HI-FIVE (Health Informatics For Innovation, Value & Enrichment) Training is a 12-hour online course designed by Columbia University in 2016, with sponsorship from the Office of the National Coordinator for Health Information Technology (ONC). The training is role-based and uses case scenarios. Also, it has additional, optional modules on other topics of interest or relevance. Although we suggest to complete the course within a month's timeframe, the course is self-paced and so you can start and finish the course at anytime during a month's time period. No additional hardware or software are required for this course. Our nation’s healthcare system is changing at a rapid pace. Transformative health care delivery programs depend heavily on health information technology to improve and coordinate care, maintain patient registries, support patient engagement, develop and sustain data infrastructure necessary for multi-payer value-based payment, and enable analytical capacities to inform decision making and streamline reporting. The accelerated pace of change from new and expanding technology will continue to be a challenge for preparing a skilled workforce so taking this training will help you to stay current in the dynamic landscape of health care. This course is one of three related courses in the HI-FIVE training program, which has topics on population health, care coordination and interoperability, value-based care, healthcare data analytics, and patient-centered care. Each of the three courses is designed from a different perspective based on various healthcare roles. This first course is from a clinical perspective, geared towards physicians, nurse practitioners, physician assistants, nurses, clinical executives and managers, medical assistants, and other clinical support roles. However, we encourage anyone working in healthcare, health IT, public health, and population health to participate in any of the three trainings. If you would like to obtain continuing medical education (CME) or continuing nursing education (CNE) credits, you will need to have eligible credentials, complete the entire course, and complete the evaluation survey at the end. The HI-FIVE team verifies after each month that these requirements have been met and then a separate certificate (fee may apply) is distributed to you from our accreditation office. Please allow time for processing. If you have any further questions about continuing education, please see our website at www.hi-fivetraining.org. Accreditation Statement The College of Physicians and Surgeons of Columbia University is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. AMA Credit Designation Statement The College of Physcians and Surgeons designates this enduring material for 12.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The planning committee members are: Rita Kukafka, DrPH, MA, FACMI; Bruce Forman, MD; Gil Kuperman, MD, PhD; Virginia Lorenzi, MS, CPHIMS, FHL7, and Victoria Tiase, MSN, BN. None of the members of the committee, who planned this CME Activity, have any relevant financial relationships to disclose. The release date is 2/1/17 and the expiration date is 1/31/18. This activity is eligible for 12 continuing nursing education (CNE) credits. Columbia University School of Nursing, Continuing Nursing Education Program is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Contracts and Payments: Overview
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來自 Columbia University 的課程
HI-FIVE: Health Informatics For Innovation, Value & Enrichment (Clinical Perspective)
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Columbia University
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Role-Based Content (OPTIONAL) - Physicians / Nurse Practitioners / Physician Assistants / Clinical Executives / Clinical Managers / Public Health Professionals
This module is optional, but has additional topics that you may be interested based on your role. We encourage you to explore any of these topics and there are also quizzes to test your learning.
與講師見面
Rita KukafkaAssociate Professor
Biomedical Informatics
Welcome to Value-Based Care, Contracts and Payments.
This is lecture a, overview of contracts and payments.
This lecture provides an overview of alternative payment model contracts.
By describing their general elements,
discussing how risk calculations can impact them.
And describing the information required for successful contract negotiation.
The learning objectives for this lecture are to
discuss general elements of alternative payment model contracts,
articulate how risk calculations can impact contracts, and
outline essential data elements and uses during contract negotiations.
This unit discusses contracts that enable parties to work together
to implement new care models.
It covers how contracts are developed and
negotiated including common elements that make up value-based contracts.
Characteristics of successful contracts and
less successful contracts are contrasted.
No legal advice is provided in this training.
Users who need legal advice should consult their counsel.
During the contracting process, parties should develop and
document a shared understanding of the required work.
Who will do what work, how the work will be evaluated, and how risks and
rewards will be allocated.
By developing clear agreement,
parties can decrease the chances of misunderstandings and disputes.
To prepare for value-based contracting, the parties need to understand their
own readiness to participate and the risks they're ready to take on.
The risk's associated with serving a patient population,
involves numerous variables.
A useful definition of risk and risk tolerance
appears in value-based contracting by Kaufman Hall and Associates.
In the value contracting context, risk is incurred through acceptance
of a fixed dollar amount in exchange for the partial, or total care,
of an identified patient population at a specified quality level.
As defined through a contract.
Risk represents the uncertainty about whether after incurring the care provision
cost, the organization will have a net gain or net loss from this arrangement.
Tolerance reflects the organization's capacity to carry the risk
without endangering its strategic operational or financial performance or
a combination there of, to an extent defined by the organization.
Before beginning contract negotiations, each party should consider and
understand the role or
roles that it is prepared paired to play in the value-based care model,
as well as the contractual arrangements that make sense for it, and how it will
work with the other organizations in the value-based arrangement.
Parties that fail to engage in these assessments
are more likely to encounter difficulty during negotiations.
Or to find themselves facing unexpected problems during performance of a contract.
For a party to assess risks they first need to understand their strengths and
weaknesses, risk tolerance and goals.
Some of the topics to evaluate include the following, each party should
assess the successes and the challenges it faces in its current operations.
As well as any gaps it would need to fill,
in order to successfully participate in a value-based model.
Because addressing any identified gaps demands resources
the organization should plan for how it would ad or shift resources and
how long any changes would take.
To assess the risks and
potential returns of a value-based arrangement hospitals health systems and
providers should develop and accurate understanding of their cost of care.
Of course, this information may be difficult to develop, and
many providers cannot accurately calculate their current costs.
Recently, a survey by the Health Information Management System Society or
HIMSS, found that only three percent of respondents
felt their organization was well-prepared to move to a value-based payment model.
And fewer than a third of respondents were able to produce profit margin and
cost of care data in an automated way.
The parties need to assess their own financial position and
how much risk their organization is prepared to accept.
To understand how they maybe affected by potential contractual terms, organizations
should develop financial scenarios for their potential costs and savings.
Each organization considering value-based contracting needs, it's leadership and
financial teams to carefully consider these issues.
Each party needs to consider how value-based approaches fit in to it short
and long-term goals and
identify it's goals for participation in value-based payment models.
An organization should consider what role it can successfully play in a value-based
contract arrangement.
To position itself for success, an organization
also may engage in process improvements as part of its preparation for contracting.
Each party should also evaluate the other organizations proposing to participate in
the value-based contract.
If a party has established relationships with the other organizations,
it should identify and address any problem areas.
When a party will be working with other organizations for
the first time it should evaluate that organization to understand the feasibility
of forming good, trusted relationships.
Each party should assess existing capabilities to share data among
participating organizations.
Make no assumptions about what data will be available and easily used.
Among the questions to consider are what do electronic health record or EHR,
health information exchange or HIE, population health, customer
relationship management and analytics capabilities do the organizations have?
To what extent are those systems interoperable?
What privacy and security concerns need to be addressed for
the organizations to share data?
How prepared are the organizations to produce timely reports and
dashboard information so that providers can do targeted quality improvement?
If the parties are planning to use care coordinators or
patient navigators as part of a care management strategy,
what information do they need to access and how will they access it?
Does each participating organization have consistent billing and
coding capabilities, sufficient to produce needed data?
The parties also should assess the compatibility of all participants needs
and goals.
If there are areas of conflicting goals they should evaluate their ability to
compromise to promote mutual success.
And the party should evaluate whether additional roles need to be filled
to make the model successful.
If there are gaps, and the party should consider whether they will need to bring
in any additional organizations, or whether participating organizations may
add stuff or contracted support in considering participation in a value-based
arrangement, the experience represented by the participants can be a success factor.
Among medicare Accountable Care Organizations or ACOs for
example, some data suggests that increased experience with value-based payment.
Was associated with a greater likelihood of positive financial outcomes.
In considering participation in a value-based arrangement and
what level of risk to assume, it is critical for
the parties to know as much as possible about the patient population.
Obtaining the desired data, however, can be difficult.
No single party is likely to have comprehensive data, and
there may be challenges in sharing data.
Organizations may collect different data elements and format data differently, so
combining data across sources often is difficult.
The parties should start early to identify data sources and
evaluate the available data.
First, it is important to know the number of patients to be covered by a proposed
contract and the geographic area to be served.
Understanding the patient attribution methodology is also important.
Next, the parties should evaluate the population's health and
the services currently used and projected to be needed.
This evaluation may include questions about the population's age and
sex, disease prevalence, and severity and utilization patterns.
Social determinants of health factors such as income, education,
employment, and geographic hotspotting.
Cost burdens such as high co-pays that could cause patients to avoid or
delay seeking care.
Depending on the type of value-based arrangement being considered,
the parties also may assess their capacity to minimize the rate at which patients
seek care outside the network.
For example, if the parties are considering an ACO arrangement and
evaluating their ability to control the total cost of care, they should consider
how often patients are likely to seek care outside the ACO network and
how they might be encouraged to seek care within the network.
The parties should also evaluate how out-of-network referrals will be handled
under the potential contact.
For example, the parties should consider will out-of-network
referrals be treated differently depending on whether the referral is
needed because of an access issue for timely appointments, as supposed to be
needed because of a complex medical issue requiring a particular specialist?
Does the contract measure timeliness for referral appointments?
If a patient who is covered under a value-based contract goes to a provider
that is listed in-network on the plans provider directory, but
that listing is incorrect, how will the visit be covered?
Will the patient be liable for the added expense when the directory is not correct?
Are there any services that need to be carved out of the agreement?
The risks an organization is willing to tolerate depends on its position and
goals.
Each organization should be prepared for a range of scenarios,
including the possibility of multiple risks occurring at the same time.
The assessments the parties do while preparing for
contracting helps them understand the resources that are in place so
they can evaluate the likelihood that they, and other participating
organizations, will be able to meet all the contractual obligations.
They should also assess opportunities to mitigate risks, and
the possible consequences of any failure to meet obligations.
To understand risks related to contractual obligations, the parties
will ask questions, such as, will the right care be delivered to the patients?
What is the capacity of the provider network,
including the number of providers and their specialties?
What size of patient panels will providers be responsible for?
Will administrative functions, including staffing, coding, and
contract administration, be properly done?
To evaluate actuarial risks, the parties need to understand the patient
population's needs and the cost to meet those needs.
As noted earlier this includes questions about the population's health and
expected utilization, as well as the costs of delivering care.
Each party also needs to assess its own financial position under different
assumptions, in case its estimates of costs turn out to be incorrect.
For organizations such as hospitals and health systems, that often do not have
actuaries on staff, it maybe prudent to obtain outside help with this analysis.
Transitioning to a value-based model can demand a lot of organizational resources.
Each organization must consider how other organizational priorities are affected
when staff time and other resources are focused on the value-based arrangement.
As the parties move from pre-contracting assessments into contract negotiations,
they need to address multiple issues.
Contracts should clearly lay out the obligations of each party.
In a value-based arrangement with multiple participants, it is important to identify
all of the participants and their roles and responsibilities,
including administrative, governance, data sharing, which should address content,
frequency and timeliness, delivery of patient care and quality.
This is a rapidly changing environment, and
different models are being explored around the country.
The contract should include provisions for
decision-making needed to address changing conditions.
Establishing a process may enable parties to avoid later problems.
For example, an organization that withdrew from participation in a pioneer ACO,
observed that its model was not flexible enough to respond to changes that occurred
when the participating organization expanded, and
essentially doubled the ACO's size.
The parties should work closely with their legal counsel to assure that
the value-based arrangement complies with applicable laws and regulations.
For example, in a bundled payment arrangement, there may be the need for
a hub for a distribution of payments to the individual providers.
In the case of an ACO, or
a ACO-like arrangement, administration may be especially complex,
involving a separate legal entity with particular governance provisions.
Counsel can help the parties structure their arrangements to be consistent with
antitrust and other legal requirements.
The contract also needs to be clear about the population to be served,
including who is in the population, the geographic area and
how patients will be attributed to providers.
The Health Care Transformation Task Force's key elements to consider in ACO
agreements notes the primary objective of any attribution model
should be to allow patients to become active participants in their care,
while enabling providers to be held accountable for the appropriate patients.
The contract also should specify the contract performance period.
A longer performance period allows the parties more time to work through initial
set up and move into actual performance under the contract.
A contract could specify an initial performance period and
potential extension periods.
In addition, in case there is need to end the contract early,
the contract should specify conditions in which a party might terminate the contract
before the end of the performance period, and
how the parties will unwind their agreement under those conditions.
Providers in a traditional fee-for-service, or FFS,
environment generally are paid for services as the services are delivered,
with the full risk of the cost of care assumed by the payer.
At the other end of the spectrum, in accountable care arrangements,
the providers bears at least some accountability to manage costs,
report quality metrics or achieve improved population health outcomes.
Across the spectrum of value-based arrangements, there are a number of
different ways the contract can specify payment and allocate financial
responsibilities among purchasers, payers, providers and patients.
The parties to a value-based payment contract
must come to a clear understanding of payments and budgets,
including looking at opportunities to improve quality and decrease costs.
A value-based contract addresses how providers are paid and
provide meaningful incentives for improvement.
There is no simple answer about the level of payment incentives that motivate change
in how care is delivered.
In interviews of provider organizations that tied physician compensation to
performance measures in 2014, incentives to primary care physicians
were found to run from a low of 8.5% of compensation to a high of 60%.
Some organizations also included other types of incentives and
supports designed to tap into physicians' intrinsic motivations for patient care.
The parties need to agree on what services will be covered by the contract and
how payments will be made.
For example, a contract could include some value-based components
such as bundled payments for some services.
While other services maybe paid on a traditional fee for service spaces.
If bundled payments are used,
the parties need to define the covered episodes of care and the price.
Possibly incorporating factors such as the severity of the patient's condition.
In contracts where risk is shared, the party should determine whether limitations
will be included to protect parties from extreme outliers.
When savings are shared, there needs to be agreement about how the shared savings
will be allocated among the providers.
Who have contributed to the outcome for the patient.
Incremental strategies to increase value based arrangements may include a variety
of approaches such as incentives for meetings specified quality benchmarks.
Extra payments tied to specific activities such as payments to clinics that
are certified as patient centered medical homes.
Or payments for care coordination and management.
For example,
the chronic care management fee under the Medicare physician fee schedule, for
non face to face care coordination services that meet specified criteria.
For shared savings, the parties must decide how to share savings or
cost increases.
In an upside arrangement, providers share in savings of cost reductions but
are not financially responsible if costs increase.
In an arrangement including both upside and
downside risk, providers are also responsible for cost increases.
As explained, in Value Based Contracting by Kaufman, Hall and Associates.
In a shared savings contract with upside only arrangements,
hospitals and healthcare systems receive savings payments for efficiencies.
And benefit from decreasing the number of services,
while meeting measures of quality.
For providers to realizing a net gain, the savings payment must
offset the laws of revenue associated with decreasing the number of service units.
If the shared savings contract includes both upside and
downside arrangements which introduce risk.
Providers receive a savings payment if care is delivered efficiently, but
also receive a deduction if efficiencies are not realize.
If providers can not decrease cost, they lose revenue.
In capitation contracts, providers are paid on per member per month basis for
all of the cost of providing upon care.
If the cost of providing care to the members is higher than expected,
providers realize lower profits.
In partial capitation,
the agreed upon care could be limited to particular conditions or services.
In global capitation, the payments cover all of the care that the patient needs.
The parties could also draft a contract with financial structures to promote
greater efficiency over time.
For example, the Executive Director of the Healthcare Transformation Task Force
recommends whatever the financial structure of a contract is,
it should have two options available.
One model should be based on historical claims which is more effective for
moving high cost providers into structures that decrease cost.
The other model should be based on regional cost trends.
So providers can continue to become more efficient.
Ideally an ACO that starts in the first model
would shift to the second model over time.
Measuring performance is a key component of value based contracting.
And the parties need to agree on metrics and how they are produced.
To do so, the parties need to agree on how they will share and use data.
And maintain both confidentiality and data quality.
The parties to a value based contract need to select measures and
identify measurement periods.
Measurements should be relevant, evidence based and timely so
that the information provides a basis for action.
Alignment across other reporting requirements can help reduce the cost and
frustrations of reporting.
The parties may choose a measure set developed through an alignment process.
For example in February, 2016, the Core Quality Measures Collaborative.
Published version one of a consensus course set for
ACO, PCMH and primary care measures.
The set contains measures for cardiovascular care, diabetes.
Care coordination, indoor patient safety, prevention and wellness.
Utilization and cost and or overuse, patient experience,
behavioral health and pulmonary measures.
The set also lists future areas for measure development.
The parties might select other measures to address needs
of particular patient populations.
Depending on the measure selected, the parties could set measurement reporting
periods to align with other reporting requirements.
Setting targets is another essential element of measuring performance.
The party should come to agreement on the targets to be reached for
the agreed upon metrics.
The parties to a value based contract will want to explore the pros and
cons of different approaches and tailor the targets to their situation.
A fixed threshold target, where providers are rewarded for
achieving a set performance rate.
Provides clarity but may not motivate ongoing improvements.
Relative targets, that is metric scoring that compares multiple providers and
rewards some percentage of the top performers.
Such as the top 25% present other challenges and
often are disliked by providers.
Relative metrics can be difficult for providers
because they cannot tell in advance where they will fall in the rankings.
Also, if a measure has been unused for some time and is topped out or
nearly topped out.
There may not be a meaningful difference in performance between those who
are rewarded and those who are not.
Improvement targets where providers are measured against their past performance
may penalize those who performed well early.
Some approaches set multiple fix threshold targets.
So rewards are available on a continuum.
For example, Emory Healthcare Network uses a tiered incentive plan.
Where the bonus for
primary care physicians depends 10% on overall ACO performance.
20% on performance of the local health network against quality and cost targets.
And 70% on individual performance on approximately 25 metrics.
Finally, there should be a process for
data and information gathering in order to generate essential knowledge.
Again, this requires an understanding of the health IT infrastructure and data.
For example,
different organizations may have different policies on matching patients to records.
That is, determining whether Maria Garcia, who has an appointment with Dr.
Ann Nguyen today.
Is the same person who had an appointment with Dr. George Smith a year ago.
The parties need to think through how to match patients across different care
settings.
As well as their capabilities to attribute patients to providers for measurement.
To ensure that all parties have confidence in the measures,
the parties need to produce report that are timely and reliable.
And this requires setting standards for data elements and formats.
Timeliness and other processes to reduce administrative burdens.
As the parties look ahead to implementation of the value
based arrangements, a number of considerations arise.
High quality patient centered care should be at the heart of
any value based arrangement.
To support this kind of care,
the parties to the value based contract need strategies for coordinating care.
And ensuring communication among members of the patient's care team.
Including the patient and family members or friends selected by the patient.
The relationships among the participants in the value-based arrangement
are critical.
To work successfully over the long term,
the participants need good working relationships and trust.
In addition, for any value-based arrangement,
it is important to involve physicians and other clinicians in setting direction.
In early stages, clinician engagement includes involving physicians
to select measures that make sense.
Clinicians also need to be involved in determining the incentives that will
move the dial on quality improvement and
identifying when technical assistance will add value.
On an on-going basis, clinicians
need to be able to see the connections to the value based arrangement goals.
Among the tools to support value based arrangements, robust data and
health IT infrastructure are critical to manage population health
while ensuring high quality and keeping costs low.
Tools may include Electronic Health Records or
EHRs, Customer Relationship Management or
CRM tools, Risk Stratification Tools, Analytics and
Predictive Modelling, and Patient Registries and Population Health Tools.
Health Information Exchange or HIE Services which allow care teams to share
data and may include functionalities such as alerts to a care team in events
such as a patient being seen in an emergency department.
The parties also need to be ready to adapt in a changing environment.
Adaptability to changing targets and
a readiness to embrace innovation can help organizations thrive.
Organizations that remain stuck in their thinking or
approach may miss opportunities for improvement.
Negotiating a value-based contract may require shifts in thinking.
To begin with, each organization needs the buy-in and support of it's own leadership.
If an organization's leadership is still grappling with its strategic direction,
the organization may not be prepared to come to the negotiating table.
As the parties begin discussions, the negotiation teams should focus on
mutual long-term success, as opposed to an adversarial approach focused
on short-term gains for individual participants.
Because transparency and trust are key to long term relationships,
those qualities should be nurtured from the beginning of the party's interactions.
To help promote that approach, each party may consider the needs of the other
participants and where each organization can help reduce uncertainty or
ease administrative burdens.
In addition, the parties should evaluate the opportunities to lower costs
while improving quality.
For example, where can the parties work together to help hospitals and
providers avoid unneeded care, such as duplicative tests,
to adhere to best practices on over utilized services such as low
back imaging, to prevent hospital acquired conditions.
Participants in value base contracts should not fixate on maintaining
their current pricing, but instead should consider their profit margins and
financial sustainability in value based scenarios.
Each organization will want to include a number of skill sets and
perspectives in its negotiation team.
This includes contracting, legal and
regulatory, finance, quality management and improvement and clinical.
Remember that if physicians and other providers are not included, it will
be difficult to achieve buy-in among those who work most closely with patients.
For quality improvement work to succeed, clinicians must be actively engaged, and
have a feeling that the work is consistent with clinical realities, not a sense that
an initiative is being foisted on them or distracting them from patient care.
This concludes lecture A, Overiew of Contracts and Payments.
In this unit we described the process of preparing for contracting, contract
elements, thriving in a value-based system, and successful negotiation teams.
Through this overview,
you learned about general elements of alternative payment model contracts,
risk calculations affecting contracts, and finally, essential data elements and uses.
