Policy and clinical practice in the new era of health care quality
ASSIGNMENT: Policy and clinical practice in the new era of health care quality
- Discuss about the healthcare transformation and how this has improved quality and healthcare delivery, decreased health care costs, and improved health outcomes. Include the ACA, Health Care Planning and Learning Action Network by Obama in 2015, MACRA legislation, MIPS, APMs (Alternative payment models). Basically do a summary of this first article by Kuebler. But we need 2 references, so can add anything from the 2nd one below that talks about APMs.
- Please write it in an organized manner and don’t go over 2 pages
Kuebler, K. (2017). Health policy and clinical practice in the new era of quality. The Journal for Nurse Practitioners, 13(2), e87-e89. DOI:10.1016/j.nurpra.2016.07.029 (I also downloaded this article)
“The Patient Protection and Affordable Care Act (PPACA), commonly referred to as the Affordable Care Act (ACA) or, colloquially, Obamacare, was signed into law in the United States in 2010. This regulatory overhaul of the U.S. healthcare system was enacted to increase the quality and affordability of health insurance, lower the uninsured rate, and reduce the costs of healthcare for individuals and the government. The Affordable Care Act has had a huge impact on hospitals and primary physicians, making them transform their practices financially, technologically, and clinically to "drive better health outcomes, lower costs, and improve their methods of distribution and accessibility"
US healthcare system is transforming to population based health with the help of the Health Care Planning and Learning Action Network.
April 27th, 2016 executive notice by the US Department of Health and Human Services issued key provisions to the Medicare Access and Summary CHIP Reauthorization Act of 2015, (MACRA). MACRA replaced the 1997 Sustainable Growth Rate formula for determining Medicare reimbursement. MACRA provides a new approach in Medicare reimbursement based on value and quality care. MACRA legislation is guided by the Quality Payment Program, directing two paths for Medicare reimbursement: The Merit-based Incentive Payment System (MIPS), or the Advanced Alternative Payment Model (APM).
The 2010 passage of the largest and most complex legislation in United States health care history has prompted massive changes. These innovative changes are directly linked to a new system that provides incentives for quality patient-centered outcomes that adhere to the 3-part tenets of the Affordable Care Act, better health and better care that is cost-effective. This new era of clinical transparency and quality metrics requires the application and implementation of evidence-based practice
In January 2015, President Obama created the Health Care Planning and Learning Action Network used to direct reimbursement changes in the US, and Secretary Burwell announced the new and evolving health care system of value versus volume and the commitment from the administration to create a transparent delivery of primary and specialty health care based on value and quality.
MACRA Legislation
The implementation of these reimbursement and practice changes are led by a unified framework called the Quality Payment Program.3 The 2 paths of care include the Merit-Based Incentive System (MIPPS) and Advanced Payment Models (APMs). Each of these reimbursement tracks provide incentives when providers, practices, organizations, or health systems demonstrate and meet or exceed the quality and value metrics uniquely determined by type of practice and patient care population served. The MACRA changes the manner in which Medicare will reward providers for value over volume. It provides incentive payment for providers through MIPS and bonus payment for provider participation in eligible APMs.4
MIPS
MIPPS will replace the current Medicare measures used to determine quality and value. The Physicians Quality Reporting System, the Value Modifier (VM) program, and the Medicare Electronic Health Record (EHR) Incentive Program's or Meaningful Use will be grouped together under MIPPS.3 Congress streamlined and improved on these individualized programs into 1 merit-based incentive payment. The Centers for Medicare & Medicaid Services (CMS) suggests most Medicare providers (physicians, NPs, physician assistants, and certified registered nurse anesthetists) will participate in the quality paymentprogram through MIPPS.3
Advanced APM
Under MACRA legislation, APMs are a way other than MIPS for Medicare to pay for quality and value. APMs primarily include innovation care models funded and awarded by the CMS Innovation Center (CMMI), Medicare Shared Savings Program, and/or any demonstration under the Health Care Quality Demonstration Program or federally funded demonstrations.3,6
Under MACRA legislation, the following are required of providers and participants by APM:
Use a certified EHR (minimum requirement of 50% use of EHR between providers).
Payment is based on quality measures similar to the MIPS quality performance category. There is no set number of measures; however, APMs are required to report at least 1 outcome measure.
Identify the ability to take on financial risk for monetary losses if not meeting quality measures or be identified as a Medical Home Model defined by CMMI.3,6
Medical home models that have not expanded by CMMI criteria will be responsible for alternate financial and risk benefit ratios.3
The current legislation by MACRA has determined the following APMs: 1) Shared Savings Program, 2) Accountable Care Organization Next Generation Model, 3) Comprehensive End Stage Renal Disease Care, 4) Comprehensive Primary Care, and 5) Oncology Care Model. The CMS has agreed to annually evaluate and partner with innovative APMs that meet criteria and undergo evaluation by the US Department of Health and Human Services Technical Advisory Committee appointees (11 members).
The American Medical Association has issued a statement to encourage medical organizations, associations, or societies to use a 5-step approach in developing APM proposals submitted to the Technical Advisory Committee who then make recommendations directly to the CMS.7 These steps include the following:
Establish a committee of physicians willing to invest in the time to develop an APM.
Demonstrate an opportunity to improve specific patient care that can result in reductions to care costs and identify current practice barriers that prevent providers from implementing these improvements.
Target specific payment changes required to overcome practice barriers. APMs should work to overcome these barriers.
Determine if the benefits for patients and the savings for payers (eg, Medicare) can validate any costs associated with appropriate payment changes.
Participate in an APM that removes barriers to improve care and demonstrate successful patient-centered outcomes that are cost-effective.
***FOR THE PAPER COCLUSION, BESIDES YOUR CONCLUSION, ADD THIS AS WELL (Paraphrase):
“The APN is in an ideal position to remain informed and knowledgeable about the influence and impact that health policy and legislation make on his or her clinical practice and reimbursement processes. The Affordable Care Act has generated significant changes in the health care delivery system. APNs who implement the best evidence-based practice guidelines found from the Agency for Health Research and Quality and adhere to quality and value metrics can succeed in the transparent delivery of competent, safe, comprehensive, and cost-effective care for the escalating Medicare patient population”.
***We need to reference 2 articles so use this one as a second one:
Wiler, J., Miller, H. & Harish, N. (2017). Creating successful alternative payment models, The American Journal of Accountable Care, 5(1), 51-53. Retrieved from https://www.ajmc.com/journals/ajac/2017/2017-vol15-n1/creating-successful-alternative-payment-models
ABSTRACT
The Medicare Access and CHIP Reauthorization Act of 2015 encourages development of physician-focused alternative payment models (APMs). This creates the most significant opportunity in 2 decades to meaningfully redefine how physicians are paid for their services. Whether this results in better care and lower spending, and whether it helps or harms physician practices, will depend heavily on how the HHS implements APMs. In this article, we draw on the experience of past and present payment reforms to suggest principles for successfully designing APMs.
The American Journal of Accountable Care. 2017;5(1):51-53
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 encourages the development of physician-focused alternative payment models (APMs). This creates the most significant opportunity in 2 decades to meaningfully redefine how physicians are paid for their services. Whether this results in better care and lower spending, and whether it helps or harms physician practices, will depend heavily on how HHS implements APMs. In this article, we draw on the experience of past and present payment reforms to suggest principles for successfully designing APMs.
Five Principles for Successful APMs
1. Provide the Resources Needed to Deliver Higher-Value Care
An overarching goal of APMs is to slow the growth in healthcare expenditures. However, APMs, which blindly incent decreased utilization of services, can worsen access to care and health outcomes for patients.1 Adding penalties based on quality can protect some patients, but harm others whose care needs fall between the many cracks in current quality measures.
A major weakness in the current fee-for-service (FFS) systems is lack of payment for many high-value services that could address patient needs at lower costs. For example, patient education and self-management support can help patients with chronic disease to avoid hospitalizations, but they are not adequately supported by payers. Similarly, supervised exercise therapy can achieve equal or better outcomes than surgery for many patients with diseases such as peripheral artery disease and joint osteoarthritis, but it is not adequately supported by the current payment systems. A successful APM will give physicians the flexibility and resources they need to deliver higher-value approaches to patient care.
2. Hold Physicians Accountable Only for the Aspects of Cost and Quality They Can Control
A second weakness of traditional FFS payment is that it neither rewards nor penalizes physicians based on the overall cost of treating a patient’s problem or the outcomes achieved. In contrast, capitation payment systems reward physicians for avoiding high-need patients and penalize them for costs they cannot control. The reasons capitation systems were abandoned in the past was not a lack of adequate information technology or quality measures, but rather the inappropriate transfer of full insurance risk to physicians. Many current payment reforms that hold physicians accountable for all spending on their patients create the same problems under a different name.
There is a middle ground between FFS and full-risk global payments.2 In many pilot programs, physicians have demonstrated the willingness and ability to reduce costs and improve quality for the services they both deliver and order if they have the resources needed to do so. A successful APM will hold physicians accountable for aspects of costs and quality they can control (eg, how many tests they order, which procedures they perform, how well they prevent avoidable complications), but not for the things they cannot (eg, the services ordered by other physicians for different health problems, increases in the prices of drugs they prescribe).
3. Improve Payment for Specialty Care, Primary Care, and Inpatient Procedures
Most payment reforms to date have taken 3 forms: primary care medical homes, bundled/episode payments for inpatient procedures, and accountable care organizations (ACOs). Although high-quality primary care, inpatient surgeries, and care coordination are essential to higher-value healthcare, the majority of services are delivered outside of inpatient settings and by specialists, not primary care physicians. Not every acute condition is something that good primary care can prevent, and the mere fact that services are more “coordinated” does not mean they are achieving the highest value.
Although a majority of healthcare spending is associated with a small proportion of patients who have multiple health problems or require very expensive services, most patients receive healthcare services for individual problems. Every patient deserves high-quality, affordable care, and for many patients, that care will be delivered by a specialist in an outpatient setting, not by a primary care physician, a hospital, or a care manager employed by an ACO.
In order to deliver higher-value care, the barriers that specialists face under the current payment system must be removed. Primary care medical homes and surgical episode payments are not readily adaptable to most types of specialty care,3 and it is neither necessary nor desirable to force every patient to be part of a large ACO in order to receive better care. Appropriately designed APMs are needed in every specialty so that all patients can benefit from higher-value care.4
4. Allow Flexibility to Customize Service Delivery Approaches to Local Resources
The significant variation in care delivery within and across regions has been well documented. Much of this variation is avoidable and represents an important opportunity for physicians to improve quality and reduce costs under an APM. However, some of the variation reflects fundamental differences in the resources that communities have available to deliver care. A patient who has an acute stroke may be managed by an internist, neurologist, intensivist, or stroke specialist depending on where that patient lives; similarly, patients with back pain may be managed by internists, physiatrists, pain management specialists, or spine surgeons in different communities. Local regulations, workforce capacity, disease epidemiology, and patient expectations significantly impact how care must be delivered.
To be successful, APMs must allow flexibility in the types of services to be delivered and the types of providers who can deliver those services. Success should be measured based on outcomes, not on adherence to 1-size-fits-all standards for structure or processes, and performance benchmarks must reflect differences in the costs and outcomes that are achievable in rural areas, inner-city communities, and so on.
5. Minimize Administrative Burden
The complexity of current payment models and the systems used to administer them have significantly increased the costs of healthcare in the United States without corresponding improvements in outcomes. APMs represent an opportunity not only to improve care delivery, but to eliminate unnecessary administrative burdens. Just as care delivery should be redesigned to eliminate waste, no administrative requirements should be included in APMs unless the likely benefits will significantly exceed the costs.
Conclusions
By encouraging APMs, MACRA provides an unprecedented opportunity to encourage innovations in care delivery. However, just because a payment model is different does not mean it will be better. The success of APMs will depend heavily on how they are designed and implemented. We believe that these 5 principles can guide the development of APMs that enable better outcomes for patients at a more affordable cost and that physicians can enthusiastically support.
