Value Based Reimbursement: The New Reality

© 2015 Health Catalyst
www.healthcatalyst.com
Proprietary and Confidential
Value Based Reimbursement:
The New Reality

Objectives
 Definitions
 Measures for 2015
 Results
 Challenges
 MedPAC recommendations
Discuss latest announcements on Value Based1
Status of CMS programs2
Preparation for VBP3

From 2015 Health leaders media industry survey
Survey Results
10%
28%
33%
6%
11%
4%
3%
4%
0%
5%
10%
15%
20%
25%
30%
35%
Not pursuing Investigating Pilot underway Pilot done,
rollout not
scheduled
Pilot done,
rollout
scheduled
Rollout nearly
done
Full rollout Do not know
Organization Status on Value Based Payment
N=580
http://www.healthleadersmedia.com/slideshow.cfm?cont
ent_id=312213&pg=2© 2015 Health Leaders Media

Proprietary and Confidential 4
Kaufman Hall Survey Update April 2015
Announcements
22%
42%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Aug 14 Feb 15
7%
22%
0%
5%
10%
15%
20%
25%
Aug 14 Feb 15
Hospitals Currently >10% Value Based
Hospitals Expectation Within 24 months
>50% Value Based
Source: Kaufman, Hall & Associates, LLC, Media release, April 2015

Announcements
CMS in January
30 percent of payments will be tied to alternative payment models (ACOs or
bundled payment arrangements) by the end of 2016. Payments related to
these models will increase to 50 percent by the end of 2018.
85 percent of all traditional Medicare payments will be tied to quality or value
by 2016 and 90 percent by 2018 through programs such as Hospital Value
Based Purchasing and Hospital Readmissions Reduction.
Commercial in January
The Health Care Transitional Task Force stated that 75 percent of their
respective businesses will be operating under value-based payments by 2020.
5

CMS current state
Currently, the nation is at about 50% for value-based
spending, and 20% in bundles, episodes, or ACOs.
"We have about 30% of Medicare beneficiaries in
Medicare Advantage, 20% in alternative payment
models like ACOs, and growing. The minority of
Medicare patients, right now, are in traditional-fee
for-service," Patrick Conway, MD, CMS acting
principal deputy administrator
6

Announcements
Congress in April 2015
SGR (Sustainable Growth Rate), Repealed and Revamped with Value
Based Purchasing
“Mayo Clinic is pleased with today’s bipartisan action,” President and
CEO John Noseworthy, MD. “Mayo has actively supported the repeal
and replacement of the SGR for years. This ends 17 years of
uncertainty for hospitals and physicians and moves
Medicare towards paying for quality and efficiency. This is important for
patients, taxpayers and long-term solvency of Medicare. The road to
value-based payment will be challenging. We believe the next step
must be to develop performance measures that accurately differentiate
levels of care and complexity of patients.”
7

Improve health and save money
Bruce Broussard,
Humana President and CEO
Key to change
8
New paradigm
Take my company. At Humana, results for more than 1
million Medicare Advantage members in pay-for-value
agreements reflected better quality, outcomes and costs:
better HEDIS [Healthcare Effectiveness Data and
Information Set] scores and Star ratings, fewer trips to the
emergency department among our members, and a 19
percent cost reduction.

Poll Question #2
Which would be your preferred payment system
for your organization? 352 respondents
 Fee for service – 23%
 Bundled payment – 20%
 Accountable care organization – 43%
 None of the above – 15%
9

MedPAC
Medicare Payment
Advisory Commission
 Policy formulation
 Recommendations to congress
(March 2015)
Complex and
fragmented system,
multiple coverage,
payments and different
rules for each setting
Payment Reform
 Implement more broadly
 Coordinate across settings-rate
determined by most efficient
setting to deliver care
Delivery system
reforms
 Monitor performance
 Adopt on broader scale

Fun Facts
11,000 Baby Boomers are
aging into Medicare daily.
The U.S. population is
about 320 million, which
makes 2015 "the first year
healthcare spending will
reach $10,000 per person,"
according to a Forbes
report.
11
Source: Your Favorite Seuss written and illustrated by Dr. Seuss, Random House, 2014

Measure
12
WSJ: How should quality in health care be measured and are we looking at the
right things?
Scott Wallace, visiting profession at Dartmouth.
The quality programs grew out of two realizations: Health care is unsafe and outcomes
are poor. But there is no single measure of a doctor’s or hospital’s quality that will fix
those problems. Instead, we’re measuring processes. Of the 123 different metrics in
the government’s Hospital Compare website, 102 measure processes. That’s
important, but it has become too burdensome for the benefit it delivers.

Core Goals for NQF
13
 Align quality measures among all payers
 Identify more actionable, meaningful measures
 Achieve greater consistency and rigor with consumer information
 Leverage new technology and big data to identify and assess
quality metrics
 Make sure measure reflect actual clinical quality, not factors like
socioeconomic status that are out of health systems' control
 Attribute results to specific providers
 Improve consumer engagement
Christine Cassel, MD, President and CEO of
National Quality Forum

Models
14
Payment Methodology Quality Cost
Cost low low
Fee for Service low medium
Per case / outpatient grouping low medium
% of charges low low
Add quality metrics medium medium
Shared savings (+, +/-) medium/high medium/high
Bundled payment low medium/high
Add quality metrics medium/high high
Shared savings (+, +/-) medium/high high
Capitation medium/high high
Add quality metrics high high
Shared savings (+, +/-) high high
Incentive for Improvement

Fee for Service
15
Definition:
Payment received for each “necessary” service, generally
prospective in nature, rates set for each case or grouping
History: Hospital DRGs initiated in 1983 by CMS for
cost control
Inpatient
MSDRG
Outpatient
APC
Professional
Fee schedule

Fee for Service
16
Incentive: Little for quality, ability to keep surplus if
payment above cost
1
23
4
Success
factors
Know your
costs
Document
severity
Work with
providers within
facility
Analytical
capabilities

Medicare FFS payments by venue
2008 to 2012
17
OutpatientClinic Care Inpatient SNF Home Hlth Hospice
$ 152 Billion
11.8%
372 Billion
28.7%
447 Billion
34.5%
$ 133 Billion
10.3%
$ 90 Billion
6.9%
$ 48 Billion
3.7%
LTCH/IRF
$ 53 Billion
4.1%
Clinic Care Outpatient Inpatient SNF LTCH/IRF Home Health Hospice
75%

Hospital Medicare Margins
18
-20%
-15%
-10%
-5%
0%
5%
10%
15%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Hospital Medicare Margins
IP OP OverallSource: MedPAC report March 2015

Performance of hospitals
19
Relatively
Efficient
(268)
Other
(1,846)
Relatively Efficent…
Other (1,846)
Number and Share of Hospitals
13%
87%
2%
8%
6%
-6%
8%
5%
-8%
-6%
-4%
-2%
0%
2%
4%
6%
8%
10%
Overall Medicare
margin, 2013
NonMedicare margin,
2013
Total margin, 2013
Relativity Efficient Other
Margin
Performance Metrics 2013 Risk Adjusted
84%
97%
90%
102% 101% 102%
0%
20%
40%
60%
80%
100%
120%
Composite 30 day
mortality
Readmission rates Standardized Mediare
cost per disharge
Relatively Efficient Other
There are hospitals with positive
Medicare margins and high quality
results.

High cost, high variability
20

Variation
21

High cost, high variability
22

Inpatient vs Outpatient
23
-20%
-10%
0%
10%
20%
30%
40%
2006 2007 2008 2009 2010 2011 2012 2013
Medicare Per Beneficiary
OP Services per Beneficiary IP Discharges per Beneficiary

Physician Payment in 2013
MedPAC Concerns
24
876,000
Providers
573,000
Physicians
Undervalue primary care
Preserve access
Repeal SGR (Sustainable Growth Rate)
Increase shared savings opportunities

MedPAC survey results
25
0% 10% 20% 30% 40% 50% 60% 70% 80%
Very Satisfied
Some Satisfied
Some Dissatisfied
Very Dissatisfied
Medicare (>65)
Private Insurance (50-64)
Satisfaction with quality of healthcare in 2014
Excludes don’t know, no healthcare in past 12 months
Source: MedPAC telephone survey 2014

SGR Dead, Value Based Plan
2015 to 2019 annual .5% increase
2019 5% bonus for participation in innovate care
delivery model. At least 25% (this threshold
increases over time) of the Medicare revenue from
alternative payment models like patient-centered
medical homes and accountable care organizations.
Streamline the quality report requirements for various
programs like EHR Incentive Programs and
Physician Quality Reporting System(PQRS).
26

Patient Centered Medical Home
27
Demonstrate
6 standards
for NCQA
Enhance access and
continuity
Identify and
manage patient
population
Plan and manage
care
Provide self-care and
community support
Track and
coordinate care
Measure and
Improve care

Affordable Care Act - 5 years old
Number of new payment models that move the needle further toward
paying health care providers for the quality of the care they give
patients, instead of the quantity of care. In these alternative payment
models, providers have a financial incentive to coordinate care for
their patients and get the right care to the right patient the first time.
Progress
More than 400 Medicare ACOs participating in the Shared Savings
Program and the Pioneer ACO Model have generated a combined
$417 million in savings for Medicare.
Improve the quality of health care, contributing to 50,000 fewer
patient deaths in hospitals due to avoidable harms, like an infection
or medication error, and 150,000 fewer preventable Medicare
hospital readmissions.
28

Hospital Programs- Readmission
29
• Third year of program, 3% maximum penalty
• Conditions: Heart failure, AMI, pneumonia,
hip/knees, COPD, CABG (2017)
• Proposed to expand definition of pneumonia
39 71
428
2,100
840
0
500
1000
1500
2000
2500
-3% -2 to -2.99% -1 to -1.99% -.01 to -.99% 0%
2015 Readmit Penalty

Results
Touting encouraging progress toward improving
quality and lowering healthcare costs, the Centers for
Medicare & Medicaid Services' chief medical officer
attributed a 2% decline in admissions and emergency
department visits.
30

Reduced Heart Failure
Readmissions
31
29% reduction in 30-day readmits
14% reduction in 90-day readmits
120% increase in f/u appointments
78% increase in med reconciliation
87% increase in f/u phone calls
84% increase in teach back

Value Based Purchasing
Budget Neutral Program
1.75% At risk/Bonus for 2016
32
160
1,541
1,381
7
-
200
400
600
800
1,000
1,200
1,400
1,600
1,800
>1% .01 to .99% .0 to -.99% >-1%
2015 Value Based Purchasing

VBP Clinical Measures
33
Active
Inactive
Key:
FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
AMI-7a
Fibrinolytic Therapy Received Within 30 Minutes of
Hospital Arrival Going away
AMI-8a
Primary Percutaneous Coronary Intervention (PCI)
Received Within 90 Minutes of Hospital Arrival
HF-1 Discharge Instructions
IMM-2 Influenza Immunization Going away
PN-3b
Blood Cultures Performed in the Emergency
Department Prior to Initial Antibiotic Received in
Hospital
PN-6
Initial Antibiotic Selection for Community-Acquired
Pneumonia (CAP) in Immunocompetent Patient
SCIP-Inf-1
Prophylactic Antibiotic Received Within One Hour Prior
to Surgical Incision
SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3
Prophylactic Antibiotics Discontinued Within 24 Hours
After Surgery End Time
SCIP-Inf-4
Cardiac Surgery Patients with Controlled 6:00 a.m.
Postoperative Serum Glucose
SCIP-Card-
2
Surgery Patients on a Beta Blocker Prior to Arrival That
Received a Beta Blocker During the Perioperative
Period
SCIP-VTE-1
Surgery Patients with Recommended Venous
Thromboembolism (VTE) Prophylaxis Ordered
SCIP-VTE-2
Surgery Patients Who Received Appropriate Venous
Thromboembolism Prophylaxis Within 24 Hours Prior
to Surgery to 24 Hours After Surgery
SCIP-Inf-9
Postoperative urinary catheter removal on
postoperative day 1 or2
PC-01
Elective Delivery Prior to 39 Completed Weeks
Gestation .

VBP- continued
34
Outcome Measures FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Mort-30-AMI AMI 30 day mortality rate
Mort-30-HF HF 30 day mortality rate
Mort-30-PN Pneumonia 30 day mortality rate
AHRQ PSI compositeComposite for patient safety
CLABSI Cental line blood associated infection
CAUTI Catheter-Associated Urinary Tract Infection
SSI Surgical site infection- colon and abdominal hysterectomy
Efficiency Measures FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
MSPB-1 Medicare spending per beneficiary
Patient experience of care measure FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Hospital Consumer Assessment of Healthcare Providers and Systems Survey
(HCAHPS)
Communication with nurses
Communication with physicians
Responsiveness of Hospital Staff
Pain Management
Communication about Medicine
Cleanliness and Quietness of Hospital Environment
Discharge Information
Overall rating of hospital
Propose adding care coordination in 2017

Metric weights by year
Value Based Purchasing
35
70%
45%
20%
10% 10%
30%
30%
30%
25% 25%
25%
30%
40% 40%
20% 25% 25%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Clinical Process Patient Experience
Outcome Measures Efficiency Measures
Achievement
My hospital compared to all hospitals
Improvement
My hospital compared to my
baseline performance
Hospital National
Measure Baseline Performance Benchmark Threshold Achieve Improve Points
SCIP-1 -prophylactic ABX
received w/n 1 hr prior to
surgical incision
98.55 99.22 99.98 97.35 7 4 7
Proposed update for 2016
Safety 20%
Efficiency 25%
Clinical process 30%
Patient experience 25%

Hospital Acquired Conditions
36
FY 2014 Final Inpatient PPS Rule
Creates HAC Reduction Program
with two Domain measurements that
overlaps in its entirety with existing
HAC program and VBP.
2015
723 Hospitals received 1% penalty
2016
1% Penalty
Proposed –reweight domain, add
more measures to PSI-90, add more
measures to domain 2

Study at Adventist Health, FL
Researchers found that a patient who suffers
temporary harm during a hospital stay costs the
provider $2,187. If the patient suffers a greater harm,
the cost to the hospital is $4,617.
The Adventist study followed more than 21,000
patients treated by its 24 hospitals between 2009 and
2012. By increasing patient safety and reducing harm
incidents, it was able to save $108 million in total
costs and $18 million in negative contributions to its
margins.
Journal of Patient Safety, March 23, 2015
37

Growing Dollars At Risk- Hospital
38
Source: CMS website
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
2013 2014 2015 2016 2017
Medicare $ At Risk
HAC
Readmit
VBP
MU

PQRS
39
The Physician Quality Reporting
System (PQRS) has been using
incentive payments, and will begin to
use payment adjustments in 2015, to
encourage eligible health care
professionals (EPs) to report on
specific quality measures.
EPs who do not participate in 2013 and
receive a payment adjustment will be
paid 1.5% less than the Medicare
PFS(Physician Fee Schedule) amount
for services provided in 2015.
Increases to 2% in 2016.

Value Based Modifier
Matrix for payments
40
Low cost Average cost High cost
High quality +2X* +1X* 0
Medium quality +1X* 0 -0.5%
Low quality 0 -0.5% -1.0%
*Eligible for additional payments
X value depends on negative adjustments

California Program for Physicians
41
P4P
 Began in 2003, public report,
common measures
 10 Health Plans, 200 Physician
Groups, 9M members
 Focus on measure/improve
quality, costs continue to rise
 2013 Transition to Value Based,
Shared savings program for
quality and resource use (cost).

Metrics for Physician Practices
42

American Academy of
Orthopaedic Surgeons (AAOS)
43
Across the various meetings, one message rings loud:
there is an increasing need to achieve and demonstrate
value in orthopedics.
The transition from a fee-for-service model towards
value-based care increasingly ties financial
reimbursement to a physician’s performance. As a result,
physicians are calling on their colleagues to play a
greater role in value-based care by employing evidence-
based practices and tracking quality outcomes.
Source: Service Line Strategy Advisor

Bundled Payment
44
Definition: Single comprehensive rate for entire
episode of care generally within defines time limits
and includes all providers of care. Provider takes
accountability for episode.
History: Demonstration projects in 90’s and early
2000’s
 Popular with employers
 CMS started in 2013

Bundled Payment
45
Incentive: Quality relates to readmissions, ability coordinate care
For example, the Lewin Group recently released the first analysis of
the Medicare bundled payment program. The conclusion was
decidedly inconclusive: “We are limited in our ability to draw
conclusions about the effects of (the Bundled Payments for Care
Improvement program) because of the small sample sizes and short
time-frames.”
Know your
costs, team
includes
clinical and
financial
Know the
conditions
and your
population
Work with
providers to
see big
picture of
care
May be
good
starting
point
Success factors:

Bundled Payment
46
Acute Acute/Post Post Acute
Payment Retrospective Retrospective Retrospective Prospective
Participants 3 44 14 37
Organizations 12 2180 4727 17
Episode All acute patients, all DRGs
Selected DRGs, hospital
plus post-acute period
Selected DRGs, post-acute
period only
Selected DRGs, hospital
plus readmissions
Services included
in the bundle
All Part A services paid as
part of the MS-DRG
payment
All non-hospice Part A and
B services during the initial
inpatient stay, post-acute
period and readmissions
All non-hospice Part A and B
services during the post-
acute period and readmits.
All Part non-hospice A and
B services (including the
hospital and physician)
during initial inpatient stay
and readmissions
48 Bundled Payment Groupings
Major joint upper extremity
483 Major joint and limb reattachment procedure of upper extremity with
complication or comorbidity or major complication or comorbidity

Spine
47
Bundled Payment
Covers preoperative to post operative
Results: ALOS 6 to 4.89
Readmit down 14%
IP Rehab 41% to 29%

New programs and payment
Medicare continues to pay the “old” way and do a reconciliation at
the end for ACO/Bundled Payment- Retrospective
Hospital paid based on IP MSDRG and OP APC, fee schedules.
Physician paid on fee schedule.
48
Cost Trend
Benchmark
Actual
Potential
savings

Tracking for bundled payments
49

Capitation
50
Definition: Specific amount paid in advance for all health
care services of a population. Usually paid on a per
member per month (PMPM) basis. Provider has total
accountability and risk.
History: Used by managed care organizations in late
1990’s. Huge consumer backlash. Medicare started new
models in 2012. CMS models:
Pioneer 19
participants
MSSP (Medicare
shared Savings)
404 participants
Next generation
ACO

Capitation
51
Incentive: Quality metrics and cost benchmarks,
providers can elect upside only or upside and downside
for shared savings.
Know your
costs
Document
severity
Work with
providers
across
continuum
Have good
data for
analysis
Success factors:

CMS ACO results
52
Higher quality,
patient
experience than
benchmarks
Improvement in
quality and
patient
experience
measures
Generated
$417 M in
savings for
Medicare Qualified for
shared
savings
payments of
$460 M

Analysis in ACO
53

www.healthcatalyst.comProprietary and Confidential
Framework
54

= Negative Impact = Positive or Negative = Positive Impact
Knowledge Asset
Type
Discounted
FFS
Per Diem
Per Case Bundled Per Case
Condition
Capitation
Full
Capitation
CMS Commercial CMS Commercial
Workflow
Diagnostic Variation
Standing Orders
MedicationSelection
Triage
Patient Safety
Ambulatory Treatment
and Monitoring
Indications for Referral
Indications for
Intervention
Considerations
Workflow
Diagnostic Variation
Standing Orders
Substance Selection
Triage Criteria
Patient Safety
Treatment and
Monitoring Algorithms
Indications for Referral
Indications for
Intervention
25

Poll Question #3
Which payment system best aligns quality and
cost?
 Fee for service
 Bundled payment
 Accountable care organization
 None of the above
56

Framework for Value Capture
Category Strategy Example
Change to price setting
mechanism
Value Based Pricing Fasteners
Auction Google adwords
Demand driven pricing Airlines
Name your own price/pay
what you want
Priceline
Change the payer Two sided market 20 Minuten
Change payer in value
constellation
Carbon for water
Internal budgeting Executive education
Change the price
carrier
Change the carrier Netflix
Bundle/unbundle Telecommunication
All inclusive Cruise
Change the timing Installed base pricing Gillette
Futures contracting Presold hotel rooms
Changing the segment Target costing Xiameter
Self-segmented fencing Coupons
57
Source:
Innovation is not
worth much if you
do not get paid for
it.
Stefan Michel
HBR Oct 2014

Preparation/Assessment
58
What is not in alignment metrics, incentives, compensation?
What do we need to learn for new environment?
How do we get there? What is success?
Where do we want to be?
Where are we now with payers, network?

Starting Point
59

$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
2012 2013 2014 2015 2016
Millions
Medicaid
Employee group
Medicare advantage
Commercial
4% 5% 6%
15%
17%
60
At Risk Net Revenue to 46% by 2016
29%
Medicare
Shared Savings
At risk- Develop Plan

Contracting strategy. Contracting analysis should be
informed by data-driven criteria, such as:
At-risk tools
Volume “Directability” Alignment
How much member
volume does the
payer have to drive
to your provider
network?
How strong is the
payer’s health
benefit program
gradient (delta
between plan
payment for in-
network vs. out-of-
network services)
How exclusive is
the contract with the
your provider
network?

Transformation accelerators
62
Content
Accelerators
Deployment
Accelerators
Analytic
Accelerators
How do we change?What are we doing?
What should we be doing?

Final questions
Can we
measure the
value equation
both the cost
and the quality
pieces?
Are we focused
on outcomes?
Are we creating
value for the
patient? Have
we eliminated
waste?
Do you have a
cost accounting
system to
support this
measurement?
Do we triage to
least expensive
treatment
center with best
outcomes?
Do we focus on
the consumer?
Thanks to Dale Sanders for these ideas.

Choosing Wisely
Wise imaging
Wise
medications
Wise labs
Preventative
Care Visits
According to the Institute of Medicine, up to 30% of
healthcare delivered in the U.S. is unnecessary and
may cause harm.
Intermountain Health Care has guides for adults
and children on their website.
Adults:
https://intermountainhealthcare.org/ext/Dcmnt?ncid=52
2448817
Children:
https://intermountainhealthcare.org/ext/Dcmnt?ncid=52
2448814
Underused
Care
http://www.choosingwisely.org/

Thank you.
65

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