Transcript Slide 1

NASHP
Learning the ABCs of
APCs and Medical Homes
October 5, 2010
Foster Gesten, MD
New York State Department of Health
[email protected]
1
Outline
• NY Background
• What are we trying to fix?
– Why didn’t managed care fix it?
• Medical Home Standards and Payments
– Wide vs Deep
– Going it alone and/or playing in the sandbox
• Trust and anti-trust
• Challenges and Opportunities
2
Background: Medicaid
• 5 million members - $47 billion
• Most in managed care plans (1115 waiver since 1997)
but complex and expensive populations remain in FFS
– 20 health plans
– Carve outs (pharmacy, SA, MH for some)
• SCHIP (Child Health Plus) separate program but
delivered through health plans
• Medicaid and public and private plans regulated
through same organization in state health department
3
Enrollment
4
Enrollment as of December 31st of each year
Source: DOH/OHIP Recipient Summary Fact, Child Health Plus and EPIC
What are we trying to fix?
• Rightsizing balance of inpatient and outpatient care
expenditures
• Excess of preventable admissions (and readmissions)
• Years of quality reporting…good, getting better, but
good enough?
• Institutional care settings
• Primary care standards and the chronic care model –
time to raise the bar
• Disparities
5
Inpatient Spending Per Enrollee
Significantly Exceeds National Averages;
Spending on Ambulatory Care Has Lagged
Ave Cost per Eligible
1200
1000
800
600
400
200
0
Inpatient
Physician
Dental
NY
Outpatient Hospital
Lab/Xray
US
Source: CMS, 2008 Statistical Supplement
Table 13.26
6
Despite High Spending, NY Performs
Average (or Poorly) on Some Key Quality
Indicators
2009 Commonwealth State Scorecard on Health System Performance
Care Measure
National Ranking
Overall
21
Equity
11
Prevention and Treatment
22
Avoidable Hospital Use
50
2009 AHRQ State Snapshots
Clinical Area
State
Rating
Trend
Diabetes
Weak
Same
Heart Disease
Average
Slightly Better
Maternal and Child Health
Average
Getting Worse
Respiratory Disease
Weak
Getting Worse
7
7
New York
Focus on Payer
How Does the Quality of Care for
Medicaid Compare to the US?
8
New York Medicaid Managed Care vs National
Effectiveness of Care Measures
NYS Medicaid 2008
National Medicaid 2008
Monitoring Persistent Medications
86.6
82.6
Appropriate Testing - Pharyngitis
80.5
61.4
Breast Cancer Screening
66.8
50.8
Cervical Cancer Screening
73.4
66.0
Childhood Immunization Status
77.4
73.7
Cholesterol Management – LDL-C <100
46.8
40.1
Comprehensive Diabetes Care – Eye
Exams
62.0
58.8
Comprehensive Diabetes Care – Good
HbA1c Testing
37.9
32.9
Controlling High Blood Pressure
65.0
55.8
Follow-Up After Hospitalization for
Mental Illness – 30 days
78.4
61.7
Care for Children w/ ADHD Med. –
Continuation
60.7
39.5
Lead Screening
86.4
66.7
9
Result
The Executive Budget of 2009-10:
Medicaid
•
Enabling legislation: Authorized the Department to
implement a Statewide initiative to incentivize the
development of PCMHs to improve health outcomes
through better coordination and integration of patient care
– No savings assumed – primary care ‘investments’ from savings
achieved in (overdue) inpatient payment reductions
– ~ $66 million growing to $140 million in year 3
•
Medical home standards are the National Committee for
Quality Assurance’s (NCQA) Physician Practice
Connections® -Patient Centered Medical Home™ (PPC®PCMH™) Recognition Program
•
Program implementation- July 1, 2010; Hospital OPD
participation still pending CMS approval
10
Medicaid Reimbursement For
PPC®-PCMH™
• Medicaid providers receive a payment
commensurate with their level of NCQA PCMH
designation (Level I- $2 pmpm, II - $4pmpm, or III$6pmpm)
– ‘Enhanced’ payment of qualifying claims (primary care
E&M code) for FFS
– PMPM from health plans for MMC
• State adds to premium and directs payments to recognized
providers for common amounts
• Level I incentive ends 2013
• Evaluation
11
• P4P?
Regional Multi-payer Demonstration
• Enabling 2009 legislation (including anti-trust) and
budget (Medicaid)
– $3-4 million
• Rural upstate NY
• 35 practices (including multi-site FQHC), 5 hospitals,
over 130 providers
– Around 100k patients
• 8 payers, including Medicaid and State Employee
Plan
• NCQA level 2 or 3 in first year….‘plus’
• $7pmpm
• Medicare application/invitation (MAPCP)
12
Challenges/Opportunities
• Multi-payer most promising, and most difficult
• Alignment with HITEC
• ACA
– More business, more imperative
– ‘health homes’?
• Beyond the home to the ‘hood’
• Journey, not destination
• Sustainability
– Interest
– Resources
– Primary care pipeline
13