By Sarianne Gruber
Twitter: @subtleimpact
The success of New York State’s healthcare rests on the best strategies and implementations for value-based care and value-based purchasing. At the annual New York eHealth Collaborative Digital Health Conference, Patrick Roohan, Director at the NY State Department of Health opened the presentation with this year’s figures for “insuring” the health of New Yorkers. In 2016, the average cost of family coverage for insurance in the State of New York rose to $19,630, an increase of over $12,000 from 2006. Mostly due to the significant portion of cost sharing that New Yorkers are putting towards healthcare. Premiums and deductibles account for 10% of a family’s median income, as of the current year the median household income is $56,000. The ramification of these costs has set the count to 7 million people in New York State now covered by Medicaid, Child Health Plus, or the Essential Plan of New York. “While the department and I obviously advocate for people to be insured, the fact that 7 million people now qualify for these programs is obviously related to the first number. Basically, what is going on is that insurance is becoming too expensive for many in the middle class,” shared Roohan. Supported by very low rates of uninsured persons due to a lot of the expansions, statistics show how well Medicare Manage Care has done with high rates of accessibility to care, plus lower rates of smoking and obesity. Work remains on lowering hospital use and improving vaccination rates.
Value-Based Payments: The Seesaw Effect for Payers and Providers
Roohan led the discussion with two leading healthcare executives, Arthur Ginelli, President of the Mount Sinai St. Luke’s & Mount Sinai PPS, and Dr. Kristofer Smith, Senior Vice President at Northwell Health, addressing their experiences and challenges on “navigating” value-based care with providers and payers. The speakers shared comparable opinions on several key topics.
“Value-based payments is different for different sectors and different for different payors,” stated Ginelli. On a high level, he clarified the various programs: Medicare has its own set of value-based payment methodologies, one in place for hospitals and now MACRA for physicians. Medicaid has introduced value-based payments both through managed care and now through DSRIP. On the commercial side, providers have begun to enter into negotiations with payors, which will most likely increase a number of payments at risk for value.
Smith and Ginelli both concurred that the signs of provider responsiveness to value-based payments have been marked with a significant reduction in readmissions, a reduction of hospital acquired conditions, and a decrease in patient admissions (or admits per 1000). As to which groups are benefiting from this realignment of incentives to outcomes and quality – definitely the patients. The corresponding markers of unnecessary and unwanted suffering have been slowly going down. Benefits accrued to payers indicate much lower growth rates for Medicare spending over last 5 years. Commercial payers have also benefited from the spillover effect from the work of Medicare, particularly around in hospitalizations and ED visits. However, on a side note with new changes from yesterday’s revenue, Smith expressed a need for sensitivity since different providers “feel” them differently.
On the topic of shared savings programs and Medicare ACOs, organizations that have stayed with accountable care models over time have seen success rates increase. ACOs where there are few hospitals, or provider only or physician only practice running an ACO tend to perform better. So far results have been mixed within the alternative delivery system models, and the number of organizations that have been able to share in the savings is a minority given the total number of performing ACOs. “We still have learning to do on about what works and what doesn’t. The transition from volume to value and the transition from payments that are structured on a fee service basis to payments that incorporate some form of value consideration in how providers are compensated will be a long ‘are’. Kaiser has been doing this a long time, and we are relatively new to this work,” Ginelli pointed out.
Need for Alignment and Harmonizing Multiple New York State Programs
New York State Value-based care purchasing core of initiatives includes Medicare, MACRA, the State Innovation Model Grant, Advanced Primary Care Model, DSRIP and commercial insurers. It is incredibly difficult to figure out how to be successful across the diversity of programs without alignment. The challenge is successfully figuring out the overlap across all of these programs, otherwise we won’t be able to sustain success.
“The infrastructure to be successful for quality, the total cost of care, care management, by population health and standard is expensive. If you are a physician group or a hospital system and you go down a path of building infrastructure by a program, you will find yourself with an incredibly expensive overlapping redundant confusing setup of programs and personnel,” testified Smith. Unequivocally, the importance of aligning these programs. He explained that from the provider side, you have to be relentless in detecting program overlap. And not treat these as individual verticals programs. Think about the competencies around analytics, quality and care transitions, and as each new program comes in introduce layering competencies within each program or else you won’t be able to sustain success. On the flipside, what we need is certain conveners. Different payors can’t all have different quality measures then you need lots of different processes by contract. The state of California regulates the quality measures across all the payers. There needs to be a move to harmonization of programs by codes that hold the dollar.
Measure Madness: Handling the Multiplicity and Overload of Metrics
Roohan says the term is “measure madness” and it is a reality. When New York ABD program contracted with Optum, and they automatically created 650 measures. “They are doing this because they can because they have a customer who wants every one of those. But the reality we hear from providers is that we can’t do blood pressure control six different ways. It is a real problem across payers which needs to be addressed.
“What is the cost of this alignment?” Roohan asked. Ginelli answers that first we have to add technology infrastructure to keep track of the multiplicity of measures. DSRIP is already a head of the game because they have a whole team set up for reporting. That is one payor and one big program. For multiple payors, like Medicare and also the commercial space, it becomes necessary to make more investments in IT and people to manage performance. He expressed to the audience that what he fears as a hospital executive in a fee for service model your dashboard is easy. “You get up every morning, you look at your census, surgeries, and discharges. And you compare them to last year’s or last month’s, and you can get a sense of where you are every day. I attempted to envision what a dashboard is for life in the VBP world and multiple VBP contracts, and I don’t know what that dashboard is. Is it multiple dashboards with conflicting information and significant time lapses? What is worrisome is whether there is an efficient way to get sufficient real time data?” questions Ginelli. He deems that without streamlining and harmonizing data, it will become a more challenging task to create a real-time reporting structure. With the investment for this type of infrastructure, he maintains that clinical operations and the clinicians will have accurate to enough data to make appropriate real-time decisions relative to the allocation of resources and relative to performance. On a pensive note, Roohan adds, if we spending time measuring we are not spending time improving. And the whole idea was to measure, get a baseline and try to improve from that, which appears somewhat to be lost. He also cited from a March 2016, Modern Healthcare article that healthcare is spending $50,000 per primary care physician on measures on retrieving information from insurance companies. The cost is about $15 billion a year. Think about that…is that well spent?