Matt Keelin- TCPi Program Manager

Carol Greenlee MD- TCPi Faculty

CO PTN

TCPi Learning Collaborative December 15, 2017

High Value Care & It’s Impact on Cost

Think Possibilities

Be alert to possibilities for how your practice can

reduce unnecessary utilization (waste) in order to:

Optimize the benefits and reduce the cost and/or harms for your

patients

Reduce wasteful spending in order to have monies for beneficial

services (and avoid rationing), to help all in our health care system

Optimize the Value of the care attributed to you (and position your

practice for Value Based Payments)

Be engaged, energized & ready to share

Anyone feeling the pain ?

Anyone here seeing the effects of high medical costs?

Effects on patients?

Personal?

We spend too much on health care –

~18% of U.S. GDP (2.7 trillion)

$10,348 per capita annually

Higher Premiums

Larger Deductibles

Vicious Cycle

Missed care > Higher costs

Far reaching impacts…

>$9000 per capita

Out of Reach

Impact on Our

Community

Limits wages

Limits hiring

Public/ Local Budgets:

Health Coverage vs

Services

Household Budgets:

up to 50% of expenses

Did you know?....

An estimated 30% of all health care

spending is spent on waste

~$750 billion of “health care waste” annually

Waste in health care defined as “Healthcare spending

that can be eliminated without reducing

the quality of care.”

30% (30 cents of every dollar)....

What would happen to your

Household if 30% of every dollar

went for waste ?

What other industry or business

could survive 30% of their budget

being spent on waste ?

Who “controls” most of the wasteful spending?

? Fraudulent individuals

? Patients

? Clinicians (physicians and advance practice providers)

? Insurance companies

? Hospital administration

? Big Pharma

Clinicians are responsible for 87%

of wasteful spending

Ordering More Services…

Areas of greatest expenditures and most rapid growth:

Tests

Imaging

Procedures

Estimated Sources of Excess Costs in

Health Care (2010)

Category Estimate of Excess Cost

Unnecessary Services

Inefficiently Delivered Services

Excess Administrative Costs

Prices That Are Too High

Missed Prevention Opportunities

Fraud

$210 billion

$130 billion

$190 billion

$105 billion

$ 55 billion

$ 75 billion

IOM 2010

The Disconnect

Current payment models are problematic

Fee for service (FFS) – no feedback loop to promote higher

value care (no skin-in-the-game)

The person providing the service gets paid without regard to

quality(outcome) or

value(whether the service was needed or not, or the cost)

The person ordering the service doesn’t pay for the service

Current payment models do not support

healthcare reform (delivery of higher value care)

Value Based Payment (VBP)

What is it?

HealthCare.Gov Definition

Linking provider payments to improved performance by health care providers.

This form of payment holds health care providers accountable for

both the cost and quality of care they provide. It attempts to reduce

inappropriate care and to identify and reward the best-performing providers.

“Some skin-in-the-game”

How will clinicians be held accountable

for costs ?

QPP

MIPS: Resource Use performance category

10% of composite score for 2018 reporting period

30% (by law) for 2019 reporting period

Score derived by CMS, nothing to calculate or submit

APMs: thresholds, capitation, bundles and/& shared savings

Total Cost of Care (TCOC) attributions

Example: CPC+ practices are receiving TCOC data for the specialists

that they utilize;

Help them select which specialists are “higher value”

It is not just reporting…

Need to achieve higher VALUE Improved outcomes Reduced costs

Value = Quality (Benefit)/Cost Goal = “get the most for the money”

High Value Care = Get the best patient outcomes for the best cost Ensure patients get care that benefits them (improves

outcome) = higher quality Reduce care that adds cost without adding benefit (or that

may potentially cause harm) = lower costs

High Value Care = only “low cost” care

Options: Low benefit/ low cost (generic antibiotic for viral infection)

Low benefit/ high cost (MRI for most low back pain)

High benefit/high cost (biologic for RA; gastric bypass poorly

controlled T2DM)

High benefit/low cost (vaccines, VTE prophylaxis)

Want to reduce utilization of services that do

not add benefit or contribute to better outcomes

i.e. reduce waste (low value care)

What can You do to Reduce Waste…

Start with focus on High Impact areas:

Reduce Unnecessary or Preventable Utilization

Low Value Testing and Procedures (add cost without benefit but with potential harm) Duplicated

Unnecessary

Preventable Admissions Hospital Admissions

Hospital Readmissions

ED visits

Reduce Wasteful Testing & Procedures Unnecessary Duplicative

Pre-op testing that is not indicated for condition/ surgery or anesthesia type

Routine ordering of CT scan “with & without” contrast

Testing or treatment that does not contribute to diagnosis or management Shot gun evaluations or lack of

clarity on newer guidelines for evaluation and/or monitoring requirements

CT/MRI of head for low trauma head injury

MRI & other imaging for low back pain without alarm signs

Use of antibiotics for viral or self-limited conditions

Pre-op testing already done by referring practice

Referral situations

Co-management situations

Contaminated culture specimens

Imaging with wrong preparation or methodology

Low-Value Services Delivered Frequently for

Medicare Patients

Low-value cancer screening

Low-value diagnostic and preventive testing

Low-value preoperative testing

Low-value imaging

Low-value cardiovascular testing and procedures

Low-value surgical procedures

Affected 25%-42%

of Medicare beneficiaries

(see handout for specific items)

The 10 most costly low-value services in Virginia Ranking by use Waste index

1. Baseline lab tests for low risk patients having low-risk surgery

2. Stress cardiac or other cardiac imaging in low-risk, asymptomatic patients

3. Annual EKGs or other cardiac screening for low-risk, asymptomatic patients

4. Routine head CT scans for ED visits for severe dizziness

5. EKGs, chest x-rays, or pulmonary function tests in low-risk patients having low-risk surgery

6. Population-based screening for vitamin D deficiency

7. PSA-based screening for prostate cancer in all men, regardless of age

8. Routine imaging for uncomplicated acute rhinosinusitis

9. Routine annual cervical cancer screening in women ages 21–65

10. Imaging for low-back pain within the first six weeks of symptom onset, in absence of red flags

The 10 most costly low-value services in Virginia Ranking by use Waste index

1. Routine but unnecessary Pre-op testing

Baseline lab tests for low risk patients having low-risk

surgery

EKGs, chest x-rays, or pulmonary function tests in low-

risk patients having low-risk surgery

See Handout for example of Pre-op testing Guideline

Preop Testing Unit Cut Costs by 47% by

Applying Guidelines A study presented at Anesthesiology 2017 in Boston from the American Society of Anesthesiologists

A team from the Rutgers New Jersey Medical School reduced the volume of preanesthesia testing and cut costs by 47% by applying patient-centered practice guidelines, developed by the National Institute of Health and Care Excellence (NICE) and the American Society of Anesthesiologists.

By changing the ordering rules and applying the guidelines, the team cut the average monthly cost of testing from $172.70 per patient to $83.89. They estimate that about 25% of all testing done before the guidelines was inappropriate.

No change in clinical outcomes was associated with the reduction in testing.

…also reduced the number of patients who needed testing. The average number of patients in the PAT clinic who required any preoperative tests declined from 231 to 193 per month, a decrease of 16.5%.

"A lot of these test were done out of habit, more so than specific clinical consideration as to what each individual needed," said lead author, Somdatta Gupta, MD. "We focused on individual needs."

Orthopedic Group in Chicago Preparing for Bundled Payment Model

The cost of “Routine” testing:

Routine 2-hour post-op CBC ($50 test)

Analysis showed spent $25 K for One abnormal

CBC that changed management

Spent $25,000 when could have spent $50…and had

that money for other things in the bundle

What would you do if this was your budget?

Removed from routine order set

Now order only if a reason (bleeding, fever, etc.)

Take a minute….

What do you think “drives” over-testing and/or

overtreatment?

What are the “downstream costs” of overtesting or

overtreatment…financial & personal?

Drivers of Overuse/ Low Value Care

Patient/Public assumptions &/or misperceptions All risks can be lowered

The lower the risk, the harder to reduce/ more potential harm

Fixing something always better Vascular lesion in asymptomatic person

Early diagnosis is better (“birds, rabbits, turtles”) Prostate cancer, thyroid cancer, etc.

More data is better Incidentaloma epidemic

Action (doing something) is better than inaction Action can be “high stakes” (back surgery)

Newer is better Metal-on-metal hip fiasco

End of life (avoiding death) “how long vs how well” one lives

Role of Shared Decision

Making

Drivers of Overuse/ Low Value Care

System level Financial Incentives (“do more, get more”)

Malpractice concerns

Desire for certainty /reassurance

Performance Metrics

e.g.A1c <7, <8 vs >9%

Practice Culture/ available technology

Differences in training (medical school, postgrad)

Time constraints

Patient satisfaction (“keeping patients happy”)

Recent cases

of patient

law suites for

receiving

unnecessary

care and

associated

risks and

harms

Kaiser Health News

“So Much Care It Hurts: Unneeded Treatment Only

Adds to Patients' Ills”

Possible Ways To Reduce The Use Of Low-Value Care

Survey of Physicians:

Malpractice reform - 92%

Specific, evidence-based recommendations in a

format designed for patients that physicians could

use to discuss why some care may be unnecessary -

92 %

Spending more time with patients - 88 %

Changing financial rewards - 72%

"What am I going to do with the answer?"

“I saw a consult with sudden kidney failure. The patient's kidneys stopped working after a cardiac catheterization; the intravenous dye was too much for his system. The cath was done because he was short of breath. This was more likely because his left lung was being destroyed by cancer. That he could not breathe because he had a chest full of malignancy was ignored, in favor of an improbable diagnosis -- unstable heart disease. More importantly, no one had asked, before they invaded his heart and wiped out his kidneys, ‘Are we going to fix the coronary arteries of a patient with advanced lung cancer?’”

“It boils down to this: Have a clear understanding of how a particular test is going to change the plan. Do not go hunting in the dark and do not be fooled that unnecessary tests bring reassurance. They bring confusion. A test only has value if it improves life. Occasionally, we need to remind ourselves that this is the purpose of the practice of medicine anyway.”

James C. Salwitz is an oncologist

Consider downstream “costs”…

Case of Ms. B. Ms. B. is a 57-year-old woman presenting to the ED with chest pain

She has a history of recurrent UTIs; has no dysuria or urinary frequency

Afebrile & WBC count is 5.5

How would this test result alter your management?

This patient underwent testing (although tests may not have been

indicated)

Urinalysis: cloudy, 11-50 WBC, 11-50 RBC, 2+ bacteria

Urine culture: + >100,000 E. coli

What is your management decision now that you have these test results?

Choosing Wisely: Don’t treat asymptomatic

bacteriuria with antibiotics.

Inappropriate use of antibiotics to treat asymptomatic bacteriuria (ASB), or a significant number of bacteria in the urine that occurs without symptoms such as burning or frequent urination, is a major contributor to antibiotic overuse in patients.

use of antibiotics to treat ASB is not clinically beneficial and does not improve morbidity or mortality.

The overtreatment of ASB with antibiotics is not only costly, but can lead to C. difficile infection and the emergence of resistant pathogens, raising issues of patient safety and quality.

Exceptions: pregnant patients patients undergoing prostate surgery or other invasive urological surgery kidney or kidney pancreas organ transplant patients within the first year of

receiving the transplant

Case of Ms. B.

The E. coli urine isolate was resistant to ampicillin and trimethoprim-

sulfamethoxazole but susceptible to ciprofloxacin

Ms. B. was discharged to complete 7 days of oral ciprofloxacin

She returned 1 week after completing therapy with fever, abdominal

pain, and watery diarrhea; a stool Clostridium difficile PCR assay was

positive

Ms. B. was intolerant to oral metronidazole and was switched to oral

vancomycin x 10 days

Calculate the cost: www.guroo.com

healthcarebluebook.com, clearhealthcosts.com,

www.newchoicehealth.com/Directory/Procedure,

Much more

than the cost

of the initial

Urinalysis

Take a minute….

What examples of testing done by your practice might not be

needed ?

How can unnecessary testing effect your patient outcomes?

What examples can you think of for testing done by your

practice that are duplicative?

Duplicative testing – “pure waste”

Drivers for Duplicative testing

Unavailability of test results

Estimated repeat testing at least 33% of cases

Uncoordinated Care

Poor information sharing / communication

Lack of agreement on who does what when

Suggestions for Reducing Duplicative testing

Use of QHN (the Health Information Exchange)

Ensure high value referrals & care coordination

Which requires more time/work?

Pull result in from QHN Order test (duplicate)

Open QHN

Log in

Enter patient name/DOB

Scan through labs

Click on desired lab result

“Send” result to your EMR

Discuss with patient face-

to-face

Order-Enter lab &

diagnosis code

Print or send to lab

Staff hands order to patient

Phlebotomy

Review result in “in-box”

Type & Send message to

staff to call patient with

results

Handle questions

Remember to close note

Remember the Golden Rule

& Patient-Centered Care

Take a minute….

How can your practice reduce preventable

“admissions”? Hospital admissions

Readmissions

ED visits

Improve Access “Same day”-”Urgent”- “911” appointment spots

Exacerbations/post-op complications

Adverse Drug Events

Acute issues (+ Pregnancy test, etc.)

Urgent f/u after initial consult, testing or procedure

e.g. biopsy returns + for malignancy

other Suggestions:

• Mark with a special color on

schedule template

• Utilize times that may also

be used for other activities

• Start by adding an urgent est

patient appointment at the

end of the day

• Consider doing patient

survey of care needs

Improve Patient Self-Management

ED Cost Comparison:

Pre- and Post-Entry

Southwest Pediatric PTN

Improve Transition Care

Denver Health ENT Intervention • Postop Phone Call from RN

• Clarify postop care instructions

• Trouble shoot problems

Improve End-of-Life-Care

Early Palliative Care Is Key Driver in Reducing Costs Palliative Care in Oncology Symposium 2017

Palliative care can substantially reduce

healthcare costs, and when initiated early, it is a key driver in lowering expenditures, according to a new study

… average savings of approximately $3000 per patient

One study conducted at Johns Hopkins Medicine found that opening a palliative care unit saved the facility $367,751 in direct costs.

Cost & Quality connect us

…..like an Aspen Grove

What actions can you take….

To identify an over-utilized service (screening, testing, procedure,

treatment, facility, etc.) that your practice can impact (reduce)

To collect baseline data on that service, if possible

To design an approach or intervention (improvement plan)

around that service

To monitor for improvement

MIPS

Resource Use performance component

10% of composite score for 2018 (full year) reporting period

30% (by law) of score for 2019 reporting period

Score derived by CMS, nothing to calculate or submit

Combination of Total per Capita Costs + Medicare

Spending per Beneficiary

For 2018 will utilize Value Based Payment Modifier (VM)

Will use 2018 part A & B claims data and compare your

practice (TIN) to other practices for same time period

(the full year of 2018) (not to a historic benchmark)

Recommendations

Be ready to go with interventions by early 2018

Focus on the high impact items for reducing waste

(unnecessary or preventable services)

Focus on interventions that will reduce costs (as reflected in

claims data) in immediate future

Look at 2016 Cost component on your practice QRUR

Ability to do a ‘deep dive’ to see which services and/or patients

drove costs attributed to you

Use this data to help select & design intervention for your practice

Ensure use of specific ICD codes vs general or “unspecified”

codes (for adequate classification of disease severity)

Quality and Resource Use Reports: QRUR

Lower is Better

High Impact Interventions to Reduce Waste

Intervention ideas presented today for reducing waste/costs

Use of QHN to avoid duplicate testing

Improve the referral process (Medical Neighbor)

Appropriate (not “routine”) pre-op or pre-procedure testing

Also post-op testing individualized vs routine

Same day urgent appointment spots

Improve patient self-management & support

postop f/u phone call

Palliative care/hospice care

What are you doing? What ideas do you have?

From: Measuring Low-Value Care in Medicare

JAMA Intern Med. 2014;174(7):1067-1076. doi:10.1001/jamainternmed.2014.1541

Service Counts and Associated Spending Detected by Measures of Low-Value Care Table Title:

TCPi Resources ACEP (E-QUAL Network)

https://www.acep.org/Advocacy/Reduce-Avoidable-Imaging-Initiative

https://www.acep.org/Advocacy/Chest-Pain-Imaging-Initiative

American College of Physicians High Value Care https://www.acponline.org/clinical-information/high-value-care

American College of Radiology https://rscan.org/resources/topic-specific-resources http://www.acr.org/quality-safety/appropriateness-criteria/acr-

select

AMA STEPS Forward https://www.stepsforward.org/modules/choosing-wisely https://www.stepsforward.org/modules/cds-imaging

TCPi Resources Choosing Wisely

http://www.choosingwisely.org/

Consumer Health Choices http://consumerhealthchoices.org/campaigns/choosing-wisely/

Network for Regional Healthcare Improvement (NRHI) http://www.nrhi.org/work/multi-region-innovation-

pilots/choosing-wisely/

CMS Medicare Quality and Resource Use Reports (QRUR) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/2016-QRUR.html