WHIO Symposium May 13, 2011. Goals of WHIO To aggregate health care data from sources across...
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Partnership for Healthcare Payment Reform WHIO Symposium May 13, 2011
WHIO Symposium May 13, 2011. Goals of WHIO To aggregate health care data from sources across Wisconsin to create a single reliable data source to be used
Goals of WHIO To aggregate health care data from sources across
Wisconsin to create a single reliable data source to be used by
multiple stakeholders to examine variations in efficiency, quality,
safety and cost To improve the quality, cost, safety and efficiency
health care in Wisconsin by sharing the results with providers,
purchasers and consumers To support provider quality improvement
initiatives To encourage value-based health care choices by
consumers
Slide 3
WHIO Members and Subscribers The Alliance Anthem Blue Cross and
Blue Shield of Wisconsin Greater Milwaukee Business Foundation on
Health Humana United Healthcare of Wisconsin WEA Insurance Trust
WPS Health Insurance Wisconsin Collaborative for Healthcare Quality
Wisconsin Hospital Association Wisconsin Medical Society Wisconsin
Department of Employee Trust Funds Wisconsin Department of Health
Services Aspirus Aurora Health System Bellin Health Dean Health
Plan Group Health Cooperative South Central Wisconsin Gundersen
Lutheran Health Plan Health Tradition Health Plan/Mayo MercyCare
Insurance Network Health Plan Physicians Plus Insurance Prevea
Health Plan Security Health Plan ThedaCare Unity Health Plan UW
Population Health Institute
Slide 4
Using the Data: Wisconsin Payment Reform Initiative Launched
with the premise that: Aligning the incentives of payers,
providers, employers and patients, Measuring quality and cost of
care at a granular level, and Publicly reporting outcomes Will:
Improve the quality of care delivered and reduce its cost by
rewarding those who reduce waste and develop more effective,
efficient processes
Slide 5
And This is Important Because Health care spending now tops 18%
of US GDP Premium growth crowds out wage increases, is
unsustainable for employers 1:6 (50+ million) Americans is enrolled
in Medicaid 1:6.5 (47+ million) Americans is enrolled in Medicare
1:6 (50+ million) Americans is uninsured
Slide 6
History of WPRI November 2009 WHIO creates WPRI Steering
Committee April 2010 Steering Committee hosts WPRI Leadership
Summit 170 C Level leaders from stakeholder organizations Agreed to
form Acute, Chronic, Preventive Care Workgroups to develop pilot
projects Hypothesis: The outcomes for patients treated for a
specific condition will improve, and costly complications or
exacerbations of the patients condition will be avoided, if the
payment system fosters competition among providers at the level of
the medical condition based on the quality of care delivered and
the total cost of services.
Slide 7
Pilot Conditions Acute Care chose total knee replacement
Chronic Care chose adult diabetes Preventive Care chose composite
measure of screenings for: Breast Cancer Cervical Cancer Colorectal
Cancer
Slide 8
Partnership for Healthcare Payment Reform Our Mission: The
Partnership for Healthcare Payment Reform supports the voluntary
engagement of Wisconsins diverse healthcare stakeholders in
assessing, designing, testing and implementing innovative,
comprehensive approaches to healthcare payment reform in order to
improve the quality and affordability of healthcare in Wisconsin
and advance the health status of Wisconsin residents.
Slide 9
Guiding Principles/Values Collaboration: We rely on shared
sense of purpose among participants Openness/Transparency:
Communicate learnings, engage all parties. Patient Centeredness:
Payment reform should enhance patient experience of care. Synergy:
PHPR will provide relevant, Wisconsin-based leadership, building on
national trends
Slide 10
Guiding Principles/Values Evidence-based: Use data to select
high value projects; assess promising practices Continuous
Learning: Our understanding of what best supports value in
healthcare continues to evolve Impact: Pilot approaches that are
both replicable and scalable
Slide 11
Why Are 60+ Organizations Participating in Design Efforts?
Opportunity to align incentives among payers Maximize purchasing
strategies Collaborative nature of the workbuilding on Wisconsins
tradition and healthcare assets Shared learning Commitment to
quality Opportunity to test what we know we have to do Sense of
responsibility/duty to sustainable healthcare system
Slide 12
Current Status: Acute Care Pilot Bundled payment for total knee
replacement (single knee) Commercially insured patients ages 18 64
Includes 90 day warranty period to cover complications, device
failure
Slide 13
Why Pilot Bundled Payments? Bundled payments have been shown to
improve quality and efficiency of care* Medicare scheduled to pilot
episode of care bundled payments beginning January 1, 2013 Few
multi-payer bundled payment efforts in the countryWisconsin can
lead the way Participation in PHPR bundled payment pilot allows
manageable testing of larger payment reforms to come *See, e.g.,
http://www.gao.gov/new.items/d11126r.pdf; Cromwell J, et al., Cost
savings and physician responses to global bundled payments for
Medicare heart bypass surgery. Health Care Financ Rev. 1997
Fall;19(1):41-57.http://www.gao.gov/new.items/d11126r.pdf 13
Slide 14
Acute Care Pilot Overview What Services? Bundled payment for
Total Knee Replacement (one knee) Episode period begins at
admission and concludes 90 days from hospitalization Revision
procedure performed during episode period resulting from patient
complications or device failure Patient complications arising
during anchor admission Treatment of complications related to
either anchor or revision admission (any service setting)
Readmission during the 90-day episode period for listed DRGs
14
Slide 15
Acute Care Pilot Overview, contd. Whos Included? Patients
presenting for the index procedure without: Clinical history that
demonstrates a clinical condition of active cancer, HIV/AIDS, or
End Stage Renal Disease Body Mass Index (BMI) of 40 or greater Over
age 18 and under age 65 on the date of surgery Covered (as primary
plan) by a participating employer and health plan at the time of
admission 15
Slide 16
Acute Care Pilot Overview, contd. How Will Bundled Payments
Work? Bundler (hospital, IPA, PHO) negotiates bundled payment
Provider bills upon patient discharge and at end of episode period
Payer pays negotiated amount to bundler Bundler distributes payment
to TKR bundle team members 16
Slide 17
TKR Bundle Quality Measures MeasureWho Collects and Reports To
Whom How Often SCIP Cardiology 2HospitalCMS/ PHPR Quarterly SCIP
VTE 2HospitalCMS/ PHPR Quarterly Length of
StayHospitalPHPRQuarterly Readmission/Revision Rates for
TKRPayers/WHI O PHPR6 months Complications (infection rates, DVT,
PE) Payers/WHI O PHPR6 months Patient SatisfactionHospitalHCAHP S/
PHPR Quarterly Outcomes Measure (WOMAC, KSS, KOOS, etc.) depending
on what provider uses ProviderPHPRQuarterly Patient facility with
activities of daily living pre-op vs. post-op (being developed)
ProviderTBD 17
Slide 18
Acute Care: Next Steps Expressions of interest requested by May
20 or as soon as feasible Targeting go-live of September 1, 2011
Workgroup meeting this afternoon open to potentially interested
pilot participants
Slide 19
Current Status: Chronic Care Pilot Project Adult diabetics
covered by commercial plans WCHQ quality measures Begin with shared
savings and transition to global payment over time Payers retain
insurance risk; providers take clinical/performance risk Consider
opportunities to work on local community engagement around
nutrition, physical activity, obesity prevention/reduction 19
Slide 20
Why Pilot Shared Savings/ Episode of Care Payments?
Condition-based, episode of care payments are expected to improve
quality and efficiency of care* Pilots propose to start with shared
savings and transition to full global payment Participation in PHPR
chronic care payment pilot allows manageable testing of larger
payment reforms to come Few multi-payer episode of care payment
efforts in the countryWisconsin can lead the way *See, e.g.,
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC554918/;
http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2008/Jun/Evidence-
Informed-Case-Rates--Paying-for-Safer--More-Reliable-Care.html?doc_id=689893http://www.ncbi.nlm.nih.gov/pmc/articles/PMC554918/
http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2008/Jun/Evidence-
Informed-Case-Rates--Paying-for-Safer--More-Reliable-Care.html?doc_id=689893
20
Slide 21
Diabetic Services Bundle Adults 18-64 with diabetes Without
HIV, cancer, suicide, ESRD, pregnancy Include the following
ICD-9-CM codes: 250.xx, v45.85, v53.91, v58.67, v65.46 Establish
outliers to exclude expensive surgical claims 21
Slide 22
Chronic Care: Payment Model
Slide 23
Diabetic Pilot Outcomes Measures MeasureWho Collects and
Reports* To Whom How Often Good Control Hemoglobin A1C (target <
7.0% or