The concept that payment for health care should be based on quality and clinically meaningful outcomes is not new, but the current breadth, variety and rapid adoption of value-based models is unprecedented. Value-based payment models now include accountable care organizations (ACOs), patient-centered medical homes (PCMHs), bundled and episode-based payments, and pay for performance structures.
There are now more than 600 Medicare and non-Medicare ACOs. This is more than a 300% increase from the end of 2011 when the first 32 Medicare ACOs were announced, at which time there were approximately 160 private sector ACOs. The increase in PCMHs is no less remarkable with a 5-year increase from 28 in 2008 to nearly 6,000 in late 2013 – and that only includes those with NCQA accreditation.
Value-based purchasing further emphasizes the ripple effect and spider web of CDI, HIM and Quality. Everyone “knows” about value-based purchasing, but what is it comprised of?
Value-based purchasing (VBP) is both a broad and narrow quality measurement tool. Broadly defined, pay for performance (P4P)/ VBP is payer-developed metrics to measure value compared to reimbursement given. Two examples are accountable care organizations (ACOs) and bundled payments. A narrow definition is a program mandated by the Affordable Care Act of 2010 and administered by CMS. VBP has been in development for almost 10 years but was formally introduced for FY 2013. Through the Medicare program, incentive payments are made to hospitals based on either how well they perform or improve against their own baseline on each domain comprising VBP. There are four domains: clinical process of care, patient experience of care, outcome (FY 2014 forward) and efficiency (FY 2015 forward). Each domain is assigned an associated weight. For example, in FY 2015 clinical process is 20 percent of the total VBP score, patient experience is 30 percent, outcome is weighted at 30 percent and efficiency rounds it out at 20 percent. Continue reading
Value-based purchasing (VBP), a program authorized by the Patient Protection and Accountable Care Act of 2010, authorizes the Centers for Medicare & Medicaid Services (CMS) to base a portion of hospital reimbursement payments on how well hospitals perform in 25 core measures. The goal of the VBP program is to incentivize hospitals to improve care by starting to base reimbursement on quality of care delivered. This program focused on how patients rate their hospital experience, and how well hospitals follow certain standards of care. Some of the VBP core measures ask the following:
• Were blood cultures performed in emergency department prior to initial antibiotic?
• Were prophylactic antibiotics discontinued within 24 hrs after surgery end?
• How often was pain well controlled? Continue reading
Yes. To achieve real success in population health we need health care consumers to actively engage in the behaviors necessary to secure their health. “Patient” engagement is the holy grail of health care. However, despite decades of research into health behavior and ways to change it, we don’t seem to be any closer. I think that is about to change.
Disruptive technologies are proliferating in response to the new cultural phenomena of the “quantified self.” This movement believes each of us is a rational creature responsive to data and if we can only get enough indisputable facts about our daily life, then we can manage/change our behavior. Therefore, everything in our lives must be tracked. This assumption is debatable — some people do not need a scale to know if they are gaining weight, a look in the mirror will do. However, for others, including myself, we seem to automatically airbrush that image in the mirror, so a little rude data every now and then may be necessary.
Maintenance of Situational Awareness, or SA, is crucial to all of our endeavors. It is the perspective and sense of what is going on around us. One would like to say it is an appreciation and evaluation of all that is relevant to the target pursuit plus extra detail to be stored away for access at a later date – often without a direct application in mind. To appreciate all aspects of an endeavor or project is an aspiration, and, depending on the context, unrealistic. In such cases, we depend on team members to help create a shared mental model. Maintaining SA is an active and incessant process. Common speech recognizes this concept in remarks such as “…missing the forest for the trees” or “…functioning with blinders on.” Continue reading
American health care continues to rank as the least cost-effective system in the developed world. Why? You might be tempted to say that, until recently, there was no incentive to change. A purely economic view is that the costs to healthcare providers have been greater than the payoff.
The economic landscape is changing. Quality reporting, value-based purchasing, Meaningful Use, risk-based contracts, and other reforms have created rewards and penalties intended to improve the value of health care. Will they work? Well. . . Ask instead, “How could they fail?” Continue reading
I have the opportunity to travel around the country, interacting with health plans and provider systems as they work out new payment models and new systems of care delivery, and I see an intense interest in these new models coupled with many theories on their pathway to success.
Weighed against the medical literature, three things are apparent:
- Most of the theories on improvement focus on processes that may have small relevance to outcomes.
- Most of the interventions at play are in very early stages and are very incremental.
- Interventions most likely to be linked to big outcomes are culturally challenging and being held at bay for the moment.
A major impact on outcomes requires bold action. Continue reading
I was fortunate to serve on the NQF Task Force on Risk Adjustment for Socioeconomic Status or other Sociodemographic Factors (SDF)i. This report generated more comments than any other NQF Task Force Report – ever. Of the 700 comments received in reaction to the draft report, the vast majority (more than 98%) were in favor. CMS was one of a very small number of institutions opposed to the initial report. While the final report contains significant modifications to the initial report, much of the spirit and substance remains. Continue reading
I previously discussed how selection of principal diagnosis may impact quality. This ripple effect (like a pebble on a pond) may occur when one works in a silo, ignoring other departments such as quality. If only the ripple effect was the lone “offender” in which CDI and coding may impact quality outcomes. Consider a spider web: intricately designed and seeming impervious. However, as strands get broken, the web collapses.
In review, CDI professionals and coders are tasked with obtaining and capturing a complete picture of the patient’s encounter for appropriate reimbursement, accurate reflection of severity of illness (SOI) and risk of mortality (ROM) and outcomes of care. Historical models of CDI programs and coding processes focused predominately on the first two tasks, without acknowledgement of how this may affect quality outcomes (potentially fracturing the spider web). Continue reading
Earlier this year, The Journal of the American Medical Association (JAMA) published a widely publicized but limited article on medical homes in Pennsylvania that found little improvements in quality and no improvements in costs or utilization associated with medical homes. The authors concluded medical homes may generally “need further refinement” — a phrase that was taken by many in the press to mean that medical homes “don’t work.”
Subsequently, there has been much debate and little clarity around the promise of medical homes. Continue reading