Williamson Presentation to OKAMA Oct 21-2015 - EMS in Oklahoma

EMS IN OKLAHOMAToday & Tomorrow

Presentation by:H. Stephen Williamson, President of the Emergency Medical Services Authority (EMSA)

Presented to:Oklahoma Ambulance Association (OKAMA)

October 21, 2015

Triple AimPro

vider /

Supplier

Cost ReportValued-Based Purchasing

Bundling Payments

Accountable Care

Organization

Institutes For Medicine

High-Quality

Care

SGR

OIG

Medpac ?

OVERVIEW OF REFORM

The Health Care Environment

Payment ReformQuality

Initiatives

• Alternative Payment Models• Value-Based Purchasing

• Alternative Transport Destination

• Treatment without Transport

• Clinical Measures• Cost Reporting

THE SHIFTING SANDS: HHS’ BETTER, SMARTER, HEALTHIER PLAN

OMG

Smarter

Better Health Reform

Alternative Payment

Models

Currently 20%

50% by 2018

Value-based

Purchasing

90% by 2018

DOES IT EVEN MATTER?

25%

24%

12%

12%

8%

6%

5%

3%3%

1% Total Spending 2013 = $574 billionManaged CareInpatient HospitalPhysician Fee SchedulePrescription drugs provided under Part DOtherOutpatient HospitalSNfHome HealthHospiceDME

WHAT IS SGR?

The Medical Sustainable Growth Rate (SGR) was a method used by CMS in the United States to control spending by Medicare on physician services.

President Obama signed a bill into law on April 16, 2015, the Medicare Access and CHIP Reauthorization Act of 2015, which ended use of the SGR. The measure went into effect in July 2015.

INSTITUTE FOR HEALTHCARE IMPROVEMENT

IHI was officially founded in 1991, but our work began in the late 1980s as part of the National Demonstration Project on Quality Improvement in Health Care, led by Dr. Don Berwick and a group of visionary individuals committed to redesigning health care into a system without errors, waste, delay, and unsustainable costs.


Crossing the QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21ST CENTURY

NEW RULES FOR RADICAL REDESIGN IN HEALTH CARE

CHANGE THE BALANCE

STANDARDIZE WHAT MAKES SENSE

CUSTOMIZE TO THE INDIVIDUAL

PROMOTE WELLBEING

CREATE JOY IN WORK

NEW RULES FOR RADICAL REDESIGN IN HEALTH CARE

MAKE IT EASY

MOVE KNOWLEDGE, NOT PEOPLE

COLLABRATE AND COOPERATE

ASSUME ABUNDANCE

RETURN THE MONEY

Institute for Healthcare Improvement


The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim.”


Triple Aim

Improving the patient experienceImproving the health of populationReducing the per capita cost of health care



CONCEPT DESIGN

IHI’s innovation team developed a concept design describing an initial set of components of a system that would fulfill the IHI Triple Aim.

Focus on individuals and families

Redesign of primary care services and structures

Population health management

Cost control platform

System integration and execution


WHY TRIPLE AIM?

The U.S. health care system is the most costly in the world, accounting for 17% of the gross domestic product with estimates that percentage will grow to nearly 20% by 2020.

[Source: National Healthcare Expenditure Projections, 2010-2020. Centers for Medicare and Medicaid Services, Office of the Actuary)

At the same time, countries with health systems that out-perform the U.S. are also under pressures to derive greater value for the resources devoted to their health care system.

Aging populations and increased longevity, coupled with chronic health problems, have become a global challenge, putting new demands on medical and social services.


BENEFITS OF TRIPLE AIM

• Healthier populations, in part because it will identify problems upstream and outside the acute health care.

• Patients can expect less complex and much more coordinated care and the burden of illness will decrease.

• Importantly, stabilizing or reducing the per capita cost of care for the population will give businesses the opportunity to be more competitive, and provide communities opportunity to invest in schools and quality of life.

MEDPAC

The Medicare Payment Advisory Commission is a nonpartisan legislative branch agency that provides the U.S. Congress with analysis and policy advice on the Medicare program.

• Government Accountability Office (GAO) report in 2007

• GAO again reported in 2012 “… that in the absence of temporary Medicare ambulance relief, Medicare reimburses ambulance service providers below cost.”

The Moran Company Executive Summary

WHY THE MORAN COMPANY?

American Tax Payer Relief Act (ATRA) of 2013• Congress mandated the Centers for Medicare and Medicaid

Services (CMS) to conduct studies to determine how to collect accurate financial data from the ambulance industry for use in future evaluation of Medicare payment rates and possible payment system reform.

• In doing so, Congress instructed CMS to confer with the industry in its research. The research supported by the AAA prior to the completion of this report has been shared with CMS in the interests of furthering its work.


WHAT THE MORAN COMPANY FOUND

Major challenges to a requirement for cost reporting include:• Ambulance operations have evolved in response to the

requirements of state and local jurisdictions and not in response to payers. As a result, terminology and data describing ambulance services are not standardized across the industry and data concepts fit jurisdictional reporting requirements that have a high degree of variation.

• Ambulance operations across the U.S. are overwhelmingly small at the National Provider Identifier (NPI) level, with very limited administrative resources that make it difficult for these organizations to produce accurate and detailed data.


WHAT THE MORAN COMPANY FOUND

Fire department and hospital-based ambulance operations often have their cost data blended with other data from the parent institution, such that ground is not treated as a cost center.

Some states, counties, and municipalities have ambulance services that rely partially or entirely upon volunteers, which would require such resources to be monetized to be comparable to operations with all paid staff.


THE MORAN COMPANY

“….The AAA has endorsed a TMC report with recommendations for standardization of data and metrics, and endorses the “hybrid data collection methodology” proposed by TMC. TMC determined that typical Medicare cost reporting as an annual requirement of all ambulance operations would not produce reliable data at this time, and would not represent a cost-effective approach to collecting the data needed for future rate setting.“


THE MORAN COMPANY

The “hybrid data collection methodology” recommended by TMC includes two types of data collection:

• The first would involve all ambulance operations completing a very short (8-10 question) survey for each of their NPIs, providing basic descriptive information to characterize key aspects of ambulance operations that have been determined by TMC’s research to have a bearing on the interpretation of financial data.

• Secondly, “…this simple data collection would be updated periodically at an interval to be determined by CMS. These data would not be expected to change often, and therefore, annual updating may not be cost effective.”

PROVIDER/SUPPLIER

Institutes for Medicine noted in its 2007 report on the future of emergency medical care:

• “When illness or injury strikes, Americans count on the emergency care system to respond with timely and high-quality care.”

• Similarly, health care providers trust their patients to ambulance service for providing medical services when they must be transported between facilities or home.

Being deemed a “provider” rather than a “supplier” is the first step toward recognizing the clinical component of ambulance services and appropriately incorporating ambulance services into the broader health care coordination and reform discussions.

Supplier Provider

THE RATIONALE FOR CHANGE

Ambulance services have changed dramatically since the benefit was first introduced into the Medicare program. The IOM summarized these changes in its 2007 report:

• Emergency care has made important advances in recent decades: emergency 9-1-1 services now link virtually all ill and injured Americans to immediate medical response; organized trauma systems transport patients to advanced, life-saving care within minutes; and advances in resuscitation and life-saving procedures yield outcomes unheard of just two decades ago.

LIMITATIONS

Despite the clear acknowledgement that health care services are being provided by ambulance services throughout the country, current law defines ambulance services not as “providers,” but as “suppliers.”

Without provider status, ambulance services are viewed as suppliers that are interchangeable with other modes of transportation.

While an ambulance may not always be required to transport a patient, a patient who requires medical services immediately before, during or immediately after transport does require ambulance services.

LIMITATIONS

The lack of provider status artificially limits the role that ambulance services and emergency medical technicians can play in community and public health programs, as well as other reform models, that could improve overall community health and reduce health care spending by focusing resources on the most efficient and effective method of providing care.

“PROVIDER” HAS GREATER OBLIGATION TO MEDICARE BENEFICIARIES

“Providers of services” and “providers” must:

• Undergo a survey or participate in an accreditation process to be appropriately certified to participate in Medicare. As part of this effort, they must meet “Conditions of Participation,” which essentially outline the basic services required by statute.

• Sign a participation agreement with CMS that contains requirements that are consistent with obligations on suppliers today.


As part of the participation agreement, the provider agrees to:

• Limit its charges to beneficiaries to the costs of non-covered services and the deductible, coinsurance, and other charges allowed under federal law;

• Make adequate provision for the refund of amounts incorrectly collected from beneficiaries;


• Disclose the hiring of any individual who, at any time during the year preceding employment, was employed in a managerial accounting, auditing, or similar capacity by the provider’s Medicare intermediary or carrier;

• Bill other primary payers before billing Medicare in accordance with statutory and regulatory requirements concerning alternative insurance coverage.


“Providers of services” and “providers” must also submit claims electronically. Small providers (defined as having fewer than 25 full-time employees) are not required to submit electronic claims. Generally, claims must be submitted by the close of the calendar year after the year in which the services were furnished. The same assignment rules apply to providers and suppliers.

EXAMPLE OF POTENTIAL CONDITIONS OF PARTICIPATION FOR AMBULANCES

SERVICES

Virtually all providers in the Medicare program are subject to Conditions of Coverage/Conditions of Participation, which set a federal standard for how providers operate and interact with beneficiaries.

EXAMPLE OF POTENTIAL CONDITIONS OF PARTICIPATION FOR AMBULANCE

SERVICES

Patient Rights

Safety

Personnel

Compliance with Other Laws

Organization / Administration

National Business Coalition on Heath's Value-based Purchasing Council

VALUE-BASED PURCHASING:A DEFINITION

Value-based purchasing:• is a demand side strategy to measure, report, and reward

excellence in health care delivery.• involves the actions of coalitions, employer-purchasers,

public-sector purchasers, health plans, and individual consumers in making decisions that take into consideration access, price, quality, efficiency, and alignment of incentives.


VALUE-BASED PURCHASING:A DEFINITION

Effective health care services and high-performing health care providers are rewarded with improved reputations through public reporting, enhanced payments through differential reimbursements, and increased market share through purchaser, payer, and/or consumer selection.


A FRAMEWORK FOR EFFECTIVE VALUE-BASED PURCHASING

Value-based purchasing and the concept of rewarding high-quality health care by public recognition, differential payments, and consumer selection is not possible without first measuring performance. Performance measurement should be conducted on multiple levels, including health plans, hospitals, physician groups, and individual health care practitioners.


Measurement should be able to answer the question, “Is care safe, timely, efficient, effective, equitable, and patient-centered?”

Each of these six elements is critical – one does not take precedence over another, nor should one be emphasized over another.

Measurement must be able to provide actionable information on cost, quality, and appropriateness of care.

What is needed is agreement on market signals and comparison measures among providers, with the overall goal being driving towards outcomes measures, since that is what will drive improvements in the system.




Just as rewarding excellence is impossible without measurement, measurement is impossible without:

The establishment of all-payer, all-

provider community

databases with administrative,

claims, clinical data and patient survey

data

Ability to access aggregate data from multiple

sources

Reliable performance

measurement and a critical arena for

coalition and health plan focus

Rewarding excellence


EXAMPLES OF VALUE-BASED PURCHASING

Accountable Care Organizations (ACOs) –The goal is to get patients the right level of care while avoiding unnecessary spending. CMS is heavily involved in ACOs, but there are also private insurers that have formed ACOs.

Defined group of patients

Doctors

Hospitals

Other health care

providers

Coordinated care & chronic disease

management

Coordinated care & chronic disease

management


Bundled payments – A lump sum paid to health care providers to provide treatment for a given condition instead of paying for individual treatments or services. Payments are made based on the expected cost of treating the patient for a defined episode. Since providers assume some financial risk if the costs of providing services exceeds what’s expected, the idea is to discourage unnecessary health care spending.




Patient-centered care – A cultural approach that takes into account the needs and concerns of the patient in the provision of healthcare.

Patient-Centered Medical Home (PCMH) – When all of

a patient’s health care is coordinated by a single provider, usually a primary care physician, to ensure patients receive the appropriate level of care and to avoid duplication. The goal is to encourage a partnership between the patient and the PCMH to improve outcomes and reduce costs. Both ACOs and PCMH rely on value-based purchasing.

HCAHPS SCORES

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care.

HCAHPS (pronounced "H-caps"), also known as the CAHPS Hospital Survey, is a survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience.

While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS, there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally and nationally.

HCAHPS SCORES

Three broad goals have shaped HCAHPS: • First, the survey is designed to produce data about patients'

perspectives of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers.

• Second, public reporting of the survey results creates new incentives for hospitals to improve quality of care.

• Third, public reporting serves to enhance accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment.

H.R. 745 MEDICARE AMBULANCE ACCESS, FRAUD PREVENTION AND REFORM ACT

Title I: Medicare Ambulance Relief• Permanently incorporates into the Medicare

ambulance fee schedule rates the current temporary 2 percent urban, 3 percent rural, and super rural bonus payments.

• The Secretary of HHS is required to submit a report to Congress detailing the features of a reformed payment system for ambulance services under the Medicare program no later than January 1, 2020.


Title II: Dialysis Transport Reform• Requires the Secretary of HHS to establish a process for

providing prior authorization for non-emergency basic life support (BLS) ambulance transport of Medicare beneficiaries to and from dialysis center.

• Requires the Secretary to describe the process publicly no later than June 30, 2016, with national implementation on January 1, 2070.

• Defines all entities that provide ambulance services as “providers” under Medicare.


Title III: Medicare Ambulance Payment Reform• Directs CMS to establish a data collection system no later

than July 1, 2016, for ambulance providers which would define national prototype ambulance entities, establish specific allocation methods and data elements for each type, and be implemented through a survey of representative organizations.

• Beginning July 1, 2017, providers selected to provide cost information and who do not comply with the request of the required data will receive a 5% reduction to their payment for 1 year. CMS must consult with stakeholders.

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Williamson Presentation to OKAMA Oct 21-2015 - EMS in Oklahoma

Healthcare

Transcript of Williamson Presentation to OKAMA Oct 21-2015 - EMS in Oklahoma