside of traditional CMS demonstration process through shared savings program – Can collaborate or build upon private-sector and state-based ACOs • Evaluation Methods Based on Pre-Specified Benchmarks – New law authorizes pre-post budget projection approach that uses historical spending and utilization data to develop quantitative, pre- specified targets to track ACO performance • Broad Range of ACO Payment Models – Broader than current Medicare shared savings demonstrations – Benchmark based on projected absolute growth in national per capita expenditures – One-sided and two-sided/symmetric shared savings models – Range of partial capitation models can be established to replace a portion of fee-for-service payments
  13. 13. 13 ACOs in the Affordable Care Act • Medicare Shared Savings Program Starts Jan. 1, 2012 – Regulations from CMS expected around December 2010 – Qualifying Medicare ACO requirements: • Willingness to be accountable for quality, cost, and overall care of Medicare fee-for-service beneficiaries for a minimum of three years • Have a formal legal structure to receive and distribute shared savings • Have at least 5,000 assigned beneficiaries with sufficient number of primary care ACO professionals • Report on quality, cost, and care coordination measures and meet patient- centeredness criteria set forth by the HHS Secretary • May initially focus on one-sided shared savings models • Center for Medicare and Medicaid Innovation (CMI) to Evaluate Broad Range of Payment and Delivery Reforms by Jan. 1, 2011 – $10 billion appropriated for FY2011 to FY2019 – ACO and related pilots expected before the start of the 2012 Shared Savings program to test different ACO concepts • Interaction with Other Payment Reforms – Health IT Meaningful Use Payments – Payments for Quality Reporting and Improvement – Readmission-related payment incentives – Other Medicare Payment Reform Initiatives
  14. 14. 14 ACOs can strengthen ongoing reform efforts  Medical home  Episode, readmission initiatives  HIT Medical & social service coordination ACOs can operate in conjunction with current payment structures  FFS  Bundled payments  Partial/full capitation ACOs Confusing aims Fragmented care ACOs Provide Transition Path, Reinforcement for Value-Focused Payment Absent or poor measurement Wrong financial incentives
  15. 15. 15 Important Caveats • Accountability for assigned patients lies with the ACO, not individual providers alone • Providers are part of the ACO system of care • Providers affiliated with an ACO, even exclusively, can refer patients to non- ACO providers Unique primary provider assigned for each patient Unique primary provider assigned for each patient No “lock in” of patients to the ACO (not a gatekeeper model) No “lock in” of patients to the ACO (not a gatekeeper model) Assigned based on where they received primary care in the past Assigned based on where they received primary care in the past Minimizes “dumping” of high risk or high cost patients Minimizes “dumping” of high risk or high cost patients Beneficiary Attribution
  16. 16. 16 • New payment model: shared savings if quality targets met – Current per-capita spending for assigned patients determined from claims – Spending target is negotiated (private payers) or determined (Medicare) – If actual spending lower than target, savings are shared – IF quality targets are also achieved Actual Shared Savings ACO Launched Target Projected Incentives Aligned with Aims
  17. 17. 17 Advanced • ACOs use more complete clinical data (e.g., electronic records, registries) and robust patient-generated data (e.g., Health Risk Appraisals, functional status) • Well-established and robust HIT infrastructure • Focus on full spectrum of care and health system priorities Intermediate • ACOs use specific clinical data (e.g., electronic laboratory results) and limited survey data • More sophisticated HIT infrastructure in place • Greater focus on full spectrum of care Beginning • ACOs have access to medical, pharmacy, and laboratory claims from payers (claims-based measures) • Relatively limited health infrastructure • Limited to focusing on primary care services (starter set of measures) Measures should be outcome-oriented, span population and continuum of care, become more sophisticated along with care capabilities Meaningful Performance Measures
  18. 18. 18 • Providers to Whom Patients are Assigned: – Deliver primary and preventative care services to ACO patients (e.g., Internal Medicine & Family Practice, Endocrinology, Geriatrics, etc…) – Core responsibility for managing total cost and health • Other Specialists with Potential for High Resource Use and Care Impact: – Manage chronic diseases as well as resource intensive acute events (e.g., General Surgery; Hospitalists; Oncology, Orthopedics; etc…) • Other Specialists with some Potential to Impact Resource Use and Procedure Quality and Efficiency: – Typically do not have an ongoing relationship with patients (e.g., Anesthesiology; Radiology; Emergency medicine, etc…) • Long-Term Service and Support Providers: – Integrate or contract with other providers to provide care coordination and support services – Wellness, monitoring and adherence for chronic diseases – Less costly substitution for traditional health care • Non-Contracted Providers: – Providers not contracted with ACO can still provide care for patients ACO Provider Roles
  19. 19. 19 Next Steps from CMS • Regulations for the Medicare Shared Savings (ACO) program expected around Dec 2010 – Framed in terms of “Triple Aim”: Improve the health of the population; enhance the patient experience of care; and, reduce, or control, the per capita cost of care – Some form of patient notification likely to be required – Expect use of core set of nationally consistent performance metrics to measure progress – Expect to build on private/ multipayer payment reforms • Center for Medicare and Medicaid Innovation (CMI) – To evaluate pilot payment and delivery reforms beginning 2011 – $10 billion appropriated for FY2011 to FY2019 – Activity on ACO and related pilots expected before the start of the 2012 Shared Savings program, to test different ACO concepts • Opportunities for Interaction with Other Payment Reforms – Health IT Meaningful Use Payments, Grants – Payments for Quality Reporting and Improvement – Dual Eligible Initiatives – Regional and private-sector initiatives
  20. 20. 20 Benefit Reforms Based on Value • Money Follows the Person – Payments Directed by Beneficiary – Not Restricted by Coverage – Adjustments Based on Severity – Higher satisfaction and better outcomes for same/lower costs • Medicare Part D Experience – Benefit tiers now based on value (or drug cost?) – Much lower costs than projected • Implications for Health Care Reform – Benefit design reforms to support wellness, better adherence and healthier behaviors – More comprehensive and more personalized application of tiering: “Centers for Excellence” including LTSS – CLASS Act Implementation
  21. 21. 21 Better Evidence • Patient-Centered Outcomes Research Institute • Improving Infrastructure – Consistent Measures • Supported by ACOs, other payment reforms – Research Networks • Comparing Practices, Policy Reforms
  22. 22. 22 2009-10 Network 2010-11 Network Information-Seeking Conceptual Implementation • Focused on defining the ACO model and describing its technical components (e.g., patient attribution, performance measurement, etc.) • Included regular webinars, ACO materials, and discounts to events • Over 100 members including provider groups, payers, and policymakers • Provides practical leadership on how to implement an ACO especially in light of emerging Federal/state ACO regulations and pilots • Includes implementation-focused webinar series, exclusive member- driven conferences, Brookings- Dartmouth ACO newsletter, other web-based resources, and ACO implementation groups • Open to all parties interested in advancing accountable care – 1st webinar in late November Brookings-Dartmouth ACO Learning Network
  23. 23. 23 Time is Now • Alignment Strategy for Higher Value Now – Care reforms + payment reforms, before reimbursement tightens further – Stepwise, not too disruptive or incremental • Better Data to Support Care Improvement, Quality Measures – Faster and more meaningful access to needed data – Guidance from regional and national efforts for consistent performance measurement – Get paid for it (or collaborate with providers who get paid for it) by Medicare, Medicaid and private payers • Movement Toward Sustainable Payment Reform – Partner with other providers to improve care, track and share savings – Consider implementing now with private plans, states, community collaborations (will have momentum for coming CMS support) – Take integrated view of Medicare/Medicaid payment opportunities – Work on new contractual approaches with device and drug manufacturers that claim better outcomes, lower overall costs • Opportunities for Technical Support – CAST – ACO Learning Network – Expanding Federal support: ONC/Beacon support, HIT “Extension Centers,” Multiple Pilots