Criteria for Performance Achievement Excellence
Over the next eight years the ACA will phase in a series of comprehensive healthcare reforms that were nearly a century in the making following failed attempts by scores of U.S. presidents and sessions of Congress. One of the most significant steps in this process takes place this year with the establishment of the Center for Medicare and Medicaid Innovation, which will seek to reduce the cost of these federal entitlement programs without skimping on quality. In anticipation of these changes, IOLAG members sought recommendations from 20 forward thinkers in the healthcare industry as to how hospitals and their physicians should reform the delivery and financing of care. The group homed in on five key points that include:
1. Reimbursement reductions to hospitals for being “readmission outliers.”
2. Value-based purchasing of healthcare services.
3. Bundling payments for services to hospitals across episodes of care.
4. ACOs as part of Medicare’s “Shared Savings Program.”
5. Integrated electronic health information technology (HIT) systems.
Under the ACA, hospitals whose readmission rates exceed a severity-adjusted “excess ratio” will receive successive 1 percent reductions in the base-operating DRG payment beginning in federal fiscal years 2013 through 2015, according to the group.
As part of the ACA’s Hospital Value-Based Purchasing Program, incentive payments would be tied to performance standards for treating Medicare patients as part of a three-year pilot program from October 2012 to 2015 that could be made permanent by 2017. Conditions would include acute myocardial infarction, pneumonia and surgical care. Proponents of population health improvement believe this approach gives patients more control over their healthcare decisions, producing trusted accountability systems and verifiable community health assurance outcomes that hold healthcare providers accountable for cost, quality and value.
As a corollary to value-based purchasing, the IOLAG pointed out that “culture of health” programs and other tools can help savvy employers prevent a host of chronic conditions, as well as improve outcomes and quality of life. A broader application produces neighborhood culture of health efforts that foster prudent lifestyle, health and wellness choices across larger populations in the community at large, resulting from a convergence of interests and support systems, structures and processes.
“The difficulty in maintaining an individual’s focus on the adoption and persistence in achieving a healthy lifestyle lies at the heart of our healthcare crisis,” notes Mark Bloomberg, M.D., chief medical officer of HealthNEXT and an adjunct lecturer in health policy and management at the Harvard School of Public Health. “We spend almost half of our waking hours at work and yet the workplace remains for the most part an uninvolved and even hostile environment for the promotion of favorable lifestyle choices. Moreover, there is often no coordination between what health benefits an employer provides and what, if any, incentives employees are offered to make healthier choices. Making matters much worse, there is minimal effort to influence what community practices do to promote better health and, if addressed at all, such efforts rarely integrate with programs that might be offered at work. Identifying all employees and dependents as a defined population to whom a series of aligned efforts can be offered holds the key to creating a well-developed culture of health, which will absolutely achieve serious reductions in both direct and indirect healthcare costs.”
Neighborhood cultures of health is the solution Americans have been searching for all along to achieve a work-life balance of physical, emotional, intellectual, social and spiritual health with consumers who long for improving their economic well-being and quality of life.
Informed opinion leaders believe value is built on four essential elements: trustworthiness and trust, engagement and incentive alignment, relevant information, and distinct choices. The IOLAG defines value (and value creation) and the convergence of population health promotion pillars as meaningful productive interactions and personalized experiences of consumers that result in thriving people.
Population health promotion means that individuals will have greater control over decisions affecting their optimal health realization and are motivated by recognized population well-being elements: optimal health, financial security, work-life balance achievement and total well-being.
“Health promotion is the art and science of helping people discover the synergies between their core passions and optimal health, enhancing their motivation to strive for optimal health, and supporting them in changing their lifestyle to move toward a state of optimal health,” says Dr. Michael P. O’Donnell, editor in chief of the American Journal of Health Promotion.
Defining optimal health as “a dynamic balance of physical, emotional, social, spiritual and intellectual health,” he says lifestyle change can be facilitated through learning experiences that enhance awareness, increase motivation and build skills, as well as opportunities that open access to environments that make positive health practices the easiest choice.
A national pilot program on payment bundling is slated to launch no later than January 1, 2013, when hospitals, physicians, skilled nursing facilities, home health agencies and others who treat patients across the continuum of care must submit data on quality and other measures to be paid for the services they provide. The conduit for such payment will be a “Qualified Electronic Medical Record” as defined by the Health Information Technology for Economic and Clinical Health Act (HITECH) component of the American Recovery and Reinvestment Act (ARRA) of 2009.
”Electronic medical records serve as the core HIT systems to capture the clinical data to be used for the new quality improvement programs that are needed to support bundled payment and other new payment methodologies,” says Dr. Ron Parton, chief medical officer of Symphony Corporation.
Providers of services and supplies may band together as ACOs no later than January 1, 2012, to manage and coordinate the quality, cost and overall care of groups involving at least 5,000 Medicare beneficiaries. It’s worth noting that since the end of last summer, 40 health systems joined Premier Healthcare Alliance’s ACO Readiness Collaborative to prepare for their new role under the ACA.
While the IOLAG noted that the ACA does not specifically address HIT, its inclusion in the HITECH portion of the ARRA is expected to help drive transformational changes in the delivery and financing of care. In essence, hospitals and physicians will be expected to use health information technologies to more freely exchange information en route to reducing cost and improving patient care. With new reimbursement methodologies rewarding the use of HIT, the group believes information technology can burnish value-based purchasing by fairly compensating hospitals and physicians for investing in a more efficient delivery system.
Parton explains that ACOs will develop more highly integrated clinical data warehouse and sophisticated population HIT technologies to improve quality and reduce unnecessary medical costs. ”An ACO must be able to identify high-risk groups of patients, provide them with effective nurse case management and educational programs, and measure the effectiveness of their care by systematically tracking interventions and measuring outcomes,” he says.