Presentation to Mass Neurologic Association


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Presentation to neurologists on "staying relevant" in the changing healthcare world.

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Presentation to Mass Neurologic Association

  1. 1. Remaining  Relevant  in  the  Changing   Health  Care  Payment  and  Care   Delivery  Systems       Daniel  Hoch,  Ph.D.,  MD,  FAAN   OutpaAent  Medical  Director   Department  of  Neurology     MassachuseCs  General  Hospital     MassachuseCs  Neurologic  AssociaAon   November  7,  2013  
  2. 2. Source:  OMB    
  3. 3. NaAonal  Health  System  Performance  06/07              Life Expectancy Per Capita Spending (PPP$) Australia                              81.2                        3122   Belgium                79.4                          3183   Canada                                                  80.7        3678   France                                                    80.7        3554   Germany                                            79.4        3328   Greece                                                    79.5        3101   Ireland                                                    78.9        3082   Italy                                                              80.5        2623   Japan                                                          82.6        2512   Netherlands                                  79.8        3383   Norway                                                  80.2        4521   Portugal                                                78.1        2080   Spain                                                            80.9        2388   Sweden                                                    80.9        3119   Switzerland                                      81.7        4312   U.K.                                                                79.4        2764   U.S.A.                                                      78.                      6714     Copyright  Marc  J  Roberts  2012  
  4. 4. Copyright  Marc  J  Roberts  2012  
  5. 5. How  do  you  squeeze  $  800  billion  out  of  a   system  where  labor  is  the  main  cost?      hronic  condiAons   •  Coordinated  care  for  c •  Enhance  horizontal  integraAon   •  EMR  adopAon  (as  decision  support  and  for   communicaAon)   •  Reduce  hospital  readmissions   •  IncenAves  to  reduce  cost,  increase  quality   through  sharing   •  Cap  the  rate  of  medical  inflaAon  (1%  over  CPI)    
  6. 6. Other  Reasons  to  Care?  The  SGR  Fix   (Senate  Finance,  House  Ways  and  Means)     •  permanently  repeal  the  SGR  update     •  Reform  fee-­‐for-­‐service  (FFS)  through   –  focus  on  value  over  volume   –  encourage  parAcipaAon  in  alternaAve  payment  models  (APM)       A  new  “value-­‐based  performance  (VBP)  payment  program”   would  be  used  to  adjust  payments  beginning  in  2017.    This   new  VBP  program  essenAally  combines  all  the  current   incenAve  and  penalty  programs  (e.g.,  value-­‐based  modifier,   meaningful  use,  PQRS)  into  one  budget-­‐neutral  program.     Payments  could  be  increased  or  decreased  significantly,   depending  on  how  well  a  physician  scores  relaAve  to  others   on  a  composite  performance  score  
  7. 7. SGR  Fix-­‐  ConAnued   •  Physicians  parAcipaAng  in  certain  alternaAve   payment  models,  including  the  paAent-­‐ centered  medical  home,  would  be  exempt   from  the  VBP  program   •  HHS  would  publish  uAlizaAon  and  payment   data  for  physicians  on  the  Physician  Compare   web  site  
  8. 8. Goals  of  this  presentaAon:   •  Be  able  to  assess  your  readiness  to  take  part  in  new   payment  and  delivery  systems   •  Know  where  to  find  resources  that  can  help  with  this   transiAon   •  Understand  the  data  that  is    available  as  part  of  new  care   delivery  systems   •  Know  where  to  find  quality  measures,  their  role,  and  how   you  can  use  them   •  Understand  potenAal  roles  for  your  pracAce  in  medical   homes/neighborhoods,  and  how  to  add  value  to  that   collaboraAon   •  Understand  the  role  of  paAent  engagement  in  these  new   processes  of  care    
  9. 9. New  Payment  Models   Pay  for  reporAng   Pay  for  performance   Method  of   Delivery   ACOs   •  Hospital  Created   •  Physician  Created   •  Insurer  Founded   •  CMS  inspired   Shared  Savings   ACO-­‐like   Bundled  payments   CapitaAon   New  PracAce   Models   •  PCMH   •  PCMH-­‐N  
  10. 10. Gemng  Ready-­‐  Look  Around  At   What  Is  Happening  In  Your  Area   •  There  are  almost  certainly  novel  pracAce  and   payment  efforts  in  your  area.  Find  out  about  them.     –  How  many  faciliAes   –  How  many  clinicians   –  Primary  Care  vs.  specialists   •  Governance   –  Are  specialists,  specifically  neurologists,  engaged  in  leadership   –  Has  the  organizaAon  or  pracAce  reached  out  to  neurologists   •  What  is  the  role  of  payers   –  Are  there  exisAng  collaboraAve  care  models  with  payers   •  Are  other  Neurologists  in  the  area  taking  part  in  the   new  models  
  11. 11. Consider  Your  Role  In  New  Models     •  What  are  the  proposed  or  exisAng  new  roles.     –  –  –  –  How  will  the  neurologist  be  integrated  into  the  new  model   Will  the  processes  of  care  be  a  big  change   Is  there  an  expected  Ame  table   Are  some  neurologists  already  changing  pracAce  processes     •  Possible  roles   •  Curbside  consultaAon/Pre-­‐consultaAon  (telephone,  email,   other)   •  Teleneurology   •  On  or  off  site  collaboraAve  care   •  Do  you  have  to  work  with  a  hospital?  If  not,  how  will  your   pracAce  change?    
  12. 12. Assess  Your  Value  to  the   Community   Consider  paAent  and  physician  surveys.   Determine  your  market  share.   Do  you  have  outcome  measurements?   What  is  your  relaAonship  to  the  hospital  (s)   What  is  your  primary  care  group  referral   base?   •  What  is  the  exisAng  technology  infrastructure   that  you  contribute?   •  •  •  •  • 
  13. 13. Value  =  Cost/Quality     New  models  will  be  Value  based.     •  You  can  reduce  costs  without  reducing  quality   •  You  can  increase  quality  without  increasing   costs   It  will  be  excepAonally  difficult  to  integrate,   collaborate  and  increase  value  without  shared   data   •  EHR,    outcomes  measurement  and  cost   accounAng  systems  must  support  the  new   mode  relaAonship  between  providers.      
  14. 14. You  Have  An  Impact  On  Value   •  Tests  –  guidance  to  care  team  on  appropriateness  of   studies   •  UAlizaAon-­‐  Is  a  given  test  or  intervenAon  necessary   •  PopulaAon  management:   –  PotenAal  model  in  the  way  generalists  have   worked  together  with  endocrinologists  on   diabetes  management   –  Registries  
  15. 15. Quality  Will  be  Measured  and   Used  to  Determine  Value     •  NaAonal  push  for  meaningful  outcomes   measures,  not  process  measures   •   AAN  must  idenAfy  meaningful  paAent   outcomes   •   Neurologists  must  take  accountability  for   helping  paAents  reach  meaningful  outcomes  
  16. 16. Payment  will  be  Modified  Based   on  Value   Quality  Score   §  Payment  adjustment  to  begin  in  2017  for  all  providers  (based  on  2015   reporAng  data)   –  Certain  ACOs  excepted   •  Quality  of  care  is  a  composite  score   –  CombinaAon  of  quality  measures   •  •  •  •  •  •  Clinical  care   PaAent  experience   PaAent  safety   Care  coordinaAon   Efficiency   PopulaAon/Community  Health   •  Assigned  a  level  of  high,  average,  or  low  quality   •  Measured  against  naAonal  mean   Modified  From  J.  Fritz  and  D.  Evans,  2012  
  17. 17. Payment  will  be  Modified  Based   on  Value   Cost  Score   •  Total  costs   •  Total  costs  for  beneficiaries  with  specific   condiAons  (COPD,  heart  failure,  coronary   artery  disease,  diabetes)   •  Assigned  a  level  of  high,  average,  or  low   •  Measured  against  naAonal  mean   Modified  From  J.  Fritz  and  D.  Evans,  2012  
  18. 18. Value-­‐Based  Payment  Modifier   •  For  Groups  of  25  or  more   •  Quality  Aers   –  9  combinaAons   –  VBPM  ranges  from  2%  to  -­‐1%     Low  cost   Average  cost   High  cost   High  quality   +2.0x*   +1.0x*   +0.0%   Average   quality   +1.0x*   +0.0%   -­‐0.5%   Low  quality   +0.0%   -­‐0.5%   -­‐1.0%  
  19. 19. The  AAN  has  an  Aggressive  Program   to  IdenAfy  Quality  Measures   •  AAN  has  embarked  on  an  intensive  program  to   develop  quality  measures   –  Measures  available  now:  DemenAa,  Parkinson’s   Disease,  Epilepsy,  Stroke   –  Measures  available  in  2013  -­‐  ALS,  Distal  Symmetric   Neuropathy   –  Measures  available  in  2014-­‐  Headache,  Muscular   Dystrophies,  update  to  PD   –  Measures  available  in  2015  –  MS,  update  to  Epilepsy   •  See   hCp:// measurements  
  20. 20. Federal  Programs  Encourage  Quality   Measurement   The  AAN  has  requested,  and  views  as  criAcal,  the  inclusion  of   neurologist  developed  measures   •  Meaningful  Use  Stage  2   –  DemenAa  CogniAve  Assessment     Physician  Quality  ReporAng  System  (PQRS)  Applicable  neurology   measures  for  2013  reporAng:   •  Epilepsy  –  3  individual  measures  for  claims  or  registry  reporAng   •  DemenAa  –  9  measures  in  group  for  claims  or  registry  reporAng   •  Parkinson’s  disease  –  6  measures  in  group  for  registry  only   reporAng   •  Sleep  –  4  measures  in  group  for  registry  only  reporAng   •  Stroke  –  5  InpaAent  measures  for  claims  or  registry  reporAng   •  Low  back  pain  –  4  measures  in  group  for  claims  or  registry  reporAng  
  21. 21. ReporAng  is  Being  Simplified       UnAl  this  year,  quality  reporAng  as  part  of   Meaningful  Use  and  under  PQRS  were  not  well   coordinated.  BUT     •  StarAng  in  2013,  you  may  saAsfy  the  meaningful   use  Clinical  Quality  Measures  by  parAcipaAng  in   the  PQRS  –Medicare  EHR  incenAves  pilot.     •  In  2014  the  two  quality  reporAng  systems  will   have  essenAally  merged,     –  MU  and  PQRS  will  have  overlapping  measures     –  PQRS  and  MU  will  share  a  reporAng  mechanism.    
  22. 22. Quality  ReporAng  Is  Local  as  Well   AAN  has  a  partnership  with  CE  City  to  report  measures   through  a  registry   –  The  2013  sets  were  live  in  late  May   –  CE  City  -­‐    hCp://   –  Registry  info  hCps://     •  All  payers  have  quality  reporAng  programs  that  feed  into   their  pay-­‐for-­‐performance  or  value-­‐based  contracAng   programs.     –  AAN  Staff  are  reviewing  the  cost  and  quality  measures  being   used  in  private  payer  programs,     –  MeeAng  with  private  payers  to  understand  their  programs   –  AAN  will  have  a  resource  for  members  that  outlines  the  cost   and  quality  metrics  used  in  programs  by  Fall  2013.       Based  on  the  latest  reports  available,  in  2011,  only  20.8%  of   eligible  neurologists  parAcipated  in  PQRS.    
  23. 23. The  Choosing  Wisely  Campaign   Engages  PaAents  in  Quality     •  A  campaign  to  make  paAents  AND  physicians  aware  of   some  common  procedures  that  are  clearly  of  liCle  value   •  The  AAN  suggesAons  for  neurologic  care   –  EEGs  are  not  helpful  in  headache   –  CaroAd  US  should  not  be  done  in  simple  syncope  (no  other   associated  signs  or  symptoms)   –  Do  not  use  bubalbital  or  opioids  in  migraine  except  as  a  last   resort   –  Don’t  prescribe  interferon-­‐beta  or  glaAramer  acetate  to   paAents  with  disability  from  progressive,  non-­‐relapsing  forms  of   mulAple  sclerosis.     –  Don’t  recommend  CEA  for  asymptomaAc  caroAd  stenosis  unless   the  complicaAon  rate  is  low  (<3%)  
  24. 24. You  Should  be  Engaged  in  ReporAng   AND  CreaAng  Metrics   •  There  will  be  opportuniAes  to  shape  local  efforts  to   improve  quality     –  Payers  want  to  know  that  efforts  are  underway  to   measure  and  improve  quality   –  Internal  efforts  in  large  groups  may  rely  on  unique  process   or  outcome  measures  and  reporAng   Examples-­‐     –  Timely  communicaAon  to  referring  physicians   –  Wait  Ames  for  an  appointment   –  Average  wait  once  in  the  doctors  office   –  And  many  more…  
  25. 25. These  Changes  in  Healthcare  Require   New  PracAce  RelaAonships   •  The  PaAent  Centered  Medical  Home  (PCMH)  exemplifies   many  of  the  ideas  that  will  guide  new  relaAonships  criAcal  to  the   future  payment  and    delivery  systems   –  Pa:ent  Centered-­‐  RelaAonship  based,  with  aCenAon  to  the  whole   person   –  Comprehensive  care-­‐  The  Primary  care  home  will  meet  a  majority  of   the  paAents  medical  and  mental  health  needs   –  Coordinated  care-­‐  engaging  with  all  parts  of  the  health  care  system   from  specialists  to  hospitals  and  nursing  homes   –  Accessible  services-­‐  shorter  wait  Ames,  in-­‐person  and  electronic   availability.   –  Quality  and  Safety-­‐  commitment  to  measurement  of  quality  and   process  improvement,  use  of  decision  support  and  evidence-­‐based   pracAce.    
  26. 26. Specialists  Will  Be  Part  Of  The   Medical  Home  Neighborhood     •  Specialists  can  work  together  with  the  PCMH   in  many  possible  ways.   –  TradiAonal  ConsultaAon   –  Off-­‐site  collaboraAve  care   –  On-­‐site  collaboraAve  care   –  Principle  care   –  The  NCQA  has  developed  a  set  of  principles   for  the  PCMH  neighbor  hCp://  
  27. 27. Greater  CommunicaAon  and   CollaboraAon       Off-­‐Site   •  Neurologist  is  available  by  phone,  email,  specialized  IT  portal.     –  Curbside  or  “pre  consultaAon”  may  be  all  that  is  needed   –  PCP/team  ozen  managed  meds,  intervenAon   –  Complexity  and  comfort  zone  of  PCPs  drive  process.     On-­‐site   •  Embedded  with  the  PCMH   –  More  real-­‐Ame  interacAons     –  Great  opportunity  for  educaAon   –  Co-­‐management     A  “stepped  approach”  may  dictate  who  manages  the  paAent  in  either   model.    
  28. 28. “Principle  Care”  May  Be  a  Model   for  Some  PaAents/Neurologists   Neurologist/Team  serve  as  the  principle  care  providers     •  Response  to  the  younger,  otherwise  healthy  paAent  who   feels  they  only  need  a  neurologist.     –  MS,  Epilepsy,  etc.   PCP  is  the  “neighbor”   •  The  neurology  pracAce  will  need  addiAonal  resources  to   help  with  tasks  that  PCMH  teams  may  normally  do   •  Neurologist  will  want  to  have  experience  with  populaAon   management  concepts     As  paAent  ages,  and  health  issues  expand,  PCP  becomes  the   “home”,  Neurologist  the  “Neighbor”  
  29. 29. Providing  Principle  Care  as  a  “Medical   Home”  Will  Not  Be  Easy   •  Access  and  ConAnuity  –     –  Azer  hours  and  electronic  access     –  Provide  culturally  and  linguisAcally  appropriate  services   •  IdenAfy  and  Manage  PaAent  PopulaAons  –     •  Plan  and  Manage  Care  –     –  Registries  to  proacAvely  remind  paAents  of  overdue  care   –  Implement  evidence-­‐based  guidelines  using  point-­‐of-­‐care  reminders   –  IdenAfy  high  risk  paAents   –  Manage  medicaAons   •  Provide  Self-­‐Care  Support  –     –  –  –  –  Provide  educaAonal  resources   IdenAfy  and  refer  to  community  resources   Provide  self-­‐management  tools  and  plans     Include  paAents  and  their  families   •  Track  and  Coordinate  Care  –   •  Measure  and  Improve  Performance  –     –  tesAng  and  referral  tracking   –  managing  care  transiAons   –  Quality  metrics  and  reporAng   –  Include  the  paAent  experience  of  care  
  30. 30. The  Way  You  Work  With  Pateints   Will  Change   •  In  addiAon  to  new  professional  relaAonships  and   payment  models,  there  will  be  new  relaAonships   with  paAents   •  “Engagement”   –  Partnering  with  paAents  so  that  they  are  drivers  of   their  care,  rather  than  passive  passengers   •  There  are  many  organizaAons  that  can  help   –  Consumers  Advancing  PaAent  Safety   •  hCp://   –  Informed  Medical  Decisions  FoundaAon   •  hCp://   –  InsAtute  for    PaAent  and  Family  Centered  Care   •  hCp://   –  Society  for  ParAcipatory  Medicine   •  hCp://  
  31. 31. Most  Medical  Care  Occurs  Outside   the  Office  or  Hospital   Ferguson’s  inverted  pyramid  
  32. 32. Why  You  Should  Collaborate  with   PaAents   •  PaAents  are  already  collaboraAng  with   each  other,  and  doctors!   –  They  are  online  in  vast  numbers   –  They  talk  to  each  other  online   –  They  do  research  online   –  They  include  medical  professionals  in  their  social   networks  (even  if  we  don’t  know  it)   –  Some  rate  doctors  and  hospitals.     –  Almost  70%  feel  that  coordinaAon  of  care  is  a   problem,  30%  feel  it  is  a  major  problem.      
  33. 33. The  Pew  Internet  Project  Finds:   •  34%  of  Internet  users  have  read  descripAons  of  other   people’s  experience  with  health   •  25%  of  Internet  users  have  watched  health  related  videos   online.   •  24%  of  Internet  users  have  looked  up  informaAon  about   drugs  online   •  18%  of  Internet  users  have  looked  for  other  paAents  with   their  concerns     •  16%  of  Internet  users  have  consulted  doctor  raAngs.   •  15%  of  Internet  users  have  consulted  raAngs  for  hospitals  or   faciliAes.      
  34. 34. PaAents  Can  Be  Integrated  Into  The   Workflow:  Experience  At  Kaiser   Compared  Provider–PaAent  e-­‐mail   users  and  nonusers  (  >35,000   paAents)     Found  improved  HEDIS  measures  in   those  with  hypertension  and  diabetes     BeCer    HA1C  values   BeCer  screening   Lower  BP   Zhou,  Y.  Y.,  et.  Al    (2010).  Improved  quality  at  Kaiser  Permanente  through   e-­‐mail  between  physicians  and  paAents.  Health  affairs  (Project  Hope),   29(7),  1370-­‐5.  doi:10.1377/hlthaff.2010.0048  
  35. 35. There  Are  Many  Other  Examples  Of   Impact  Of  PaAent  Engagement   •  Bedside  presentaAons  reduce  apprehension  in   paAents  and  may  increase  accuracy  of  data   •  Sharing  of  notes  with  paAents  is  rare,  but  when   it  is  promoted,  paAents  express  “considerable   enthusiasm  and  few  fears”  about  sharing   notes.     •  Walker  et  al.  AIM  2011   •  Why  is  this  important?  We  know  coordinaAon   of  care  is  a  problem,  but  paAents  also  see  it..    
  36. 36. There  are  Many  Tools  You  Can   Use  to  Increase  Engagement   •  Shared  decision  aids-­‐   –  Informed  Medical  Decisions  FoundaAon     –  Programs  to  aid  paAents  in  understanding  risks,   outcomes  and  the  views  of  other  paAents   •  Portals,  and  other  IT   –  MeeAng  MU   –  “Engaging”  paAents  in  your  pracAce   •  Behavioral  Health/Behavior  Change   –  MoAvaAonal  interviewing   •  Style  of  interacAng  helps  paAent  take  control  of   their  health  on  their  terms  
  37. 37. Summary  Points     •  Health  care  reform  will  include  major  changes  in   how  neurologists  are  paid  and  the  way  they   provide  care   •  CoordinaAon  of  care,  use  of  teams,  and  new   processes  of  care  will  proliferate   •  You  can  make  the  transiAon  by  understanding   your  present  processes,  costs  and  outcomes.     •  Focus  on  the  value  you  bring  to  the  paAent’s   care.     •  Do  not  be  afraid  to  jump  in  and  work  with  our   colleagues  who  are  pioneering  these  changes.    
  38. 38. Resources  for  Assessing  the  Delivery   Models     •  Overview     –  hCp://   –  hCp://   •  Accountable  Care  OrganizaAons   –  hCp://   –  hCp://   •  PaAent  Centered  Medical  Homes   –  hCp://   –  hCp://   •  Webinars  from  AMA   –  hCp://    The  AAN  will  launch  a  new  website  to  help  keep  many  resources  in   one  place,  someAme  in  June.    
  39. 39. Resources  for  Assessing  Payment   Models   •  Overview  from  the  AMA   –  hCp://www.ama-­‐ payment-­‐opAons.pdf   •  Bundled  Payments   –  hCp://   •  Global  Payments   –  hCp:// comprehensive   •  Pay  for  Performance   –   •  Pay  for  ReporAng   –  hCp://