Health Care Payment Learning Action Network: Financial Benchmarking

The Health Care Payment Learning Action Network (HCPLAN) has released a white paper on performance measurement within alternative payment models (APMs).  HCPLAN work products will be considered by the Centers for Medicare and Medicaid Services (CMS)  for implementation of the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) and other health care payment reform initiatives.  This white paper was developed by the Population-Based Payment Work Group and documents principles and recommendations for financial benchmarking.

In shifting away from fee-for-service payments to alternative payment models, financial benchmarking becomes a key challenge to design and implement. Many accountable care organizations have complained that both national benchmarking and benchmarking based on one’s own performance have the unintended consequences of dis-incentivizing participation of “high performers”, who already have demonstrated the capacity to deliver higher quality and lower cost care, in current alternative payment models. CMS and other payers developing and implementing such models have to achieve a balance between raising the performance of all providers, reducing regional variations in expenditures, and continuing to support innovation and improvement among those high performers. Another debated issue is whether financial benchmarks should adjusted based on patient risk characteristics, especially for safety net providers who historically have served patients without regular care or continuity of care, and often have multiple and more complex health conditions.

The white paper uses the following principles for financial benchmarking:

  • Trust among payers, providers, purchasers, and consumers is essential for managing population-based payment models over time as benchmarks are updated, rebased, and risk adjusted;
  • Financial benchmarks in population-based payment models should incentivize high-quality, efficient care, enable accountability, and establish a target that fairly rewards provider organizations;
  • Payers should transparently communicate to providers the risk-sharing parameters involved in participating in a population-based payment model, such that providers can access the information they need to fully comprehend the risks associated with participation, understanding that there is an inherent tradeoff between simplicity and precision in payment design, and that it may not be possible to precisely quantify risk ahead of time;
  • Successful approaches to financial benchmarking must simultaneously encourage participation while meeting financial, quality, and access objectives; and
  • The effect of financial benchmarks is to enable 1) efficient provider organizations to succeed; 2) struggling organizations to improve; and 3) failing organizations to fail.

And the white paper makes the following recommendations for financial benchmarking:

  • Approaches to financial benchmarking should encourage participation in the early years of the model’s progression, while driving convergence across providers at different starting points toward efficiency in the latter years;
  • The initial baseline should be based on provider-specific spending, taking into account the provider organization’s history and local market forces;
  • Updating and rebasing of the initial benchmark should not be based on provider-specific changes in spending;
  • Updating and rebasing of the initial baseline should drive convergence around local spending rates as quickly as local conditions allow, with an eventual movement to regional rates in the medium to long term;
  • There are multiple pathways to convergence but the end point is what matters;
  • Risk adjustment must strike a fine balance such that providers who serve higher-risk or disadvantaged populations are not unduly penalized and disadvantaged populations do not receive substandard care;
  • The state-of-the art of risk adjustment is likely to change over time, and it will be important to keep up with recent developments that improve the precision of risk-adjustment approaches;
  • Risk-adjustment models should minimize the connection between utilization and risk score;
  • Successful risk-adjustment models should accurately predict spending at the population and subpopulation levels, but it is not important for models to accurately predict spending at the individual level; and
  • Population-based payment models should not disrupt care for needy populations, and risk adjusting for socioeconomic status (SES) may be one way to accomplish this;  nevertheless, SES adjustments should not be a mechanism for forgiving lower care for needy populations.

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Health Care Payment Learning Action Network: Patient Attribution

The Health Care Payment Learning Action Network (HCPLAN) has released a white paper on patient attribution within alternative payment models (APMs).  HCPLAN work products will be considered by the Centers for Medicare and Medicaid Services (CMS)  for implementation of the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) and other health care payment reform initiatives.  This white paper was developed by the Population-Based Payment Work Group and documents principles and recommendations for patient attribution.

Patient attribution has been one of the most challenging elements in developing and implementing payment reform models such as accountable care organizations. Providers have been urging application of prospective attribution and more flexibility to “recruit” or incentivize participation by patients. CMS has been reluctant to yield the ability of Medicare fee-for-service beneficiaries to choose any Medicare provider, which favors retrospective or concurrent attribution.

Moreover, commercial insurance models usually are based on “open-access” that allow choice of providers (although many insurance plans increasingly offer options for “narrow networks” of providers in exchange for lower insurance premiums and co-payments). Shifting these commercial models to value-based payments present similar challenges.

The white paper makes the following recommendations:

  • Encourage patient choice of a primary care provider;
  • Use a claims/encounter-based approach when patient attestation is not available;
  • Define eligible (primary and specialty care) providers at the beginning of the performance period;
  • Provide transparent information to patients about their attribution;
  • Prioritize primary care providers in claims/encounter-based attribution;
  • Consider subspecialty providers if no primary care encounters are evident;
  • Use a single approach for attribution for performance measurement and financial accountability;
  • Use the patient attribution guideline nationally for commercial products;
  • Alignment among commercial, Medicare, and Medicaid populations may be possible with adjustments; and
  • Regardless of whether prospective or concurrent attribution is used, providers should receive clear, actionable information about patients attributed to them.

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Health Care Payment Learning Action Network: Performance Measurement

The Health Care Payment Learning Action Network (HCPLAN) has released a white paper on performance measurement within alternative payment models (APMs).  HCPLAN work products will be considered by the Centers for Medicare and Medicaid Services (CMS)  for implementation of the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) and other health care payment reform initiatives.  This white paper was developed by the Population-Based Payment Work Group and documents principles and recommendations for performance measurement.

Performance measurement currently faces multiple challenges, including a cacophony of measures with confusing results, the lack of available data to calculate important metrics, and burdens associated with capturing and reporting data. The Work Group conceives of measurement systems as being composed of three components, each of which is needed to reward providers who deliver high-value health care: 1) measure sets; 2) methods for evaluating performance on measures (e.g., performance scoring); and 3) methods for using performance assessments to adjust payment.  In other words, in order to explicitly reward providers who deliver high-value health care via the payment model, measurement systems must necessarily specify measures, employ some method for calculating overall performance scores, and adopt some approach for adjusting payments in light of those performance scores.

The white paper outlines the following principles for performance measurement:

  • Performance measurement is foundational to the success of population-based payment models to advance better outcomes for all patients and populations;
  • Because population-based payment models address the full continuum of care, measure sets have to span the full continuum across time, across providers, and across settings;
  • The measures required for the long-term success and sustainability of population-based payment models are fundamentally different from the measures used in traditional fee-for-service payment models; and
  • To promote better results for patients and populations, the use of performance measurement for payment in population-based payment models must create meaningful incentives for improvement.

The white paper makes the following recommendations:

  • To support the long-term success and sustainability of population-based payment models, future-state measures must be based as much as possible on results that matter to patients (e.g., functional status) or the best available intermediate outcomes known to produce these results;
  • Because fragmentation across population-based payment models can undercut success, reliance on core measure sets is valuable; continued innovation and refinement are needed to ensure measure sets are comprehensive, parsimonious, and outcome oriented;
  • A governance process is needed to oversee and accelerate the development, testing, and use of new, high priority measures for population-based payment models;
  • In service of a future state that employs measures that are outcomes-oriented, the infrastructure nationally must be sufficient to systematically collect, use, and report clinically rich and patient-reported data;
  • Providers in population-based payment models should have meaningful incentives to deliver high-quality care, achieve favorable health outcomes, improve patient care experiences, and manage the total cost of care;
  • Measurement systems should define performance targets in a way that motivates ongoing improvement across the performance continuum, promotes best practice sharing, avoids a forced curve that mandates winners and losers, and enables long-term planning and commitment to improvement;
  • Whenever possible, measure targets should be set in absolute (not relative) terms, established prior to the measurement period and fixed for a minimum of one year, although ideally for the full contract term;
  • Measure targets should include a range of scores on each measure to enable the incentive system to reward both performance and improvement; and
  • Adherence to good measurement science and implementation (e.g., sample size requirements, demonstrated reliability and validity, national acceptability, clinical importance, and the opportunity for a provider to improve before being held accountable under the new model) is critical to achieving the desired results from performance measurements in population-based payment models.

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Health Care Payment Learning Action Network: Data Sharing

The Health Care Payment Learning Action Network (HCPLAN) has released a white paper on data sharing within alternative payment models (APMs).  HCPLAN work products will be considered by the Centers for Medicare and Medicaid Services (CMS)  for implementation of the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) and other health care payment reform initiatives.  This white paper was developed by the Population-Based Payment Work Group and documents principles and recommendations that should guide approaches to data sharing in population-based payment models. The goal should be to share important patient data to inform clinical decision making, allow payers to assess provider performance, and support increased alignment across public and private payers.

Data sharing currently faces multiple challenges, including proprietary approaches to data collection and reporting, inconsistent and underdeveloped data architecture, a lack of funding and standards, and technical limitations to the collection of rich clinical and patient-reported data. The white paper recommends the following principles for data sharing:

  • Data sharing is foundational for the successful operation of population-based payment models and makes it possible for stakeholders to carry out their respective roles;
  • Data sharing in population-based payment models will need to be fundamentally different from data sharing in traditional fee-for-service models;
  • Data sharing for population-based payment models requires multi-stakeholder relationships built on trust, cooperation, and transparency;
  • Identifiable, patient-level data should follow the patient;
  • De-identified, population-level data should be treated as a public good; and
  • Providers who participate in population-based [payment models with multiple payers will need to receive, use, and share data with each of them, giving rise to complexities that may benefit from collaboration with third-party data intermediaries.

The white paper makes the following recommendations:

  • Payers and providers should identify in advance aligned approaches and policies for data sharing to support population-based payment models;
  • For data to follow the patient, payers and providers should collaborate on approaches to patient identifiers that enable mapping across systems and data types (e.g., clinical, administrative, and patient-reported data); this effort should be scalable;
  • Payers, providers, purchasers, and patients should convene a multi-stakeholder group to recommend solutions that assure patients that their personal data are appropriately used;
  • Requirements for data sharing should be made explicit in agreements between purchasers and payers that participate in population-based payment  models;
  • Payers should give patients and purchasers easy access to information on what it costs to see different providers for the same, common procedure, alongside relevant quality indicators; and
  • Payers, providers, and purchasers should actively participate in pilot programs to evaluate approaches to the sharing of data across multiple payers and providers.

The white paper also discusses a number of use cases and includes several case studies that provide examples how the principles and recommendations could be implemented.

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Health Research & Education Trust: Creating Effective Hospital-Community Partnerships to Build a Culture of Health

The Health Research & Education Trust of the American Hospital Association has published this guide for creating effective partnerships between hospitals and health systems and their local communities.  The guide was funded by the Robert Wood Johnson Foundation, which is promoting the concept of a “culture of health”, creating a society that gives all individuals an equal opportunity to live the healthiest life they can, whatever their ethnic, geographic, racial, socioeconomic or physical circumstances may be. The guide is based on 50 interviews with hospital, health system, and community leaders from 25 diverse communities to determine common themes and successful approaches for developing effective collaboration. The guide shares lessons learned in:

  • identifying community health needs and reaching consensus on priorities;
  • identifying potential partners;
  • creating sustainable partnership structures
  • overcoming obstacles; and
  • assessing interventions and partnerships.

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Health Research & Education Trust: Hospital-Based Strategies for Creating a Culture of Health

The Health Research & Education Trust of the American Hospital Association has published this guide on how hospitals can support community health improvement. The guide was funded by the Robert Wood Johnson Foundation, which is promoting the concept of a “culture of health”, creating a society that gives all individuals an equal opportunity to live the healthiest life they can, whatever their ethnic, geographic, racial, socioeconomic or physical circumstances may be. The guide is based on a review of 300 community health needs assessments, and provides strategic considerations for hospital engagement in community health improvement. Hospitals can be promoters, conveners, anchors, and specialists in community health improvement. The guide also suggests measures that can be used to evaluate such efforts:

  • Social cohesion and shared value of health: measure perceived norms and social capital; evaluate community engagement or measuring actions that signify participation in promoting health in the community, such as providing volunteer care or participating in a charity sporting event
  • Multisectoral collaboration to build health partnerships: measure strength, nature and quality of collaborations along with number of innovative partnerships
  • Improved and equitable opportunity for healthy choices and environments: measure social and environmental factors and availability of resources; consider equity across the population
  • Improved quality, efficiency and equity of health and health care systems: measure health outcomes, health care system quality and equity across demographics

Finally, the guide has ten case studies about hospitals that have successfully implemented some of the strategies described in the guide.

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Centers for Medicare and Medicaid Services: Comprehensive Primary Care Plus Regions Announced

The Centers for Medicare and Medicaid Services (CMS) has announced the 14 regions (in 16 states) that will be participating in the Comprehensive Primary Care Plus (CPC+) program for Medicare fee-for-service (FFS) beneficiaries:

  • Arkansas: Statewide
  • Colorado: Statewide
  • Hawaii: Statewide
  • Kansas and Missouri: Greater Kansas City Region
  • Michigan: Statewide
  • Montana: Statewide
  • New Jersey: Statewide
  • New York: North Hudson-Capital Region
  • Ohio: Statewide and Northern Kentucky: Ohio and Northern Kentucky Region
  • Oklahoma: Statewide
  • Oregon: Statewide
  • Pennsylvania: Greater Philadelphia Region
  • Rhode Island: Statewide
  • Tennessee: Statewide

The program is an multi-payer initiative so each region has identified public and private payers that have tentatively agreed to participate:

Link to Original Source

To support the delivery of comprehensive primary care, CPC+ includes three payment elements, with two payment “tracks”:

  1. Care Management Fee (CMF): The program will provide participating primary care practices a non-visit based CMF that will be paid per Medicare beneficiary per month. The amount is risk-adjusted for each practice to account for the intensity of care management services required for the practice’s specific population. These Medicare CMFs will be paid to the practice on a quarterly basis. Practices participating in Track 2 will be eligible for higher CMFs.
  2. Performance-based incentive payment: CPC+ will prospectively pay and retrospectively reconcile a performance-based incentive based on how well the practice performs on patient experience measures, clinical quality measures, and utilization measures that drive total cost of care. Practices participating in Track 2 will be eligible for higher incentive payments.
  3. Payment under the Medicare Physician Fee Schedule: Primary care practices participating in Track 1 will continue to bill and receive payment from Medicare FFS as usual. Primary care practices participating in Track 2 practices also will continue to bill as usual, but the FFS payment will be reduced to account for CMS shifting a portion of Medicare FFS payments into Comprehensive Primary Care Payments (CPCP), which will be paid in a lump sum on a quarterly basis. However, given the expectations that Track 2 practices will increase the comprehensiveness of care delivered, the CPCP amounts will be larger than the FFS payment amounts they are intended to replace.

The program and new payments will begin January 2017.  In addition, practices that participate in CPC+ may qualify for additional incentive payments available for the Advanced Alternative Payment Models in the proposed Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program (performance year proposed to also begin January 2017).

CPC+ has 13 requirements for Track 1 practices and 24 requirements for Track 2 practices:

Link to Original Source

Here is a Frequently Asked Questions and answers for primary care practices:

Link to Original Source

CMS also has released a video explaining the program:

Primary care practices in the participating regions have until September 15, 2016 to apply to participate in CPC+. Practices applying to participate in Track 2 must secure support from their health IT vendor to support and participate in the program. CMS will be hosting numerous webinars before September 15 to provide additional information about the program.

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National Academies of Sciences, Engineering, and Medicine: Integrating Health Literacy, Cultural Competence, and Language Access Services

The Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) has published a summary of a workshop on integrating health literacy, cultural competence, and language access services. Health care organizations are searching for approaches that will enable them to provide information and services to all persons from diverse backgrounds in terms of age, race, culture, and language skills, in a manner that facilitates understanding and use of information to make appropriate health decisions and utilize health care services effectively.

The workshop included presentations and discussions about the opportunities that the implementation of the Affordable Care Act and other health care delivery system changes are creating to support the integration of health literacy, cultural competence, and language access services. There also were presentations and discussions about the issues and challenges in such integration, and some real-world approaches that health care systems are taking to address those issues and challenges. Breakout groups focused on the implications of integration of health literacy, cultural competence, and language access services for research, for policy, and for services and care. In accordance with the policies of the National Academies of Sciences, Engineering, and Medicine, the workshop did not  establish any conclusions or recommendations about needs and future directions, and the workshop summary only reports on issues identified by the speakers and workshop participants.

The October 2015 workshop was sponsored by the Roundtable on Health Literacy, which is planning followup activities.

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Fenway Institute: Building Patient-Centered Medical Homes for Lesbian, Gay, Bisexual, and Transgender Patients and Families

This issue brief published by the National LGBT Health Education Center of the Fenway Institute uses the framework of a patient-centered medical home (PCMH) to improve health care and health outcomes for lesbian, gay, bisexual, and transgender (LGBT) patients and families. As an underserved and vulnerable population, LGBT people experience disparities in both health care and health status.

The issue brief provides practice improvement actions for improving care for LGBT patients and families that are linked to national standards for PCMHs. If a health care provider is going through the process of achieving PCMH recognition, these practice improvement actions can be used for a parallel evaluation of effectiveness in building a PCMH for LGBT patients and families. Those providers who have already achieved PCMH recognition can use this template to assess their current effectiveness in establishing a PCMH for LGBT patients and families.

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Why We Will Keeping Dancing

OrlandoLivesMatter

Over 26 years ago, I went to a gay club for the first time. I had just turned 30, finally coming out as a gay man to my closest friends, my family, and at work. The first few times I went to the gay clubs, I was terrified. Back then, I didn’t drink very much (one beer would make me dizzy), and I was painfully shy.

But there was something about the diversity of faces and bodies, the freedom with which people danced, and the energy of the music, that melted away my self-consciousness… and I soon realized that I just wanted to dance…to literally move my body and physically release all the worrying, all the internal struggle to come out, all my “praying away being gay”…and just dance…

And so the Box and I-Beam, and then Club Townsend, the End Up, 1015 Folsom, 715 Harrison, Club Eight, Ruby Skye and many other spaces became my places of refuge, places of creating community, places of liberation. In that journey, I was supported by my now-husband John, and then by dozens and dozens of friends (many who might be reading this).

Many other gay clubs around the U.S. (Los Angeles, San Diego, Sacramento, Honolulu, Seattle, Las Vegas, Denver, Minneapolis, Chicago, Houston, New Orleans, Atlanta, Boston, New York, Philadelphia, Washington, DC, Miami) and, luckily for me, around the world (Canada, Mexico, Brazil, Argentina, England, France, Spain, Portugal, Italy, Hong Kong, China, Thailand, Singapore, Australia), now are vital parts of my stories of my life as a gay man. Many of these clubs have long been gone, now condominiums and office buildings and retail stores; but others continue to welcome and host thousands of gay men on their dance floors. Those gay clubs continue to be the spaces that hold those stories, those coming out experiences, those vital moments in the lives of so many gay men like me.

So when the news of the mass killings at the Pulse gay club in Orlando finally began to sink in for me, I was flooded with my own memories of so many hours on the dance floors of so many gay clubs.

Almost every gay man will have his own stories about the gay clubs he has been to: the friends, lovers, boyfriends, and husbands met, the DJs who spun magical mixes, the songs that made us jump high in the air and get down low, the laser lights that flashed across the dancing bodies, the go-go dancers we admired, the live performances we cheered and sang along to, the flaggers who brought the colors of the rainbow onto the dance floor, the glow sticks that lit up our faces, the icy popsicles in the middle of morning, the sunrises we greeted when we finally left the club, and so much more…

And that is why it is so horrifying and so personal to learn that a killer invaded one of our sacred spaces, and ended the lives of so many. So many who could have been my friends. So many who could have been me.

That is why this mass killing hurts so much, has wounded each of us so deeply…

What gives me some solace and hope in my grief and anger is to read about the lives of the 49 men and women who were killed, to learn how their parents, their families, their friends, their co-workers – everyone in their lives – all testify to the life, the love, the kindness, the humor, the happiness, that each of them brought into the world. It gives me hope that soon, both our families of origin and our families created on the dance floors of gay clubs will just become “our family”.

As a gay man of color, I am especially grateful to learn how so many Latino families accepted and supported their gay sons, their gay brothers. This is a coming out moment for gay Latinos in the U.S.; through this horrific tragedy, we have eroded some of the invisibility of our gay Latino sons, our gay Latino brothers, our gay Latino cousins, our gay Latino friends…

But prayers and vigils and memorials are not enough.

We need to enact comprehensive federal, state, and local legal protections against discrimination based on sexual orientation and gender identity in employment, housing, credit, and public accommodations (including public bathrooms). We need to stand up to the National Rifle Association and enact common sense legislation prohibiting ownership of assault weapons and high caliber ammunition. And we need to insist on the adoption and continuous accountability for public policies and private business practices that fully recognize and unequivocally support all lesbian, gay, bisexual, and transgender people – as your family members, neighbors, co-workers, members of your faith communities, in every occupation and profession, elected officials, and community leaders.

And we who are lesbian, gay, bisexual, and transgender people – and our families, friends, and allies – must re-commit ourselves to work harder, to speak out louder, to act up more boldly, to give more, to do everything we can to achieve the full equality and liberation of all the members of our diverse communities.

In the names of those killed in Orlando, we will keep dancing…

For reflections that inspired mine, see:

Daniel Leon-Davis, The site of the Orlando shooting wasn’t just a gay nightclub. It was my safe haven, Fusion,net, June 12, 2016

Justin Torres, In praise of Latin night at the Queer Club, Washington Post, June 13, 2016

Richard Kim, Please Don’t Stop the Music, The Nation, June 12, 2016

 

Posted in Lesbian, Gay, Bisexual and Transgender Health, The iBau Blog | 7 Comments