L. Allen Dobson, Jr, MD; Marcia Guida James, MS, MBA; Margaret E. O’Kane, MPH; Peter Salgo, MD; and Jed Weissberg, MD
In this segment, the participants considered how healthcare reform and the PPACA might shape the future of the quality enterprise and VBP. The panel also identified important issues and key takeaways that can inform stakeholder efforts to implement healthcare reform and drive quality.
PPACA and the Quality EnterpriseMajor Components
The Handwriting Is on the Wall
There’s just no viable future for a healthcare system that’s hospital-centric, episode-centric, and procedure-centric. And it’s not just CMS that’s throwing down the gauntlet. So are employers and private insurers.
— Selberg J. Payment reform as we speak.
Institute for Healthcare Improvement.
Audio program. July 21, 2011.
Here are the major PPACA components that directly implicate the quality enterprise:
Patient-Centered Care: The Law of the Land
More—and more refined—national priorities and goals
Emphasis on collecting data and performance measures
Extensive public reporting
Collaborative VBP that includes collaboration— PPACA requires that a final VBP model design be determined by 2012; the hospital VBP program becomes effective October 1, 2012.
CMS will rate Medicare Advantage health plans using a 5-star rating system based on a composite measure of care quality, access, provider responsiveness, and patient satisfaction. Star ratings will be publicly reported. High-performing plans will receive financial rewards.
Beginning in 2013, hospitals will be eligible to receive incentive payments for Medicare patients with high-volume conditions (ie, chronic heart failure, acute myocardial infarction, pneumonia, surgeries, and healthcare-associated infections). Other delivery settings (eg, ambulatory surgery centers, home health aides, and skilled nursing facilities) and physician reimbursement will follow shortly thereafter.
By January 2016, VBP programs must be in place for psychiatric hospitals, PPS-exempt oncology centers, hospice programs, long-term care hospitals, and rehabilitation hospitals. Lower-volume facilities, such as critical access hospitals, will participate in a parallel program. Hospitals not meeting certain minimum standards will be excluded from the incentive scheme.
The message to the healthcare community is unmistakable. VBP is an integral part of the PPACA. Because patient-centered care is a cornerstone of VBP, and because patient service and satisfaction will figure prominently in the CMS rating system, patient-centered care is, in effect, the law of the land. “It’s been decided,” said Dr Salgo. “Along with payment reform, collaborative care delivery, and state-of-the-art HIT systems, [a] patient-centered focus is vital to ultimately improving outcomes and bending the cost curve.”
Patient-centered care means more than customer service and satisfaction. It involves patient education, engagement, and incentives, and designing care plans at the patient level.Measures With Consequences
The PPACA will accelerate the evolving shift in quality measures from simple process measures relating to what care is delivered toward measures relating to how care is delivered in order to discern patient outcomes, and will also tie in financial consequences. For example:
PPACA and VBP
HACs will be publicly reported, and for those hospitals, payments will be reduced.
Health plans and provider organizations will be required to report on readmissions, and payments will be reduced for preventable readmissions.
Hospitals with excessive readmission rates will face the prospect of a mandatory QI program.
Since the PPACA incorporates VBP tenets, the VBP initiatives that predated the PPACA should continue to evolve, including:
Increasing the focus on chronic care and rewarding the effective management of chronic care episodes.
Linking payment to patient outcomes.
Increasing the emphasis on patient engagement.
Small employers can pursue VBP through cooperatives and business coalitions. Private health plans can modify P4P programs to incorporate efficiency measures and a combination of gain- and risk-sharing incentives. States can improve purchasing programs by using CMS data to benchmark plan performance.Panelist Views on What’s Next
The panelists offered their individual ideas on what’s next for the quality enterprise in the wake of the PPACA, and what worries them.
Mr White hopes for better orchestration and coordination throughout the healthcare domain, including accountability for health plans, providers, and employers. “I’d like to see employers doing what they have direct influence over [by] giving employees incentives to stay healthy,” he said.
The HITECH Act is part of the ARRA of 2009. ARRA imposes phased-in requirements for adoption and “meaningful use” of EHR technology and to that end, authorizes CMS to provide reimbursement incentives.
According to Ms James, the reform legislation will accelerate quality standardization. Dr Weissberg made a related point; he hopes the HITECH Act and meaningful use provisions will enable capturing patient-reported measures of functional status and pain. “This would allow us to better fine-tune care,” he said.
The panelists are excited about the prospect of freely flowing, meaningful data and the flexibility to apply the data to improve quality, delivery systems, and outcomes. To Dr Dobson, the flexibility theme relates to the community focus that is central to the quality enterprise. “Healthcare and medical matters are usually concentrated in our largest academic centers and cities,” he said, “but every US citizen deserves better care than they’re getting. We have to be flexible enough to provide it in all locales.”
Flexibility may be difficult to attain, even though the reform scheme calls for it. Regulators are traditionally inflexible in altering published standards. On the other hand, this reform environment inherently militates against intransigence. “We don’t know all the answers in advance,” said Dr Dobson, “so we can’t simply write a playbook of ultra-specific regulations.”
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