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HCP LAN

Building a Patient-Centered Health System:LAN Learnings Webinar

January 27, 201612:00 – 1:15 pm EST

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Welcome

Anne GauthierLAN Project Leader, CMS Alliance to Modernize Healthcare (CAMH)

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Session Objectives

Learn:How to create a culture of patient engagement

What is meaningful engagementHow to take a ‘whole-person’ orientationHow to design ‘with’ not ‘for’ patients

Lessons from cancer care delivery reform

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Agenda

Time Topic

12:00 – 12:05 pm Opening Remarks

12:05 – 12:15 pm Guiding Committee Updates and Q&A

12:15 – 12:50 pm

PANEL: Building a Patient-Centered Health System Meaningful Patient/Family Engagement in Alternative Payment

Models Payer Perspective

12:50 – 1:10 pm Questions from LAN Participants

1:10 – 1:15 pm Upcoming LAN Activities and Closing Comments

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Guiding Committee Report

Mark SmithCo-chair, LAN Guiding CommitteeVisiting Professor, University of California at Berkeley and Clinical Professor of Medicine, University of California at San Francisco

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Goals

2016

30%

In 2016, at least 30% of U.S. health care payments are linked to quality and value through APMs

2018

50%

In 2018, at least 50% of U.S. health care payments are so linked.

These payment reforms are expected to demonstrate better outcomes and lower costs for patients.

Adoption of Alternative Payment Models (APMs)

201630%

201850%

Better Care, Smarter Spending, Healthier People

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The Health Care Payment Learning & Action Network (LAN) has Established 7 Groups with Varying Purposes

LAN Guiding Committee

Purchaser Affinity Group

Consumer and Patient Affinity Group

State Engagement

Group

APM Framework & Progress Tracking

Work Group

Payer Collaborative

Clinical Episode Payment (CEP)

Work Group

Population-Based Payment (PBP)

Work Group

For Public Release

Release of APM Framework White PaperJan 12, 2016

The framework is a critical first step toward the goal of better care, smarter spending, and healthier people.

• Serves as the foundation for generating evidence about what works and lessons learned

• Provides a road map for payment reform capable of supporting the delivery of person-centered care.

• Acts as a "gauge" for measuring progress towards adoption of alternative payment models

• Establishes a common nomenclature and a set of conventions that will facilitate discussions within and across stakeholder communities

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LAN Payer Collaborative Vision and Charge

Vision Brings together industry leaders of both public and private health plans to inform the LAN's approach for measuring progress of APM adoption against the LAN’s goals of 30 percent adoption by 2016 and 50 percent adoption by 2018.

Charge• Share insights on APM adoption and health plan reporting capabilities

• Provide feedback and clarifications on draft metrics and proposed methods for measuring progress

• Engage in efforts to build and pilot measurement approach

• Serve as advisors in the development of an approach for a full-scale, nationwide data collection effort of national and regional commercial, Medicaid and Medicare Advantage health plans

• Make recommendations for how best to gather data on the metrics

• Participate in a longer-term, larger effort to understand where we are as a nation

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PBP and CEP Work Groups

Population-Based Payment (PBP)

Work Group

Sprints Launched Patient Attribution Financial Benchmarking Performance Measurement Data Sharing

Clinical Episode Payment (CEP)

Work Group

Sprints Launched Elective Hip and Knee ReplacementFuture Sprints Maternity Cardiac Care

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LAN Communications

Join work group affiliated communities to provide input on work group productsPaymentNetwork@MITRE.org

Keep updated on the latest LAN info through our newsletter

Visit the LAN website to learn more and find resources

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Save the Date: LAN Summit Spring 2016

⁻ April 25 – 26, 2016, Sheraton Tysons, VA

⁻ Call for Abstracts & Registration opening soon

⁻ Updated information will be available on the LAN Summit website.

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Q & A

What questions do you have about the Guiding Committee report?

Use the chat window in your webinar dashboard

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Moderator: Building a Patient-Centered Health System

Alan BalchCEO, Patient Advocate Foundation

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Panel: Building a Patient-Centered Health System

Sara Van GeertruydenExecutive Director, Partnership to Improve Patient Care (PIPC)

Lauren MurrayDirector, Consumer Engagement and

Community Outreach for the National Partnership for Women & Families

Michael KolodziejNational Medical Director, Onology Solutions, Office of the Chief Medical Officer, Aetna

Building a Patient-Centered Health System

Presentation to LAN Participants

January 27, 2016

PIPC Today• Founded in 2008, PIPC began as a coalition focused on

patient-centeredness in research, advocating strongly for the creation of PCORI.

• PIPC has evolved into the leading stakeholder hub for patient-centeredness in research, payment, and delivery of healthcare.– PIPC’s membership has grown to 53 advocacy groups– PIPC has engaged another 15-20 non-member patient groups in

our roundtables– PIPC has earned the reputation as the authentic voice of patients

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Creating a Culture of Patient Engagement

• Formalize avenues to provide a meaningful voice to patients in research and the creation and testing of APMs;

• Ensure value and quality definitions driven by value to patients;• Foster informed choices from the range of clinical care options

through shared decision-making, and by empowering patients with accessible, understandable evidence to achieve their personal treatment goals. 

• Avoid a singular focus on cost-containment and protect against a “one-size-fits-all” approach to patient care. 

• Support access to new medical advances.

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Achieving Outcomes that Matter to Patients

• Considerations include:– The range of endpoints, care outcomes and treatment goals that

matter to patients;  – Factors that influence differences in value to patients within

populations;  – Differences in perspectives and priorities between patients,

caregivers, people with disabilities, consumers and beneficiaries; 

– How patients want to be engaged in their health care and treatment decisions, and characteristics of meaningful shared decision-making to support this. 

– Patient engagement at the policy-development level.

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The Challenge: APMs Provide Value to Whom?

• Value to the patient should be reflected in APMs.– Policies should support patients to be active

and informed participants in their own care.– Shared decision-making tools should inform

patients and caregivers on all treatment options, as well as impacts based on patient needs, preferences, and outcomes.

– There is no one algorithm for value!

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Patient Advisory Panel: Pathway to Meaningful Input

• Identify key areas that would benefit from patient input– Consider a number of patient-centered factors:

• process for monitoring and updating patient care plans; • preferences and choices of applicable individuals; and whether models place

the applicable individual at the center of the care team. • Assist with the evaluation of APMs

– Funding provided in MACRA for measure development and endorsement – focus on outcomes that matter to the individual patient.  

• Develop and apply the required patient-centeredness criteria to APMs. – Section 1115A of the Affordable Care Act calls for evaluation of payment models

against “patient-centeredness criteria” (i.e. updating care plans).– Provide a structured patient-focused framework to guide CMMI’s work.– Does model deny or limit coverage of benefits for Medicare beneficiaries?

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Take Home Message

• Patients and patient groups should be engaged in the development, implementation and evaluation of APMs based on criteria for patient-centeredness developed by patients – not surrogate voices.

For Public Release

Panel: Building a Patient-Centered Health System

Sara Van GeertruydenExecutive Director, Partnership to Improve Patient Care (PIPC)

Lauren MurrayDirector, Consumer Engagement and

Community Outreach for the National Partnership for Women & Families

Michael KolodziejNational Medical Director, Onology Solutions, Office of the Chief Medical Officer, Aetna

Meaningful Patient/Family Engagement in Alternative Payment Models

Lauren MurrayDirector, Consumer Engagement & Community Outreach

Health Care Learning Action Network WebinarJanuary 27, 2016

About Us

National Partnership for Women & Families The National Partnership for Women & Families is a nonprofit, nonpartisan consumer advocacy group

dedicated to promoting fairness in the workplace, access to quality health care, and policies that help women and men meet the dual demands of work and family. We have been working for more than 40 years to improve access to high quality, affordable care for all.

Signature Health Care Initiatives Coalition for Better Care

Engage patients and consumers in health care payment and delivery system reform policy initiatives and in the design of new models of payment and care delivery.

Consumer Partnership for eHealth Advance health IT initiatives and policies that meet the needs of patients and families.

Consumer Purchaser Alliance Leading collaboration of consumer and employer groups focused on improving care and reducing

costs through performance measurement and payment

More information is available at www.NationalPartnership.org.

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“Whole person” Orientation: clinicians understand the full range of factors affecting a person’s ability to get and stay well; treatment recommendations align with patients’ values, life circumstances and preferences

Coordination and Communication: Patients & families are considered central members of the care team, and a clinical team member serves as “quarterback” – helping coordinate care, navigate the system and facilitate communication between all members of the team

Patient Support and Empowerment: expanding patients’ and caregivers’ capacity to get and stay well and support for self-management tools and services that are developed with them (not for them)

Ready Access: getting appointments when needed, accommodating barriers such as language or physical or cognitive problems. Consumers also see the high cost of health care and insurance as an access problem

What Patients/Families Want

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Better Care Better Health Outcomes Better Experience Lower Costs

Patients/Family Caregivers care about: Clinicians Getting better Waste and inefficiency

We Want the Same Things

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Meaningful engagement is not: Compliance Improved Self-Management and Healthy Behaviors Smart Consumerism Education Campaigns Provision of Financial Rewards Doing “What’s Best for Patients” Designing Patient-Centered Care Without Patients

Commonly Held Views of “Patient Engagement”

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“Patients, families, their representatives, and health professionals working in active partnership at various levels across the health care system – direct care, organizational design and governance, and policy making – to improve health and health care.” SOURCE: Carman, Kristin; Dardess, Pam; Maurer, Maureen; Sofaer,

Shoshanna, Adams Karen; Bechtel, Christine; Sweeney, Jennifer. “Patient and Family Engagement: A Framework for Understanding The Elements And Developing Interventions and Policies.” Health Affairs 32 No.2 (2013): 223-231.

Engagement Redefined

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Partnership to improve health and care: Engagement in Care – partnership to better manage care and

improve health status based on patient’s own goals Shared decision making, joint goal setting, developing care plans

Engagement in Redesign – working to redesign care Care coordination and transitions in care, phone call volume, wait times,

improving patient experience

Engagement in Governance – setting policy for initiatives or organizations Board of Directors, setting job descriptions, setting national qualification

criteria or payment policies for medical home initiative, etc.

Engagement in Communities – working with community groups in redesigning care and governing systems/organizations/policies

Advising on community resources and facilitating connections to community supports, serving on governing boards, etc.

Every Level, Every Stage

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Framework for Engagement

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Example

Comprehensive Primary Care InitiativeWhat Patients and Family Caregivers Say They Want:

“Whole-Person” Care

Coordination and Communication

Patient and Family Support

Ready Access

=

CPC Goals: Manage High Health

Care Needs and Deliver Preventive Care

Coordinate Care Across the Medical Neighborhood

Engage Patients and Caregivers

Ensure Access to Care 32

Options for Patient/Family Engagement

^Program years spans calendar years. Year 1 – 2013-14, Year 2 – 2014-15, Year 3 – 2015-16.** Survey/PFAC Council combination option not officially specified for Year 1

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PFAC Improvement Initiatives

Access to Care Wait times Extended hour availability Walk-in visits

Communication Accessibility of information Phone system navigation

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Care Coordination Whiteboards

Patient/Family Engagement Online patient portal use Patient education materials Self-management support Shared decision making tool

implementation Advance Directives

Work with patients and families to: Assess and re-design or enhance patient self-

management support programs (Milestone #2) Identify barriers accessing care (Milestone #3) Review, analyze, and discuss patient experience data

(Milestone #4) Test the best ways to implement the shared decision-

making tools (Milestone #7) Design (or help re-design) the electronic patient portal

(Milestone #9) Identify existing challenges within the practice and ask

patient and family advisors to meet to discuss solutions

More information on CPCI Milestones.

Partnering to Achieve CPC Milestones

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Leadership – Walk the Talk;  Identify Champions Careful Selection – Right Fit; All stakeholders Coaching/training – Continuous feedback and support Good Practice – Trust, Transparency, Relationships Meaningful Engagement – No

Window-Dressing/Rubber Stamping Don’t wait – Early Engagement; Priorities, Principles Avoid Tokenism/Don’t Marginalize – No new silos Beware Stereotypes – “Old culture” thinking Don’t ignore - Time, Resources, Power

Best Practices

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For More Information

Contact us:Lauren MurrayDirector, Consumer Engagement & Community Outreachlmurray@nationalpartnership.org (202)986-2600

Follow us:

www.facebook.com/nationalpartnershipwww.twitter.com/npwf

Find us:

National Partnership Website

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For Public Release

Panel: Building a Patient-Centered Health System

Sara Van GeertruydenExecutive Director, Partnership to Improve Patient Care (PIPC)

Lauren MurrayDirector, Consumer Engagement and

Community Outreach for the National Partnership for Women & Families

Michael KolodziejNational Medical Director, Onology Solutions, Office of the Chief Medical Officer, Aetna

Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutions

Can reimbursement reform be patient centered? Learnings from cancer delivery reform

Michael Kolodziej, M.D., FACPNational Medical Director, Oncology Solutions, Aetna

Aetna Inc.

Why health plans are concerned about cancer careChallenge #1: Expense• Cancer treatments cost $137B in medical spend

and growing. 1

• The bulk of costs are driven by care delivered during diagnosis and end-of-life phases.2

• There is no obvious relationship between cost and quality

Challenge #2: Delivery• Despite more efficient care at lower costs in the

community setting, an increasing percent of care is being delivered in the hospital outpatient department.3

• New care delivery models, like medical homes, can improve quality and reduce costs but may be challenging for practices to implement. 4

1. NCI Cancer Prevalence and Cost of Care Projections. 2012. Represents medical costs only. 2. MedStat Cancer Cost Data. 2012 3.Journal of Oncology Practice, “Improving Wait Time for Chemotherapy in an Outpatient Clinic.” January 2012. 4. Interviews with community Oncologists. September 2012.

1. NCI Cancer Prevalence and Cost of Care Projections. 2012. Represents medical costs only. 2. MedStat Cancer Cost Data. 2012 3.Journal of Oncology Practice, “Improving Wait Time for Chemotherapy in an Outpatient Clinic.” January 2012. 4. Interviews with community Oncologists. September 2012. 40

Aetna Inc.

Traditional managed care solutions have had minimal impact

• Pay less• Manage more (prior auth)• Narrow networks• Shift responsibility to member (co-pay)• Pay for performance (process measures)• Shift risk (capitation)

Impact has been smallAggravation has been large

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Aetna Inc.

Aetna Oncology Solutions: our goals

• Get the right treatment to the right patient at the right time.

• Optimize the patient experience and the patient outcome.

42

Aetna Inc.

Although we spend more on cardiac care, cancer is the most costly medical condition per caseAnd its cost is increasing at 2 to 3 times the rate of other costs.

Cancer care is the leading

edge of medical cost

trend.1996 2010

0%

1000%$55 B

$123 B

Annual Increase

Cancer Drugs 20%Cancer Medical 12-18%Health Care 9%US GDP 3%

Medical Rx 23% 43%

Inpatient 19% 23%

Radiology 23% 14%

Specialist Physician 12% 8%

Aetna's top cost drivers in cancer care 2014

ALL PTS CHEMO PTS

Source: www.cancer.gov/newscenter/pressreleases/2011/CostCancer2020 Source: 2014 CY Claims; Commercial & Medicare; All Funding; Excludes AGB/SH/SRC

43

Aetna Inc.

Oncology reimbursement reform must:

• Control costand

• Improve quality

Payers are pursuing two dominant reform models

• Clinical Pathwaysand

• Oncology Medical Home

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Aetna Inc.

There is a disconnect between the cost of innovation and the value it brings

Source: The JAMA Network. Five years of cancer drug approvals: innovation, efficacy, and costs. Available at: http://oncology.jamanetwork.com/article.aspx?articleid=2212206. Accessed January 12, 2016.

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Aetna Inc.

Clinical pathways are one approach to promoting evidence based, value driven care

46

Aetna Inc.

How can pathways be patient centric?

47

Aetna Inc. 48

Aetna, Inc.

Aetna Inc.

What are the PCMH joint principles?

• Personal physician— Each patient has an ongoing relationship with a personal physician— Personal physician leads a team of individuals that takes responsibility

for the ongoing care of patients— Personal physician is responsible for providing for all the patient’s health

care needs or arranging care with other qualified professionals

• Care is coordinated across health care system

• Quality and safety are hallmarks of the medical home

• Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication

• Payment recognizes the added value provided to patients who have a patient-centered medical home

Aetna Inc.

Practice quality reporting is mandatory

Advanced Care Planning

Patient Support Services Satisfaction

Aetna Inc.

Analytics are key to process improvementBREAST ABC ONCOLOGY - BREAST

2012 2013

COMMERCIAL MEDICARE COMMERCIAL MEDICARE

Grand Total - FOCUS BCL MEMBERS 542 6 548 93

FOCUS MBR CHEMO COSTS AT PRAC (TIME PERIOD) $12,336,674 $24,740 $12,811,033 $898,159

AVG PMPY $22,761 $4,123 $23,378 $9,658

ACTIVE CHEMO MBR MONTHS @ PRAC 2,707 18 2,658 407

ACTIVE CHEMO PMPM @ PRAC $4,557 $1,374 $4,820 $2,207

AVG ACTIVE CHEMO MONTHS SEEN** 5.0 3.0 4.9 4.4

IP FOCUS MBR AVG LOS AVG LOS 4.99 6.50 5.69 7.04

ER VISITS PER FOCUS MBR PY VISITS 1.60 1.00 1.49 1.60

FOCUS MBR YRLY MCC COSTS (SEE BELOW) $26,510,932 $94,050 $28,019,064 $2,325,577

AVG FOCUS MCC COST PMPY $48,913 $15,675 $51,130 $25,006

FOCUS MCC CATEGORY BREAKDOWN

AMB FACILITY - UPMPY UPMPY $6,489 $690 $7,118 $1,555

EMERGENCY - UMPY UPMPY $2,560 $0 $3,494 $624

IP FACILITY - UMPY UPMPY $22,842 $169 $26,037 $20,476

LAB - UMPY UPMPY $700 $972 $808 $389

MEDICAL RX - UPMPY UPMPY $35,125 $9,735 $36,296 $18,349

RADIOLOGY - UPMPY UPMPY $10,959 $7,900 $11,053 $4,926

SPEC PHYSICIAN UPMPY $2,237 $1,198 $2,699 $2,042

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Aetna Inc.

CMMI Oncology Care Model is an Oncology Medical Home

Management fee plus shared savingsAll cancers6 month episodeRequirementsNavigatorIOM care plan24 hr “coverage”Data use for quality improvement/guideline adherenceStage 2 meaningful use

The CMMI OCM will be a powerful catalyst of change

Aetna Inc.

Current reform efforts are a necessary transition to full transfer of risk in a patient centric fashion

Payer $ Risk Timeline: executed over 3 yearsProvider $ Risk

We are here

Base

Pay

men

t

Traditional Fee-For-Service

Provider(s) paid on the basis of volume of services

Fee-For-ServiceShared Savings

Oncologists paid on a FFS basis deliver care against a preset group of quality and cost benchmarks to determine shared savings at practice level

Episodic Bundling

Monthly payment for some services + FFS, delivered to a patient for a specific condition over a defined period, with shared savings recoupment (minus PMPM)

Global Payment

Bundled payment for some or all services delivered to a patient for an episode of care for a specific condition over a defined period

Traditional Fee-For-Service

Pathway Programs withShared Savings

Oncology Patient Centered Medical Home

Bundled Payment per Disease and Episode

Pay For Performance (P4P)

Incr

emen

tal

Paym

ent Financial incentives that reward providers for the achievement of a range of payer

and provider objectives, including delivery efficiencies, submission of data and measures to payer, and improved quality and patient safetyNeed to develop 2-tiered inventive program to allow oncologist to ACO relationship to work: 1) ACO organization 2) Physician practice

Today’s Payment Mechanisms Evolving Payment Mechanisms

Physician Incentives

Aetna Inc.

Conclusions

1. Ongoing reimbursement reform efforts have the potential to profoundly improve the value of cancer care but are transitional.

2. Current models are much more patient centric than previous models of care.

3. Partnerships between cancer care providers, payers, and patients will allow the realization of a true patient centric model that improves quality and controls cost.

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Q & A

What questions do you have about Building a Patient-Centered Health System?

Use the chat window in your webinar dashboard

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Key Upcoming Dates

Upcoming LAN webinars

February 9, 2016 Draft Patient Attribution and Financial Benchmarking White

Papers

February 24, 2016 Value-Based Payment for Individuals

with Chronic Illness

For Public Release

Get Involved!

Register online Visit our site Ask a questionPaymentNetwork@MITRE.org