PRACTICE TRANSFORMATION. Moving Towards A Future of Team Based Care. Michael A. Kolber, PhD, MD

Transcription

1 PRACTICE TRANSFORMATION Moving Towards A Future of Team Based Care Michael A. Kolber, PhD, MD 1

2 2 Financial Disclosures: None

3 Thomas Cole, The Voyage of Life: Childhood

4 4 Medicare Passed into Law 1965

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6 (Organization for Economic Cooperation and Development)

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10 Thomas Cole, The Voyage of Life: Youth

11 Goal: Improve Quality while Reducing Costs Many insurance companies spend a substantial portion of consumers premium dollars on administrative costs and profits, including executive salaries, overhead, and marketing. The Affordable Care Act requires health insurance issuers to submit data on the proportion of premium revenues spent on clinical services and quality improvement, also known as the Medical Loss Ratio (MLR). It also requires them to issue rebates to enrollees if this percentage does not meet minimum standards. MLR requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, with the review provisions imposing tighter limits on health insurance rate increases. If they fail to meet these standards, the insurance companies are required to provide a rebate to their customers.

12 Goal: Improve Quality while Reducing Costs Increasing Managed Care Penetration Increasing Reporting Pressures by CMS Merit-Based Incentive Payment System (MIPS) CMS Site Equalization CMS-Hierarchical Condition Categories

13 Goal: Improve Quality while Reducing Costs Increasing Managed Care Penetration Increasing Reporting Pressures by CMS Merit-Based Incentive Payment System (MIPS) CMS Site Equalization CMS-Hierarchical Condition Categories

14 The 2012 Florida Statutes Title XXX Chapter 409 Part IV Medicaid Managed Care Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance Program (MMA) The Florida Medicaid program has implemented a new system through which Medicaid enrollees will receive services. This program is called the Statewide Medicaid Managed Care Managed Medical Assistance program. The Managed Medical Assistance program is comprised of several types of managed care plans - Health Maintenance Organizations - Provider Service Networks - Children s Medical Services Network Most Medicaid recipients must enroll in the MMA program.

15 KAISER FAMILY FOUNDATION

16 Goal: Improve Quality while Reducing Costs Increasing Managed Care Penetration Increasing Reporting Pressures by CMS Merit-Based Incentive Payment System (MIPS) CMS Site Equalization CMS-Hierarchical Condition Categories

17 Goal: Improve Quality while Reducing Costs Increasing Managed Care Penetration Increasing Reporting Pressures by CMS Merit-Based Incentive Payment System (MIPS) CMS Site Equalization CMS-Hierarchical Condition Categories

18 Goal: Improve Quality while Reducing Costs Increasing Managed Care Penetration Increasing Reporting Pressures by CMS Merit-Based Incentive Payment System (MIPS) CMS Site Equalization CMS-Hierarchical Condition Categories

19 Medicare Risk Adjustment Risk adjustment allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries. By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. Risk adjustment is used to adjust bidding and payment based on the health status and demographic characteristics of an enrollee. Risk scores measure individual beneficiaries relative risk and risk scores are used to adjust payments for each beneficiary s expected expenditures. By risk adjusting plan bids, CMS is able to use standardized bids as base payments to plans.

20 Fundamental Question: How does one provide improved quality, with reduced cost? It is this question that is driving non-executive medicine practices towards Risk Models It is this question that is driving practices towards towards a more patient centered medical home model supported through these APM

21 Thomas Cole, The Voyage of Life: Manhood

22 REDEFINING PATIENT CARE Coordinate Care Improve Access to Care Needs assessment-transportation, wills, food, housing Increase patient satisfaction-patient centered Reduce hospital admissions and pharmacy costs Provide comprehensive care Enhance Quality and Safety

23 Team Based Care Approach-PCMH A patient centered medical home model uses a team based approach in care rather than care revolving solely around a physician. Health extenders RNs, LPNs, Medical Assistants Mental Health Social Workers, case managers, CHW, care coordinators Pharmacists Physicians May extend model to include (sub)specialists and bundle care costs A patient centered medical home model uses an electronic medical record To evaluate and document patient outcomes/improvement To create chronic disease registries for consolidating care To assist in addressing quality metrics To evaluate population health outcomes

24 Thomas Cole, The Voyage of Life :Old Age