The Changing Health Care Payment Landscape What Can (and Should) Employers do?
2 PBGH Members
3 Three Questions • What’s changing? • How are employers reacting? • What can you do?
4 Repeal and Replace is About Public Coverage • Most people remember this…
5 Repeal and Replace is About Public Coverage • But not this…
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 Successful campaign completed Piloting value-based payment Regional coalition meetings held
13 Improving Maternity Care
14 1. Meet with hospitals • Ask them to report low-risk C-section rates directly to you and/or adopt a QI improvement initiative !! !!
15 2. Ask health plan to use VBP 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
16 3. Review benefits package • Ensure coverage of less utilized services that can improve outcomes and patient experience. • Midwives • Birth centers • Doulas • Group prenatal care
17 4. Beneficiary incentives • Tiered or narrow networks • Link to hospital C-section rates in online provider directories • Reference pricing • Patient engagement materials and tools
18 Employer Centers of Excellence Network
19 ECEN CoE Locations Virginia Mason Medical Center Seattle, WA Mercy Hospital, Springfield Springfield, MO Kaiser Permanente Irvine Medical Center Irvine, CA Johns Hopkins Bayview Medical Center Baltimore, MD Geisinger Medical Center Joints Danville, PA Spines Scripps Mercy Hospital Bariatrics San Diego, CA Charlotte, NC spine CoE & San Antonio, TX bariatric CoE launching Summer 2017
20 ECEN Program Snapshot by Condition Spine Joint Replacement Bariatric Surgery Procedures January 1 st , 2014 April 1 st , 2015 January 1 st , 2016 Launch Date Number of CoEs 4 4 3 Bundled Price 20-30% 20-30% 30-40% (average discount) Virtual review, travel for Virtual review, travel Virtual evaluation in-person evaluation for in-person Format Travel for surgery and/or surgery (one evaluation and/or trip) surgery (two trips*) Inpatient and All inpatient Site of care All inpatient procedures ambulatory procedures procedures All patients receive Includes initial outpatient One year standardized Other features comprehensive in- physical therapy virtual follow up person assessment Data Reporting Volume Completed Cases: 1645 Completed Cases: 269 starting mid-2017
21 Lowe’s Improved Outcomes through ECEN $600,000 savings in 2014 from ECEN higher quality 2014 Quality Metric 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% *Results of a claims analysis of primary joint replacement (DRG 470) patients who received usual care via Lowe’s carrier benefit versus ECEN patients
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 What Else? • Challenge grants for regional pilots • Employer ACO assessments • Rx toolkits
26 PVN Payment Reform Challenge Grants • Maternity care • Primary care • Avoidable ED use • Cardiac care • Joint replacement Awarded Under development
27 Health Plans’ Self-Reported ACO Results
28 Employers looking “under the hood”
29 Some Employer Rx Options • PBM transparency through collaborative audit processes or other 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
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.”
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