- Email: [email protected]
Getting what we pay for
President’s Message
Getting what we pay for
Diana J. Mason, PhD, RN, FAAN
One of my favorite Edge Runner stories was told to me by board member Eileen Sullivan-Marx, PhD, RN, FAAN, now Dean at the College of Nursing at New York University. At the time, she headed the University of Pennsylvania School of Nursing’s LIFE program called Living Independently For Elders, a Program for AllInclusive Care of Elders (PACE; Medicare.gov, n.d.), with capitated payments by Medicare and Medicaid. Designed to keep older adults living independently in their homes rather than in nursing homes, PACE was first developed by Jennie Chinn Hansen, PhD, RN, FAAN, another fellow and Edge Runner who founded On Lok in San Francisco. The model has spread across the country and should be a frontline community service. Eileen told the story of an elderly woman with chronic respiratory problems who spent a particularly hot and humid summer cycling in and out of the emergency department because of acute respiratory distress. Under PACE’s capitated model that pays a flat monthly per person fee for all care, the school assumed financial risk for the care of LIFE’s population of older adults. If the patient stayed out of the emergency department and hospital, financial benefit would accrue to LIFE and, thus, the school. If the patient requires care that costs more, the LIFE program must cover that. This particular patient was clearly suffering and costing too much, so the program staff did a deeper dive into what was contributing to her exacerbations. They discovered that she lived in a housing project with no air conditioning. The LIFE program decided to buy her an air conditioner. It stopped the emergency department visits. Now, imagine asking an insurance company or Medicare or Medicaid under a fee-for-service model to pay for an air conditioner. It wouldn’t happen, even though doing so might reduce health care costs
far more than the cost of the air conditioner. This simple patient example illustrates the limitations of fee-for-service payment approaches. They don’t focus on what patients need and want to live healthier lives. They focus on episodic rather than continuing care that is relationship centered, and they reward volume and lead to unnecessary screenings and proceduresdall of which drive up health care costs without necessarily improving health and clinical outcomes. Of course, the fear is that providers will simply withhold more expensive levels of care, even if the patient needs them, but that’s where linking payment to quality measures and value comes in. At the end of January, the Centers for Medicare and Medicaid (CMS) announced that it would accelerate the linking of 30% of fee-for-service and bundled payments to quality measures under Medicare by the end of 2016 and as much as 50% by 2018. Recognizing that doing this only for Medicare will not get us the reform we need, CMS reported that it would launch a Health Care Action Learning and Payment Network to engage insurers, providers, employers, consumers, and other key stakeholders in exploring ways to accelerate this movement to global, value-based payments (CMS, 2015). At the end of 2014, before this CMS announcement, Academy Chief Executive Officer Cheryl Sullivan, MSES, and I met with Patrick Conway, the Deputy Administrator for Innovation and Quality and Chief Medical Officer at CMS. He leads the Center for Medicare and Medicaid Innovation that is charged with testing new payment and care delivery models. We talked with him and some of his staff about several of the Edge Runner models of care, noting that many of these nurse innovators see global payment methods as the way to promote the health of individuals, families, and communities. We called for speeding up the movement from fee-for-service payment approaches to global payments of one form or another. I’m pleased to share that we were subsequently invited to participate in a White House launching of the Health Care Action Learning and Payment Network. Cheryl Sullivan represented the Academy and nursing at this meeting on March 25, 2015. The Edge Runner program is a signature initiative of the Academy. Originally developed to help highlight the innovative work of nurses, the “Raise the Voice” initiative showcases the work of the Edge Runners, providing examples and direction for policy development by the Academy, CMS, and the nation. It informs our work on strategic goal 1, continuing to
Nurs Outlook 63 (2015) 236e237
influence health care reform in the direction of the Triple Aim, and strategic goal 2, influencing the broad range of factors that affect the health of people. You can read more about the Edge Runner models of care at www.aannet.org/edgerunners. We continue to welcome applications from potential Edge Runners. For more information, go to www. aannet.org/raisethevoice. Reforming payment models is essential to get what we want from health caredbetter quality, better health, and lower costs.
references
Centers for Medicare and Medicaid Services (CMS). (2015). Health care payment learning and action network. Retrieved from http://innova tion.cms.gov/initiatives/Health-Care-Payment-Learning-andAction-Network/. Medicare.gov. (n.d.). PACE. Retrieved from http://www.medicare. gov/your-medicare-costs/help-paying-costs/pace/pace.html
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Author Description Diana J. Mason, Rudin Professor of Nursing and Codirector, Center for Health, Media & Policy, Hunter, College, New York, NY; and Professor, City University of New York, NY. Diana J. Mason, PhD, RN, FAAN, President American Academy of Nursing Washington, DC Corresponding author: Diana J. Mason, 455 W 44th, Street, #22, New York, NY 10036. E-mail address: [email protected] Available online 1 April 2015 0029-6554/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2015.03.005
Getting what we pay for
Diana J. Mason, PhD, RN, FAAN
One of my favorite Edge Runner stories was told to me by board member Eileen Sullivan-Marx, PhD, RN, FAAN, now Dean at the College of Nursing at New York University. At the time, she headed the University of Pennsylvania School of Nursing’s LIFE program called Living Independently For Elders, a Program for AllInclusive Care of Elders (PACE; Medicare.gov, n.d.), with capitated payments by Medicare and Medicaid. Designed to keep older adults living independently in their homes rather than in nursing homes, PACE was first developed by Jennie Chinn Hansen, PhD, RN, FAAN, another fellow and Edge Runner who founded On Lok in San Francisco. The model has spread across the country and should be a frontline community service. Eileen told the story of an elderly woman with chronic respiratory problems who spent a particularly hot and humid summer cycling in and out of the emergency department because of acute respiratory distress. Under PACE’s capitated model that pays a flat monthly per person fee for all care, the school assumed financial risk for the care of LIFE’s population of older adults. If the patient stayed out of the emergency department and hospital, financial benefit would accrue to LIFE and, thus, the school. If the patient requires care that costs more, the LIFE program must cover that. This particular patient was clearly suffering and costing too much, so the program staff did a deeper dive into what was contributing to her exacerbations. They discovered that she lived in a housing project with no air conditioning. The LIFE program decided to buy her an air conditioner. It stopped the emergency department visits. Now, imagine asking an insurance company or Medicare or Medicaid under a fee-for-service model to pay for an air conditioner. It wouldn’t happen, even though doing so might reduce health care costs
far more than the cost of the air conditioner. This simple patient example illustrates the limitations of fee-for-service payment approaches. They don’t focus on what patients need and want to live healthier lives. They focus on episodic rather than continuing care that is relationship centered, and they reward volume and lead to unnecessary screenings and proceduresdall of which drive up health care costs without necessarily improving health and clinical outcomes. Of course, the fear is that providers will simply withhold more expensive levels of care, even if the patient needs them, but that’s where linking payment to quality measures and value comes in. At the end of January, the Centers for Medicare and Medicaid (CMS) announced that it would accelerate the linking of 30% of fee-for-service and bundled payments to quality measures under Medicare by the end of 2016 and as much as 50% by 2018. Recognizing that doing this only for Medicare will not get us the reform we need, CMS reported that it would launch a Health Care Action Learning and Payment Network to engage insurers, providers, employers, consumers, and other key stakeholders in exploring ways to accelerate this movement to global, value-based payments (CMS, 2015). At the end of 2014, before this CMS announcement, Academy Chief Executive Officer Cheryl Sullivan, MSES, and I met with Patrick Conway, the Deputy Administrator for Innovation and Quality and Chief Medical Officer at CMS. He leads the Center for Medicare and Medicaid Innovation that is charged with testing new payment and care delivery models. We talked with him and some of his staff about several of the Edge Runner models of care, noting that many of these nurse innovators see global payment methods as the way to promote the health of individuals, families, and communities. We called for speeding up the movement from fee-for-service payment approaches to global payments of one form or another. I’m pleased to share that we were subsequently invited to participate in a White House launching of the Health Care Action Learning and Payment Network. Cheryl Sullivan represented the Academy and nursing at this meeting on March 25, 2015. The Edge Runner program is a signature initiative of the Academy. Originally developed to help highlight the innovative work of nurses, the “Raise the Voice” initiative showcases the work of the Edge Runners, providing examples and direction for policy development by the Academy, CMS, and the nation. It informs our work on strategic goal 1, continuing to
Nurs Outlook 63 (2015) 236e237
influence health care reform in the direction of the Triple Aim, and strategic goal 2, influencing the broad range of factors that affect the health of people. You can read more about the Edge Runner models of care at www.aannet.org/edgerunners. We continue to welcome applications from potential Edge Runners. For more information, go to www. aannet.org/raisethevoice. Reforming payment models is essential to get what we want from health caredbetter quality, better health, and lower costs.
references
Centers for Medicare and Medicaid Services (CMS). (2015). Health care payment learning and action network. Retrieved from http://innova tion.cms.gov/initiatives/Health-Care-Payment-Learning-andAction-Network/. Medicare.gov. (n.d.). PACE. Retrieved from http://www.medicare. gov/your-medicare-costs/help-paying-costs/pace/pace.html
237
Author Description Diana J. Mason, Rudin Professor of Nursing and Codirector, Center for Health, Media & Policy, Hunter, College, New York, NY; and Professor, City University of New York, NY. Diana J. Mason, PhD, RN, FAAN, President American Academy of Nursing Washington, DC Corresponding author: Diana J. Mason, 455 W 44th, Street, #22, New York, NY 10036. E-mail address: [email protected] Available online 1 April 2015 0029-6554/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2015.03.005