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Maryland Management Meeting Plenary Slide Intervention


									                      TREATMENT RESEARCH INSTITUTE
                                  Applying Science to Transform Lives

                  Maryland Management
                    Meeting Plenary
                      December 13, 2010

                              Jack Kemp
                   Treatment Research Institute (TRI)

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I.   Contemporary Understanding of
II. Good and Modern System
III. Health Care Reform and Parity
IV. System Innovation and Improvement
V. Health Care Payment and Financing
VI. QI via Performance Management
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I. Contemporary Understanding
         of Addiction

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               Core Foundation

• Health Care Arena – Addiction is a
  HEALTH problem:
     • Part of mainstream healthcare

• Chronic not acute condition:
     • Purchasers will need to change contracts, funding
       mechanisms and expectations
     • Treatment programs will need to change from acute to
       chronic care design and service delivery
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               Core Foundation

• Medication Assisted Treatment (MAT)
     • New medications for addiction
     • Psychotropic meds for co-occurring MH disorders

• Recovery is the goal
     • Treatment prepares for recovery
     • Continuing care
     • Disease & self management

• Recovery Support
     • Recovery Coaches/Linkage Coordinators
     • Family and other “community strengths” support
     • Return to treatment program for “tune ups”, etc.

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The ACUTE Care Model

  The concept of “CURE”

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      A Nice Simple Model

  Substance Abusing Patient


Non- Substance Abusing Patient
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        Acute Care Assumptions

•   Some fixed amount or duration of treatment will
    resolve the problem

•   Treatment Completion is a goal and expected

•   Evaluation of effectiveness should occur following
      • Poor outcome means failure
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      In Chronic Illnesses . . .

• The effects of treatment do not last very
  long after care stops

• Patients who are out of treatment or
  contact are at elevated risk for relapse

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      So, For Treatment….

• One goal is to retain patients at an
  appropriate level of care and monitoring

• Another goal is to prepare patients to do
  well in the next level of care

• The effects of treatment are evaluated
  during treatment – not post-discharge
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          New Expectations

• Programs are responsible for results
  during treatment
• Treatment offers choices – adaptive care
• Easy transition between levels of care and
  treatment programs
     •Collaboration vs. competition among
• Recovery Oriented Systems of Care:
     •Continuing care and self-management
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 Some System and Program Changes

• New funding models to purchase care
    •System integration not autonomous
    •Episode-based and Bundling services
    •Collaboration across treatment agencies
• Connecting payment to performance:
    •Reward Quality not Quantity
    •Performance based contracting
    •Incentives for results
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II. Good and Modern System
   (SAMHSA Draft May 28, 2010)

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• ACA recognizes that early intervention …
  treatment of mental health and substance
  use disorders are an integral part of
  improving and maintaining overall health.
• Integration of primary care and behavioral
  health are essential. (1)

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           Overview of ACA

• Fundamentally will change or improve what
  services will be available to individuals who
  have mental and substance use disorders. (2)
  – Benefit packages must include SUD
• Create additional incentives to coordinate
  primary care, mental health and addiction
  services. (2)
  – Health homes for chronic health conditions
  – Grants for co-located primary and specialty care

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• Grounded in a public health model that
  addresses the determinants of health,
  system and service coordination, health
  promotion, prevention, screening, and
  early intervention, treatment, and
  recovery support to promote social
  integration and optimal health and
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• Mental health and addiction services need
  to be integrated into health centers and
  primary care practice settings where most
  individuals seek health care. (3)
• In addition, primary care should be
  available within organizations that
  provide mental health and addiction
  services. (3)

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• Preventing and treating mental and
  substance use disorders is integral to
  overall health. (4)
• Effective care management is key to
  coordinating health and specialty care. (4)
• Technology will be an important tool in
  delivering services. (4)

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• Reimbursement strategies must be implemented
  to align incentives and control costs. This
  includes paying for outcomes rather than paying
  for additional quantities of services. (5)
• Services that are proven effective or show
  promise of working will be funded; ineffective
  services and treatments that have not shown
  promise will not be funded. (5)

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    Proposed Continuum of Services

•   Health Homes
•   Prevention and Wellness Services
•   Engagement Services
•   Outpatient and Medication Services
•   Community Supports and Recovery Services
•   Intensive Support Services
•   Other Living Supports
•   Out of Home Residential Services
•   Acute Intensive Services (10)

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 Empowered Health Care Consumers

• Participant direction of services allows
  individuals … to choose, supervise and in some
  instances, purchase the effective supports they
  need rather than relying on professionals to
  manage these supports. (11)
• The concept of participant-directed services goes
  well beyond the intent of person-centered
  planning and active participation in service
  planning. (11)

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Quality and Performance Management

• The law will also help payers to “rethink”
  how payment strategies link performance
  improvement and payment while moving
  away from the current incentives to
  provide more care without evidence of
  improved outcomes under fee-for-service
  models. (13)

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      Continued Partnerships

• The good and modern system focuses on
  the need for better integration of primary
  care and behavioral health. This does not
  supplant the continued need to work with
  other systems that serve individuals with
  mental and substance use disorders.
  – e.g., criminal justice, child welfare, education,
    etc. (13)

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III. Health Care Reform
       and Parity

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            New Enrollees

• Additional 32 million will have health care
• 16 million new Medicaid enrollees
• 5 to 6 million with mental health and
  substance use disorders
• ALL will be guaranteed coverage for

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  Health Insurance Exchanges

• To be established by 2014
• MH/SUD must be part of benefit package
• Parity will apply
• Requires HHS to award grants to states to

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Substance Abuse
            Substance Use Disorders Treatment
               under Health Care Reform:
            Welcome to the Healthcare System

                                Richard Rawson, Ph.D.*
                                Thomas E. Freese, Ph.D.*
                        UCLA Integrated Substance Abuse Programs
                  Pacific Southwest Addiction Technology Transfer Center
*Authors of the following 8 slides.

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 How will the universe of SUD
care change today through 2014?

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Distribution of Alcohol (or Drug) Problems

            Severe        Treatment


         Moderate                      Intervention


2M people (0.8%) receiving treatment*
21M people (7%) have problems
needing treatment, but not receiving it*

    ≈ 60-80M people (≈20-25%)
    using at risky levels

                  US Population:
               US Census Bureau, Population Division
                        July 2009 estimate
                         *NSUDH, 2008
         In treatment (2 Million)

• Diagnosable problem with substance use
• Referred to treatment by:
   • Self
   • Family
   • Criminal Justice

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    In need of treatment (21 Million)

• Reported problems associated with use
• Not in treatment currently
   • 1.1% Made an effort to get treatment
   • 3.7% Felt they needed treatment, but
     made no effort to get it.
   • 95.2% Did not feel that they needed

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                    Using at risky levels (60-80 Million)
These people
need services,
                 • Do not meet diagnostic criteria
   but will
                 • Level of use indicates risk of developing
 never enter
                   a problems.
the treatment
                 • Some examples…
                       Drinks 3-4 glasses of wine a few
                       times per week
                       Pregnant woman occasionally has
                       a shot of vodka to relieve stress
                       Adolescent smokes marijuana
                       with his friends on weekends
                       Occasionally takes one or two
                       extra vicodin to help with pain
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As long as the specialty care programs
(AOD treatment programs) are the only
places which address SUD:
– most people with severe problems will not
  receive treatment.
– virtually all with risky use will not receive
  professional attention.

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“If Mohamed will not go to the
mountain, the mountain must
     come to Mohamed”

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• Very large number of people will now
  have health care insurance that will pay
  for addiction treatment.
• Many who never sought treatment before
  are expected to do so in the future.
• The type of care many will need is not
  generally offered at present – need new
  treatment models and services.

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• Health insurance will pay for clinical
  services – probably not recovery support
• Medicaid, Medicare and Health Plans will
  test new payment models that reward
  results, promote coordination of care and
  collaboration among practitioners.

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• For the States and SA Authorities right NOW:
     • Build collaborative partnerships with Medicaid,
       Primary Care (e.g., FQHC’s), Insurance
       Commissioner, Health Plans
     • Have a voice in Health Insurance Exchanges,
       Health Homes
     • Watch for federal grant opportunities
     • Keep abreast of Health Care Reform

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•Provide leadership to treatment provider
 community and other stakeholders
•Assist treatment agencies to become
 Medicaid eligible providers and to join
 health plan provider panels
     » Help providers learn how to bill Medicaid
       and other insurers

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IV. System Innovation and

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           Commonwealth Fund Data Brief

            “Opinion Leaders Views on
  Delivery System Innovation and Improvement”

K. Stremkis, K. Davis, A.M. Audet; The Commonwealth Fund Data Brief, “Health Care
    Opinion Leaders’ Views on Delivery System Innovation & Improvement,” July 2010

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    Delivery System Innovation and

• 225 respondents to survey from health
 care delivery, academia and research,
 business, health insurance industries,
 government, labor and advocacy groups.

• 9 of 10 health care leaders believe current
  financial interests and lack of incentives
  for integration are significant barriers

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    Delivery System Innovation and

• Majority of leaders support the proliferation of
  integrated models of care but also support
  safeguards and performance measures for
• ACA promotes delivery system innovation and
  improvement through more coordinated and
  accountable models and provides incentives for
  programs to organize themselves via:
  – Accountable Care Organizations (ACO’s)
  – Patient Centered Medical Homes
  – Bundled and Global Payment for care.
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1. Current financial interests and incentives
2. Lack of financial incentives for
3. Lack of alignment of public and private
   payer policies and practices
4. Culture of physician autonomy
5. The way in which providers are
   currently trained

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6. Lack of availability for technical
   assistance to undergo necessary
7. Patient preference for open access to
   providers and services.

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1. Integrated delivery systems will be an
   effective model for moving the U. S.
   health care system to more accountable
2. Providing special payment arrangements
   and financial incentives to providers will
   be effective strategies for promoting

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3. Development of performance metrics
   and increases in transparency and public
   reporting should receive high priority.
4. Concerned about undue market power
   and dominance among provider groups.

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V. Health Care Payment &
     Financing Reform

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           Disruptive Innovation
                    (NY Times 2/1/09)

• Concept pioneered by Clayton Christensen from
  Harvard Business School
• Old business models based on treating illness
  not promoting wellness
  – Hospitals benefit from full beds and repeat visits
  – No financial incentive to keep patients healthy
• Acute disease drove the costs


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           Disruptive Innovation

• Disruptive innovation will shape healthcare
  systems to provide a continuum of care focused
  on each individual’s needs, instead of focusing
  on the crises.
• Fixed fee, integrated systems
• Routine cases handled through lower cost
• Follow patients wherever they go within an
  integrated system
• Integrated systems are the disruptive innovation
  needed to be turned loose on healthcare

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          Commonwealth Fund Issue Brief

   “Developing Innovative Payment Approaches”

S. Guterman & H. Drake, The Commonwealth Fund Issue Brief, “Developing Innovative
    Payment Approaches: Finding the Path to High Performance,” June 2010

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• New Center for Medicare and Medicaid
  Innovation has mandate to develop
  innovative payment models to improve
  health care delivery.
• Report recommends that Center:
  – Try a variety of approaches that will
    encourage and reward more integrated care
  – Work with public programs and private
    payers to provide consistent incentives for
    providers and patients.
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Payment and Delivery System Reform

• Current system is fragmented and
  coordination of care is often lacking.
• Inadequate communication among
• A vacuum of accountability for the total
  care of patients.
• Payment methods fuel this fragmentation
  and fosters the lack of accountability.
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Payment and Delivery System Reform

• Fee for service emphasizes provision of
  services by individual providers rather
  than care that is coordinated across
  providers to address the patient’s needs:
  – Volume rather than value is rewarded.
• Changing the way health care is organized
  and delivered requires a change in the
  way it is paid for.

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Payment and Delivery System Reform

• Reforms must include an array of
  approaches that are compatible with
  providers’ current organizational
• At the same time, the reforms must
  establish rewards and requirements that
  encourage high quality and value and
  create incentives to offer more
  coordinated care.

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Payment and Delivery System Reform

• As payment methods and incentives
  change, providers will be able to innovate
  in response to those incentives.
• The right incentives can encourage
  providers to work together, to take
  broader responsibility for the patients they
  treat and the resources they use.
• They can encourage and reward ever-
  increasing levels of accountability.
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 Major Payment and Delivery System

1. Medical/Health Homes – a team of
   health professionals provides a
   comprehensive set of medical services,
   including care coordination.
2. Accountable Care Organizations
   (ACO’s) – feature local effective
   management of a full continuum of
   services, shared savings and
   performance measurement.

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 Major Payment and Delivery System

3. Bundled Payment – providers receive a
   fixed amount to cover a specified set of
   services, usually related to a particular
   event, illness or individual.
     • Strong incentive to for providers to manage the
       resources they use to provide that set of services.

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  Successfully Implementing Payment

• Payment pilots should not be limited to
  Medicare but should also include Medicaid and
  other public programs as well as the private
• An array of payment models, gain-sharing and
  risk-sharing arrangements and reward systems
  should be included and the process should allow
  for flexibility in modifying those models as
  experience is gained.

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 Successfully Implementing Payment

• Shared savings might be used to provide a
  direct incentive for efficiency
• Linking the distribution to measures of
  quality improvement can safeguard
  quality and encourage efficiency.
• A key requirement is the establishment of
  an explicit set of objectives and a system
  for monitoring performance in relation to
  these objectives.
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• These types of social experiments are not
  conducted in laboratories but in a world in
  which the policy environment is constantly
• Hence, the ability to maintain strict controls is
  limited and attempts to do so can be
• Evaluations must deal with imperfect controls
  and incomplete data.
• Rather than being fixed in stone, payment
  models should continue to evolve as experience
  with them is gained.
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     Payment Reform Models

• Health Homes

• Accountable Care Organizations (ACO’s)

• Episode-based Payment
    • Prometheus Payment Model

• Pay for Performance
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  Theory and Conceptual Foundation

• Economic theory holds that individual
  purchasers compare their implicit
  assessment of value against the explicit
  price to make optimal purchasing

• In health care, this relationship has been
  almost non-existent because buyers and
  payers are not typically the patients who
  receive the care.                      TRI
  Theory and Conceptual Foundation

• Insurers and payers have not made any
  distinctions in payments to providers who
  exhibit differences in quality.

• New models are being tested to bring this
  relationship between prices and value, as
  reflected in quality care, into a closer

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Health Homes

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          Health Home Functions and

• Patient-centered:
        • Relationship based with an orientation toward the
          whole person
        • Actively supports patients to learn to manage and
          organize their own care at the level they choose
• Comprehensive Care:
        • Accountable for the large majority of patient’s
          physical and mental health care needs, including
          chronic care and prevention/wellness
        • Requires a team of care providers
*AHRQ, Patient Centered Medical Home,

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Health Home Functions and Attributes

• Coordinated Care:
    • Coordinates care across all elements of the broader
      health care system, including specialty care
    • Builds clear and open communication among
      patients, their families, the medical home and
      members of the broader care team
• Superb Access to Care:
    • Provides accessible services with shorter waiting
    • Responsive to patients’ preferences
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Health Home Functions and Attributes

• A systems-based approach to quality and
    • Commitment to quality and quality improvement
       – evidence based medicine and clinical support tools
       – performance measurement and improvement
       – sharing robust quality and safety data.

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Accountable Care Organizations

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        Accountable Care Organizations

• Basic concept – holding a set of providers
  responsible for the health care of a
• This set of providers is an Accountable
  Care Organization

MedPac Report to Congress, “Improving Incentives in the Medicare Program,” June 2009

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• Includes at least primary care physicians,
  specialists and hospitals

• Defining characteristic – the ACO
  members agree to accept joint
  responsibility for the quality and cost of
  care received by their ACO patients.

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• Goal – to create an incentive for providers
  to constrain growth in volume while
  improving quality of care
• ACO member providers are held jointly
  responsible for quality and cost metrics
• Expected to improve coordination of care
  and reduce duplication of services

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• If the ACO meets both quality and cost
  targets, members receive a bonus

• If the ACO fails to meet both, no bonus
  and possible withholds

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• Idea is to create a set of incentives strong
  enough to overcome the incentives in fee-
  for-service system for increased volume
  without improving quality

• ACO’s are being envisioned as one tool to
  induce change in the health care delivery

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           What’s in the ACA re: ACO’s?

• Medicare:
     – Establishes a Medicare shared savings program for
       ACO’s to take effect in January, 2012
     – Not pilots but permanent option
     – Specifics left to Secretary of HHS: design of program
       will evolve over time
     – FFS will continue but new incentive payments will be

Health Affairs, “Health Policy Brief, Accountable Care Organizations,” August 2010

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     What’s in the ACA re: ACO’s?

• Medicaid:
  – Authorizes experimentation
  – New Center for Medicare and Medicaid
    Innovation will test a variety of new payment
    and delivery models for both programs
  – Possibilities:
    • risk-based, comprehensive payment for groups of
    • Coordinated care programs for chronic conditions

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Episode Based Payment

Prometheus Payment Model

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             Episode Based Payments

• Essentially bundles payment for some or all
  services delivered to a patient for an episode of
  care for a specific condition over a defined

• Episodes of care have two dimensions:
          • Clinical – what services or clinical conditions comprise the
          • Time – reflects the beginning, middle and end of an episode
*National Institute for Health Care Reform Policy Analysis, Episode-Based Payments:
   Charting a Course for Health Care Payment Reform, Jan, 2010

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        Episode Based Payments

• For chronic conditions, an episode could
  be defined as a period – a month or a year,
  for example – of management of the
  condition, including all the services
  provided during the period.

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Prometheus Payment

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       PROMETHEUS Payment

• Taking up IOM’s challenge, a group of
  experts from healthcare financing, law,
  medicine, quality improvement, research
  and economics, convened in 2004 to
  develop a new provider payment model.
• Seeks to transform health care payment by
  moving away from unit of service
  payment to episode of care payment.

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       PROMETHEUS Payment

• Tests paying for individual, patient
  centered treatment that fairly rewards
  providers for coordinating and providing
  high quality care.
• Centers on packaging payment around a
  comprehensive episode of care that covers
  all patient services related to a single

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        PROMETHEUS Payment

• Covered services are determined by
  commonly accepted clinical guidelines or
  expert opinion that lay out tested,
  medically accepted methods for best
  treating the condition from beginning to
• The services are calculated into
  “Evidence-informed Case Rates” (ECR’s),
  which creates a specific budget for the
  entire care episode.                    science
        PROMETHEUS Payment

• ECR’s include all the covered services
  related to the care of a single condition,
  bundled across all the providers who
  would treat a given patient for a given

• What makes PROMETHEUS different is
  its strong incentive for clinical
  collaboration to ensure positive patient
  outcomes.                             TRI
         PROMETHEUS Payment

• Provider is paid monthly for the duration
  of the ECR an amount which reflects 90%
  of the agreed upon rate.
• 10% holdback is paid based on the results
  of the Scorecard:
     • Quantifies whether the salient elements of the
       Clinical Practice Guideline (CPG) were provided,
       the patient’s experience of the care, and the
       patient’s outcomes.
     • 70% of the score based on what the provider
       himself does; 30% reflects what other providers
       treating the patient does.                        science
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    PROMETHEUS Practice Nexus

• Intended to foster clinical collaboration
  and flexibility in how care is provided, so
  long as the salient elements of the CPG are
• Because all providers in the ECR do better
  financially when they improve quality,
  PROMETHEUS encourages collaboration
  among providers, especially those who
  score highly on the scorecards.
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Pay For Performance

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• Fee for service payments encourage overuse,
  while capitated payments encourage under-use.
• Neither systematically rewards excellence in
• P4P incentive programs are designed to
  overcome these limitations by aligning financial
  reward with improved outcomes.
MedVantage & ViPS, “Pay For Performance Incentive Programs in Healthcare,” 2003.

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• A pay for performance system is a remuneration
  arrangement in which a portion of the payments
  is based on performance assessed against a
  defined measure.
• Typically, there is another component of the
  remuneration that is independent of the amount
  at risk.
• The terms merit and bonus pay are also used to
  describe similar systems.
Congressional Research Service Report for Congress, “Pay-for-Performance in Health
   Care,” November 2006.                                                           science
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Impact of Private Sector P4P Programs

• Rewarding Results grant program funded
  by RWJF and California Healthcare
  Foundation, and administered by the
  Leapfrog Group

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Impact of Private Sector P4P Programs

• Financial incentives motivate change – provided
  they are large enough to make a difference.
• Non-financial incentives also can make a
• Engaging physicians is a critical activity – they
  must be brought in early as collaborators to
  ensure that the goals are clinically meaningful.
• There is no clear picture yet of return on

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Impact of Private Sector P4P Programs

• P4P is not a magic bullet – it is one of a
  number of activities that can work to
  improve healthcare quality and change
  the way it is delivered and financed.

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    MedVantage P4P Survey (2008)

     N = 62 P4P Program Responses
• What Results do you attribute to P4P?
    • 84% - Performance on clinical measures improved
    • 66% - Improvement was statistically significant
• What changes do you anticipate making?
    • 65% - Expand scope or number of measures used
    • 53% - Change performance domains or relative
      weighting of measures
    • 0% - Discontinue the program

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     P4P Goals and Strategies

• Incentive programs are about behavior
• They have to be focused, therefore, on the
  people responsible for affecting change.
• P4P is not a magic bullet – it is one of a
  number of activities that can work to
  improve healthcare quality and change
  the way it is delivered and financed.
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  Elements Common to P4P Programs

• A set of targets or objectives that define what
  will be evaluated
• Performance standards for establishing the
  target criteria
• Measures to determine whether the targets have
  been achieved
• Rewards – typically financial incentives – that
  are at risk, including the amount and the
  method for allocating payments among those
  who meet or exceed the reward threshold.

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• Purchaser sets the expectations:
     •Based on science/research/proven practice
     •Defines the expectations and results

• Who can best provide what I want?

• Contracts and pays for performance and
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   Critical Elements of Design

• Buy-in/Commitment

• Matching Goals with Mechanisms

• Reward Structure

• Continuous Evaluation with Feedback

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   P4P Design Implications for Purchaser

• Design P4P system to require
  collaboration among providers, including
  continuity of care i.e., movement from one
  level of care or one setting to another as
  well as continuing care

• Include rewards for collaboration with
  other providers in across treatment
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• Pay a % of base contract for providing
  agreed upon/contracted services
  – Pay remainder for achieving critical
    performance targets

• Pay incentives for meeting agreed upon
  performance targets

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  Contact Information

        Jack Kemp
Treatment Research Institute

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