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June Purchaser Learning Group
Today’s Agenda • Welcome • Purchaser Strategies for Higher-Value Health Care •
Suzanne Delblanco, Catalyst for Payment Reform
• Learning from the May 12th Regional Learning Session • Group Discussion
Purchaser Strategies for Higher-Value Health Care
Suzanne F. Delbanco, Ph.D. Executive Director 6/8/17
Agenda AGENDA
Who We Are and Our Goals How Purchasers Can Transform the Health Care Market Why Alignment of Incentives Matters
Why Local Market Dynamics Matter How to Work with Your Health Plan
How to Track Progress and Hold the Health Care System Accountable A Shared Agenda June 8, 2017
www.catalyze.org
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WHO WE ARE
June 8, 2017
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About CPR
An independent nonprofit corporation working to catalyze employer, public purchasers and others to implement strategies that produce higher-value health care and improve the functioning of the health care marketplace.
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• 3M • • Aircraft Gear Corp. • • Aon Hewitt • Arizona Health • Care Cost • Containment • System (Medicaid) • AT&T • The Boeing Company • • CalPERS • City and • County of San • Francisco • • Comcast • • Dow Chemical Company
www.catalyze.org
Equity • Healthcare • FedEx Corporation • GE Google, Inc. Group Insurance Commission, • Commonwealt h of MA • The Home Depot • Mercer Ohio Medicaid Ohio PERS • Pennsylvania Employees • Benefit Trust Fund
Pitney Bowes Qualcomm Incorporated South Carolina Health & Human Services (Medicaid) TennCare (Medicaid) Wal-Mart Stores, Inc. The Walt Disney Company Wells Fargo & Company Willis Towers Watson
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CPR’s Goals 1. Effective Payment Reform: 20% of payments will flow through methods proven to improve value by 2020. 2. Innovative Health Care Purchasers: Health care purchasers will become more educated and activated on the use of benefit designs, payment methods, and other tactics that support higher-value health care. 3. Better Health Care Marketplace: Through greater visibility and competition, the health care marketplace will be more responsive to the needs of those who use and pay for health care. June 8, 2017
www.catalyze.org
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HOW PURCHASERS CAN TRANSFORM THE HEALTH CARE MARKET
June 8, 2017
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Purchaser Track Record Standard quality measurement and reporting sparked by The Leapfrog Group
Pay for performance sparked by Bridges to Excellence (incubated by an employer) Payment reform movement in private sector sparked by CPR Price transparency movement sparked by CPR And many other examples‌ June 8, 2017
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Key Ingredients of Transformation TRANSPARENCY: insight into quality and prices, building block for other reforms
BENEFIT DESIGN: incentives for consumers
PROVIDER NETWORK DESIGN: guidance for consumers, leverage for payers, volume for providers
PAYMENT REFORM: financial incentives for providers
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Transparency Transparency provides insight into what’s happening in the health care system. •
Helps health care purchasers and consumers understand the value of what they are buying.
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Highlights and reduces unwarranted quality and price variation in the health care system.
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Enables high-value benefit designs and payment reforms.
Specifications
Model RFP
Report Card on State Price Transparency Laws June 8, 2017
www.catalyze.org
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Benefit Design Cost Sharing Value-based insurance design (V-BID) High-deductible health plan (HDHP) Tiered networks Narrow networks Reference pricing Alternative sites of care Centers of excellence
Contingent Coverage Preauthorization Step therapy Precertification Continued stay review
The most innovative experiments focus on cost sharing
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Provider Network Design Upon defining what constitutes a high-value health care provider, payers and purchasers can form networks of providers that meet this definition and offer varying ranges of provider choice to consumers. To form such a provider network, health plans contract with providers:
PAYER: Makes provider “innetwork� giving provider increased patient volume.
PROVIDER: Agrees to deliver care at lower negotiated rates.
A high-value provider network is a select group of in-network providers in a given health plan. June 8, 2017
www.catalyze.org
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Payment Reform Base Payment Models Fee For Service
Charges
Fee Schedule
Bundled Payment
Per Diem
DRG
Episode Case Rate
Global Payment
Partial Capitation
Full Capitation
Increasing Accountability, Risk, Provider Collaboration, Resistance, and Complexity
Performance-Based Payment or Payment Designed to Cut Waste (financial upside & downside depends on quality, efficiency, cost, etc.) June 8, 2017
www.catalyze.org
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Growth of Payment Reform The vast majority of reforms are layered on fee for service
2016-2017 2013-2015
2011 11% of payment is value oriented
2010
50%+ ?
40+% of payment is value oriented
1-3% of payments tied to performance The level of payment reform in the market has been steadily rising
Most common reforms are pay for performance & shared savings; bundled payment is the least common June 8, 2017
www.catalyze.org
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HOW TO WORK WITH YOUR HEALTH PLAN
June 8, 2017
www.catalyze.org
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Relationship with Health Plans at the Crux Aligning your sourcing and contracting approach with other purchasers ensures that together you are pushing health plans to implement the high-value strategies you need to succeed. As more purchasers demand the same thing, health plans have a business case for changing how they serve customers. Standard RFI questions are a common tool for sourcing and comparing health plan proposals. Model contract language solidifies the purchaser’s ask and articulates clear expectations for payment and delivery reform.
User groups help you and your plan stay on track and on the same page.
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Standard Health Plan RFI Questions There are 5 main sections of the RFI and 5 optional sections. REQUIRED
OPTIONAL
1. Tracking Progress on Payment Reform
1. Future Planned Payment and Delivery Strategies
2. Describing Payment and Delivery Reform
2. Assessing Accountable Care Organization Strategies
3. Maternity Care Payment and Delivery
3. Pharmacy Strategy and Payment and Delivery Reform
4. Price and Quality Transparency
4. Behavioral Health Care and Payment and Delivery Reform
5. Network and Benefit Design Strategies
June 8, 2017
5. Payment Reform for Total Joint Replacement www.catalyze.org
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Model Contract Language: Four Sections Value-Oriented Payment and Delivery of Care: Focuses on creating and implementing payment and delivery reforms designed to cut waste and/or improve the quality of care. Transparency: Focuses on providing information to compare quality and price among providers and services. Market Competition: Focuses on enhancing competition among providers and reducing unwarranted price and quality variation in the market. Tracking Progress: Focuses on the provision of ongoing reports to purchasers on each program’s impact on health care quality and costs. June 8, 2017
www.catalyze.org
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Health Plan User Groups (HPUGs) CPR’s HPUGs bring together plan representatives and their customers, moderated by CPR. The HPUG Toolkit provides host organizations with what they need to convene and manage the user group process: • Step-by-step instructions • Detailed timeline • Invitation templates • Agenda templates • Discussion guide • Health Plan User Group Progress Report June 8, 2017
www.catalyze.org
CPR has found success implementing HPUGs with members -others can replicate the process.
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HOW TO TRACK PROGRESS AND HOLD THE HEALTH CARE SYSTEM ACCOUNTABLE
June 8, 2017
www.catalyze.org
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Payment Reform Evaluation Framework Data demonstrating effectiveness of payment reforms are limited - there is a pressing need to amass more evidence about the impact of various approaches and to compare outcomes across programs. The PREF establishes a standard evaluation process for payment reform programs that could support mid-course corrections, cross learning, and identify successful approaches that we should replicate and disseminate.
Domains Critical for Evaluation Program design Feasibility \
Cost Quality And specific elements within those domains
Available for purchasers free of charge at www.catalyze.org June 8, 2017
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Scorecard 2.0
How much, what types, and which combinations (hybrids) of payment reforms have been implemented to date.
Whether these payment reforms are having their intended impact on the quality, efficiency, and cost of health care.
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A SHARED AGENDA
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A Shared Purchaser Agenda One purchaser alone cannot move the market to deliver value. But many purchasers working together to achieve the same goals, asking for the same things, and leveraging a critical mass of demand can create real change. This means collaborating with individual purchasers, as well as employer coalitions and other stakeholders.
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What Shall We Push Next? Our eyes are set on evaluation – the need for rigorous and consistent assessment of progress and outcomes. Great there’s been so much activity – but is it making a difference? Serious attention to evaluation and willingness to share results is going to take pressure from purchasers. Time to demand transparency June 8, 2017
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Support for Purchasers
IMAGE HERE
June 8, 2017
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Support for Purchasers
IMAGE HERE
June 8, 2017
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QUESTIONS?
Suzanne Delbanco, Ph.D. Executive Director sdelbanco@catalyze.org
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Learning from May Regional Learning Session
Improving Maternity Care
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Why was the toolkit created? • Maternity care second largest employer healthcare expense • Low risk C-section rates have increased over 50% in last 20 years (26.9% nationally) • On average costs $10,000 more than natural birth • 8 out 10 women who have C-sections deliver by C-section in all subsequent births
What does this mean for Central Ohio? • C-section rates vary widely among states and hospital systems • Ohio average 26.3%1 Healthy People 2020 Target 23.9% • Of hospitals reporting in our region rate varies between 12.7% and 31.3%2 1 Ohio Department of Health, Ohio Hospital Compare 2 The Leapfrog Group, Hospital Ratings
What Can Purchasers Do?
What Can Purchasers Do? 1. Assess the Problem
What Can Purchasers Do? 2. Establish Relationships
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Recruit physician partners
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Ohio Prenatal Quality Collaborative
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Purchaser Learning Group
What Can Purchasers Do? 3. Take Action •
Eliminate financial incentives for inappropriate C-sections
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Ensure access to high-value services in benefit package
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Encourage the use of high value services
What Can Purchasers Do? 4. Maintain Accountability •
Continue to monitor
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Maintain relationship with providers
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Publicly recognize high-value partners
What can this lead to? •
Lower costs and high ROI.
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Less time away from work.
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Healthier patients.
Questions?
Group Discussion • Are you interested in the PLG leading to action? • If so, is the toolkit a good place to start? • What efforts is your organization making to reduce medically unnecessary maternity care?
Closing Next PLG Session • September 14th, 10:00 – 11:30AM • Nationwide & Ohio Farm Bureau 4H Center
Additional Learning Sessions • August 25th 8:30 – 11:30AM o Dough Hough, Author, Irrationality in Healthcare • November 7th 8:30AM – 4:30PM o Care Coordination Forum • December 8th 8:30 – 11:30AM o TBD