This document discusses the importance of state involvement in controlling rising health care costs. It notes that while past efforts at all-payer rate regulation failed due to pushback, new models like Accountable Care Organizations (ACOs) and bundled payments show promise if implemented correctly. The document outlines some key errors of the past to avoid, such as providers taking on too much risk too quickly. It also emphasizes the need to control rising post-acute care spending and ensure new models improve care coordination and value. Massachusetts' experience expanding coverage and regulating prices is discussed as an example for other states.
Martin Gaynor: "Supersized: The Rise of the Hospital Giants," 5.19.15reportingonhealth
Martin Gaynor's presentation from "Supersized: The Rise of the Hospital Giants," a ReportingOnHealth.org webinar, 5.19.15
http://www.reportingonhealth.org/content/supersized-rise-hospital-giants
Modern Relationships Between Physicians, Hospitals, and Long-Term Care Provid...PYA, P.C.
PYA Consulting Manager Aaron Elias co-presented “Modern Relationships Between Physicians, Hospitals, and Long-Term Care Providers in a Time of Risk-Based Contracting,” along with Jeanna Palmer Gunville, a shareholder at Polsinelli.
The Changing Healthcare System and Impact of MACRAPYA, P.C.
PYA Principal Lori Foley and Consulting Senior Aaron Elias co-presented “The Changing Healthcare System and Impact of MACRA” at the Physician Insurers Association of America’s CEO/COO Meeting.
The Medicare Access & CHIP Reauthorization Act (MACRA) dramatically affected Medicare reimbursements to healthcare providers, as well as provided a new framework for rewarding quality care and reporting on quality measurements. This incentive-based system has the potential not only to change how medicine is practiced, but influence patient perception of care. The presentation will provide the latest information on MACRA implementation, and will detail how the aforementioned changes will impact miscellaneous professional liability insurers.
Martin Gaynor: "Supersized: The Rise of the Hospital Giants," 5.19.15reportingonhealth
Martin Gaynor's presentation from "Supersized: The Rise of the Hospital Giants," a ReportingOnHealth.org webinar, 5.19.15
http://www.reportingonhealth.org/content/supersized-rise-hospital-giants
Modern Relationships Between Physicians, Hospitals, and Long-Term Care Provid...PYA, P.C.
PYA Consulting Manager Aaron Elias co-presented “Modern Relationships Between Physicians, Hospitals, and Long-Term Care Providers in a Time of Risk-Based Contracting,” along with Jeanna Palmer Gunville, a shareholder at Polsinelli.
The Changing Healthcare System and Impact of MACRAPYA, P.C.
PYA Principal Lori Foley and Consulting Senior Aaron Elias co-presented “The Changing Healthcare System and Impact of MACRA” at the Physician Insurers Association of America’s CEO/COO Meeting.
The Medicare Access & CHIP Reauthorization Act (MACRA) dramatically affected Medicare reimbursements to healthcare providers, as well as provided a new framework for rewarding quality care and reporting on quality measurements. This incentive-based system has the potential not only to change how medicine is practiced, but influence patient perception of care. The presentation will provide the latest information on MACRA implementation, and will detail how the aforementioned changes will impact miscellaneous professional liability insurers.
Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse...PYA, P.C.
PYA Senior Manager Chris Beckham co-presented “Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny” with Ross Burris of Polsinelli at the American Health Lawyer Association’s (AHLA) Physicians and Hospitals Law Institute, February 8-10, 2016.
Sustainable Growth Rate? Goodbye for Good!PYA, P.C.
PYA Staff Consultant Aaron Elias spoke to attendees of the Georgia Healthcare Financial Management Association’s (HFMA) Spring Institute May 6, 2015, on the implications of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
PYA Principal Martie Ross presented the keynote address, “The March to MIPS: The Merit-Based Payment System,” at the Kansas Medical Group Management Association 2016 Fall Conference, September 21-23, 2016, at the Overland Park Marriott in Overland Park, Kansas.
The presentation will include:
An introduction to the Medicare Merit-Based Incentive Payment System (MIPS).
A discussion of the four components of the MIPS composite score.
An exploration of the penalties and bonuses associated with the MIPS composite score, as well as the reputational impact of the publicly reported MIPS composite score.
PYA Principal Carol Carden and Senior Manager Angie Caldwell presented “Hot Topics in Physician Compensation” at the Kentucky Society of CPAs (KY CPA) Health Care Conference, May 18, 2016. The presentation explored the latest developments in physician compensation structure, as well as considerations related to stacking compensation elements, the role and impact of quality incentives, the latest in affiliation models, and population health initiatives.
This Accountable Health Communities Model webinar was held on Wednesday, February 10, 2016 from 3:00 – 4:00pm EST. The webinar focused on the anticipated role of state Medicaid agencies in the model.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
Big Data: Implications of Data Mining for Employed Physician Compliance Manag...PYA, P.C.
PYA Consulting Manager Kristen Lilly presented “Big Data: Implications of Data Mining for Employed Physician Compliance Management” during a webinar for the Georgia chapter of the Healthcare Financial Management Association (Georgia HFMA), March 31, 2016.
The presentation explored:
Public relations and litigation risk from the public dissemination of data by the government.
Internal use of broad spectrum analytics in employed physician compliance management.
Determination of risk tolerance and the customization of “outside the box” analytics.
Benchmarking, monitoring, and defining physician-focused risk area reviews.
MACRA: Restructuring Medicare ReimbursementPaul B. Tripp
Everyone must rethink their approach to the delivery of care. It is no longer a viable option to maintain the fee-for- service (FFS) mindset. New measures from CMS will push healthcare to the next level of reform where the patient is increasingly at the center of care and care payment.
The CMS Innovation Center held the second in a series of webinars for potential applicants to Health Care Innovation Awards Round Two. The webinar held Wednesday, June 12, 2013 1:30pm – 3:00pm EDT, focused specifically on the first two of the four innovation categories.
- - -
CMS Innovations
http://innovations.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
Presentation Explores Many Contexts of Community BenefitPYA, P.C.
PYA Principal David McMillan gets to the bottom of the definition of community benefit in “Community Benefit: One Term, Many Contexts,” a presentation given at the 2013 AICPA Healthcare Industry Conference.
Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse...PYA, P.C.
PYA Senior Manager Chris Beckham co-presented “Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny” with Ross Burris of Polsinelli at the American Health Lawyer Association’s (AHLA) Physicians and Hospitals Law Institute, February 8-10, 2016.
Sustainable Growth Rate? Goodbye for Good!PYA, P.C.
PYA Staff Consultant Aaron Elias spoke to attendees of the Georgia Healthcare Financial Management Association’s (HFMA) Spring Institute May 6, 2015, on the implications of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
PYA Principal Martie Ross presented the keynote address, “The March to MIPS: The Merit-Based Payment System,” at the Kansas Medical Group Management Association 2016 Fall Conference, September 21-23, 2016, at the Overland Park Marriott in Overland Park, Kansas.
The presentation will include:
An introduction to the Medicare Merit-Based Incentive Payment System (MIPS).
A discussion of the four components of the MIPS composite score.
An exploration of the penalties and bonuses associated with the MIPS composite score, as well as the reputational impact of the publicly reported MIPS composite score.
PYA Principal Carol Carden and Senior Manager Angie Caldwell presented “Hot Topics in Physician Compensation” at the Kentucky Society of CPAs (KY CPA) Health Care Conference, May 18, 2016. The presentation explored the latest developments in physician compensation structure, as well as considerations related to stacking compensation elements, the role and impact of quality incentives, the latest in affiliation models, and population health initiatives.
This Accountable Health Communities Model webinar was held on Wednesday, February 10, 2016 from 3:00 – 4:00pm EST. The webinar focused on the anticipated role of state Medicaid agencies in the model.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
Big Data: Implications of Data Mining for Employed Physician Compliance Manag...PYA, P.C.
PYA Consulting Manager Kristen Lilly presented “Big Data: Implications of Data Mining for Employed Physician Compliance Management” during a webinar for the Georgia chapter of the Healthcare Financial Management Association (Georgia HFMA), March 31, 2016.
The presentation explored:
Public relations and litigation risk from the public dissemination of data by the government.
Internal use of broad spectrum analytics in employed physician compliance management.
Determination of risk tolerance and the customization of “outside the box” analytics.
Benchmarking, monitoring, and defining physician-focused risk area reviews.
MACRA: Restructuring Medicare ReimbursementPaul B. Tripp
Everyone must rethink their approach to the delivery of care. It is no longer a viable option to maintain the fee-for- service (FFS) mindset. New measures from CMS will push healthcare to the next level of reform where the patient is increasingly at the center of care and care payment.
The CMS Innovation Center held the second in a series of webinars for potential applicants to Health Care Innovation Awards Round Two. The webinar held Wednesday, June 12, 2013 1:30pm – 3:00pm EDT, focused specifically on the first two of the four innovation categories.
- - -
CMS Innovations
http://innovations.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
Presentation Explores Many Contexts of Community BenefitPYA, P.C.
PYA Principal David McMillan gets to the bottom of the definition of community benefit in “Community Benefit: One Term, Many Contexts,” a presentation given at the 2013 AICPA Healthcare Industry Conference.
Healthcare Consumerism and Cost: Dispelling the Myth of Price TransparencyHealth Catalyst
The world of healthcare costs is confusing and messy for both patients and providers. Many providers don’t fully understand their costs and therefore struggle to meet the increasing pressure for greater price transparency for consumers. With price transparency rules finalized and implementation looming, many providers are racing against the clock to adapt business practices to meet regulations and communicate the implications to consumers. And each organization’s financial health depends on transparency, as uncertainty about costs keeps many patients from seeking care.
Deb Gordon, seasoned healthcare executive and author of the book, “The Health Care Consumer’s Manifesto: How to Get the Most for Your Money,” and Pat Rocap, Director of Cost Management Services at Health Catalyst, examine the relationship between cost and pricing as the path to transparency for consumers. Deb and Pat provide expert analysis and practical advice to help you become a savvier provider and consumer when it comes to healthcare pricing and spending.
- The implications of federal price transparency regulations.
- The connection between healthcare costing and pricing.
- How to start your organization’s journey to understand costs and why it matters.
- Why price transparency is important to both patients and providers.
The changing landscape of health care in the US -- drivers and outcomesGregory Travis
The United States has the worst health care outcomes among its OECD peers. It also has the highest health care costs within the OECD. What are the reasons for this and what changes can we anticipate going forward?
Read the scenario that you will use for the Individual Projects in ea.pdfashokarians
Read the scenario that you will use for the Individual Projects in each week of the course. The
Centers for Medicare and Medicaid Services (CMS) has taken on a more visible role in health
care delivery. Many changes have transpired to improve patient safety along with the
implementation of additional quality metrics, and these changes impact reimbursement rates
Likewise, the Patient Protection and Affordable Care Act has changed the reimbursement fee
structure of Medicare and Medicaid reimbursement for health care services. Other legislation
including the HITECH Act and the Medicare Authorization and CHIP Reactivation Act of 2015
(MACRA) all impact how healthcare organizations receive reimbursement and demonstrate use
of data to improve quality and delivery of patient care Mr. Magone, CEO of Healing Hands
Hospital, has asked you to join the \"Future of Healing Hands Task Force, and your first
assignment is to work with the Hospital Chief Financial Officer, Mr. Johnson, and provide a
summary of the current regulations regarding Medicare reimbursement including how MACR
impact reimbursement if/when Healing Hands coordinates delivery of services by affiliating with
physician practices For this assignment, write a 2-3 page report that you will deliver to Mr.
Magone on how the new CMS initiatives and regulations impact the organization\'s revenue
structure. In your presentation, address the following questions: Why did CMS become more
involved in the reimbursement component of health care? How does CMS\'s involvement impact
the reimbursement model for Healing Hands Hospital and other health care organizations If
CMS reimbursement regulations for Medicare and Medicaid change, does it follow that other
insurance providers change heir policies on reimbursement? What tools can be implemented to
ensure organizations such as Healing Hands Hospital and physician practices are meeting the
policies and procedures set forth by CMS? Identify 3 tools from the CMS Web site that are
helpful in meeting the requirements for Medicare reimbursement set forth by CMS
Solution
Part-a & part-b:
The physician’s work, practice expense, and malpractice, RVU values, CMS (centers for
Medicare and Medicaid services) is required to control overall expenditures in health care
organization. Therefore, CMS become highly involved in the reimbursement component of
health care to patients as per their \"insurance packages\". The CMS\' involvement in “budget
Neutrality” & the reimbursement model at Healing Hand hospital & other health care
organizations is mainly for physician RVU based payments from Medicare & Medicare that can
control its physician costs by adjusting physician payment rates based on “previous periods in a
calendar year” as per federal acts and regulations. The Medicare is going to control physicians
costs according to “medical procedures and medical visits of their record” in a Jan- 1 ending Dec
31. Conversion Factor is main basis to control the physician costs ac.
4508 Final Quality Project Part 2 Clinical Quality Measur.docxblondellchancy
4508 Final Quality Project
Part 2: Clinical Quality Measures for Hospitals
Overview
This activity focuses on Quality Measures for Hospitals. The activity uses online resources from
the CMS website. The Clinical Quality Measures for Hospitals activity focuses on the Hospital
Value Based Purchasing (VBP) Program
Background
The National Quality Strategy (NQS) was first published in March 2011 as the National Strategy
for Quality Improvement in Health Care, and is led by the Agency for Healthcare Research and
Quality on behalf of the U.S. Department of Health and Human Services (HHS). Today, the NQS
serves as a guide for identifying and prioritizing quality improvement efforts, sharing lessons
learned, and measuring the collective success of Federal, State, and public‐ and private‐sector
healthcare stakeholders across the country.
The Aims of the NQS are threefold:
Better Care: Improve the overall quality by making health care more patient‐centered,
reliable, accessible, and safe.
Healthy People/Healthy Communities: Improve the health of the U.S. population by
supporting proven interventions to address behavioral, social, and environmental
determinants of health in addition to delivering higher‐quality care.
Affordable Care: Reduce the cost of quality health care for individuals, families,
employers, and government.
To align with this, CMS has set goals for their Quality Strategy. These include:
• Make care safer by reducing harm caused in the delivery of care
– Improve support for a culture of safety
– Reduce inappropriate and unnecessary care
– Prevent or minimize harm in all settings
• Strengthen person and family engagement as partners in their care
• Promote effective communication and coordination of care
• Promote effective prevention and treatment of chronic disease
• Work with communities to promote best practices of healthy living
• Make care affordable
CMS’s vision states that if we can find better ways to pay providers, deliver care, and distribute
information than patients can receive better care, health dollars are spent more wisely, and
there are healthier communities, a healthier economy, and a healthier county. It is with this in
mind that they have created multiple quality payment programs.
In January 2015, the Department of Health and Human Services made an announcement that
set in place measurable goals and a timeline to move the Medicare program towards paying
providers based on the quality of care rather than the quantity. This was the first time in the
history of the program that explicit goals were set. They invited private sector payers to match
or exceed these goals as well. These goals included:
1. Alternative Payment Models
a. 30% of Medicare payments tied to quality or value through Alternative Payment
models by the end of 2016 and 50% by the end of 2018
2. Linking Fee‐For‐Service payments to Quality/Value
a. 85% of all Medi ...
4508 Final Quality Project Part 2 Clinical Quality Measurromeliadoan
4508 Final Quality Project
Part 2: Clinical Quality Measures for Hospitals
Overview
This activity focuses on Quality Measures for Hospitals. The activity uses online resources from
the CMS website. The Clinical Quality Measures for Hospitals activity focuses on the Hospital
Value Based Purchasing (VBP) Program
Background
The National Quality Strategy (NQS) was first published in March 2011 as the National Strategy
for Quality Improvement in Health Care, and is led by the Agency for Healthcare Research and
Quality on behalf of the U.S. Department of Health and Human Services (HHS). Today, the NQS
serves as a guide for identifying and prioritizing quality improvement efforts, sharing lessons
learned, and measuring the collective success of Federal, State, and public‐ and private‐sector
healthcare stakeholders across the country.
The Aims of the NQS are threefold:
Better Care: Improve the overall quality by making health care more patient‐centered,
reliable, accessible, and safe.
Healthy People/Healthy Communities: Improve the health of the U.S. population by
supporting proven interventions to address behavioral, social, and environmental
determinants of health in addition to delivering higher‐quality care.
Affordable Care: Reduce the cost of quality health care for individuals, families,
employers, and government.
To align with this, CMS has set goals for their Quality Strategy. These include:
• Make care safer by reducing harm caused in the delivery of care
– Improve support for a culture of safety
– Reduce inappropriate and unnecessary care
– Prevent or minimize harm in all settings
• Strengthen person and family engagement as partners in their care
• Promote effective communication and coordination of care
• Promote effective prevention and treatment of chronic disease
• Work with communities to promote best practices of healthy living
• Make care affordable
CMS’s vision states that if we can find better ways to pay providers, deliver care, and distribute
information than patients can receive better care, health dollars are spent more wisely, and
there are healthier communities, a healthier economy, and a healthier county. It is with this in
mind that they have created multiple quality payment programs.
In January 2015, the Department of Health and Human Services made an announcement that
set in place measurable goals and a timeline to move the Medicare program towards paying
providers based on the quality of care rather than the quantity. This was the first time in the
history of the program that explicit goals were set. They invited private sector payers to match
or exceed these goals as well. These goals included:
1. Alternative Payment Models
a. 30% of Medicare payments tied to quality or value through Alternative Payment
models by the end of 2016 and 50% by the end of 2018
2. Linking Fee‐For‐Service payments to Quality/Value
a. 85% of all Medi ...
The CMS Innovation Center hosted a special webinar featuring Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer, on Monday, November 10, 2014 from 10:30am – 11:30 am ET. Dr. Conway will provided an update about the work of the CMS Innovation Center and the models being tested to improve better care for patients, better health for our communities, and lower costs through improvement for our health care system. Opportunities for questions were provided.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
A critical analysis of purchasing mechanism in China's Rural Health Insurance...resyst
This presentation was given at the International Health Economics Association (iHEA) World Congress in Milan, in July 2015. It includes results and policy implications from the RESYST Purchasing Study conducted in China.
Recruiting in the Digital Age: A Social Media MasterclassLuanWise
In this masterclass, presented at the Global HR Summit on 5th June 2024, Luan Wise explored the essential features of social media platforms that support talent acquisition, including LinkedIn, Facebook, Instagram, X (formerly Twitter) and TikTok.
Navigating the world of forex trading can be challenging, especially for beginners. To help you make an informed decision, we have comprehensively compared the best forex brokers in India for 2024. This article, reviewed by Top Forex Brokers Review, will cover featured award winners, the best forex brokers, featured offers, the best copy trading platforms, the best forex brokers for beginners, the best MetaTrader brokers, and recently updated reviews. We will focus on FP Markets, Black Bull, EightCap, IC Markets, and Octa.
Top mailing list providers in the USA.pptxJeremyPeirce1
Discover the top mailing list providers in the USA, offering targeted lists, segmentation, and analytics to optimize your marketing campaigns and drive engagement.
Building Your Employer Brand with Social MediaLuanWise
Presented at The Global HR Summit, 6th June 2024
In this keynote, Luan Wise will provide invaluable insights to elevate your employer brand on social media platforms including LinkedIn, Facebook, Instagram, X (formerly Twitter) and TikTok. You'll learn how compelling content can authentically showcase your company culture, values, and employee experiences to support your talent acquisition and retention objectives. Additionally, you'll understand the power of employee advocacy to amplify reach and engagement – helping to position your organization as an employer of choice in today's competitive talent landscape.
At Techbox Square, in Singapore, we're not just creative web designers and developers, we're the driving force behind your brand identity. Contact us today.
Personal Brand Statement:
As an Army veteran dedicated to lifelong learning, I bring a disciplined, strategic mindset to my pursuits. I am constantly expanding my knowledge to innovate and lead effectively. My journey is driven by a commitment to excellence, and to make a meaningful impact in the world.
Digital Transformation and IT Strategy Toolkit and TemplatesAurelien Domont, MBA
This Digital Transformation and IT Strategy Toolkit was created by ex-McKinsey, Deloitte and BCG Management Consultants, after more than 5,000 hours of work. It is considered the world's best & most comprehensive Digital Transformation and IT Strategy Toolkit. It includes all the Frameworks, Best Practices & Templates required to successfully undertake the Digital Transformation of your organization and define a robust IT Strategy.
Editable Toolkit to help you reuse our content: 700 Powerpoint slides | 35 Excel sheets | 84 minutes of Video training
This PowerPoint presentation is only a small preview of our Toolkits. For more details, visit www.domontconsulting.com
Event Report - SAP Sapphire 2024 Orlando - lots of innovation and old challengesHolger Mueller
Holger Mueller of Constellation Research shares his key takeaways from SAP's Sapphire confernece, held in Orlando, June 3rd till 5th 2024, in the Orange Convention Center.
LA HUG - Video Testimonials with Chynna Morgan - June 2024Lital Barkan
Have you ever heard that user-generated content or video testimonials can take your brand to the next level? We will explore how you can effectively use video testimonials to leverage and boost your sales, content strategy, and increase your CRM data.🤯
We will dig deeper into:
1. How to capture video testimonials that convert from your audience 🎥
2. How to leverage your testimonials to boost your sales 💲
3. How you can capture more CRM data to understand your audience better through video testimonials. 📊
1. The Importance of State
Involvement In Controlling
Health Spending
Stuart H. Altman
Sol Chaikin Professor of Health Policy
The Heller School for Social Policy and Management
Brandeis University
5. Private Insurance Payments Used To Pay For Lower
Government Payments
180%
Hospital Payment-to-Cost Ratios
157.4%
160%
140%
130.0%
138.0%
120%
100%
92.0%
80%
85.0%
Medicare
Medicaid(1)
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
60%
Private Payer
Source: Avalere Health analysis of American Hospital Association Annual Survey data, 2005, for community hospitals.
(1) Includes Medicaid Disproportionate Share payments.
6. State Regulation of Health Care
Spending Not New
All But Maryland Dropped All-Payer
Rate Regulation Because of PushBack By Hospitals and More Liberal
Medicare Payments
7. While Past Efforts Failed--We Cannot Give Up---Failure
Has Serious Consequences
9. Cumulative Increases in Health Insurance
Premiums, Workers’ Contributions to Premiums,
Inflation, and Workers’ Earnings,
2000-2010
16 0%
147%
14 0%
12 0%
103%
114%
10 0%
88%
80 %
60 %
36%
40 %
24%
20 %
0%
27%
21%
20 00
20 01
20 02
20 03
20 04
20 05
Notes: Health insurance premiums and worker contributions are for family premiums
based on a family of four.
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011.
Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual
Inflation (April to April), 1999-2011. Bureau of Labor Statistics, Seasonally Adjusted
Data from the Current Employment Statistics Survey, 1999-2011 (April to April).
20 06
20 07
20 08
20 09
20 10
Healt h I nsur an ce Pr em i um s
Workers' Con t rib ut i on t o Pr emi um s
Workers' Earn in gs
Ov er all I nf lat i on
10. The Primary Issue--Should States Promote More Effective
Market Activities or Develop
“All Payer” Regulatory System
11. If Markets Are to Work!
Need to Foster a “Value-Based”
Delivery System
13. Concerns About Current System
• Care Often Delivered in an Uncoordinated and
Fragmented Way
–
–
–
–
Lack of Information Sharing
Duplicative Testing
Poor Care Coordination
Mismanaged Care Transitions
• Limited Use of “Cost Effectiveness” in How
We Use and Pay for Services
• Few Constraints on Prices for New Drugs
and Devices
15. ACO’s and Bundled Payments Offer
Some Real Opportunities --• They Encourage Integration of Care
• Where Possible Substitute Less Expensive for More
Expensive Care
• Reduce the Use of Marginal and Ineffective Care
• Limit the Stockpiling of Substitutable types of
Services
– They Facilitate the Working Together of Hospitals,
Physicians , Post Acute Care and Other Health
Professionals
– They Lower the Cost of Expensive Treatments
– Bundled Payments Can Be an Interim Step To a
Global Payment System
16. Why ACO’s and Bundled
Payments
• They Allow Providers to Decide What is
Appropropriate Care
• They Reward Care That is Less Fragmented
and Minimizes Duplicative and Wasteful
Services
• They Permit Care Providers To Pay for Services
Not Traditionally Considered as Health Care
Services
18. The Errors of The Past
• Providers (Physicians and Hospitals) Were
Required To Take More Financial Risk Than
They Could Afford or Understand-• Individuals Were FORCED Into Plans They
Didn’t Chose and Didn’t Like-• Quality of Care Measures Were Limited So
Choice of Plan (By Employers) Was Based
Primarily on Costs
19. The Errors of The Past
• For Bundled Payments
– The Medicare DRG Payment System Only
Included Hospital Services
– The Medicare DRG Bundled Payment
System Only Covered Medicare
Beneficiaries
20. ACO’s and Bundled Payments Designed
To Avoid Problems of The 1990’s
• Providers Required To Assume Limited Risk
– ACO’s is a “Shared Savings System”. Each
Groups Starts From Their Current Spending
Levels and Downsides Risk Limited
• Patients Will Not Be Locked Into a Delivery
System They Don’t Trust
– Patients Need to Sign Up With PCP But Can
Change PCP or Network With No Penalty
• Attaining or Exceeding “Quality Standards
Provider Eligibility for Payment Depends on ”
21. ACO’s and Bundled Payments
Designed To Avoid Problems of The
1990’s
• The Medicare Bundle Will Include
Physicians Services and Post Hospital Care
In Addition to Hospital Services (It does
Not Include Pre-Hospital Care)
• Medicare is Encouraging (But Not
Requiring) Non-Medicare Patients to Be
Included in Future Bundled Payment
Systems
22. Key To Success of ACO’s
An Effective Primary Care System
(Many Specialty Groups Wary of a
Return to the 1990’s)
1990’s
23. The Key To Making Bundled
Payment Work
Control Post-Acute
Care Spending!!!
24. Avg. 2008 Medicare Payment for In-Hospital Care
for Select DRGs
Source: RTI Inc, Post-Acute Care Episodes: Expanded Analytic File, June 2011
24
25. 2008 Medicare Acute and Post-Acute Payments
for Inpatient-Initiated 90-Day Episodes
Source: RTI Inc, Post-Acute Care Episodes: Expanded Analytic File, June 2011
25
26. Major Concerns of Current
Environment
• ACO’s and Bundled Payments Use “Shared
• Savings” Approach and Not “Fixed Budgets”
• Both Approaches are Voluntary
• Patients Have The Right to Opt Out of ACO’s
• Many Important Systems Not Participating
27. Nevertheless States Need To Be
Active Participant In Promoting
These New Delivery System
Options
Limit Regulatory Hurdles and Provide
Financial Assistance to Financially
Stressed Systems (Because of
Unfavorable Payer Mix)
28. But States Need to Guard Against
Big Integrated System Using Market
Power To Extract Higher Private
Payments
29. Letting Private Market
(Commercial Insurers and
Individual Providers) Set Rates
Can Lead to Significant
Differences in Payment
Amounts
Are They Justified?
29
31. Relative 2008 Massachusetts Blue
Cross Hospital Payment Rates
Source: BCBSMA data submitted to the attorney general. Red = teaching hospitals.
31
32. Massachusetts First State To Pass
Universal Coverage Legislation
Commonwealth Has Long History of
Expanding Coverage and Regulating
Health Spending
Brandeis University
32
34. Expanded Activity In Private
Insurance Market
• After State Set Limits on Premium
Increase (Could Be Below Underlying Health
Service Trend)
– Insurers Restructure and Toughen
Payment Models
– Introduce Limited and Tiered Network
Plans
– Increase in High Deductible Plans
34
36. Massachusetts Enrollment in Global Payment
About 22 Percent of State Residents
Pioneer ACO*
Medicaid & Commonwealth Care
Medicare Advantage
Other
Tufts
HPHC
Commercial
Members
Blue Cross
Source: The Boston Globe, February 13, 2012. Figures for Pioneer ACO are estimated.
38. Chapter 224: Cost Control & Payment Reform
Alternative
Payment
Models
Medicaid
Payment
Reform
Annual
Spending
Targets
Health
Workforce
Support
Review Provider
Price Variation
New State
Oversight
Bodies
Health IT
Requirements
Administrative
Simplification
Brandeis University
ACO
Certification
& Oversight
Health
Planning
Transparency
& Reporting
Requirements
Infrastructure
Support
38
39. Spending & Delivery Reform Oversight
Health Policy Commission*
(11-member board)
Distressed
Hospital Fund
$135M
Executive
Director and
Staff
Payment
Reform Fund
$11.5M
Center for Healthcare Information and Analysis
* In EOHS but not subject to EOHS control. Exempt from state civil service requirements and pay scales.
41. Sub-Committees of Commission
Cost Trends and Market Performance
–
Quality Improvement and Patient Protection
Establish the annual health care cost
▪
Conduct annual cost trends
hearings and issue a final report on
health care trends.
Examine the impact of health system changes
on the quality of health care in the
Commonwealth, including the impact on
patient access to care, and on the providers
of health care, including front-line
practitioners and health care workers.
▪
Establish the role and responsibilities of the
Office of Patient Protection.
▪
Track the progress of efforts regarding
mental health coverage parity and ensure the
integration of mental health, substance
abuse disorder and behavioral health services
with physical care in the development of new
care delivery and payment models.
▪
Develop guidance relative to the prohibition
of mandatory overtime for hospital nurses.
growth benchmark for total health
care expenditures in the
Commonwealth.
–
–
–
41
Conduct cost and market impact
reviews of health providers and
health plans proposing significant
market changes to the health care
industry, considering the impact of
these changes on cost, access,
quality, and market
competitiveness.
Oversee the development and
implementation of performance
improvement plans for certain
providers and plans.
42. Sub-Committees of Commission
Care Delivery and Payment System Reform
–
–
–
Establish a provider organization
registration program.
▪ Develop and administer a competitive grant
program to enhance the ability of certain
distressed community hospitals to implement
system transformation.
Develop and implement standards for a
certification program of PatientCentered Medical Homes (PCMH) and
Accountable Care Organizations (ACOs)
and develop model payment standards
to support PCMHs.
▪ Develop strategies for engaging with various
Administer a competitive grant program
to foster the development and
evaluation of innovative health care
delivery, payment models, and quality
of care measures.
▪ Develop strategies for helping consumers
–
Coordinate the advancement, adoption,
and measurement of alternative
payment methodologies.
–
Coordinate with the DOI regarding the
development of regulations relative to
the certification of risk-bearing
provider organizations.
42
Community Health Care Investment and
Consumer Involvement
constituencies and a communications plan for
educating providers, businesses, consumers,
and the general public regarding the
implementation of Chapter 224.
navigate health care cost and quality.
▪ Conduct an investigation relative to increased
adoption of flexible spending accounts, health
reimbursement arrangements, and health
savings accounts.
▪ Work with other state agencies to minimize
duplicative requirements.
44. Massachusetts Statewide Heath Care
Spending Targets (All Payer)
Billions
5.9%/yr
3.1%/yr
6.2%/yr
3.6%/yr
Source: Author’s calculation based on historical state spending estimates and projected national health spending growth from
the CMS Office of the Actuary and targets set forth in Chapter 224.
Brandeis University
45. States Must Also Be Mindful of
What Is Happening in National
Market
46. Average Annual Percent Change in National
Health Expenditures, 1960-2011
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary,
National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type
of service and source of funds, CY 1960-2010; file nhe2010.zip).
47. Slow Down May Be Permanent
• David Cutler (Harvard) Believes Many Small
Positive Changes In Market
– Providers Becoming More Efficient
•
•
•
•
Less Hospital Acquired Infections
Reduced Re-Hospitalization
More Patient Cost Sharing
Greater Use of Limited and Tiered Insurance Networks
• States Becoming More Active In Slowing
Total Spending
48. The Recession is Only About One-Third of the
Slowdown
Real, per capita medical spending
In 2005 dollars
Actuary Forecast
Gap
Actual +
Recession
Actual
Source: Authors’ calculations based on data from the Bureau of Economic Analysis and the Centers for Medicare and Medicaid Services
49. Past Efforts To Control Spending
---Regulation in 1970’s
---Managed Care in 1990’s
Strong Negative
Reactions To Both
Lets start with some DRGs that are probably pretty common in your hospitals
And here’s what Medicare pays … and most of you are probably not making much of a margin on these – particularly the medical DRGs.
Guess what … these rates aren’t going to go up much. So how are you going to maintain your margins?
Bundled payment is one opportunity