Health Reform & the Delivery System:  A New Medley of

Payment & Incentives

Anne K. GauthierSenior Fellow

National Academy for State Health PolicyOctober 6, 2010

1

Overview Numerous provisions

in PPACA promote movement toward a high-performance health delivery system

State opportunities and obligations to promote high quality, efficient care

Strategic coordination & alignment of activities

Data collection, aggregation, & standardization for performance measurement

Public reporting and transparency of cost & quality data

Payment reform & alignment of financial incentives to encourage value-based purchasing

Consumer engagement to drive policy change & encourage care self-management

Provider engagement in policy making & transforming care delivery

State Activities and Strategies to Improve Quality & Efficiency

STRATEGIC COORDINATION & ALIGNMENT OF ACTIVITIES

Need to evaluating how current initiatives will align with ACA ex. HITECH

Increased coverage expansions need cost containment mechanisms

Reform efforts span across varying state and federal agencies

Strategic Coordination & Alignment of Activities : State Challenges

Collaboration to improve system performance National Strategy to Improve Health Care

Quality Will emphasize quality and efficiency in delivery

system; establish priorities for system improvement

Center for Quality Improvement and Patient Safety (AHRQ)

Will identify best practices, develop tools, disseminate information, and build capacity at state and local level

Interagency Working Group on Health Care Quality

Will coordinate reform efforts to avoid duplication, develop streamlined process for reporting and compliance, and assess alignment across public and private sectors

Strategic Coordination & Alignment of Activities: State Opportunities in ACA

DATA COLLECTION, AGGREGATION, & STANDARDIZATION FOR PERFORMANCE MEASUREMENT

States lack…

standardized measures streamlined data aggregation access to Medicare data complete datasets

Small/ rural practice integration of data implementation and reporting requirements

Data Collection, Aggregation, & Standardization: State Challenges

Creation of standard measures AHRQ developed provider-level quality

measures Convention of stakeholders to develop quality

measures, and standards for reporting and payment in fed. programs

Medicaid Quality Measurement Program

Streamlined data aggregation Program Integrity Database Integration of quality reporting

with EHR

Data Collection, Aggregation, & Standardization: State Opportunities in ACA

Complete datasets for population based approaches Incentive payments and penalties under the

Physician Quality Reporting Initiative Release of Medicare claims data Required reporting on

value-based purchasing Fed-state Diabetes Report Card Health plan quality reporting as

part of exchange participation

Data Collection, Aggregation, & Standardization: State Opportunities in ACA

PUBLIC REPORTING AND TRANSPARENCY OF COST & QUALITY DATA

Identification of useful information Complexity of issues Consumer confusion

Fed-state alignment of measures/ data linkages

Public Reporting & Transparency of Cost & Quality Data: State Challenges

Publically reported data to inform decision making HHS collection, aggregation, & reporting of

quality data Disclosure of financial relationships among

providers, suppliers, & manufacturers Access to CMS hospital-acquired condition data Annual reports from the Payment and Advisory

Board on health care for Medicare beneficiaries Public availability of quality reporting initiatives Physician Compare website

Public Reporting & Transparency of Cost & Quality Data: State Opportunities in ACA

PAYMENT REFORM & ALIGNMENT OF FINANCIAL INCENTIVES TO ENCOURAGE VALUE-BASED PURCHASING

Medicare participation Lack of coordination in PPACA rollout Preclusion of participation in programs

because of previously established programs

Conflict with current state initiatives Federal prioritization of

payment reform

Payment Reform & Alignment of Financial Incentives: State Challenges

Innovative payment reform models Center for Medicare and Medicaid Innovation Health home program for those with chronic

conditions HHS guidelines on value-based design

Medicare Participation Payment adjustments based on provider

productivity FFS modifier based on value HHS programs for value-based purchasing in

specialized facilities Proposals from Independent Payment Advisory

Board to improve quality

Payment Reform & Alignment of Financial Incentives: State Opportunities in ACA

Multi-payer payment models Medicare Shared Savings Program => ACOs Medicaid demos to test bundled payments,

global captivated systems, and pediatric ACOs Medicare bundled payment pilot

Incentives to reduce hospital-acquired conditions

Reduction of Medicare payments related to preventable readmissions

No Medicaid payments for hospital-acquired conditions

Payment Reform & Alignment of Financial Incentives: State Opportunities in ACA

CONSUMER ENGAGEMENT TO DRIVE POLICY CHANGE & ENCOURAGE CARE SELF-MANAGEMENT

Perception of reform as limiting choice

Access issues outweigh quality issues for consumers

Patients already limited in ability to participate in making decisions about own care

Consumer Engagement to Drive Policy Change & Encourage Self-Management: State Challenges

Inclusion of consumers in strategy development Consumer advisory council to advise

Independent Payment Advisory Board on consumer impact of payment reforms

Tools for informed decision making Patient-centered education by

exchange plans Grants to develop patient decision

aids & disseminate best practices Test of payment models that

support shared decision making Patient Navigator grant program extended

Consumer Engagement to Drive Policy Change & Encourage Self-Management: State Opportunities in ACA

PROVIDER ENGAGEMENT IN POLICY MAKING & TRANSFORMING CARE DELIVERY

Perverse payment incentives Lots of coaching/ training necessary Resistance to change Lack of forums to share

programmatic input

Provider Engagement in Policy Making and Delivery Transformation: State Challenges

Provider engagement in quality initiatives Provider implementation of quality

improvement strategies in order to contract with exchange plans

Provider inclusion on Independent Payment Advisory Board

Provider support for quality improvement Physician feedback program with new reports

and data analysis Grants for health professional curricula on

patient safety and quality improvement IOM study on best practices for clinical

guidelines

Provider Engagement in Policy Making and Delivery Transformation: State Opportunities in ACA

Provider support (cont.) Comparative effectiveness research by the

Patient-Centered Outcomes Research Institute State grants to create interdisciplinary teams

to support primary care physicians in creating medical homes

Primary Care Extension Program to support, assist, and educate primary care providers• Grants to establish State Hubs to coordinate with

quality improvement organizations and health education centers

Grants to support community-based collaborative care networks for safety-net hospitals and FQHCs

Provider Engagement in Policy Making and Delivery Transformation: State Opportunities in ACA

Reform is an opportunity for program transformation Not just “supersizing” existing programs

ACA provides opportunities to build momentum on current quality and efficiency efforts Ex. ARRA reforms

Quality and efficiency should notbe divorced from coverage expansions

Keys Themes from States

States face dire staff and financial challenges in implementing ACA Scarce resources; pressure to

implement mandatory reforms

Leadership is critical to advancing state agendas

Federal officials can learn from the efforts of leading states

Keys Themes from States

Thanks to…

Jill Rosenthal Abby Arons Program Director, NASHPIntern, NASHP

Christina MillerResearch Assistant, NASHP

For further information…

Rosenthal, J., Gauthier, A., Arons, A. State Strategies to Improve Quality and Efficiency: Making the Most of Opportunities in

National Health Reform, Forthcoming CMWF/ NASHP publication, October 2010

Anne GauthierSenior Fellow, NASHPagauthier@nashp.orghttp://www.nashp.org