PYA Principal David McMillan addressed the 2013 Florida Institute of Certified Public Accountants Health Care Industry Conference and offered a consultant-turned-linguist perspective on “Learning the New Language of Healthcare.”
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
PYA Speaks the New Language of Healthcare
1. Page 0April 25, 2013
Florida Institute of Certified Public Accountants
Learning the New
Language of Healthcare
April 25, 2013
2. Page 1April 25, 2013
Florida Institute of Certified Public Accountants
What am I Trying to Say?
Everyone knows these…
LOL Laughing out loud
SMH Shaking my head
BRB Be right back
JK Just kidding
BFF Best friends forever
BTW By the way
But what about these?
PQRS Patient Quality
Reporting System
PCMH Patient Centered
Medical Home
CIN Clinically Integrated
Network
VBP Value-Based
Purchasing
3. Page 2April 25, 2013
Florida Institute of Certified Public Accountants
ACO
CIN
PHO
VBP
PQRS
Are We Speaking the
Same Language?
4. Page 3April 25, 2013
Florida Institute of Certified Public Accountants
But health reform isn‟t just changing the industry we work in –
it‟s changing the language we speak.
Healthcare Has Changed!
Payers
Healthcare Facilities
Specialists
Primary Care Physicians
Patients
Moving from… Moving toward…
Patients
Primary Care Physicians
Healthcare Facilities
Specialists
Payers
5. Page 4April 25, 2013
Florida Institute of Certified Public Accountants
U.S. Healthcare Today:
High Cost, Questionable Quality
Where is the Value??
$2,729 $2,870 $2,902
$3,470 $3,696
$7,538
Japan Italy Spain Sweden France U.S.A.
Total Health Expenditures
per Capita
1 France
2 Italy
7 Spain
10 Japan
23 Sweden
37 U.S.A.
WHO's Ranking of Health
by Country
Source: Organization for Economic Co-operation and
Development (2010), "OECD Health Data", OECD Health
Statistics (database).
6. Page 5April 25, 2013
Florida Institute of Certified Public Accountants
Today’s Healthcare:
Moving from Volume to Value
• FFS: Fee-for-Service
– The primary method of healthcare reimbursement that incentivizes
providers to provide higher volumes of services because payment is
solely dependent upon the quantity of services provided, not the
quality
– Payments are issued retrospectively
– FFS has been proven to raise healthcare costs
because it promotes overutilization
• As U.S. healthcare costs associated with FFS skyrocket,
significant efforts have been taken to link payment to the
quality and efficiency of care provided instead of volume.
7. Page 6April 25, 2013
Florida Institute of Certified Public Accountants
Bundled
Payments
Partial
Capitation
Global
Payment
Fee-for-
Service
Shared
Savings
Visitor
Symptomatic
Acute Needs
Services & Supplies
Unit Based
No Financial Risk
Patient
Episode
Most Common
Conditions
Packaged Treatments
Efficiency Based
Partial Financial Risk
Person
Overall Health
Community Health
Characteristics
Manage Well-Being
Outcome Based
Full Financial Risk
Evolution of Reimbursement
8. Page 7April 25, 2013
Florida Institute of Certified Public Accountants
The Healthcare System of the Past
Patients
Physicians/Providers Payers
Hospitals & Other
Providers
Inefficiency
Information
Economics
9. Page 8April 25, 2013
Florida Institute of Certified Public Accountants
Hypothetical
Episode 1: Hip Replacement
• Orthopedic surgeon
• Surgery
- Anesthesia
- Pathology
• Acute Care
• Rehabilitation
- PT
Martha is a 67-year-old women who needs a hip replacement.
- payment
- payment
- payment
- payment
- payment
Develops rash – dermatology consult - payment
Episode 2: Nine months later
• ED
• Admitted for pneumonia
• Treated by hospitalist
• Consulted by cardiologist
- payment
- payment
- payment
Episode 3: Six months later – Well Check
• Gaping hole in information
• Information from previous two
episodes of care may never reach
primary care provider
- Drug interactions
- Duplicative testing
- payment
11. Page 10April 25, 2013
Florida Institute of Certified Public Accountants
What Does “Value” Look Like?
VALUE=
QUALITY COST EFFICIENCY+ +
12. Page 11April 25, 2013
Florida Institute of Certified Public Accountants
What is a “Value-Based
Payment” Model?
Value-Based Payment:
A payment model which rewards healthcare providers
for meeting certain predetermined performance
measures related to quality and efficiency
Efficiency: The state or quality of achieving
maximum productivity with minimum
wasted effort or expense.Quality: The standard of something as
measured against other things of a similar
kind; the degree of excellence of
something: “quality of life;” also the
general excellence of standard or level.
Value: The regard that something is held to
deserve; the importance or preciousness
of something: “Your support is of great
value.”
13. Page 12April 25, 2013
Florida Institute of Certified Public Accountants
Value: The Answer to FFS?
VBP: Value-Based Purchasing
CMS reimbursement model shifting away from paying
providers based only on volume of services provided
Creates incentives to encourage healthcare providers to
render high quality care and lower total costs
Goal is to foster joint clinical and financial accountability
14. Page 13April 25, 2013
Florida Institute of Certified Public Accountants
HVBP: Hospital Value-Based Purchasing
CMS initiative that adjusts acute-care hospitals‟ payments for the quality of care that
they provide to Medicare beneficiaries – quality over volume!
Hospitals‟ payments adjusted for how closely they follow best clinical practices and
how well the hospital enhances the patients‟ experiences of care
When hospitals follow proven best practices, patients receive higher quality care and
see better outcomes.
Value: HVBP
“Several industries have transformed themselves with human errors in mind. The airline industry is a
favorite example. As a result of air craft design, regulation, the use of checklists, and other systems
designs, we are almost guaranteed to reach our final destination safely. According to data collected
between 2000 and 2005, the chances of a fatality on a US airline flight was one in 22.8 million.”
– IHI Open School, Not Just Great Ideas: The Surgical Safety Checklist and the ICU Walker.
15. Page 14April 25, 2013
Florida Institute of Certified Public Accountants
• Participating hospitals began receiving
payments/penalties for quality of care October 1, 2012,
the start of FY2013. The incentive payments are based
on a hospital‟s performance during the period from July
1, 2011 to March 31, 2012.
• HVBP is based on data collected through the Hospital
Inpatient Quality Reporting (IQR) Program.
– CMS has adopted 13 of 45 quality measures
tracked in the IQR for FY2013.
Value: HVBP
16. Page 15April 25, 2013
Florida Institute of Certified Public Accountants
HVBP
• Penalties for high readmission rates
– FY12-14 for AMI, heart failure, and pneumonia;
expand list in FY15
– Reduce overall inpatient payment by 1%-3%
• Rewards and penalties based on quality
measures and patient satisfaction scores
– Begins in FY13, but based on earlier performance
• Penalties for Hospital Acquired Conditions (HACs)/Never
Events
– In FY15, top 25% in HACs will have payments reduced by 1%
17. Page 16April 25, 2013
Florida Institute of Certified Public Accountants
Value: PVBP
PVBP: Physician Value-Based Purchasing
• Physician feedback program
– Individual reports on resource use and quality of care
as compared to peer group
• Physician value-based payment modifier
– Phased in between 2015 and 2017
– 2013 performance determines 2015 modifier
– Budget neutral
– wRVU x conversion factor x VBPM
• Positive number = paid more
• Negative number = paid less
18. Page 17April 25, 2013
Florida Institute of Certified Public Accountants
• PQI: Physician Quality Incentives
– PQRS: Physician Quality Reporting System
• When created in 2007, initially named the Physician Quality Reporting
Initiative (PQRI) and included 74 clinical quality measures for
physicians to report via claims data
• Today, PQRS has over 203 quality
measures available for reporting,
including both clinical and structural,
that can be reported through claims
or accepted registries
• Paid for reporting (pay-for-reporting
or P4R), not attaining certain scores
(pay-for-performance or P4P)
PQI, PQRS, P4R, and P4P!
19. Page 18April 25, 2013
Florida Institute of Certified Public Accountants
Physician Quality Reporting System
(PQRS)
• Today - 203 quality measures available for
reporting
• Paid for reporting (pay-for-reporting or P4R),
not attaining certain scores (pay-for-
performance or P4P)
• Carrots followed by sticks
– 0.5% bonus for 2012-2014
– 1.5% penalty for 2015
– 2.0% penalty for 2016 and thereafter
20. Page 19April 25, 2013
Florida Institute of Certified Public Accountants
Other Forms of PQI
Meaningful Use Incentives/Penalties
- Stage One objectives and clinical quality measures
- 1% penalty in 2015 if not MU in 2014; 2% in 2016;
3% in 2017; 4% in 2018 or 2019
Electronic Prescription Incentive Program
- 1.0% bonus in 2011(unless received EHR bonus)
- 1.0% penalty in 2012 unless used eRx 10x by 06/30/11
- 1.5% penalty in 2013 unless used eRx 25x by 12/31/11
MU
eRx
21. Page 20April 25, 2013
Florida Institute of Certified Public Accountants
To Achieve Value, Moving Toward
Integration and Alignment
More IntegrationLess Integration
More Common
Less Common
Equipment JV
Clinical Co-
Management
Medical Directorships
ACO
Real Estate JV
Medical Home
Models
PHO/ Narrow
NetworkBundled
Payments
Professional Services
Agreement
Physician Employment
22. Page 21April 25, 2013
Florida Institute of Certified Public Accountants
Clinical Integration (CI):
The Basics
The extent to which healthcare services are coordinated
across providers, functions, activities, processes, and
operating units so as to maximize the value of services
delivered
Includes both horizontal integration (coordination of
activities at the same stage of delivery of care) as well
as vertical integration (the coordination of services at
different stages)
23. Page 22April 25, 2013
Florida Institute of Certified Public Accountants
PCMH
PCMH: Patient-Centered Medical Home
• Improves primary care through patient-
centered care, cooperation among physicians,
and coordination and tracking care over time
• Facilitates partnerships among patients, their
physicians and the patient‟s family members
• Care is facilitated by registries, health
information technology (HIT), health
information exchange (HIE), etc. to ensure
that patients receive the appropriate care at
the appropriate time in the appropriate manner
Patient-Centered Medical
Home
Primary Care
Physician
+ Coordinated Care
+ $ for Coordinated Care
24. Page 23April 25, 2013
Florida Institute of Certified Public Accountants
IPA: Independent Practice Association
• Association of medical doctors
(primary care physicians and
specialists) and other healthcare
professionals that have contracted
with most PPO, POS, and HMO
insurance plans
IPA
Specialist
Physician
Physician
Primary Care
Physician
25. Page 24April 25, 2013
Florida Institute of Certified Public Accountants
PHO
Primary
Care
Physician
Specialist
Physician
PHO: Physician Hospital Organization
• Joint venture between hospital(s)
and physician group(s)
• Acts as a single agent for managed
care contracting
• Aligns interests of hospitals and
physicians but allows each to retain
autonomy
• Opportunity to act as a vehicle to
advance clinical integration network
initiatives
Physician
26. Page 25April 25, 2013
Florida Institute of Certified Public Accountants
CIN
CIN: Clinically Integrated Network
A network of physicians working in collaboration with a
hospital, using a performance management infrastructure
to develop and implement initiatives to improve the
quality and efficiency of healthcare services
Network negotiates and contracts with payers for
improved reimbursement based on quality and efficiency
27. Page 26April 25, 2013
Florida Institute of Certified Public Accountants
What Does a CIN Do?
Coordinates continuum of care across affiliated caregivers
Implements evidence-based clinical protocols
Establishes related quality measures and performance standards
Evaluates individual performance and implements improvement plans
Partners with payers to develop contracts that drive definable clinical
improvement and efficiencies
28. Page 27April 25, 2013
Florida Institute of Certified Public Accountants
Clinical Integration:
the Road from FFS to ACO
FFS
P4P,
Bundled Payment
Partial/Global
Capitation
Payers
Providers
Hospitals
Payers
CIN
(P4P) ACO
29. Page 28April 25, 2013
Florida Institute of Certified Public Accountants
ACO: Accountable Care Organization
• Network of physicians and hospitals sharing responsibility
for providing care to patients
• Agree to manage all of the healthcare needs of at least
5,000 Medicare beneficiaries for a minimum of three years
“Think of it as buying a television. A TV manufacturer like Sony may contract
with many suppliers to build sets. Like Sony does for TVs, an ACO would
bring together the different component parts of care for the patient – primary
care, specialists, hospitals, home health care, etc. – and ensure that all of the
„parts work well together.‟ The problem today is that patients are getting each
part of their health care separately. People want to buy individual circuit
boards, not a whole TV. If we can show them that the TV works better, maybe
they'll buy it, rather than assembling a patchwork of services themselves.”
– Harold Miller, president and CEO of the Network for
Regional Healthcare Improvement
ACO
30. Page 29April 25, 2013
Florida Institute of Certified Public Accountants
MSSP
MSSP: Medicare Shared Savings Program
Pursuant to PPACA, the Secretary was directed to
implement the Medicare Shared Savings Program
(MSSP) by January 1, 2012
Financial incentive for aligned providers to
implement specific integration model
31. Page 30April 25, 2013
Florida Institute of Certified Public Accountants
MSSP ACO
• Clinically integrated networks that have
contracted with CMS to share in whatever
money the community saves
– To be eligible for shared savings, must
meet minimum performance standards for
33 ACO quality measures
– How do we know if they have “saved?”
CMS reviews the historic costs of the patients in the network
and uses that as the baseline to determine savings.
32. Page 31April 25, 2013
Florida Institute of Certified Public Accountants
MSSP ACO Functions
What Really Matters
Establish and maintain
quality assurance and
improvement program.
Promote evidence-based
medicine, patient
engagement, care
coordination, patient-
centeredness.
Compile and report
participants‟ quality
measure scores.
Distribute shared savings
and assess shared losses.
33. Page 32April 25, 2013
Florida Institute of Certified Public Accountants
Each ACO participant continues to bill fee-for-service independently
Eligibility for and level of shared savings based on performance score
Calculate actual annual Medicare spent for assigned beneficiaries
against pre-determined benchmark
Apply formula to determine share of savings (losses)
Calculating Shared Savings/Losses
34. Page 33April 25, 2013
Florida Institute of Certified Public Accountants
Episode 1: Hip Replacement
• Orthopedic Surgeon
• Surgery
o Anesthesia
o Pathology
• Acute Care
• Rehabilitation
o PT
BPP
BPP: Bundled Payment
Program
• A single “bundled” payment
covers the entire range of
services that are rendered
during a single episode of
care or over a specified time
period and are delivered by
two or more healthcare
providers
• Example: Martha‟s hip
replacement
- payment
- payment
- payment
- payment
Develops rash – dermatology consult - payment
payment
- payment
- payment
35. Page 34April 25, 2013
Florida Institute of Certified Public Accountants
Success in Bundling for
Episodes of Care
Successful
bundling for
episode of
care
Decrease Costs
• Financial/Gain-
sharing Model
Create
Efficiencies
• Re-design Care
Model
Improve Care
• Quality Focus
36. Page 35April 25, 2013
Florida Institute of Certified Public Accountants
Bundle Up!
Bundled Payments are Coming
Based on Medicare ACE
Demonstration Project –
free range ACO
Single payment for
defined group of services
within specified episode
of care
Pricing based on
discount of payer’s
historic total cost
Gain-sharing incentives
37. Page 36April 25, 2013
Florida Institute of Certified Public Accountants
Questions?
38. Page 37April 25, 2013
Florida Institute of Certified Public Accountants
Terms
ACO Accountable Care Organization
BPP Bundled Payment Program
CIN Clinical Integrated Network
eRx Electronic Prescription
FFS Fee-for-Service
HACs Hospital Acquired Conditions
HIE Health Information Exchange
HIT Health Information Technology
HVBP Hospital Value-Based Purchasing
IPA Independent Practice Association
IQR Inpatient Quality Reporting
MSSP Medicare Shared Savings Program
MU Meaningful Use
P4P Pay-for-Performance
P4R Pay-for-Reporting
PCMH Patient Centered Medical Home
PHO Physician Hospital Organization
PQI Physician Quality Incentives
PQRS Patient Quality Reporting System
PQRS Physician Quality Reporting System
PVBP Physician Value-Based Purchasing
VBP Value-Based Purchasing
39. Page 38April 25, 2013
Florida Institute of Certified Public Accountants
Thank you!
David McMillan
Principal
PYA
dmcmillan@pyapc.com
865-673-0844
Editor's Notes
Originally limited to physician-led practices, NCQA expanded the program to nurse-led practices in 2010NCQA recognizes programs that provide “first contact, continuous, comprehensive, whole person care for patients across the practice”“Whole person care” includes comprehensive care and self management support while emphasizing the spectrum of healthcare needsIf a practice can demonstrate that it provides “whole person care” and meets the other elements of the joint principles for at least 75% of its patients, it is eligible for recognition by NCQA even if it isn’t a traditional primary care practiceEven if your practice does not meet these standards, you may be eligible for NCQA’s Physician Practice Connections Recognition Program (PPC)Ideally, this care model will enable patients, especially those with chronic conditions, from getting lost in the shuffle of our complex and fragmented healthcare systemA study performed by the University of Michigan Health System found that 46% of physician practices do not currently meet the national standards to quality as a medical home – i.e., a practice which manages the ongoing care of patients and coordinates care among specialties and facilities NCQA data suggests that multispecialty physician groups have an increased likelihood for meeting medical home standardsWhat is problematic, however, is that 9 out of 10 Americans receive their healthcare services from single/small physician practicesIt is expected, however, that the increase in electronic health records and high reimbursements associated with the medical home model will gradually result in a more significant movement toward this modelPhysician practices, however, must be aware of the potential for this movement to inadvertently result hardships on those practices which do not have the infrastructure to qualify as medical homes