(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
Presentation to Mass Neurologic Association
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
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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://www.aan.com/go/pracAce/quality/
measurements
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. 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. 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://info.cecity.com/about.html
– Registry
info
hCps://aan.pqriwizard.com/default.aspx
• 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. 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. 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. 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. 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://ow.ly/kYHlx
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. “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. 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. 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://www.paAentsafety.org/
– Informed
Medical
Decisions
FoundaAon
• hCp://informedmedicaldecisions.org/
– InsAtute
for
PaAent
and
Family
Centered
Care
• hCp://www.ipfcc.org/
– Society
for
ParAcipatory
Medicine
• hCp://parAcipatorymedicine.org/
31. Most
Medical
Care
Occurs
Outside
the
Office
or
Hospital
Ferguson’s
inverted
pyramid
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. 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. 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. 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. 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. 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. Resources
for
Assessing
the
Delivery
Models
• Overview
– hCp://www.aan.com/go/pracAce/models
– hCp://cp.neurology.org/content/2/3/224.full
• Accountable
Care
OrganizaAons
– hCp://www.aan.com/go/pracAce/models/aco
– hCp://ow.ly/kOdQH
• PaAent
Centered
Medical
Homes
– hCp://www.aan.com/go/pracAce/models/pcmh
– hCp://cp.neurology.org/content/3/2/134.full
• Webinars
from
AMA
– hCp://ow.ly/kOe35
The
AAN
will
launch
a
new
website
to
help
keep
many
resources
in
one
place,
someAme
in
June.
39. Resources
for
Assessing
Payment
Models
• Overview
from
the
AMA
– hCp://www.ama-‐assn.org/resources/doc/psa/
payment-‐opAons.pdf
• Bundled
Payments
– hCp://www.aan.com/go/pracAce/models/bundled
• Global
Payments
– hCp://www.aan.com/go/pracAce/models/
comprehensive
• Pay
for
Performance
– www.aan.com/go/pracAce/models/performance
• Pay
for
ReporAng
– hCp://www.aan.com/go/pracAce/pay
