The Changing Health Care Payment Landscape What Can (and Should) - - PowerPoint PPT Presentation

The Changing Health Care Payment Landscape

What Can (and Should) Employers do?

2 PBGH Members

3

• What’s changing?
• How are employers reacting?
• What can you do?

Three Questions

4

• Most people remember this…

Repeal and Replace is About Public Coverage

5

• But not this…

Repeal and Replace is About Public Coverage

6 Public Sector Health Care Payment is Changing

7

Private Sector Health Care Payment is Changing

75% of all business activity will be in alternative payment model contracts with triple aim goals by 2020.

8 Vital roles for purchasers

• Provide input to policy leaders on APM definitions, metrics,

methods; MIPS measures

• Influence CMS and major health plans
• Expand purchaser education/awareness of APMs and payer

initiatives

• Increase number of purchaser voices in payment policy

process

• Increase number of purchasers taking steps to change

payment or benefit design

9 One Way to React

10 “Above all, try something.”

11 What Are Other Employers Doing?

12 Maternity Care Improvement Campaigns

Regional coalition meetings held Piloting value-based payment Successful campaign completed

13 Improving Maternity Care

14

• Ask them to report low-risk C-section rates directly to you

and/or adopt a QI improvement initiative

• 1. Meet with hospitals

!! !!

15

• 1. Blended Case Rate

Reimburse the same for C-sections and vaginal births

• 2. Episode-Based Bundle

Pay one bundled fee for prenatal, delivery and postpartum care

• 3. Denial of Payment

Deny payment for medically inappropriate care

• 2. Ask health plan to use VBP

16

• Ensure coverage of less utilized services that can improve outcomes

and patient experience.

• Midwives
• Birth centers
• Doulas
• Group prenatal care
• 3. Review benefits package

17

• Tiered or narrow networks
• Link to hospital C-section rates in online provider

directories

• Reference pricing
• Patient engagement materials and tools
• 4. Beneficiary incentives

18 Employer Centers of Excellence Network

19

Virginia Mason Medical Center Seattle, WA Kaiser Permanente Irvine Medical Center Irvine, CA Mercy Hospital, Springfield Springfield, MO Johns Hopkins Bayview Medical Center Baltimore, MD Geisinger Medical Center Danville, PA

Joints Spines Bariatrics

Scripps Mercy Hospital San Diego, CA

ECEN CoE Locations

Charlotte, NC spine CoE & San Antonio, TX bariatric CoE launching Summer 2017

20

Joint Replacement Spine Procedures Bariatric Surgery

Launch Date January 1st, 2014 April 1st, 2015 January 1st, 2016 Number of CoEs 4 4 3 Bundled Price

(average discount)

20-30% 20-30% 30-40% Format Virtual evaluation Travel for surgery Virtual review, travel for in-person evaluation and/or surgery (one trip) Virtual review, travel for in-person evaluation and/or surgery (two trips*) Site of care All inpatient procedures Inpatient and ambulatory procedures All inpatient procedures Other features Includes initial outpatient physical therapy All patients receive comprehensive in- person assessment One year standardized virtual follow up Volume Completed Cases: 1645 Completed Cases: 269 Data Reporting starting mid-2017

ECEN Program Snapshot by Condition

21

Lowe’s Improved Outcomes through ECEN

*Results of a claims analysis of primary joint replacement (DRG 470) patients who received usual care via Lowe’s carrier benefit versus ECEN patients

Quality Metric

2014

Carrier ECEN

Discharge to Skilled Nursing Facility 9.1% 0.0% Readmissions < 30 Days 6.6% 0.4% Revisions within 6 months 1.1% 0.0%

$600,000 savings in 2014 from ECEN higher quality

22 Boeing Direct ACO Contracting Model

Preferred Partnership (ACO)

• Improve Quality
• Enhance Member Experience
• Reduce Cost

Delivery Goals

• Incentive Only
• Maintain Employee Choice
• Simplified Approach

Markets

• Puget Sound (2015):
• Providence-Swedish Health Alliance & their partners
• UW Medicine Accountable Care Network & their partners
• St. Louis (2016): Mercy Health Alliance & their partners
• Charleston (2016): Roper St. Francis & their partners

23

ACO Plan Structure

Program Design

• Mixed Model
• Designated – Employee elects program during Annual Enrollment
• Attributed – Majority of care is delivered at ACO Partner
• ACO Network is ‘In-Network’
• PCP encouraged, but not required
• No Gatekeeper

Financial Incentives for Employees

• Lower Employee Premiums
• Higher Company Funded HSA
• $0 Primary Care Office Copay
• $0 Generic Drugs

24

Preliminary Results

Improve Quality

• Improvement in most metrics
• Better controlling Blood Pressure, Diabetes, Cholesterol
• Increased Screening Rates
• Performance Improving on Depression Management
• Higher Generic Fill Rates

Enhance Member Experience

• 15% - 35% employees enrolled
• Rating of 8.5 out of 10

Reduce Cost

• Results available later in 2017
• Partner Commitment
• Long term Investment

25

• Challenge grants for regional pilots
• Employer ACO assessments
• Rx toolkits

What Else?

26 PVN Payment Reform Challenge Grants

Under development Awarded

• Maternity care
• Primary care
• Avoidable ED use
• Cardiac care
• Joint replacement

27 Health Plans’ Self-Reported ACO Results

28 Employers looking “under the hood”

29

• PBM transparency through

collaborative audit processes or

• ther buyer leverage
• Carve out select PBM functionality
• Promote fully informed point-of-

care prescribing through APMs, vendor solutions, PBM partnerships

• Value-based benefit design—

reference pricing, retail network solutions, etc.

• Purchaser “drug trend report” that

documents performance elements across PBMs and pharmaceuticals

Some Employer Rx Options

30 What Tools Are Already Out There?

• Regional coalitions
• PBGH/CPR, PVN, NBGH employer-focused ACO toolkits
• MBGH and MHAG Rx toolkits
• PVN maternity toolkit
• Webinars, curated library etc. at www.pvnetwork.org

31 “Above all, try something.”