APRIL 16, 2020

Welcome to the Pay for Performance Update eNewsletter
Editor: Philip L. Ronning
This issue is sponsored by the National ACO Summit, the National Bundled Payment Summit,
the National Medical Home Summit, National MACRA MIPS/APM Summit,
and the National Medicare Advantage Summit

What Will U.S. Health Care Look Like After the Pandemic?
Even the most vocal critic of the American health care system cannot watch coverage of the current Covid-19 crisis without appreciating the heroism of each caregiver and patient fighting its most-severe consequences. Hospitals are being built in parks and convention centers, new approaches to sterilizing personal protective equipment (PPE) for reuse are being implemented, and new protocols for placing multiple patients on a single ventilator have been developed. Most dramatically, caregivers have routinely become the only people who can hold the hand of a sick or dying patient since family members are forced to remain separate from their loved ones at their time of greatest need. Amidst the immediacy of this crisis, it is important to begin to consider the less-urgent-but-still-critical question of what the American health care system might look like once the current rush has passed. In particular, what can the system learn from the existential challenges it faces due to the spread of Covid-19? A few broad lessons are already emerging. (Harvard Business Review, April 7, 2020)

When It Comes To Health Data, Should We Value Privacy Over Innovation?
Readily accessible health data -- the promise created by shared electronic health records (EHRs) between clinicians and facilities -- can improve the speed and effectiveness of patient care. Beyond that, the ability to synthesize and analyze that data has important implications for research and public health and has spurred innovations throughout healthcare. Unfortunately, news reports about federal lawsuits against manufacturers who covered up flaws and rushed low-quality products to market to chase $38 billion in federal subsidies highlight the potential for harm when the primacy of patient data is forgotten or given short shrift. In fact, the desire to prevent sheer confusion from occurring may be part of the recent decision to delay the long-planned release of Cerner -- the electronic medical record to link the vast Veterans Health Administration. The actual reasons have been debated, but in the long run, the decision may prove to be the safest decision for veterans in that system, the largest integrated healthcare system in the world. (Forbes, April 7, 2020)

Population Health Management Market key Vendors, Trends, Analysis, Segmentation, Forecast to 2014-2025
A rapidly changing healthcare landscape is on the horizon with a shift from fee-for-service to value-based care delivery. The rise in healthcare costs is responsible for low wage growth, savings, and reduction in global competitiveness. As measures for rising healthcare costs is gaining momentum, population health management is an increasingly feasible plan to control healthcare costs. Population health management is considered to be the most efficient and cost-effective way to manage chronic conditions across patient populations. The advantage of the PHM system is that it offers a well-managed partnership network to provide actionable analytics for providers, and offers the ability to manage multiple lines of business on a single platform. As the complexity in payment models, care delivery models and clinical needs are increasing on daily basis, the requirement for a PHM system is rising across the globe. In addition, public and private policymakers across the globe are introducing disease management programs in order to assist in the treatment of chronic illnesses. Such multidisciplinary efforts are anticipated to support the demand for PHM industry over the forecast period. Furthermore, with its potential for cost-effective and patient-centered care, PHM holds the promise of being the next revolution for quality medical delivery. On the flip side, lack of efficient healthcare IT infrastructure in developing regions will limit the industry growth to some extent. (MarketWatch, April 8, 2020)

Evidence of Upcoding in Pay-for-Performance Programs


Recent Medicare legislation seeks to improve patient care quality by financially penalizing providers for hospital-acquired infections (HAIs). However, Medicare cannot directly monitor HAI rates and instead relies on providers accurately self-reporting HAIs in claims to correctly assess penalties. Consequently, the incentives for providers to improve service quality may disappear if providers upcode, i.e., misreport HAIs (possibly unintentionally) in a manner that increases reimbursement or avoids financial penalties. Identifying upcoding in claims data is challenging due to unobservable confounders (e.g., patient risk). We leverage state-level variations in adverse event reporting regulations and instrumental variables to discover contradictions in HAI and present-on-admission (POA) infection reporting rates that are strongly suggestive of upcoding. We conservatively estimate that 10,000 out of 60,000 annual reimbursed claims for POA infections (18.5%) were upcoded HAIs, costing Medicare $200 million. Our findings suggest that self-reported quality metrics are unreliable and thus, recent legislation may result in unintended consequences.

(Harvard Business Review, March 2019)

Study Finds Diabetes Pay-for-Performance Program Reduces All-Cause Mortality
Diabetes pay-for-performance (P4P) programs may reduce all-cause mortality in patients with type 2 diabetes (T2D), according to a recent study. The study, published by Medicine, assessed the effect of a diabetes P4P program on all-cause mortality in patients with newly diagnosed T2D. The researchers recruited 5478 patients with T2D enrolled in the P4P program within 5 years after a diagnosis of diabetes between January 1, 2002 and December 31, 2010. Patients not enrolled in the P4P program were also recruited as the control group. In P4P payment models, providers, care organizations, and other healthcare stakeholders are given incentives for achieving performance objectives. Programs within the model, also known as value-based purchasing, are supported by leading insurance providers in Medicare and Medicaid as it promotes a culture that rewards providers for efficiency and penalizes high costs, poor patient outcomes, and medical errors. "Previous studies have reported that patients enrolled in P4P programs had better adherence to the guideline-recommended examinations, had better clinical processes of care (e.g. HbA1c) and intermediate outcomes, decreased diabetes-related hospitalizations and inpatient costs, but increased rates of severe hypoglycemia requiring emergency medical care and increased outpatient expenses due to more regular follow-up visits," the authors said. "Patients with type 2 diabetes are associated with a two-fold increase in mortality and a reduction in life expectancy by about 6 years compared with individuals without diabetes." The effect of the P4P program and adherence on all-cause mortality was evaluated using multivariate Cox proportional hazard models analysis, showing that a total of 250 patients had died in the P4P program group, compared with 395 in the control group (mortality rate 104 vs 169 per 10,000 person-years, respectively, P < .0001). Additionally, the control group had more comorbidities. (American Journal of Managed Care, March 23, 2020)

GP (in UK) Pay for Performance Framework Suspended
The NHS is "reviewing and where appropriate temporarily suspending certain requirements on GP practices and community pharmacies," according to operational guidance issued in a letter from NHS chief executive Sir Simon Stevens and chief operating officer Amanda Pritchard on Tuesday. These will include the QOF incentive program, HSJ understands. GPs will continue to receive the income from the QOF scheme "if other routine contracted work has to be substituted", the guidance said. This is one of several measures being taken by the NHS so it can "devote maximum operational effort to Covid-19 readiness and response". GPs have been calling for the NHS to suspend the scheme because it comes with time-consuming paperwork and obliges GPs to provide care which could be deemed superfluous in light of the current health crisis, including sometimes bringing people to the surgery, which has an infection risk. The operational guidance also said remote GP appointments should be rolled out to the elderly and vulnerable "as priority" to help with the medical response to coronavirus, according to NHS leaders. It said vulnerable patients who are expecting to have routine or planned GP appointments should have access to either video, phone, email and text message consultations. The letter adds that once the elderly and vulnerable have been set up, the focus should turn to extending digital services "to cover all important routine activity as soon as possible". Face-to-face appointments should only happen "when absolutely necessary". The letter states: "David Probert, chief executive of Moorfields Foundation Trust, is now leading a taskforce to support acute providers rapidly stand up these capabilities, with NHSX leading on primary care." (Health Service Journal, March 17, 2020)

Better Data Sharing Between Payers, Providers can Move the Needle on Social Determinants of Health
Healthcare has a data problem. Sure, there's more of it now than ever -- claims data, clinical data and social determinants of health data are all becoming ubiquitous. But sometimes the information isn't gathered, collated and shared in a robust and efficient way, and when it comes to social determinants specifically, this can be bad news for patients. Social factors play a huge role in outcomes, and yet health plans and providers often don't have all the data at their fingertips. Social determinants are any societal or life-related factors that can impact a person's health, whether they be income level, access to transportation, food insecurity or other issues. Understanding these factors is an increasingly critical component of delivering quality care, which in a value-based world can translate directly into consumers' perception of a brand. In that sense, integrating SDOH data in a meaningful way is as much a business consideration as one of care. Jason Cooper, Chief Analytics Officer of population health at pop-health analytics company HMS, said social determinants have as much of an impact on health as genetics. According to Cooper, there are five main social determinants that pose the biggest barriers to patients receiving top-shelf care. Economic stability is a big one, since the risk of having a chronic health condition is highest among those with a low income. The individual's neighborhood can also be a barrier, with crime rates, walkability and ease of access to the healthcare system all factoring into their likelihood of getting the care they need. (HealthcareFinance, March 24, 2020)

Measuring the Value of Care Management: Five Tools to Show Impact

When care management programs fail, it's rarely because they're ineffective. Most likely, it's because health systems don't have an accurate way to measure care management's success and, therefore, don't fully understand (or communicate) its impact on outcomes improvement or cost savings. For care management programs to be successful and demonstrate their value around critical metrics, such as readmissions, health systems need effective technologies and tools that leverage data to give leaders visibility into care management's processes (e.g., how it identifies high-risk and rising-risk patients and assigns them appropriately to care managers) and overall impact. This article explains the challenges health systems encounter when it comes to demonstrating and understanding the measurable value of their care management programs, and how analytics-driven applications can help prove care management's positive impact on outcomes.

This article concludes with the summary Power Point found below.

(HealthCatalyst, April 12, 2020)

Pay for Performance Update e-Newsletter is one of a family of free e-Newsletters providing a complimentary video presentation and regularly updated news and key resources on major health care issues such as ACOs, comparative effectiveness, patient safety, bundled payment, readmissions, and Medicaid. To view and subscribe to other e-Newsletters go to www.HealthCareeNewsletters.com.

Applications of Health Information Technology that Lower Healthcare Costs and Improve Quality
Presented by Stanford Clinical Excellence Research Center

Nick Bott, PsyD
2016-17 Design Fellow, Associate Fellowship Director, Stanford Clinical Excellence Research Center, Palo Alto, CA

Natalia Leva, MD
Design Fellow, Stanford Clinical Excellence Research Center, Palo Alto, CA

Dr. Clare Purvis, PsyD
Design Fellow, Stanford Clinical Excellence Research Center, Palo Alto, CA

Francesca Rinaldo, MD, PhD
Associate Director, Healthcare Design Fellowship, Stanford Clinical Excellence Research Center, Palo Alto, CA

Anoop Rao, MD
Design Fellow, Stanford Clinical Excellence Research Center, Palo Alto, CA

Courtenay Stewart, MD
Design Fellow, Stanford Clinical Excellence Research Center, Palo Alto, CA

Terry Platchek, MD
Fellowship Director, Stanford Clinical Excellence Research Center, Vice President, Performance Improvement, Stanford Children's Health, Palo Alto, CA (Moderator)