HIM 151 Chapter 10 VALUE-BASED PURCHASING
True or False: CMS uses an incremental implementation.
True
True or False: PCMH initiatives are often organized by health plans, states, payers, providers, or multiple stakeholder groups.
True
True or False: Private-sector associations and coalitions have been influential in the development of VBP/P4P systems since the 1990s.
True
True or False: The exact makeup of the ACO depends on it sponsoring healthcare organization.
True
True or False: VBP/P4P systems are more likely to use reward-based incentives than penalty-based incentives. The few penalty-based VBP/P4P systems include state Medicaid payment systems and some aspects of the CMS's VBP initiatives.
True
True or False: VBP/P4P, called the shared-savings program, is a central component of Medicare's payment policy for Accountable Care Organizations (ACOs).
True
True or False: Operations of successful VBP/P4P systems depend on fair methods of allocating rewards, meaningful incentives, effective implementation, significant targets, and suitable performance measures. Success of operations also depends on other factors, such as the characteristics of the incentives, the organizational infrastructure, the culture of quality, and the effectiveness of leadership. (Table 10.2 onpage 287).
True
True or False: The Affordable Care Act required the CMS to promote the development of ACOs by establishing the Medicare Shared Savings Program (MSSP).
True
3) Accountability
= holds individuals and organizations responsible for their performance. = Obligation to provide information about, to be answerable for, and to justify actions = Holds organizations and individuals responsible
Bridges to Excellence (BTE)
= is a family of programs to recognize and reward physicians, nurse practitioners, and physician assistants for re-engineering and improving their practices' systems, for adopting health ifnormation technology, and for delivering quality outcomes to their patients. = their programs are organized by diseases such as asthma and diabetes.
2 Patient-Centered
= provides healthcare that is relationship-based and oriented towards the whole person. = Informed engagement of patient and family = Recognition of each patient's unique needs
4 Accessible Services
= provides shorter waiting times for urgent needs, enhanced in-person hours, and around-the-clock telephone or electronic access to a care team member.
Value-based purchasing (VBP) and Pay-for performance (P4P) systems / VBP/P4P systems
= reflect a widespread movement in the healthcare industry toward improving the quality, safety, efficiency, and the overall value of healthcare. Movement seeking to improve quality, safety, efficiency, and value of healthcare = offer potential countermeasures to failures in the quality, safety, and costs of the US healthcare system. = attempt to address the system's shortcomings by rewarding quality, performance, and efficiency. = incentives are directly linked to quality, performance, measures, and financial targets. = work to motivate providers, through incentives, to deliver high-quality care in a cost-effective and cost-efficient manner. = is an international movement = are incentive-based = link incentives and performance
Process measures
= reflect compliance with guidelines or standards of care, such as the number of patients who smoke to whom physicians provide advice on smoking cessation.
I. Medicare Shared Savings Program (MSSP)
= the general concept of this program is that providers are rewarded with a portion of the savings if they reduce the total healthcare spending for their patients below the level that the payer expected. The overarching result is that THE PAYER SPENDS LESS MONEY THAN IS EXPECTED AND THE PROVIDER RECEIVES MORE REVENUE THAN IS EXPECTED. = operating under this model, ACOs that meet the quality performance standards and generate savings will share a percentage of the savings with the CMS. = permanent part of MCR = Created by ACA; became operational in 2012 = 480 ACOs serving 9 million beneficiaries (2017) = 3 Tracks
The goal of coordinated care is
= to ensure that patients get the right care at the right time.
Three different ACO programs:
I. Medicare Shared Savings Program (MSSP) II. Next Generation ACO demonstration (2016) III. Medicare ACO Track 1+model (2018)
* Fee-For-Service
Is the most common payment method in the current PCMHs, that is increased with per-member-per-month payments and P4P bonuses.
The rising cost of healthcare
have motivated payers to establish VBP/P4P systems.
Common Types of Performance Measures:
+ Structure Measures + Process Measures + Outcome Measures
FFS payment systems
= providers are paid based on the volume of services rather than on the quality of services.
2= Penalty-Based
* Individual, group, hospital, or region * Compensation withheld when targets are not met or performance is not improved * Lower fee schedule for inferior performance
1= Reward-Based
* Individual, group, hospital, or region * Rewards (compensation) when targets are met or exceeded * Higher fee schedule for superior performance * Increased payment rates for superior providers
Researchers at the AHRQ recommend that VBP/P4P systems focus on the following performance targets:
* Most significant challenges in terms of quality or cost * Proportion of population covered by the service or provider * Availability of valid and reliable performance measures
Definitions of Value
* is "usually defined as focusing on both quality and cost at the same time in purchasing and delivering health care" * is a "function of quality, efficiency, safety and cost" * includes the delivery of timely, effective, appropriate, and high quality services that result in the best possible outcomes.
PCMH model integrates the following core features of primary care:
- Continuous and long-term care - Comprehensive and prevention, wellness, acute care, and chronic care - Coordinated care across the continuum of care, including specialty care, hospitals, home health care, and community services and supports.
Patient-centered care that is focused on the needs and preferences of patients and is relationship-based with: (1) an orientation toward the whole person (2) informed engagement of the patient and family (3) recognition of each patient's unique needs with the use of the following :
- Multidisciplinary team - Electronic information systems and on-line patient portals - Chronic disease registries - Population-based management of chronic diseases - Continuous quality improvement
Additional subgoals for VBP/P4P:
- achieving a competitive edge through a focus on cost effective quality - improving coordination of care among providers
Types of VBP/P4P incentives:
- bonuses - penalties - bonuses to capitation or global payment rates - higher fee structures - shared savings - shared risk
Integrated providers include:
- primary care physicians - specialist - hospitals - healthcare insurance plans - suppliers of durable medical equipment - other services and items - other stakeholders
Sources of good performance measures include:
. Joint Commission . National Quality Measures Clearinghouse . National Quality Forum (NQF) . National Committee for Quality Assurance (HEDIS) . Agency for Healthcare Research and Quality (AHRQ) . The Leapfrog Group . CMS
Good measures have several characteristics:
. Validity . Reliability . Attributability . Acceptability . Feasibility . Sensitivity . Relevance
As defined by AHRQ, a PCMH encompasses five functions and attributes:
1 Comprehensive Care 2 Patient-Centered 3 Coordinated Care 4 Accessible Services 5 Quality and Safety
Three essential characteristics of ACOs:
1) Ability to manage patients across the continuum of care, including acute, ambulatory, and post-acute health services. 2) Capability to prospectively plan budgets and resource needs 3) Sufficient size to support comprehensive, valid, and reliable measurement of performance.
Similar to IHI, Medicare Shared Savings Program (MSSP) has a Triple Aim:
1) Better quality of care for individuals 2) Better health for populations 3) Lower growth in healthcare costs
Advantages of VBP/P4P:
1) Demonstrated commitment to providing quality care 2) Establishment of infrastructure for reporting on quality 3) Rewards for providing quality healthcare 4) Transparent process of rewards 5) Ability to focus on underserved or high-risk groups
Fundamental characteristics that VBP/P4P systems share are:
1) Measurement 2) Transparency 3) Accountability
Two key design considerations of existing models of VBP/P4P systems:
1- Recipient of reward or penalty 2- Mechanism of payment
In the operation of VBP/P4P systems, leaders face six considerations:
1- allocation and reward of incentives 2- types of incentives 3- method of implementation 4- performance dimensions and targets 5- performance measures 6- information systems
Disadvantages of VBP/P4P:
1. Implementation of intervention that is not evidence-based 2. Potential for unintended consequences 3. Difficulty in measuring processes and outcomes 4. Difficulty in assessing measures that involve patients' or clients' compliance, such as smoking cessation 5. Potential costs of implementation could be better spent on other efforts 6. Better documentation of care rather than actual better quality of care
Goals for VBP/P4P:
1. Improve clinical quality 2. Improve cost/affordability of healthcare 3. Improve patient outcomes 4. Improve the patient experience for receiving care
Major players in the private sector include the following: / Private Sector Initiatives: (These are different companies that initiated and looked at healthcare quality, making sure that data is transparent to the public, etc.)
1. Leapfrog Group Goal: positively affect the quality and affordability of healthcare by "leaping" forward 2. Altarum Bridges to Excellence® 3. Integrated Healthcare Association (IHA) of CA Goal: Performance Measures 4. National Alliance of Healthcare Purchaser Coalitions (National Alliance) Goal: Improve value of healthcare 5. National Committee for Quality Assurance (NCQA) Goal: Improve the quality of healthcare
Two Concepts of Attribution:
1. Prospective Method 2. Performance Year Method 3. Hybrid Method (from ppt slide and page 285)
Two major categories/incentives of the current VBP/P4P models:
1= Reward-Based 2= Penalty-Based
Two Current Models of VBP/P4P Systems:
1> Patient-Centered Medical Home (PCMH) 2> Accountable Care Organizations (ACOs)
Modelsof VBP/P4P
= Affordable Care Act encouraged experimentation in the design of these initiatives. = models differ because the missions and goals of healthcare organizations differ. = models vary from payer to payer, plan to plan, and program to program.
The Affordable Care Act of 2020
= expanded the use of VBP and P4P in Medicare. = Today, VBP/P4P systems are widespread as the industry moves towards rewarding value rather than volume.
2. Performance Year Method
= Assigns patients at the end of a performance year based on patients who were served during the performance year = in this method, patients attributed to an ACO are patients who were actually treated at the ACO. = this method better reflects an ACO's patient population and may allow an ACO to achieve greater success in a shared saving program.
+ Structure Measures
= Characteristics of the organization such as existence of health information technology and its degree of implementation.
3. Hybrid Method (from ppt slide and page 285)
= Combines prospective method and performance year method = under the MSSP, CMS termed this approach " preliminary prospective assignment methodology with final retrospective reconciliation". = in this methodology, an assignment is made based on past utilization, but the assignment is regularly updated to reflect patients who are no longer receiving care from the ACO. = there is a final reconciliation at the end of the performance year = End result is the same as if only the performance year method was used
+ Process Measures
= Compliance with treatment guidelines or standards of care
+ Outcome measures
= End result of activities or process, such as mortality rate
Results of ACOs thus far:
= In 2015, 31% of ACOs participating in MSSP have achieved positive bottom-line results. = CMS continues to believe that ACOs can provide better quality care while producing savings for their beneficiaries. = In 2015, CMS spent $215 million more on the MSSP than estimated. = despite the expenditures. CMS reports that the MSSP has shown modest success and the ACOs have yielded better results than the traditional PPSs that have similar quality metrics.
Experts describe three categories of ACOs based on: - size - scope of services - governance - ability to manage patients with complex chronic diseases and other characteristics:
= Larger, integrated systems that offer a broad scope of services and frequently include one or more postacute-care facilities = Smaller, physician-led practices, centered in primary care = Moderately sized, joint hospital-physician and coalition-led groups that offer a moderately broad scope of services with some involvement of postacute-care facilities
Performance Measures
= Measures (indicators) are quantitative tools that provide an indication of performance in relation to specified processes or outcomes via the measurement of actions, processes, or outcomes of care or services.
How it works:
= Medicare beneficiaries are assigned to an ACO based on their claim history = Beneficiary can use providers inside ACO AND outside of the ACO = ACO and non-ACO providers are still paid under regular Medicare PPS = ACO receives reward (shared savings) if targets are met
Track 1
= One-sided financial risk management = ACOs in this track do not assume downside risk (shared losses) if they do not lower growth in Medicare expenditures.
CYU 10.1.1 What three components do value-based purchasing (VBP) systems and pay-for-performance (P4P) systems typically link?
= Page 273 > Quality > Performance > Payment
CYU 10.1.3 List two types of VBP/P4P incentives.
= Page 274 - bonuses - penalties - bonuses to capitation or global payment rates - higher fee structures - shared savings - shared risk
CYU 10.1.2 What three reports provide the impetus for VBP/P4P systems?
= Page 275-276 •To Err is Human: Building a Safer Health System •Crossing the Quality Chasm: A New Health System for the 21st Century •Rewarding Provider Performance: Aligning Incentives in Medicare
Medicare ACO Track 1+model (2018)
= Two sided financial risk management = these ACOs assume limited downside risk (less than Track 2 oor Track 3)
Track 2
= Two-sided financial risk management = these ACOs may share in savings or repay Medicare losses depending on performance. = these ACOs may share in a greater portion of savings than Track 1 ACOs.
Track 3
= Two-sided financial risk management = these ACOs may share in savings or repay Medicare losses depending on performance. = these ACOs take on the greatest amount of risk, but may share in the greatest portion of savings when successful.
1. Prospective Method of Attribution
= Uses data from a review year to assign patients to the next performance year = when this method is used beneficiaries are attributed to an ACO based on their past visit history. However, this does not mean that patients must or will continue to receive care at the ACO for which they are attributed.
Targets
= are specific, measurable objectives against which performance can be judged. = Examples of performance targets include maintaining or improving the quality of care or meting benchmarks on profitability or efficiency.
Single Attribution
= attribution algorithms that can be applied to individual providers.
Multiple Attribution
= attribution algorithms that can be applied to multiple providers.
3 Coordinated Care
= coordinates elements of care across the continuum of care, including specialty care, hospitals, home health, and community services.
5 Quality and Safety
= demonstrates a commitment to quality care and quality improvement by engaging in evidence-based medicine and clinical decision-support tools.
The Institute for Healthcare Improvement (IHI)
= developed the TRIPLE AIM framework, which can be used to guide efforts to optimize healthcare performance.
Composite Measures
= endorsed by NQF in 2009. = are a combination of two or more individual quality measures in a single measure that result in a single score. = address mortality for selected conditions, patient safety for selected indicators, and pediatric patient safety for selected indicators.
1. Leapfrog Group
= established in November 2000 = includes large employers = the goal is to positively affect the quality and affordability of healthcare by "leaping" forward improvements in hospitals' quality and safety through rewards.
2> Accountable Care Organizations (ACOs)
= is a model for healthcare delivery and payment. = is a set of " providers who are JOINTLY held accountable for achieving measured quality improvements and reductions in the rate of spending growth". = bring together physicians, hospitals, and other healthcare providers to provide efficient (low cost) and effective (free of duplication and errors) care. = is accountable for all the healthcare costs of its designated population. = per CMS, this is a legal entity recognized under the state law. It is composed of a group of ACO participants that have established a mechanism for shared governance. = the participants coordinate the care of traditional Medicare fee-for-service beneficiaries. = is accountable for the quality, cost, and overall care of all the beneficiaries assigned to it. = are a good example of VBP programs with shared savings and shared risk = came out of Affordable Care Act
1> Patient-Centered Medical Home (PCMH)
= is a model primary care that seeks to meet the healthcare needs of patients and to improve and patient and staff experiences, outcomes, safety, and system efficiency = operational definitions of PCMH are often specific to the site and organization. = Organized by health plans, states, payers, providers or multi-stakeholder groups = this model combines the core functions of primary care with the innovations of 21st century practice. = Fee schedule in combination with PMPM and P4P bonuses = researchers found that PCMHs had a small positive effect on patients' experience of care = a small-to-moderate positive effect on staffs' experiences. = however, evidence on the PCMH model's effect was scarce and was insufficient to determine the model's effects on clinical and economic outcomes. = there was no evidence for overall cost savings
2. Altarum
= is a nonprofit health systems research and consulting organization. = blends independent research and client-focused consulting to enable better care and better health for communities. = manages Bridges to Excellence (BTE)
5. National Committee for Quality Assurance (NCQA)
= is a nonprofit organization aiming to improve the quality of healthcare and to transform healthcare quality through measurement, transparency, and accountability. = was formed in 1979 by the managed care industry and the Group Health Association of America. = provides standards with which healthcare entities can measure their performance. = uses HEDIS indicators = their widespread adoption of its performance indicators and programs makes this organization an influential organization in healthcare quality.
Quality Reporting Document Architecture (QRDA)
= is a standard for collecting and reporting data that documents compliance with performance or quality measures. = allows the creation and submission of reports in interoperable formats across vendors and disparate health information technology systems.
Health Quality Measure Format (HQMF)
= is a standard for communicating and incorporating representative measures in electronic health records (and other electronic documents).
II. Next Generation ACO demonstration (2016)
= is a two-sided model that was designed for ACOs with experience in coordination of care. = includes higher levels of risk for the ACOs than the MSSP = there are currently 44 ACOs participating in this model. = the results of the 2016 performance show 62% of this model of ACO achieved savings.
VBP
= is an element of the federal and state healthcare reimbursement systems. = is defined as a payment model that holds healthcare providers accountable for both the cost and quality of care they provide.
4. National Alliance of Healthcare Purchaser Coalitions (National Alliance)
= is an umbrella organization at the national level for employer-based health coalitions. = the purpose of this is to improve the value of healthcare provided through employer-sponsored health plans.
2) Transparency
= is essential because stakeholders need reliable and clear information about the cost and quality of healthcare, so they can make informed choices. = Act of making information available/known to the public = Stakeholders can make informed decisions
Quality
= is often assessed by conformance with quantifiable and evidence-based standards, known as MEASURES.
* Attribution / Assignment
= is the term for determining who rendered care = is important because it allows the costs of a patient's care and the outcomes of that care to be specified to a provider. = subsequently, it determines which provider receives the incentives. = is not straight forward when multiple providers are involved. = who is the main provider for that claim. Example: Attending Physician = make sure to select the correct physician = effects the profile of the physician as well
P4P
= may be defined as any type of payment system used to reimburse providers that is performance-based and that includes incentives. = align payment incentives with contractually specified performance targets. = this system have been implemented in many countries, from developing to industrialized. = the general effect of this system internationally is still unknown. Some research has shown gains in quality for specific targets.
Incentives
= may be rewards, such as BONUSES, or may be penalties, such as reduced payments.
Key advantages to incremental implementation:
= measures are tested before full-scale use = providers have time to prepare = sponsors can evaluate policies, procedures,a dn results before full-scale use
1 Comprehensive Care
= meets most patient healthcare needs, including prevention and wellness, acute care and chronic care.
Background of VBP/P4P
= on a limited basis, forms of P4P have existed since 1970s. At that time, the "Buy Right" program was aimed at corporate purchasers of healthcare. It combined quality improvement, incentives, and efficiency measures. = in the late 1990s and early 2000s, both the public and private sectors within the healthcare industry began VBP/P4P initiatives. = by the mid-2000s, more tan 100 organizations had initiated VBP/P4P systems. These organizations included health plans, employer-payer colaitions, and Medicare and Medicaid programs. = during this period, , P4P systems targeted individual physicians and health maintenance organizations. = the P4P system's incentives were based on the measure in the Health Effectiveness Data and Information Set (HEDIS) of the National Committee for Quality Assurance (NCQA) = the managed care companies are probably the first ones to use these systems, and then slowly went to Medicare.
Research on Impact
= there is little evidence to support the use of VBP/P4P systems despite their proliferation. = recently conducted comprehensive and systematic reviews of the research literature on the effects of VBP/P4P systems generally found that the evidence was inconclusive or that the results were only modestly positive. = Little evidence to support the use of VBP/P4P systems despite their proliferation See textbook for review of research = in sum, research has provided little evidence upon which leaders can base decisions about healthcare policy. = many questions remain about how to design and implement VBP/P4P to achieve their stated goals
3. Integrated Healthcare Association (IHA)
= this a nonprofit multistakeholder group was established in 2003. = is statewide with members in various health sectors including hospitals and health systems, health plans, physician organizations, pharmaceuticals, biotechnology, information technology (IT), and consulting firms, purchasers and consumers, regulators, academic institutions and foundations, and research institutions. = performance measures are similar to the HEDIS of the NCQA. = produces annual performance scores, based on these measures, for the physician organizations.
The purpose of ACOs is
= to provide coordinated high-quality care to Medicare beneficiaries.
1) Measurement
= which is the process of gathering data, comes first because stakeholders, such as patients, consumers, payers, and other decision makers must have facts. = Process of collecting data = Stakeholders have facts
The following is a list of typical measures included in VBP/P4P systems:
> Clinical process > Patient Safety > Utilization > Patient Experience > Outcomes > Structural Elements
* VBP/P4P system link
> Quality > Performance > Payment
DRIVERS in the DEVELOPMENT of VBP/P4P systems are
> reports on the US healthcare system > private-sector coalitions and associations > the federal government
Medicare Shared Savings Program (MSSP) options:
Track 1 Medicare ACO Track 1+model (2018) Track 2 Track 3
Internal Systems of data collection in information systems that leaders consider include:
^ clinical data capture ^ administrative databases ^ provider surveys ^ patient surveys ^ longitudinal claims data
The IHI Triple Aim is
•Improving the patient experience of care •Improving the health of populations •Reducing the per capita cost of healthcare
In the late 1990s and into the 2000s, DRIVERS of the VBP/P4P initiatives were a series of reports calling into question the quality, safety, and cost of US healthcare and recommending new designs of payment systems:
•To Err is Human: Building a Safer Health System •Crossing the Quality Chasm: A New Health System for the 21st Century •Rewarding Provider Performance: Aligning Incentives in Medicare