Northwestern University Feinberg School of Medicine
Northwestern Memorial Hospital
DISCLOSURES •
Consultant/speaker/honoraria: none
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Editorial Boards: American Heart Journal, American Journal of Cardiology (associate editor); Circulation; Circulation-Heart Failure; JACC- Associate Editor, HF, (2014)
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Guideline writing committees: Chair, ACC/AHA, chronic HF; member, hypertrophic cardiomyopathy, atrial fibrillation; former member, ACC/AHA Guideline Taskforce; chair, methodology subcommittee
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Federal appointments: FDA: Chair, Cardiovascular Device Panel; ad hoc consultant; NIH former CICS study section; Advisory Committee to the Director; AHRQ- adhoc study section chair; NHLBI- consultant; PCORI- methodology committee member
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Volunteer Appointments: American Heart AssociationPresident, American Heart Association, 2009-2010; American College of Cardiology, Founder- CREDO
American College of Cardiology Oregon Chapter Symposium “How to Prevent Heart Failure Readmission”
Clyde W. Yancy, MD, MSc, FACC, FAHA, MACP Magerstadt Professor of Medicine Professor of Medical Social Sciences Chief of Cardiology Northwestern University, Feinberg School of Medicine & Associate Medical Director Bluhm Cardiovascular Institute Chicago, IL
[email protected]
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Let’s start with heart failure…
Stages, Phenotypes and Treatment of HF
Prevalence and prognostic significance of HF Stages
Survival (years)
Ammar et al. Circulation 2007; 115:1563
2
Stages, Phenotypes and Treatment of HF
Pharmacologic Treatment for Stage C HFrEF
Results: Mortality Reduction Based on Number of Guideline-Recommended Therapies at Baseline
24 Month Mortality Adjusted Odds Ratios (95% CI Displayed)
Number of Therapies (vs 0 or 1 therapy)
Odds Ratio (95% confidence interval)
2 therapies
0.63 (0.47-0.85)
3 therapies
0.38 (0.29-0.51)
4 therapies
0.30 (0.23-0.41)
5, 6, or 7 therapies
0.31 (0.23-0.42)
(p=0.0026)
(p90 Attributable to inflammation and associated with elevated C-reactive protein, factor VIII and reduced vit D
Murad K, Kitzman, D. Heart Failure Reviews. 31 May 2011
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Frailty and multiple co-morbidities in the elderly patient with heart failure: implications for management
Khalil Murad1, 2 and Dalane W. Kitzman3
Update on HRRP – FY ‘14
Proportion o f Hospitals Facing No Readmissions Penalty (Panel A) and Median Amount of Penalty (Panel B), Acco rding to the Proportion of Hospital's Patients Who Receive Supplemental Security Income.
Joynt KE, Jha AK. N Engl J Med 2013. DOI: 10.1056/NEJMp1300122
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Physician Volume, Specialty, and Outcomes of Care for Patients With Heart Failure Clinical Perspective by Karen E. Joynt, E. John Orav, and Ashish K. Jha
Circ Heart Fail Volume 6(5):890-897 September 17, 2013
Copyright © American Heart Association, Inc. All rights reserved.
A, Relationship between physician volume and 30-day risk-adjusted mortality, stratified by hospital volume: adjusted for patient characteristics, physician specialty, and hospital characteristics including teaching status, hospital size, urban vs rural location, region of the country, and ownership (public, private nonprofit, private profit).
Joynt K et al. Circ Heart Fail 2013;6:890-897
Copyright © American Heart Association, Inc. All rights reserved.
Update on the HRRP- FY ‘14
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Hospital Discharge Recommendation or Indication
COR
LOE
Performance improvement systems in the hospital and early postdischarge outpatient setting to identify HF for GDMT
I
B
Before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed: a) initiation of GDMT if not done or contraindicated; b) causes of HF, barriers to care, and limitations in support; c) assessment of volume status and blood pressure with adjustment of HF therapy; d) optimization of chronic oral HF therapy; e) renal function and electrolytes; f) management of comorbid conditions; g) HF education, self-care, emergency plans, and adherence; and h) palliative or hospice care.
I
B
Multidisciplinary HF disease-management programs for patients at high risk for hospital readmission are recommended A follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of hospital discharge is reasonable Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients is reasonable
I
B
IIa
B
IIa
B
Healthcare Reform; A grand idea, an imperfect plan, a failed hypothesis?
Hmm…
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6 Multiple Pay-for-Performance Initiatives Underway 7 •
Pay-for-Performance Payment Changes Initiative
Hospital Acquired Conditions (HAC) in FY2015
•
Description • FY 2013 readmissions penalty based upon readmissions performance between July 1, 2008 and June 30, 2011 • Penalties start at 1% of Medicare inpatient revenue, rising to 3% by FY 2015
Readmissions Penalties
Distribution of HAC events per 1,000 discharges in hospitals1
Based on 16,000 annua l discharges, occurrence of 26+ HACs results in bottom quartile performance, Medicare payment penalty2
• Performance assessed on 20 quality, satisfaction metrics • Payment withhold commences at 1% in FY 2013, rises to 2% by FY 2017
Value-Based Purchasing Program (VBP)
Inclusion of Medicare Spending per Beneficiary metric in FY 2015 • All part A and B payments included during episode of care • Includes transfers, readmits, additional admits
1) Includes eight possible conditions. Penalties involve reduced Medicare inpatient payments by 1% starting in FY
Source: Centers for Medicare and Medicaid Services, “CMS Hospital Inpatient Quality Reporting Program Hospital-Acquired Condition Measures,” March 21, 2011; Health Care Advisory Board interviews and analysis.
2015 to bottom 25% of all hospitals, relative to national average.
2) Example based on Pleasantville Hospital model of 16,000 annual discharges: 25th percentile: 0 events, 50th percentile: 0.442*16=7 events,75th percentile: 1.627*16=26 events, 95th percentile: 5.202*16=82 events.
6 8
Fostering Payment Innovation From 30,000 Feet: ACA as a Grand Experiment Affordable Care Act Sets in Motion Decade of Change 2010
2011
•
2012
2013
2014
2015
2016
2017
2018
2019
2020
Medicaid Capitation Pilot Operation
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• •
Shared Savings Program (Early Adopters)
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Hospital VBP1 (Phase 1: Quality)
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Readmission Penalties for Poor Performers
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Pediatric ACO2 (Shared Savings) Pilot
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Integrated Care Demonstration (Medicaid Episodic Bundling)
Officially Announced
•
•
• •
Shared Savings Program (Competitive Pressure Expansion)
Hospital VBP (Phase 2: Efficiency)
National Episodic Bundling Pilot
•
Payment Adjustments for Hospital Acquired Conditions
1) Value-Based Purchasing. 2) Accountable Care Organization.
Source: Centers for Medicare and Medicaid Services; Health Care Adv isory Board interviews and analysis.
The critical question--
•
Will health care reform measures taken to reduce health care costs – HRRP, VBP, ACO, Bundled Payments -preserve quality, improve quality or hamper quality? HRRP
Reduce Costs
Improve Quality
yes
no
VBP
yes
?
ACO
?
?
Hospital acquired conditions
yes
?
Bundled Payments
?
?
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Conclusions • • • •
•
Health care costs may be declining, i.e., the rate of growth in health care spending is slowing Improved access to care may not be fully realized The economics of US health care remain complex and convoluted We should subject major components of health care reform – HRRP, VBP, HAC, ACO and Bundled Payments- to the scrutiny used for new drugs and devices. “first do no harm…” The Affordable Care Act is an imperfect law. At what point do we challenge its imperfection?
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