Here are the 17 Recommendations the Summit participants arrived at during the National Payment Reform Summit. We hope you use them to facilitate dialogue in your region and communities, and that collectively we keep the conversations going. Together we are stronger than we are individually.
Issue Area: How should healthcare payment systems be designed to support efforts to prevent disease, slow the progression of disease, and encourage healthy lifestyles that achieve results in future years?
Consider creating a separate pool of protect resources for high-value preventive services:
- To protect from underfunding within APM; and
- To pay for community-provided services (e.g. flu-shots, mold mitigation)
Incorporate outcome-based population health measures into risk-adjusted payment models for defined population.
- Community determines priorities via multi-stakeholder group;
- Needs to reflect community and population priorities;
- Measures focus on high-value preventive services; and
- Caution about focusing only on “evidence-based” measures
Issue Area: How can payment systems be designed to support coordinated team-based approaches to care involving multiple specialties and multiple types of providers? How should individual providers be compensated inside bundled payment, episode payment and global payment models?
Prospective global payments for episodes within global model of accountability for total costs
- From procedure to condition to population
- Must measure quality, cost and appropriateness
- Quality must include patient voice as measured by CAHPs, PROs and named (i.e., documented) patient goal
- Must include shared decision-making
- Vigorous risk-adjustment by patient
- “Quarterback” must be defined that may or may not be a physician
- Should include stop loss for outliers
- Measures of quality and cost must be transparently reported
- Pay for care coordination as part of quality
- Continue to pay primary care providers to coordinate care and to eliminate low value care
- Local entity determines the distribution of payment
Issue Area: What mechanisms should be used in payment systems to protect providers from excessive financial risk and to protect patients from under-treatment and loss of access to care?
- Limit provider risk for service costs that are outside provider control or influence.
- Use evidence-based guidelines or pathways, where appropriate – and make effort to develop both.
- Collect and report data on patient outcomes.
- Insure adequate payment to support delivery of care based on best evidence available by factoring into the payment (in some fashion):
• Cost of infrastructure
• Cost of reinsurance
• Stratification by patient characteristics [e.g., behavioral, social info + claims + clinical] if it matters and is cost effective
• Mechanism for adjustments reflecting geographic & market differences
Issue Area: How should payment systems be structured to provide adequate support for hospitals’ essential services and medical education costs while encouraging fewer hospitalizations and fewer hospital-based services?
Make payments to support hospital medical education programs, including healthcare professional training, directly rather than as add-on payments for inpatient admissions.
Create a new facility designation supported by CMS and develop a payment model that offers less than current suite of hospital services (e.g. a small hospital that should not do some services should not be incentivized to continue to offer them because they are a “hospital”)
Create a risk adjusted condition-based and global payment systems that enable a community/regional centered model that is based on a financial mechanism that encourages, and legally enables, competing facilities and providers to cooperate to deliver clinically, integrated care. Phased-in, clinically driven approach.
Issue Area: What data and analyses do providers and purchasers/payers need in order to develop and implement a successful payment model, and how should these data and analyses be provided and financed?
Require physicians have access to information on the amounts payers and patients pay for services.
Require all electronic health record systems to support the creation of custom fields and support the use of data retrieval and analysis with incentives for infrastructure for linking data and penalties for vendors that block data
Require external validation/audit for all reporting entities.
Actively seek funding to link Qualified Entities and Qualified Clinical Data Registries and patient-reported outcomes with attention to responsible use
- All payers for all data
Create valid, reliable, and standardized risk stratification methodologies
Issue Area: What changes in patient benefit designs are needed to support successful payment reform?
APM entities should have the flexibility to provide financial and non-financial incentives for patient adherence to a care plan, including:
- Shared decision-making up front
- Continuity of relationship between the provider and patient is incented
- Education and access to information for patients so they can make informed decisions and fulfill their end of the bargain
- Each part of the health care system plays a role in a continuous message to the patient
Transparency of quality performance information on providers
- Patients need to be informed as part of decision making
- Providers and plans need greater communication on data intelligence and context
- Quality of data to improve over time
- Importance of risk adjusting
Issue Area: What temporary modifications are needed in payment structures, payment amounts, performance metrics, etc., to encourage and facilitate providers and payers to make the transition to improved payment systems?
Implement APMs using multi-year contracts.
- Provide claims data, basic analytic and data-merging tools and/or technical assistance & benchmarks at no cost to providers to transition to APMs.
- Remove regulatory barriers to change.
- Insure clinical data sharing (interoperability) & provision of action tools.
- Insure that EMRs provide template for all CMS/private payer quality measures.
- Align incentives/measures across providers.
- Permit new codes, such as bundled CPT codes, for high value services.
Issue Area: How should payment systems be structured to support adequate and appropriate care for patients facing non-medical challenges as well as health problems?
Flexible payment that is budget neutral, to medical services providers, that allows the flexibility to pay for “near-health” solutions (e.g. air conditioners, ramps). Performance measures should allow flexibility on the basis of the value of outcomes including those beyond healthcare spending and on a multi-year basis.
- ½ agreed that direct payment could be to social service agencies; disagreement centered around accountability
Create community based health authorities to assume responsibility for improved, locally tailored outcomes that include social determinants of health.
- No insurance risk, just performance risk