D RISCOLL C HILDREN S H OSPITAL Presents: H EALTH C ARE R EFORM AND - - PDF document

10/5/2015 1

DRISCOLL CHILDREN’S HOSPITAL

Presents:

HEALTH CARE REFORM AND VALUE BASED PURCHASING WHAT DOES IT MEAN FOR YOU?

Mary Dale Peterson, MD, MSHCA Mary.peterson@dchstx.org

• Rewards (or penalizes) hospitals for the quality of care they

provide

• Established with the Affordable Care Act for Medicare in 2010
• An external motivator for providers to lead re-engineering of

health care delivery

• Part of the plan to implement the Triple Aim
• Improve patient experience, including quality and

satisfaction

• Improve the health of populations
• Reduce per capita cost of healthcare

What Is Value Based Purchasing?

10/5/2015 2 What Is The Cost Of Health Care In The US?

a) 10% of GDP? b) 14% of GDP? c) 18% of GDP? d) 20% of GDP

U.S. Healthcare Spending On Track To Hit $10,000 Per Person This Year

Forbes

• Jan. 4, 2015

What Are Our Outcomes For Our Spending?

U.S. Healthcare Ranked Dead Last Compared To 10 Other Countries’ Healthy Lives: The U.S. ranks last overall with poor scores on all three indicators

• f healthy lives — mortality amenable to medical

care, infant mortality, and healthy life expectancy at age 60. (The Commonwealth Fund)

10/5/2015 3 How is Texas Medicaid using VBP?

• Penalties for Potentially Preventable Readmissions

within 15 days

• Normal Newborn
• Bronchiolitis and RSV Pneumonia
• Appendectomy
• Penalties for Potentially Preventable Complications
• UTI
• C. Difficile Colitis
• Moderate Infections
• Accidental Puncture/Laceration during Invasive Procedure
• Acute Pulmonary Edema
• 1-2.5% reduction in payments for PPR and

PPC

• These are additive
• These apply to all Medicaid payments, not

just a reduction in the payments for PPC and PPR

What Are The Penalties?

10/5/2015 4 How Does This Apply To Me?

• Quality of Care
• Prevention of infection
• Using “bundles”
• HANDWASHING
• Preventing bedsores
• Patient Education especially in discharge

planning

• Coordination of care for outpatient services after

discharge

What Is An APR-DRG?

• All Patients Refined Diagnosis Related Groups (APR DRG) is a

classification system that classifies patients according to their reason of admission, severity of illness and risk of mortality

• Is a bundled payment- different from our prior payment

methodology which was more fee for service

• The APR-DRG has an average length of stay
• The weight of the APR-DRG is multiplied by the Standard Dollar

Amount to determine payment

• If the patient can be treated in a more timely manner or using

less resources, the hospital will have more “margin”

1115 Waiver And DSRIP

10/5/2015 5 1115 Waiver

• The waiver allowed expansion of managed care

in Texas

• This is a Federal matching program thru CMS
• Unfortunately, expansion of Managed Care

would decrease UPL Payments so this waiver allows for hospitals to potentially keep this money

• Uncompensated Care Pool (UC)
• Delivery System Reform Incentive Payment (DSRIP)

10/5/2015 6 DSRIP

• 5 year contract
• We are in 5th year
• Eventually the Dollars by the 5th year will be

divided 50/50 between UC and DSRIP

DSRIP

• 5 year contract
• We are in 5th year
• Eventually the Dollars by the 5th year will be

divided 50/50 between UC and DSRIP

Why Is Oral Health Important?

Oral Health is Critical to Overall Health

• “You are not healthy without good oral health…”
• C. Everett Koop
• Dental care is the most common unmet health need
• Oral disease can severely affect systemic health
• Profound disparities in oral health and access to care at

all ages

• Much oral disease is preventable

10/5/2015 7

• Pain, infection, tooth loss
• Impaired chewing &

nutrition

• Systemic complications
• ER visits, hospitalizations,

surgeries

• Extensive and costly dental

treatments (OR $5,000+)

• Missed school and work
• 52 million school hours lost/yr.

Consequences of Untreated Oral Disease Oral Health: More Than Teeth

• Patient perspective
• Aesthetics
• Self-image
• Social interaction
• Professional perspective
• Chewing
• Speech
• Complications

Prevalence Of Oral Disease

• Severe gum disease affects 19% of adults aged

25-44

• 30,000 oral cancers diagnosed annually; 8000

die

• Dental caries most common chronic disease of

childhood

• 5 times more common than asthma
• 50% in low income children- up to 70% in Native

Americans

10/5/2015 8

Early Childhood Caries And Its Consequences

Early Childhood Caries

• Early Childhood Caries (ECC)
• Infectious and transmissible
• Destroys tooth structure
• Affects children under 5
• Previously called “Nursing

Caries” and “Baby Bottle Tooth Decay”

ECC: Consequences

• Pain
• Infection
• Increased caries in permanent

dentition

• Impaired chewing and nutrition
• Below average weight gain
• Poor self esteem
• School/work absences
• Extensive and expensive dental

work

10/5/2015 9

This Is Our Goal! Caries Progression

• ECC affects the teeth that

erupt first and are least protected by saliva

• Upper incisors
• First molars
• Second molars
• ECC can begin when teeth first

erupt

• ECC rarely affects the lower incisors

Early Caries

10/5/2015 10 Moderate Caries Severe Caries

• Emphasis:
• Early oral examination
• Nutritional counseling
• Education on oral health care
• Application of fluoride varnish on “baby teeth”

“Healthy Smiles” Program Model

10/5/2015 11 Fluoride Varnish Goals

• Increase the number of providers

certified by 25

• Increase the number of infants/children

receiving treatment by 35% over baseline

• Decrease the number of children

requiring OR intervention

Oral Health – RHP4 Oral Health – RHP4

10/5/2015 12 Costs Per Member Per Year for Oral Rehab Measure, Measure, Measure

“My Plan To Fix The World’s Biggest Problem: *Measure Them!”

Bill Gates - Wall Street Journal

• Jan. 27, 2013

Closing Remarks

We must decide what our goals are, how to measure, and then use teamwork to achieve them. Ultimately, it’s all about our patients- How can we provide the best care that is accessible to all? We are the solution to improve care at a lower cost.

10/5/2015 13

THANK YOU!