Centers for Medicare & Medicaid Services Population Health at CMMI March 2012 William J. Kassler, MD, MPH Chief Medical Officer, New England Region & Population Health Models Group Center for Medicare and Medicaid Innovation
The Current System • Greatest Acute Care in the World: People come from around the world to be treated • But: 46 Million Americans lack coverage • Uncoordinated – Fragmented delivery systems with variable quality • Unsupportive – of patients and healthcare providers • Unsustainable – Costs rising at twice the inflation rate
A Future System • Affordable • Accessible – to care and to information • Seamless and Coordinated • High Quality – timely, equitable, safe • Person and Family-Centered • Supportive of Clinicians in serving their patients needs
Community Integrated Healthcare US Health Care Delivery System Evolution Health Delivery System Transformation Critical Path Community Integrated Healthcare System 3.0 Coordinated Seamless Healthcare System 2.0 Acute Care System 1.0 Outcome Accountable Care Episodic Non Integrated Care • Healthy Population Centered • Population Health Focused Strategies • Integrated networks linked to community resources capable of addressing psychosocial/economic needs • Population based reimbursement • Learning Organization: capable of • rapid deployment of best practices • Community Health Integrated • E-health / telehealth capable • Patient/Person Centered • Transparent Cost and Quality Performance • Accountable Provider Networks Designed Around the patient • Shared Financial Risk • HIT integrated • Focus on care management • and preventive care • Episodic Health Care • Lack integrated care networks • Lack quality & cost performance • transparency • Poorly Coordinate Chronic Care Management Neal Halfon, UCLA Center for Healthier Children, Families & Communities
Measures of Success Better health care: Improving patients’ experience of care within the Institute of Medicine’s 6 domains of quality: Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity. Better health: Keep patients well so they can do what they want to do. Increase the overall health of populations: address behavioral risk factors and socio-economic determinants; focus on preventive care. Lower costs: Lowering the total cost of care while improving quality, resulting in reduced monthly expenditures for Medicare, Medicaid, and CHIP beneficiaries.
Better Health • Prevention and Public Health Fund • First dollar coverage for prevention • Population-health initiatives • Million Hearts Campaign • Partnership for Patients • Health system transformation • Population-based strategies • Emphasis on quality measures
Hospitals’ Role in Population Health: Community Building IRS-approved activities: • Physical improvements and housing • Leadership development / training for community • Community health improvement advocacy • Coalition building • Economic development • Community support • Environmental improvement • Workforce development
Hospitals’ Role in Population Health:Community Health Needs Assessment New requirements under ACA. To retain tax exempt status, non-profit hospitals must: • Conduct a “community health needs assessment” at least every three years • Adopt implementation strategy to meet the community health needs identified through the assessment • Penalty: $50,000 tax for each year that a tax‐exempt hospital fails to satisfy requirement
Community Based Wellness and Prevention Programs (S. 4202b) • Environmental Scan of Community Based Wellness and Prevention Programs and Review of the Evidence • Pilot Evaluation of the Chronic Disease Self Management Program • Retrospective Evaluation of Community Based Wellness and Prevention Programs (Award Pending) e.g. Enhance Wellness, Fit and Strong, Arthritis Foundation’s Arthritis Self Management Program. • Prospective Evaluation of Community Based Wellness and Prevention Programs (in development).
Lower Costs One Third of Medical Spending is Unnecessary • Too much use of high cost care • Missed opportunities for prevention • Missed opportunities for care coordination • Chronic disease, hospital discharge, end of life • Inefficient care processes • Errors, excessive testing • Excessive administrative costs
Better Health Care / Lower Costs CMS Policy Levers • Payment policy • Value Based Purchasing Initiatives • Performance based alternatives: CMMI test of models • Benefit design • Regulation: e.g. Conditions of Participation • Leverage through collaboration • States (Public Health/Medicaid), • Private payers • CDC, AoA, HRSA, DOD, IRS
Value-based Purchasing Policies • Hospital Value-based purchasing • Inpatient Quality Report / Hospital Compare (1% penalty) • $850 million awarded to hospitals based on performance funded by a 1% withhold (2% in 2017) • Payments cut 1% for high readmission rates (3% in 2015) • Payments cut 1% for hospitals in top 25th percentile HAC • Physician Value-based purchasing • Physician Compare • Physician Quality and Resource Use Reports • Value-Based Payment Modifier implemented in 2015
The Innovation Center Identify, test, evaluate, and scale innovative ways to deliver and pay for care that can lower costs and don’t sacrifice quality. “The purpose of the Center is to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP…while preserving or enhancing the quality of care furnished.” “Preference given to models that improve the coordination, quality, and efficiency of health care services.” • Resources: $10 billion funding for FY2011 through 2019 • Opportunity to “scale up”: The HHS Secretary has the authority to expand successful models to the national level
Delivery System Transformation Strategy:How do we get from here to there • Step 1: Providers commit to change their business and clinical model • Step 2: CMS, and other payers, provide alternative models to support providers • Step 3: Providers select their models • Step 4: Explore new models together • Step 5: Evaluate and Spread successful models
Innovation Center Initiatives ACO Suite: • Shared Savings Program • Pioneer ACO Model • Advance Payment ACO Model • Accelerated and Learning Development Sessions Primary Care Suite • Comprehensive Primary Care Initiative (CPCI) • Federally Qualified Health Center Advanced Primary Care Practice Demonstration • Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration • Independence at Home • Medicaid Health Home State Plan Option Bundled Payment Suite • Bundled Payment for Care Improvement Dual Eligible Suite: • State Demonstration to Integrate care for Dual Eligible Individuals • Financial Alignment to Support State Efforts to Integrate Care • Demonstration to Reduce Avoidable Hospitalizations of Nursing Facility Residents • Medicaid Health Home State Plan Option Diffusion and Scale Suite: • Partnership for Patients • Million Hearts Campaign • Innovation Advisors Program • Care Innovations Summit Healthcare Innovation Challenge Rapid Cycle Evaluation and Research Learning and Diffusion
Accountable Care Organizations • Group of healthcare providers who: • Establish a mechanism for shared governance • Agree to be held accountable for quality, cost, and overall care of fee-for-service beneficiaries assigned to them • Invest in infrastructure, redesign care processes • Emphasis on care coordination • Emphasis on quality measurement • 33 measures, 4 domains: Patient Experience of Care, Care Coordination/Patient Safety, Preventive Health, and At-Risk Population
Accountable Care Organizations • Pioneer ACO • Experienced organizations, • Higher quality and savings targets • Higher levels of shared savings and risk • Must work in coordination with private payers (align incentives) • Advanced payment ACO • Less experienced organizations • Pre-payment to help providers invest in infrastructure • Payment recouped through earned shared savings
Primary Care / Medical Home Initiatives Medical Home Delivery model • Fee for service with monthly care management fee • Multi-payer involvement • Practice transformation • NCQA certification • Access and continuity • Health information technology • Planned care for chronic conditions and preventive care • Patient and caregiver engagement • Performance measurement and accountability: cost and quality
Primary Care / Medical Home Initiatives • Multi-payer Advanced Primary Care Practice Model • Medicare joining state-based medical home initiatives • Medicaid Health Home State Plan Option • 90% federal funding for two years for state-based Medicaid models • Medical Home Models in Federally Qualified Health Centers • Will include 500 FQHC sites supporting nearly 200,000 patients • Comprehensive Primary Care Initiative • Multi-payer initiative between public and private payers • Inviting payers & states to join with Medicare in 5-7 selected localities • Monthly care management fee to PCP
Million Hearts Campaign Unpublished estimates from Prevention Impacts Simulation Model (PRISM)
Partnership for Patients Nationwide public-private partnership. Our goals: • 40% Reduction in Preventable Hospital Acquired Conditions over three years • 1.8 Million Fewer Injuries / 60,000 lives Saved • 20% Reduction in 30-Day Readmissions in three years • 1.6 Million Patients Recover Without Readmission Potential to Save $35 Billion in Three Years
Health Care Innovation Challenge • GOAL: To identify and support a broad range of innovative service delivery and payment models that achieve better care, better health and lower costs through improvement. • Up to $1 billion committed to 3 award cycles, with individual awards ranging from approximately $1M to $30M. • Innovation Challenge projects will: • Improve care and lower costs for Medicare, Medicaid, and CHIP • Reach populations with the greatest health care needs. • Rapidly implement the proposed model. • Develop, train, and deploy workforce in support of innovative health care payment and delivery models.
Summary • Moving to Healthcare 3.0 requires the effective integration of clinical care, public health initiatives and community based efforts to address the determinants of health • All major stakeholders will have to develop new capabilities • Health care systems • Public health agencies • CMS
Our Work Continues… www.innovation.cms.gov