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The Future of GI Practice

The Future of GI Practice. MGMA 2013 Gastroenterology Preconference October 6, 2013 San Diego, California Rajeev Jain, MD, AGAF Texas Digestive Disease Consultants Dallas, Texas. Objectives. Understand what constitutes the Triple Aim Identify cost and quality objectives

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The Future of GI Practice

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  1. The Future of GI Practice MGMA 2013 Gastroenterology Preconference October 6, 2013 San Diego, California Rajeev Jain, MD, AGAF Texas Digestive Disease Consultants Dallas, Texas

  2. Objectives Understand what constitutes the Triple Aim Identify cost and quality objectives Identify the threats to gastroenterology Strategies for success

  3. Health care expenditures • Over one-sixth of the U.S. GDP • Rate of growth exceeds other sectors of the economy • Among the largest components of the Federal and states’ budgets • 1999-2009, two-thirds of middle-class family's income gains were consumed by rising health care costs* http://www.commonwealthfund.org/Infographics/2013/US-Health-Spending.aspx Auerbach DI, Kellermann AL. Health Aff (Millwood). 30(9):1630-36. 2011

  4. Health care expenditures

  5. US Mortality rate • US is among the wealthiest nations • Life expectancy and health have improved over past century • Rank 17th among peer nations in all-cause mortality US Health in International Perspective. National Research Council. January 2013

  6. Healthcare reform Affordable Care Act 2010 Patient Centered Medical Home Bundling Accountable Care Organizations Value based modifiers

  7. Reasons for quality gap Growing complexity of science and technology Increase in chronic conditions Poorly organized health care delivery systems Constraints in the use of information technology Institute of Medicine Crossing the Quality Chasm 2001

  8. Definition of high-quality care Safe Effective Patient-centered Timely Efficient Equitable Institute of Medicine Crossing the Quality Chasm 2001

  9. Value in healthcare Value = Quality/Cost Institute of Medicine The Healthcare Imperative: Lowering Costs and Improving Outcomes 2010

  10. Waste in health care Berwick & Hackbarth. JAMA. 307(14):1513-16. 2012

  11. The Triple Aim

  12. The triple aim Improving the patient experience Improving the health of populations Reducing the per capita cost Berwick, DM et al. Health Aff (Millwood). 27(3):759-69. 2008

  13. Definition of value Quality Value = Cost Outcomes x Experience Value = Cost

  14. Triple aim – population health • Income • Race/ethnicity • Disease burden • Those served by a particular health system • A particular workforce Jacobson DM, Teutsch S. An Environmental Scan of Integrated Approaches for Defining and Measuring Total Population Health by the Clinical Care System, the Government Public Health System, and Stakeholder Organizations. National Quality Forum; June 2012. • Total population: residents of a geopolitical area • Sub-populations can be defined by:

  15. Triple aim – population health Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. • Health outcomes • Mortality • Health and functional status • Health Life Expectancy (HLE) – reflects remaining years of life in good health • Disease burden • Incidence and/or prevalence • Behavioral and physiologic factors • Smoking, alcohol, physical activity and diet • Blood pressure, BMI, cholesterol and glucose

  16. Leading causes of yll in 2010 The State of US Health. JAMA. 310(6):591-608. 2013

  17. Triple aim – experience of care Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. • Surveys • Consumer Assessment of Healthcare Providers and Systems (CAHPS) • How’s Your Health • Measure sets aligned with IOM 6 aims • Safe • Effective • Patient-centered • Timely • Efficient • Equitable

  18. Cost and Quality Objectives Meaningful Use PQRS Value Based Modifier

  19. Meaningful Use

  20. What is meaningful use • Meaningful Use is using certified EHR technology to • Improve quality, safety, efficiency and reduce health care disparities • Engage patients and families in their health care • Improve care coordination • Improve population and public health • All the while maintaining privacy and security • Meaningful Use mandated in law to receive incentives www.cms.gov

  21. What are the main components • The Recovery Act specifies the following 3 components of Meaningful Use: • Use of certified EHR in a meaningful manner (e.g., e-prescribing) • Use of certified EHR technology for electronic exchange of health information to improve quality of health care • Use of certified EHR technology to submit clinical quality measures (CQM) and other such measures selected by the Secretary www.cms.gov

  22. A conceptual approach to mu Stage 3 Stage 2 Stage 1 www.cms.gov

  23. MU incentive payments, medicare www.cms.gov

  24. PQRS

  25. Physician quality reporting system • Pay-for-reporting program to promote reporting of quality information by eligible professionals (EPs) • Incentive payments are provided through 2014 to EPs and group practices who satisfactorily report data on quality measures (QMs) for covered professional services furnished to Medicare Part B FFS beneficiaries  • In 2015, a downward payment adjustment will be applied to EPs who do not satisfactorily report data on QMs for covered professional services during CY 2013.  

  26. PQRS proposed changes in 2014 • CMS proposes to add 47 new individual measures and 3 measures groups. • Screening colonoscopy - Adenoma Detection Rate • CMS proposes to retire a number of claims-based measures to encourage reporting via registry and EHR-based reporting mechanisms • Several Hepatitis C measures may be removed

  27. PQRS proposed changes in 2014 • CMS proposes to make the following changes to reporting requirements: • Increasing the number of measures that must be reported via the claims and registry-based reporting mechanisms from 3 to 9 • Changing the reporting threshold for reporting individual measures via registry to require that eligible professionals report on only 50% of the eligible professional’s applicable patients rather than 80% • Eliminating the option to report on claims-based measures groups

  28. Value Based Modifiers

  29. Value based payment modifier • 2006 Tax Relief and Health Care Act (THRCA) • Requires the establishment of a quality reporting system for eligible professionals including an incentive payment • 2008 Medicare Improvements for Patients and Providers Act (MIPPA) • “The Secretary shall establish a payment modifier that provides for differential payment to a physician or a group of physicians based upon the quality of care furnished compared to cost during a performance period.” • 2010 Patient Protection and Affordable Care Act (ACA) • Adds to the requirement for a value modifier

  30. Value based payment modifier

  31. Value based payment modifier A budget neutral payment adjustment applied based on a measure of the cost and quality of the services. Applied in 2015 to physicians in group practices with 25 or more members billing under the same TIN. The VBM will be set at -1% of all Medicare Part B allowable charges for group practices who do not participate in the 2013 PQRS.

  32. Value based payment modifier How will the score be calculated? Clinical Care Total Overall Costs For All Patients Patient Experience Total Costs For Patients with 4 Chronic Conditions Population Health Patient Safety Care Coordination Efficiency Value Modifier Amount Quality Composite Cost Composite

  33. VBPM quality-tiering approach • *Eligible for an additional +1.0x if: • reporting quality measures via the web-interface or CMS-qualified registry, and • average beneficiary risk score is in the top 25 percent of all risk scores.

  34. Penalty box

  35. Threats to Gastroenterology

  36. Disruptive threats

  37. New technology • Gastroenterology practice revenues are heavily dependent on colonoscopy • What if screening colonoscopy is supplanted by some new technology? • Colon capsule • Stool DNA • Serum markers • CT colonography • What if colonoscopy is performed by non-physicians?

  38. Payment reform “Our nation cannot control runaway medical spending without fundamentally changing how physicians are paid.” Over time, payers should largely eliminate fee-for-service (FFS). Transition to an approach based on quality and value over the next 5 years. Site of service differential should be eliminated. The Sustainable Growth Rate should be eliminated. National Commission on Physician Payment Reform, March 2013

  39. In the news

  40. Disruptive threats Healthcare reform – administrative burdens Changing referral patterns – patient steerage by integrated delivery networks (IDNs) Employment models – Cardiology! Early intervention – diseases/disorders diminish in incidence/prevalence

  41. Pathology

  42. Change in pathology services 38% Pathology services, millions 113%

  43. Change in gi pathology services Self-referral, %

  44. Pathology Percentage Change in Medicare Anatomic Pathology Services by Provider Specialty, 2008 - 2010

  45. Gao recommendations to cms • Insert a self-referral flag on Medicare Part B claim forms. • Implement an approach to ensure the appropriateness of biopsy procedures performed by self-referring providers. • Implement a payment approach that would limit the financial incentives. • HHS agrees • In 2013, technical component (88305) – 52% or 33%  in global payment

  46. Aga response to gao report

  47. Roadmap to Success for Gastroenterology

  48. Roadmap to success • Get Big • Create a Strong, Fair, Knowledgeable Governance • Culture of Quality with Committed (Paid) Leadership • Business/Comp Structure that = Cooperation and Measurement • Internal Process Improvement (Standardize) • Know Federal, State, Commercial and Regional Initiatives • HIT that meets Meaningful Use and Integrates with your Regional Health System’s EHR • Learn about Population Management • Build Capability to Assume Risk (Financial, Performance) • Total Cost of Care – Shared Risk Source: John Allen, MD, MBA

  49. Get big Reasons to Go Big Practice infrastructure Negotiating leverage Quality Professional management Allen JI.ClinGastroenterolHepatol. Jul;10(7):692-6; 2012 Persley KM, Jain R. GastrointestEndoscClin N Am. Jan;22(1):77-83; 2012

  50. Bundled Payments

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