By Bridget Gulotta, MBA, MSN, RN, Senior Consultant, and Tina Pike, MBA, MSN, HCM, RN, Senior Manager, The Camden Group
The Affordable Care Act has changed the paradigm of our healthcare system moving from rewarding providers for the quantity of care they provide, to rewarding them for the quality of care provided. Frameworks such as the Triple Aim™ developed by the Institute for Healthcare Improvement and the National Quality Strategy from the Centers for Medicare and Medicaid (“CMS”) are two of the various models aimed at improving health system performance. While these approaches differ, each focuses on the accountability and improvement of care delivery across settings for all dimensions of health along with the associated costs. Through the use of quality measurement, CMS is driving healthcare transformation in collaboration with practitioners and patients.
Develop Patient-Centric Goals
As CMS and private payer reimbursement models move from volume-to-value payments and penalties, organizational leaders are recognizing the need to develop strategies which incorporate quality into all care delivery channels. First steps to approaching this landscape shift are through the development and implementation of proactive patient-centric goals. For example, engage patients as the stewards of their own care. This is a change from the “do as I say” approach of past generations. Truly listen to patients and their goals for their health. Discuss multiple options and assess the social determinants of health in terms of barriers to goal achievement. This is an approach which brings all disciplines together in the patient’s vision. Incorporate quality improvement strategies to support the long-term sustainability of an integrated care delivery model linked to outcome metrics. This will help drive a care delivery strategy and inform care redesign.
These organizational changes are of vital importance given the recent announcement by the Department of Health and Human Services (“HHS”) regarding the timeline for shifting Medicare payments toward alternative payment models such as Accountable Care Organizations or Bundled Payment Initiatives. Starting in 2016, the target for alternative payment model reimbursement is 30 percent—increasing to 50 percent in 2018. Private payers, such as Humana and United Health Group, are following the lead of HHS and tying reimbursement to value-based arrangements. Humana aims to align 75 percent of its Medicare Advantage membership to quality of care reimbursements and UnitedHealth Group will tie $65 billion of its reimbursement to value-based arrangements, each by 2017. The landscape is continuing to shift under our feet.
Strides continue to be made in the overall quality of care delivered in the U.S. New research released by the CMS 2015 National Impact Assessment of Quality Measures Report, finds that between 2006 and 2012 there was significant improvement in reported performance rates across seven quality reporting programs. Performance on over a one-third of the measures was considered “high performing,” exceeding 90 percent in the most recent three years of collected data. Additionally, health disparities across racial and ethnic groups have narrowed.
While the overall delivery of quality of care is improving, the Hospital Readmissions Reduction Program outcomes measures (see table) have shown limited improvements in readmission rates since 2013, the first program year. Outcome measures reported in the 2014 CMS Medicare Hospital Quality Chartbook (reporting period between July 2010 and June 2013), show variation in hospital performance continues along with the persistence of geographic variation by hospital referral region. Only two regions performed better than the national average on four or more of the condition-specific readmission measures.
Impact Quality and Care Delivery
In order to move to true value-based care, the overall health, safety, and well-being of a patient must be addressed. The delivery of coordinated, quality care needs to expand from the acute setting across the continuum with an equal focus on the social determinants of health—including access to care, caregiver support, behavioral health, socioeconomic status, and health literacy.
The identification of high-risk patients along with the development of strategies to address individual patient needs and barriers to achieving them will improve the success rate of transitioning care to the post-acute setting. Key components of a “wholeistic” approach include:
- Patient/family engagement
- Tools for effective self-management of chronic conditions,
- An individualized comprehensive treatment and continuum-based care plan
- Health education for disease and medication management
- Primary care and care management follow-up
- Improved clinician-to-clinician communication/handoffs--all supported with appropriate community-based resources.
Long-term sustainable success cannot be achieved without continuous performance improvement and continuum-based key performance indicators. Delivering quality care across the continuum with a multidisciplinary methodology will impact the usual way care is delivered. Real-time dashboards will foster the analysis of both financial and clinical data allowing for comprehensive, gap in care interventions and strategy development. Staffing skillsets will continue to change and new positions will continue to be created to meet the needs of the population. We are truly in the midst of the new age of healthcare.
Ms. Gulotta is a senior consultant with The Camden Group with more than 10 years of experience in the healthcare industry, including clinical experience. She specializes in clinical integration and patient care management, with a focus in quality and performance improvement, financial analysis and budget administration, as well as regulatory compliance, and strategic planning. She may be reached at firstname.lastname@example.org or 312-775-1700.
Ms. Pike is a senior manager with The Camden Group with over 25 years of clinical, business, and management experience in the healthcare industry. Her areas of expertise include business development, strategic planning, operations management, Lean strategies, and performance and process improvement. She has a strong clinical background and has assisted organizations with patient throughput, physician and patient engagement strategies, transformational culture change, as well as, the development of care models which span across the continuum of care to help healthcare organizations transition to value-based care and population health. She may be reached at email@example.com or 585-512-3900.