`VCAL – Pulling it all together`

Health Reform Impact
June 2011
John Walton
Group/Executive VP
Resurrection Health Care
Gracie meets Lord Stanley
Charlie’s First Birthday
Welcome
Massive Change Underway
The Patient Protection and
Affordable Care Act of 2010
(PL 111-148)
Why the need for ACA?
National Health Expenditures per Capita, 1980–2007
Average spending on health per capita ($US PPP)
8000
United States
Canada
France
Germany
Netherlands
United Kingdom
7000
6000
5000
4000
3000
2000
1000
0
1980
1984
Data: OECD Health Data 2009 (June 2009).
1988
1992
1996
2000
2004
Premiums Rising Faster Than Inflation and Wages
Cumulative Changes in Components of U.S.
National Health Expenditures and Workers’
Earnings, 2000–09
Projected Average Family Premium as
a Percentage of Median Family Income,
2008–20
Percent
Percent
125
25
Insurance premiums
108%
21 21
24
22 22
20 20
Workers' earnings
100
23
20
18 18 18 18 18
Consumer Price Index
16
15
75
13
11
19 19 19
17
14
12
10
50
32%
5
25
24%
Projected
* 2008 and 2009 NHE projections.
Data: Calculations based on M. Hartman et al., “National Health Spending in 2007,” Health Affairs, Jan./Feb. 2009 and A.
Sisko et al., “Health Spending Projections Through 2018,” Health Affairs, March/April 2009. Insurance premiums, workers’
earnings, and CPI from Henry J. Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits
Annual Surveys, 2000–2009.
Source: K. Davis, Why Health Reform Must Counter the Rising Costs of Health Insurance Premiums (New York: The
Commonwealth Fund, Aug. 2009).
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2007 2008* 2009*
2006
2006
2005
2005
2004
2004
2003
2003
2002
2002
2001
2001
2000
2000
1999
0
0
Right out of a movie
Projected Savings and Effectiveness of System Reform
Provisions in Comprehensive Reform Law
2010–19 (in billions)
CBO Estimate of
Budget Savings,
Affordable Care Act
of 2010, 03/30/09
Establish health insurance exchanges
Percent Opinion
Leaders Favor,
or View as
Effective
Projected
Effectiveness
in Containing
Costs
92%b
++
Create new nonprofit plan choices
+
Review premiums and require minimum medical loss ratios
++
Incentivize primary care and prevention
$6
61%c
+
Stimulate innovative provider payment reform
–$8
97%c
+++
Create accountable care organizations
–$5
54%f
++
–$176
75%e
++
53%a
+
Control spending growth; IPAB and productivity improvement
Promote quality improvement and public reporting
Encourage Medicare private plan competition
–$201
77%c
+
Tax high premium health insurance plans
–$32
58%d
+
Authors’ views of long-term effectiveness in controlling total health system spending: Very effective = +++, Effective = ++, Somewhat
effective = +. Health Care Opinion Leaders Surveys: a Sept/Oct 2008; b Dec. 2008; c April 2009; d June 2009;
e Oct. 2009, f July 2010. IPAB = the Independent Payment Advisory Board
Source: Commonwealth Fund estimates; Congressional Budget Office, Letter to the Honorable Nancy Pelosi, Mar. 20, 2010.
Aspects of Health Reform
The Good
Positive
39+ Million Americans 133%
of federal poverty limit
covered by Medicaid.
Offer affordable health
insurance through
exchanges modeled at
Medicare payment rates.
Bending the health care cost
escalation trend line.
Aspects of Health Reform
The Bad?
Potential Payment Cuts
Value Based Purchasing with
new cost reduction & quality
incentives.
Accountable Care
Organizations changing the
delivery of care; integrated?
High cost to form.
Elimination of
Disproportionate Share
hospital funding.
Aspects of Health Reform
The Ugly!
Politics (and we’re not done yet)
Curtailment of ACA either
federally or state by state
action?
Lobbying efforts by
insurance and medical
industries?
Changing public opinion?
Hospital Reaction
Lower costs of delivering care to
current Medicare DRG payments
(excess days, transfer penalties).
Reduce high 30 day readmit penalties
for AMI, CHF and PNE; partner with
post-acute providers.
Improve quality outcomes and patient
satisfaction metrics to achieve top
Value Based Purchasing incentives.
High Opportunity Service Lines
Total Excess Days by Service Line
2/13/11 – 5/7/11
Average daily census of 112
(five acute care hospitals)
*All-payer excess days excludes behavioral, substance abuse, rehab, and neonate/newborn MS-DRGs
Source: HBI Weekly Excess Days Highlight
Monthly Excess Days Performance by Site
Site Excess Days as % of IP Days: Monthly Trending Against FY12 Target
FY11 YTD: July 2010 - April 2011
35.0%
30.0%
25.0%
Excess Days as % of IP Days
FY12 Target
Jul-10
20.0%
Aug-10
Sep-10
Oct-10
Nov-10
15.0%
Dec-10
Jan-11
Feb-11
10.0%
Apr-11
5.0%
0.0%
OLR
RMC
SFH
SJH
SMEMC
RHC
*All-payer excess days excludes behavioral, substance abuse, rehab, Diamond Headache, and neonate/newborn MS-DRGs
Source: HBI Utilization Trends Monthly Excess Days Highlight
Excess Day Reductions
Requires active case management
setting discharge date in advance.
Physician alignment (payments
currently fee for service).
Palliative care promotion.
Excellent hand off to post-acute
services: medical home, home
health, nursing home, sub-acute, &
LTACH and follow up too.
National Readmission Results
Average 30-day hospital readmission rates
are high with high area variation
– Acute MI
19.9%
– Heart Failure
24.5%
– Pneumonia
18.2%
Jul’05 – Jun’08
discharges
The goal is not zero; all hospitals have
room to improve
AHRQ 2009 Annual Conference
Michael T. Rapp, MD, JD, FACEP
Director, Quality Measurement and Health Assessment Group
Office of Clinical Standards & Quality, CMS
CMS’ goal: shift the curve
Hospitals with high readmission rates will
have lower Medicare payments in FFY’12
18
18
RHC CMS Heart Failure Readmissions
RHC CMS Heart Failure 30-Day All Cause Readmission Rate by Site
FY09 Q4 to FY11 Q3
OLR
Readmission Rate (%)
50%
RMC
.
SFH.
SJH .
SMEMC.
40%
30%
GOAL=24.7%
20%
10%
0%
09
FY
4
Q
10
FY
Q
4
09
FY
4
Q
10
FY
Q
4
09
FY
4
Q
Q
4
10
09
FY
FY
Quarter
4
Q
10
FY
4
Q
09
FY
Q
4
10
FY
4
Q
*Readmission definition is aligned with CMS definition. This chart reflects the unadjusted readmission rate.
Data Source: Horizon Performance Manager
Goal Source: C MS US National HF Readmission Rate FY06-FY09
Value Based Purchasing
Mandated by Affordable Care Act; Released 4/29/11
Rewards for achievement or improvement
Budget neutral payment changes begin with October 1,
2012 discharges reducing base operating payments for
all DRGs by 1% in FFY 2013 (increasing by .25% each
year thru FFY 2017)
Quality measures from Hospital Compare measure set:
– 20 measures (12 process/8 HCAHPS dimensions) in FFY 2013
– Adds 13 measures (3 mortality, 8 HACs, 2 IQI/PSIs) in FFY 2014
Value Based Purchasing
Purpose/Goals
Transform Medicare from a passive payer of claims to an
active purchaser of quality health care for its beneficiaries
Important step toward revamping how care and services
are paid for, moving increasingly toward rewarding better
value, outcomes, and innovations instead of merely
volume
Rewards/penalizes hospitals based on actual quality
performance rather than simply reporting data for
measures
Portion of Medicare hospital payment will be tied to
performance on quality measures
FFY 2013 VBP Measures
Acute Myocardial Infarction (AMI)
AMI-7a Fibrinolytic Therapy Received w/in 30 min
AMI-8a PCI Received w/in 90 min
Heart Failure (HF)
HF-1 Discharge Instructions
Pneumonia (PN)
PN-3b Blood Culture in ED Prior to Initial Abx
PN-6 Initial Abx Selection
Surgical Care
SCIP-Inf-1 Prophylactic Abx Timing
SCIP-Inf-2 Prophylactic Abx Selection
SCIP-Inf-3 Prophylactic Abx Discontinuation
SCIP-Inf-4 Cardiac Surg Postop Serum Glucose
SCIP-Card-2 Beta Blocker During Periop Period
SCIP-VTE-1 Recommended VTE Prophylaxis Ordered
SCIP-VTE-2 VTE Prophylaxis Timing
Patient Satisfaction
Nurse Communication (% Always)
Doctor Communication (% Always)
Cleanliness and Quietness (% Always)
Overall Rating (% 9 or 10)
Responsiveness of Hospital Staff (% Always)
Pain Management (% Always)
Communication about Medications (% Always)
Discharge Information (% Yes)
FFY 2013 Measures:
Achievement Benchmarks
Measure
Acute Myocardial Infarction (AMI)
AMI-7a Fibrinolytic Therapy Received w/in 30 min
AMI-8a PCI Received w/in 90 min
Heart Failure (HF)
HF-1 Discharge Instructions
Pneumonia (PN)
PN-3b Blood Culture in ED Prior to Initial Abx
PN-6 Initial Abx Selection
Surgical Care
SCIP-Inf-1 Prophylactic Abx Timing
SCIP-Inf-2 Prophylactic Abx Selection
SCIP-Inf-3 Prophylactic Abx Discontinuation
SCIP-Inf-4 Cardiac Surg Postop Serum Glucose
SCIP-Card-2 Beta Blocker During Periop Period
SCIP-VTE-1 Recommended VTE Prophylaxis Ordered
SCIP-VTE-2 VTE Prophylaxis Timing
CMS Achievement
Benchmark (mean
of top decile)
91.9%
100.0%
100.0%
100.0%
99.6%
99.6%
100.0%
99.7%
99.6%
100.0%
100.0%
99.9%
* To receive full achievement points (10/10), the CMS Achievement Benchmark
must be met
2013 VBP Methodology
Measure Weighting
– Clinical Process Measures: 70%
– Patient Experience: 30%
Each measure is scored based on 10 point scale
Two Ways to Gain Points:
– Achievement of National Benchmark (mean of top decile): based on
performance period (Max. points = 10/10)
– Rate of Improvement : measured by comparing scores during baseline
period to those of performance period (Max. points = 9/10)
Measure Timelines:
– Baseline Period: July 1, 2009 – March 31, 2010
– Performance Period: July 1, 2011 – March 31, 2012
FFY 2014 VBP Measures
Mortality
AMI 30-Day Mortality Rate
HF 30-Day Mortality Rate
PN 30-Day Mortality Rate
Hospital Acquired Conditions
Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Stage III or IV Pressure Ulcers
Falls and Trauma
Catheter Associated UTI
Vascular Catheter Associated Infections
Poor Glycemic Control
AHRQ Patient Safety and Inpatient Quality Indicators
Complication/patient safety for selected indicators (composite)
Mortality for selected medical conditions (composite)
Potential to be added for FFY 2014: Medicare spending per
beneficiary for period from 72 hours prior to admit to 90 days
post discharge
In memory of
a good friend and mentor of many RTs
`