Healthcare Reform:
Implications for Health
Delivery
Discussion Notes
June 2010
EXECUTIVE SUMMARY
The healthcare reform law – summary
• The CBO estimates roughly 32 million additional Americans will have health insurance by 2019.
– The law creates new insurance mandates for individuals and incentives for employers to offer
coverage as well as major reforms to the market and business practices of the health insurance
industry. It also reinforces the ties between quality and payment and provides an environment to
make progress in accountable care and wellness. There are two “waves” of coverage reforms:
•
This year:
» Elimination of lifetime limits on benefits, restrictions on annual limits
» Pre-existing condition exclusions prohibited for those 19 and younger
» Rescission (cancellation) of coverage prohibited except for fraud
» Age limit for dependent coverage extended to age 26 (in the next coverage year)
» Temporary high risk pool for adults unable to obtain health insurance because of a pre-existing condition
» Tax credits for small businesses offering health insurance
•
Beginning January 2014:
» Guaranteed issue, elimination of pre-existing condition exclusions for all age groups
» Individuals are required to obtain health coverage, fines will be assessed for non-compliance, and subsidies
are available for low income individuals (up to 400 percent of the poverty line)
» Rates can only vary based on age, geography, smoking status and family size; size of variation capped.
» Employers are not required to offer coverage, but firms with more than 50 employees will be fined if low
income employees qualify for subsidized coverage; small employers get tax incentives to provide coverage.
» Essential Health Benefit Packages establish minimum benefit, coverage and cost sharing standards for
affordable health coverage
» Eligibility criteria and funding for Medicaid programs expanded to provide coverage for all citizens up to
133% of poverty line.
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EXECUTIVE SUMMARY
The healthcare reform law- summary
• The new law also creates new requirements and reforms to improve the performance
of private sector and government health care and coverage programs
• Creation of American Health Benefit Exchanges (“Exchanges”) for each state or region
to provide a transparent electronic marketplace for affordable coverage plans offered to
individuals and small groups initially
• A variety of Medicare, Medicaid and CHIP reforms in the areas of provider
reimbursement and program cost structure
• Reduction and then elimination of the “donut hole” coverage gap for Medicare Part D
beneficiaries. Starting with $250 in 2010.
• No deductable or co-pay for Medicare preventive services
• New Medicare and Medicaid payment payment options that stress accountability for
quality and cost reduction across the spectrum of care
• An additional $310 million to fight waste, fraud, and abuse in Medicare, Medicaid and
CHIP from 2011 through 2016
• Expansion of HIPAA transaction standards and mandates to promote administrative
simplification and related cost reduction
• By January 2011, refunds by health plans that do not meet target: Individual and small
group plans medical care costs of at least 80 percent of premium and large group
plans at least 85 percent.
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March 23, 2010
• Healthcare reform signed into law
January 1, 2014
• Second wave of market reforms (insurance is
guaranteed issue; plans prohibited from imposing preexisting condition exclusions on any individuals, etc.)
By June 23, 2010
• Temporary national high risk pool established (ends in 2014)
January 1, 2011
• Medicare Advantage payment restructuring begins
• PCPs and general surgeons in shortage areas receive 10% bonus (ends 2015)
• Medicare A & B preventive services covered
January 1, 2014
• Medicaid eligibility expanded to include those at or
below 133% FPL
October 1, 2014
• Hospitals in the top quartile of hospital-acquired
conditions now subject 1% Medicare payment
reduction for a given fiscal year
By January 1, 2011
• CMS Innovation Center established
March 23, 2011
• Grants for establishing Exchanges available to states
By January 1, 2012
• Medicare shared
savings program
begins; providers can
form ACOs
2010
2011
By January 1, 2015
• EFT operating rule effective
January 1, 2013
• Eligibility verification operating rule effective
January 1, 2016
January 1, 2013 (through 2014)
• Medicaid payment rates to PCPs at least
equal Medicare rates
2012
2013
2014
October 1, 2012
• Medicare value based purchasing program begins; base DRG payment
amounts reduced by 1% for all hospitals (increases to 2% by 2017)
• Hospital readmission reduction program begins; maximum reduction to
base DRG payment amounts is 1% (increases to 3% by FY2015)
January 1, 2014
• Employers subject to penalties if affordable coverage
not offered and low income employees qualify for
federally subsidized coverage
• Plans on the individual and small group market must
include “essential benefits”
July 1, 2010
• A $250 rebate awarded to beneficiaries in the Medicare “donut hole” in 2010
Accountable care
January 15, 2014
• Independent Payment Advisory Board submits first
proposal
• Federal subsidies available for low income individuals
(up to 400% FPL)
September 23, 2010
• First wave of market reforms (Lifetime limits on coverage prohibited; prohibition
on cancellations, etc.)
Public program expansion
2015
• Individual mandate begins
January 1, 2011
• Increased funding of $310 million to combat waste fraud and abuse
Market reform
• Electronic claims operating
rule effective
• Exchanges go live
Administrative simplification
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Health Reform: SUMMARY
Individual Mandate and Subsidies
U.S. citizens will be required to be enrolled in “minimum essential coverage” starting
in January 2014.
• “Minimum essential coverage” includes:
Annual PENALTY IF NOT
ENROLLED IN MINIMUM
ESSENTIAL COVERAGE
(Whichever is higher)
– A government sponsored program such as Medicare,
Medicaid, CHIP or TRICARE
– A plan purchased on the individual market
Year
A. Flat fee
B. Percent of
household
income
2014
$95
1.0%
2015
$325
2.0%
2016 and on
$695
2.5%
– An employer-sponsored plan
– “A grandfathered health plan”, defined as any group
plan an individual was enrolled in as of March 23, 2010
– Other plans such as a state high risk pool
• Individuals who are not enrolled in minimum essential coverage in any month starting January
2014 will be subject to a penalty when they file their annual tax returns
– The penalty is either a flat fee or a designated percentage of household income (whichever is higher)
– The total penalty will be proportional to the number of months the individual lacked coverage during
the year
– Individuals under 18 will be subject to half the penalty
• Starting January 2014, individuals and families with incomes up to 400% of FPL will be eligible for
federal subsidies to help pay for health insurance
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Health Reform: SUMMARY
“Essential Benefits”
Health reform establishes a minimum standard for health insurance coverage in
2014 to address the needs of the individual and small group market segments.
• Any individual or small group market plan will need to include the “essential health benefits
package” (“essential benefits”), which by definition:
1.
2.
Includes the minimum level of standard health benefits
•
Essential benefits will be defined by the HHS Secretary and “must be equal in scope to the benefits of a typical
employer plan”
•
At a minimum the essential benefits must include ambulatory services, emergency services, hospitalization,
preventative and wellness services, prescription drugs, etc.
Offers one of four coverage levels (platinum, gold, silver, or bronze) plus a high deductible option
for people under 30
•
Options differ only by premium amount and cost sharing level
»
•
For individuals under 30, a high deductible “catastrophic” plan will also be available
»
3.
Platinum level includes the highest premium amount and lowest cost sharing level; bronze includes the
lowest premium and highest cost sharing
Must cover the essential benefits, but coverage (aside from at least 3 primary care visits) does not begin
until a $5,950 deductible is met
Places limits on out-of-pocket spending
•
For individual plans, annual out of pocket spending for essential benefits cannot exceed $5,950; for a family
plan, total annual out of pocket spending on cannot exceed $11,900
•
Annual deductibles for employer-sponsored plans in the small group market covering an individual will be
prohibited from exceeding $2,000; annual deductible for an employer-sponsored family plan in the small group
market prohibited from exceeding $4,000
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Health Reform: SUMMARY
Changes to Reimbursement and Accountable Care
The law makes changes to provider reimbursement and establishes programs under
Medicare and Medicaid to encourage new payment models that stress accountability
across the spectrum of care.
• Some changes will be made to provider reimbursement.
– In addition to a “productivity adjustment” for inpatient hospitals (a downward adjustment to a hospital’s market basket
update to account for expected productivity gains), the law implements further market basket reductions of 0.3 in FY
2014; 0.2 in FY 2015 and FY 2016; and 0.75 in FY 2017, FY 2018, and FY 2019
 This will result in payment reductions totaling an estimated $113 billion over 10 years for inpatient hospitals
– A dedicated Medicare and Medicaid Innovation Center will be established by January 2011 to test “innovative” payment
and service delivery models
– An Independent Payment Advisory Board will be established with the authority to impose payment cuts to Medicare if
costs exceed certain thresholds starting in 2014
– 10% bonus payments will be awarded to primary care physicians and general surgeons practicing in health professional
shortage areas (2011-2015)
– Medicaid payment rates to primary care physicians must at least equal Medicare payment rates in 2013 & 2014
• There will be significant financial incentives for provider organizations that demonstrate highquality, tightly coordinated and efficient care.
– By January 2012, providers will be able to form accountable care organizations (ACOs) and be eligible to share in any
savings accrued to Medicare & Medicaid
– Bundled payment pilots will be available under both Medicaid (starting in 2012) and Medicare (starting in 2013)
– Medicare’s value-based purchasing program will tie a portion of reimbursement to actual performance (rather than a
hospital’s ability to report) on metrics starting in October 2012
– Hospitals that limit preventable readmissions by 2012 and hospital acquired conditions by October 2014 will avoid
penalties imposed by new programs
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Health Reform: SUMMARY
Accountable Care: Value-Based Purchasing
Starting in October 2012, a portion of a hospital’s Medicare reimbursement will now
be tied to actual performance on quality and efficiency measures.
• Under the value-based purchasing (VBP) program, Medicare base DRG payment amounts for all
subsection (d) hospitals will be reduced starting in October 2012.
• To qualify for a value-based incentive payment, a hospital
will need to meet or exceed specified performance standards
in a given fiscal year.
Federal
Fiscal Year
Reduction in Base
DRG Payment for all
Hospitals
2013
1.0%
2014
1.25%
– Hospitals that meet or exceed performance standards for a fiscal year
will receive increased base DRG payments for all discharges in that
fiscal year
2015
1.5%
2016
1.75%
– Hospitals with higher performance scores will receive larger valuebased incentive payments
2017+
2.0%
– The amount available for value-based incentive payments will equal the
total reduction in base DRG payments for all hospitals in a fiscal year
• For federal fiscal year 2013, incentive payments will be tied to performance on quality measures
selected by the Secretary:
– Measures that cover specific conditions or procedures (AMI, heart failure, pneumonia, surgeries, healthcareassociated infections
– Measures tied to HCAHPS (consumer survey)
• For federal fiscal year 2014 and beyond, incentive payments will also be tied to efficiency
measures, including Medicare spending per beneficiary.
• HHS will make individual hospital performance scores publicly available
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Health Reform: SUMMARY
Accountable Care: Additional Inpatient Payment Adjustments
The government has specifically targeted spending on preventable hospital
readmissions and hospital acquired conditions as key areas for payment reductions.
• Starting in October 2012, CMS will establish a hospital
readmission reduction program (HRRP) focused on
conditions associated with high volume or high expenditures.
– Reduction to base DRG payment amounts for all discharges
will be based on the dollar value of each hospital’s percentage
of potentially preventable Medicare readmissions for AMI, HF,
and PN
– Overall reduction to base DRG payment amounts for all
discharges cannot exceed 1% in FY 2013, 2% in FY 2014,
and 3% in FY 2015 and beyond
– List of conditions will be expanded starting in FY 2015
– Information on hospital readmissions will be made publicly
available
APPLICABLE
CONDITIONS FOR
HOSPITAL READMISSION REDUCTION
PROGRAM
Federal Fiscal Year 2013
• Acute myocardial infarction (AMI)
• Heart failure (HF)
• Pneumonia (PN)
Federal Fiscal Year 2015*
• Chronic obstructive pulmonary disease
(COPD)
• Coronary artery bypass graft (CABG)
• Percutanueous transluminal coronary
angioplasty (PTCA)
• Other vascular
*HHS Secretary to expand to the extent practicable
• Starting in October 2014, hospitals in the highest quartile of national, risk-adjusted hospitalacquired condition (HAC) rates for a given fiscal year will be penalized 1 percent of their otherwise
applicable Medicare payment for inpatient hospital services in that year.
– The Secretary will have the authority to expand the policy to additional conditions in future years and
will be required to calculate and make publicly available information on all patient hospital
readmission rates for certain conditions
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Health Reform: SUMMARY
Accountable Care: Penalties
Reductions to DRG payment amounts will add up quickly.
• Changes to DRG payment amounts under the VBP program and hospital readmission reduction
program (HRRP) apply to the hospital’s base operating DRG amount (i.e. the DRG payment amount
prior to any adjustments made by either program)
– For FY 2013, actual DRG amounts will be:
(Base DRG amount before any adjustments x adjustment factor for readmissions1) – (Base DRG amount before any adjustments x annual VBP
reduction percentage2) + (Base DRG amount before any adjustments x VBP bonus percentage3)
• Reductions to DRG payment amounts under the hospital acquired condition (HAC) program apply to
the hospital’s base operating DRG amount after adjustments under VBP and hospital readmission
program have been applied.
•
For hospitals in the top quartile of HACs in FY 2014 and beyond, actual DRG amounts will be:
0.99 x [(Base DRG amount before any adjustments x adjustment factor for readmissions1) – (Base DRG amount before any adjustments x annual
VBP reduction percentage2) + (Base DRG amount before any adjustments x VBP bonus percentage3)]
• The maximum reduction to a hospital’s base
operating DRG amount will total almost 6 percent by
FY 2017.
1Between
.99 and 1.00 in FY13; between .98 and 1.00 in FY14; between .97 and 1.00 in
FY15 and beyond
21% in FY13; 1.25% in FY14; 1.5% in FY15; 1.75% in FY16; 2% in FY17 and beyond
3Based on hospital’ performance score under VBP program
Federal Fiscal
Year
Maximum reduction to base
operating DRG amount
(VBP, HRRP, HACs )
2013
2.00%
2014
3.25%
2015
5.46%
2016
5.70%
2017+
5.95%
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Health Reform: SUMMARY
A Significant Decrease in People Without Health Insurance
The CBO estimates that the individual mandate and expansion in Medicaid eligibility
will result in roughly 18 million newly-insured Americans in 2014 alone -- and an
additional 11 million in 2015 and 2016.
Projected Number of Non-Elderly Adults Without Health Insurance in the U.S.,
2011-2019
January 1, 2014
• Individual mandate and new employer requirements begin
• Medicaid eligibility expanded to include those at or below 133% FPL
• Second wave of market reforms (insurance is guaranteed issue;
pans prohibited from imposing pre-existing condition exclusions on
any individuals, etc.)
Source: CBO.gov, March 20, 2010
• Exchanges go live
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Health Reform: SUMMARY
Combating Waste, Fraud, and Abuse (WFA)
The law includes provisions to fight fraud and improve the program integrity of
Medicare, Medicaid, and CHIP.
• Increased funding to fight fraud and abuse (and increased penalties)
– The legislation appropriates $310 million additional funding for 2011 through 2016
– Civil monetary penalties of up to $50,000 per violation for committing fraud or abuse
– States are required to terminate entities from Medicaid if they are terminated from Medicare
• Provider screening and new enrollment requirements:
– The Secretary and OIG will establish appropriate procedures for screening providers and suppliers
– Beginning March 23, 2011, providers must disclose affiliations with suspended providers and suppliers
– Providers and suppliers must adopt their own internal compliance programs to reduce WFA
– By January 1, 2011, the Secretary will release a rule requiring providers to use their national provider
identifier (NPI) at all times
• Other provisions designed to improve program integrity:
– The OIG and DOJ will be given access to the claims and payments data of HHS and its contractors
– The RAC program will be expanded to Medicaid to identify state Medicaid overpayments
– The Secretary and HHS Inspector General will establish a self-referral disclosure protocol (SRDP)
– Physician-owned hospitals that do not have a provider agreement in place by December 31, 2010 will
be prohibited from participating in Medicare
• New requirement to report and repay Medicare and Medicaid overpayments:
– If a person becomes aware of an overpayment, then within 60 days the person must report and return
the overpayment, and notify the entity of the reason for the overpayment
– The period for submitting Medicare claims is reduced from 36 months to 12 months (eff. Jan. 1, 2010)
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Health Reform: SUMMARY
Administrative Simplification
Health reform will standardize administrative transactions and the implementation of
operating rules in an effort to improve interoperability.
• The Secretary will adopt a standard set of financial and administrative transactions to achieve:
– Price transparency at the point of care, or prior to care
– Eligibility checking (specific to physician, facility, and date)
– Real-time adjudication of claims
– Timely status reporting for electronic transactions
– Consistent data elements (i.e. no ambiguous terms or optional fields for reason or remark codes)
• The HHS Secretary is required to adopt three new sets of operating rules:
Sets of Operating Rules
Adopted By
Eligibility verification
July 1, 2011
HPs Must Certify By
Effective By
December 31, 2013
January 1, 2013
[Note that the certify by date
comes after effective date]
Electronic Funds Transfers and healthcare payment
and remittance advice
July 1, 2012
December 31, 2013
January 1, 2014
Health claims information, enrollment, premium
payments, referral certification and authorization
July 1, 2014
December 31, 2015
January 1, 2016
• Health plans must become certified by adopting the new standards or else face penalties
– By April 1, 2014, the Secretary will begin assessing annual penalties
– The penalty amount will be $1 per covered life per day until the health plan is certified
– The penalty will accumulate up to a limit of $20 pcl (or $40 pcl if plan knowingly misled HHS)
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Health Reform: SUMMARY
Other Provisions to Improve Quality and Access to Care
• Create process for developing quality measures (strategy due to Congress by
January 2011)
• Five-year funding beginning in January 2011 and continuing for five years to support
consortiums of providers to coordinate services for low income, uninsured and
underinsured.
• Fund a five year grant program beginning in FY2010 to support delivery of evidence
based , community based prevention and chronic disease management-especially in
rural areas.
• Increase funding for community health centers and National Health Service Corp by
$11 billion.
• Fund a new program to strengthen trauma care, develop demonstration programs on
new models for emergency care (including pediatric emergency care)
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Health Reform: SUMMARY
Other Provisions
Brand name pharmaceutical companies
• To help pay for reform, the federal government will impose new fees on branded prescription
pharmaceutical manufacturers and importers:
– $2.8 billion in 2012-2013; $3.0 billion in 2014-2016; $4.0 billion in 2017; $4.1 billion in 2018; $2.8
billion in 2019 and beyond
• The FDA will be authorized to approve generic versions of biologic drugs and grant biologic
manufacturers 12 years of exclusive use before generics can be developed (effective upon enactment)
Employers
• Five year funding for grants to small employers for wellness programs (begins January 2011)
• Conduct a national workplace survey of policies and programs, provide technical assistance and
resources to evaluate employer-based wellness programs.
• Allow employers to offer discounts to employees that participate in health related activities.
Health Coverage Co-ops (“Co-ops”)
• Co-ops will provide coverage through an Exchange
• A co-op must be not-for-profit, primarily engaged in provide health care coverage, licensed by the State in
which they do business, and made up of members who are beneficiaries of the insurance coverage
• Grants will be available to assist with co-op formation and start up costs beginning September 23, 2010
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Health Reform: SUMMARY
The Massachusetts Plan
The national health reform law is very similar to the one passed by Massachusetts in
2006.
• In 2006, Massachusetts already had many of the market reforms included in the national law
already in place (guaranteed issue, elimination of pre-existing condition exclusions, etc.) and
had relatively low number of uninsured.
• Similar to the requirement in the national health reform law, all adults in Massachusetts must
be enrolled in a minimum level of benefits during a given year or face a fine on their annual tax
return
• Both the Massachusetts law and the national law include subsidized coverage options to lowincome adults who are ineligible for Medicaid
• Both laws include penalties on employers over a certain size that fail to offer employees
affordable coverage and whose employees qualify for subsidies
• The Massachusetts law established an online health insurance exchange called the
Commonwealth Connector to improve access to coverage in the individual and small group
market; under the national law Exchanges will be required in every state or region by 2014
• According to the Massachusetts Division of Health Care Finance and Policy, only 2.7 percent of
Massachusetts residents were uninsured in 2009. (Massachusetts Division of Health Care Finance and Policy, October 2009)
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Health Reform: SUMMARY
Key Findings from Massachusetts
Although almost all residents in Massachusetts now have health insurance, the
increase in demand has strained capacity.
• More low income residents have access to care, but the influx of new patients has put a strain
on providers, particularly on the outpatient side
– By the fall of 2008, more than 87 percent of low-income adults in Massachusetts reported having a usual source
for care other than the emergency room, an estimated increase of roughly 102,000 people from the fall of 2006.
– However, only 44 percent of internal medicine practices in the state reported accepting new patients in 2009,
down from two thirds in 20051
– In response to the surge in demand, Massachusetts carriers are required to allow nurse practitioners to act as
PCPs
• Emergency department use did not change post-reform
– ED use remains unchanged and many residents continue to visit the ED for non-emergency conditions
– Among working age adults who had at least one ED visit between the fall of 2007 and the fall of 2008, 44 percent
said their last ED visit was for a condition that “could have been treated by a doctor had one been available.”
• There are no indications that the availability of more comprehensive individual options has
caused employers to stop offering health insurance
– 71 percent of Massachusetts adults were enrolled in employer-sponsored coverage in the fall of 2008, up from 69
percent in the fall of 2007 and 66 percent in the fall of 2006
• Public opinion of the law remains favorable overall
http://www.massmed.org/AM/Template.cfm?Section=Home6&CONTENTID=31511&TEMPLATE=/CM/ContentDisplay.cfm
For more information on the Massachusetts experience : http://assets1.csc.com/health_services/downloads/CSC_Health_Insurance_Reform_in_Massachusetts.pdf
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Implications/Advice to
Clients
Implications/Advice to Clients
Health Delivery
Organizations
Implications/Advice to Clients: Health Delivery Organizations
Health Delivery Implications
The most obvious impact of health reform is 32 million more people seeking care
• The addition of 32 million people with insurance coverage will exacerbate the existing
capacity shortage – especially in primary care.
– 16 million new Medicaid patients and 15 million patients under the mandate will enter
the system.
• 18 million new people entering in 2014, then gradual increase to 32 million by
2019
– Most patients will be new to the “system” and require help becoming effective users.
– Many will have unaddressed health issues; at least half will be at Medicaid rates.
– This will immediately create an even more severe shortage of primary care providers.
• 32 million patients equals a need for at least 11,000 more PCPs, and an
approximately 10-20 percent increase in demand for specialty care and
hospitalization.
• Without PCPs, these patients will seek care in the Emergency Department.
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Implications/Advice to Clients: Health Delivery Organizations
Health Delivery Implications
“Savings” in Medicare = cuts in reimbursement
• The CBO predicts that reductions in annual updates to Medicare fee-for-service rates will
total $196 billion through 2019.
– In addition to a “productivity adjustment” for inpatient hospitals (a downward adjustment
to a hospital’s market basket update to account for expected productivity gains), the
law implements further market basket reductions of 0.3 in FY 2014; 0.2 in FY 2015 and
FY 2016; and 0.75 in FY 2017, FY 2018, and FY 2019.
– Over the next ten years hospitals are projected to absorb $113 Billion in Medicare
adjustments; home health $40 Billion.
• The law did not make any overall changes to Medicare payments to physicians (so in theory
a big [21%] cut is still looming – and built into the economic assumptions)
• The law does provide an short term increase in Medicaid payments for primary care; they
will be raised to equal Medicare rates for two years (2013 and 2014). There will also be a 10
percent Medicare bonus for primary care and general surgeons in shortage areas for 20112015.
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Implications/Advice to Clients: Health Delivery Organizations
Health Delivery Implications
Quality performance has a potentially much larger impact on reimbursement than
the market basket and productivity adjustments.
• New requirements for quality performance for full Medicare reimbursement starting in 2013
• All Medicare DRG payments reduced 1-2 percent starting in October 2012
• Increased DRG payments for all DRGs if meet/exceed quality performance targets for
specific conditions
• Potential for 1-3 percent reductions in DRG based on readmission rates
• Up to 1 percent reduction if in the worst quartile for hospital acquired conditions
• Allows Accountable Care Organizations to share in Medicare savings starting in 2012
• Bundled payments: Medicaid (starting in 2012) and Medicare (starting in 2013)
• Accountable care organizations with shared savings (Medicare and Medicaid starting
in 2012.)
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Implications/Advice to Clients: Health Delivery Organizations
Health Delivery Implications
The net for health delivery
• Many new patients demanding care
– Need to expand capacity without raising costs
– Everyone “work to license”
• Charity care will be reduced – not eliminated (individual penalties are low, some will not
know how to sign up, illegal residents are not eligible for insurance coverage.)
• Provider’s reimbursements will be the first target to make up for any cost increases.
– New patients will be at low reimbursement
– Need to ensure quality performance to get bonuses
• Providers who can make accountable care work will win – in both the short and the longer
term.
• Quality performance will have a big impact on reimbursement
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Implications/Advice to Clients: Health Delivery Organizations
Advice to Health Delivery Organizations-Immediate Actions
• Double down on throughput improvements to increase capacity
• Accelerate quality efforts starting with specified conditions
– Reduce readmissions, redesign process to exceed quality standards
– Make quality data a by-product of care
– Use data for real-time improvement
• Align with physicians (and physician incentives) to coordinate care
• Leverage every provider to work to license
• Move as quickly as possible to increase PCP capacity (including non-physician PCPs)
• Plan for health reform, ICD-10, and meaningful use together
– Make sure ED and PCPs are meaningful users of EHRs before 2014
– Code for quality measures with ICD-10 or SNOMED
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Implications/Advice to Clients: Health Delivery Organizations
Advice to Health Delivery Organizations
Expand your thinking of your role for the longer term
• Help patients understand reform, sign up for coverage, get PCPs – avoid ED visits
• Exploit opportunities to improve wellness in the community
• Organize to manage chronic disease, manage episodes of illness
• Collaborate with commercial health plans to implement new models of care and
reimbursement
• Think like an accountable care organization – while you organize to be one.
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