Transcript Document

WELCOME
April 18,2014
This webinar will begin promptly at 1pm EDT
MAKING THE MOST OF
PAYMENT REFORM
This activity is made possible by grant number U30CS09746 from the
Health Resources and Services Administration, Bureau of Primary Health
Care. Its contents are solely the responsibility of the presenters and do
not necessarily represent the official views of HRSA.
PRESENTERS
• Host: Sabrina Edgington, MSSW, Program and Policy Specialist,
National Health Care for the Homeless Council
• Melissa Hansen, MPH, Program Principal, National Conference of
State Legislatures
• DaShawn Groves, MPH, Assistant Director, State Affairs, National
Association of Community Health Centers
• Monica Bharel, MD, Chief Medical Officer, Boston Health Care for the
Homeless Program
OVERVIEW
The role of the state in
payment reform
State efforts and health
center engagement
The Boston HCH
Program experience
HEALTH CENTERS AND PAYMENT
REFORM
• In expansion states, health centers are
expected to absorb many newly
eligible beneficiaries.
• Many high cost health system users
with complex health needs will now
have coverage.
BALTIMORE HEALTH CARE FOR THE
HOMELESS PROGRAM
TRIPLE AIM
Improved health
(outcomes)
Improved quality
(patient satisfaction)
Reduced cost
MANY PAYMENT MODELS BEING
TESTED
•
•
•
•
•
•
Global Payment
ACO Shared Savings Program
Medical Home
Bundled Payment
Hospital-Physician Gainsharing
Payment for Coordination
• Hospital Pay-for Performance
• Payment Adjustment for
Readmissions
• Payment Adjustment for HospitalAcquired Conditions
• Physician Pay-for-Performance
• Payment for Shared Decision
making
Source: Schneider, E., Hussey, P., and Schnyer, C. (2011). Payment Reform: Analysis of Models and Performance
Measurement Implications. http://www.rand.org/pubs/technical_reports/TR841.html
Making the Most of Payment Reform
Payment Reform and State Legislatures
Introduction: Payment Reform & State
Legislatures
• History of reforms
– Private market reforms
– Medicare activities
– State activities
• Payment reform efforts have accelerated in
last few years for multiple reasons
Medicaid Policies & Payment Reforms, State
Legislatures
• Improving Medicaid value is at the top of some
legislative agendas (over 520 Medicaid related bills filed)
• Driven by a number of factors:
•
•
Continual pressure on state budgets;
Health reform: challenges and opportunities;
• Reforms aimed at better care, better outcomes,
lower cost – provides potential for bipartisan
efforts (payment reform)
10
Legislative Role in Payment Reform Efforts
• Purchaser of health care
– Medicaid, state employers, other programs
• Purse strings and policymaking
– Infrastructure (e.g. HIT)
– Regulatory levers (state agencies)
• Convening key stakeholders
• Focus on Medicaid reform
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Factors to Consider
 Budgetary pressures
 ACA: challenges and opportunities
 Federally support for payment reform
Pressure on State Budgets
Revenues are expected to meet estimates,
but growth is expected to taper off.
Spending is generally on target.
Year end-balances generally have
improved.
Despite stabilizing fiscal conditions,
uncertainties persist.
Top Fiscal Issues for 2014 Legislative Sessions
Medicaid/ Health Care
Taxes and Revenues
Education
Infrastructure
Source: NCSL survey of state legislative fiscal offices, fall 2013.
State Employee Salaries and Benefits
Corrections/ Public Safety
Medicaid Expansion
State Structures for Health Insurance Marketplaces/Exchanges
NCSL Data: April 1, 2014
The “New
Coverage Gap”
Payment Reform: Federally Supported
Opportunities
• Medicaid (examples)
– Health Homes for Enrollees with Chronic Conditions
– State Innovation Models Initiative
• Medicare (examples)
– Medicare Shared Savings Program
– Medicare Value-based Purchasing Program
• Federal Employees Health Benefit Program (examples)
– Office of Personnel Management Support for Patient-Center Medical
Homes
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Triple Aim – Better Care, Better Outcomes,
Lower Cost – Medicaid Payment and Delivery
System Reforms
•Risk based managed care
•Non-risk care management
•ACOs (CCOs, RCCOs, ACEs)
•Health homes
• Integrated primary care and behavioral health
Sources:
•
Kaiser Commission on Medicaid and the Uninsured, Medicaid in a Historic Time of Transformation: Results
from a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014, October 2013, available at
http://kff.org/medicaid/
•
Joan Henneberry joined Health Management Associates 2013
19
State-Based Medical Home Initiatives
NH
VT
WA
AK
MT
ND
MN
OR
NY
WI
ID
SD
MI
WY
PA
IA
NE
OH
NV
IL
UT
CO
CA
KS
MO
IN
WV VA
KY
NC
TN
AZ
OK
NM
SC
AR
MS
HI
TX
AL
GA
LA
FL
As of August 2013
Medical home activity (45 states and Washington, D.C.)
Making medical home payments (29 states)
Payments based on provider qualification standards (27 states)
Source: NASHP
ME
MA
RI
NJ CT
DE
MD
State Innovation Models Initiative
Types of Awards
Workforce Demands of New Payment and
Delivery Models Models
New or Expanded Roles for:
– Nurses
– Behavioral Health Specialists
– Community Health Workers
– Social Workers
– Peer Specialists
– Pharmacists
– Health Coaches
Mandated Coverage for Telehealth Services
Becoming a Key Stakeholder
• Track payment reform efforts in your state (or local
area).
• Establish and maintain a relationship with
legislator(s) representing your area(s).
• Get involved in collaborative efforts.
• Self assessment of capacity (infrastructure, HIT,
workforce).
• Be clear, concise in communications.
Legislative Concerns With Payment Reform
Activities, Some Examples
•
•
•
•
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Privacy issues
Fraud and abuse
Market concerns (anti-trust)
Network adequacy and patient satisfaction
Do new payment methods improve value?
Contact:
Melissa Hansen
[email protected]
For More Information
http://www.ncsl.org/documents/health/PaymentRTK13.
pdf
Making the Most of
Payment Reform
DaShawn Groves, MPH
Assistant Director, State Affairs
National Association of Community Health Centers
Overview
• State Developments on Payment Reform Impacting
Health Centers
–Missouri (Health Homes)
–Minnesota (ACOs)
–Oregon (APM Development)
• Successfully Engaging in Payment Reform
–Considerations for PCAs
–Key Capabilities for Health Centers
–Key Steps
• Resources
Missouri
• First Section 2703 Health Homes for Chronically Ill
State Plan Amendment (SPA) targeting safety-net
providers
• 18 Health Centers
• Eligible chronic conditions include:
– Asthma
– Diabetes
– Heart disease
– BMI >25
– Development Disabilities
• State pays $58.47 PMPM
• Performance measures outlined in SPA
• Developing shared savings methodology
Missouri: Lessons Learned
–Be involved from early stages
–Set clear, simple goals
–View 2703 as a “safe” opportunity to leverage
federal funds and take a step towards capitation
Minnesota (FUHN ACO)
• Part of a three-year Medicaid payment reform
demonstration
• Ten urban health centers located in Minneapolis
and St. Paul
• Paid on PPS basis
• Total Costs of Care targets include:
– Inpatient
– Outpatient
– Professional
– Ancillary
– Some mental health and chemical health services
• Savings
– 1st 2% will be retained by state
– 98% will be split equally between the state and FUHN
Minnesota (FUHN ACO)
• Keys to Success
–Appropriate program governance
–Access to population health management technology
–Inclusion of performance management coaches
–Enhancing care coordination
Oregon
• Health centers asked PCA for methodology to
better align to PCMH model
• Delinks payment from a face-to-face visit
• Convert PPS into a capitated bundled payment
–Includes:
• Physical health services
• Mental health services after one year
• Eventually Dental services
• Able to receive incentive payments
• Three-year commitment from both parties
Oregon: Lesson Learned
• Hard to keep all the balls in the air
–APM implementation and refinement
–Bridging towards value-based pay
–Practice transformation
•
•
•
•
•
Data collection
Patient engagement
Population management
Access
Team-based care
• Clinics face many demands
Successfully Engaging in
Payment Reform
Considerations for PCAs
Considerations for PCAs
• Keep a Pulse on the Broader Payment Reform
Environment
• Build Support for Delivery System Transformation as a
Primary Goal of Payment Reform
• Secure Input in Payment Reform Design
• Encourage Innovation among Leading Health Centers
• Facilitate Development of Health Center Capacity for
Participation.
Key Capabilities
for Health Centers
Analytic Capabilities
1. Document the Value of Enabling Services
• coding in billing systems
• enabling services in EHR/PM templates
2. Assess Impact of Social Determinants
• Define and capture social determinants
Analytic Capabilities
(continued)
3. Use Data for Design, Monitoring, and
Evaluation
•
•
Develop data partnerships/ strategies to
secure data
– inpatient
– specialty care
– long-term care
– ancillary data
Use data robustly: prospectively as well as
retrospectively
Operational Capacities
• Leadership and Appetite for Innovation
• Sophisticated use of Health Information Technology
• Partnership Capabilities
Key Steps
for PCAs and Health Centers
Key Steps
• Robust understanding of payment reform efforts in the
state and local environment
• Ensure a clear, shared vision of organization’s role in
achieving the Triple Aim.
• Critically assess current operations and capabilities.
• Work collaboratively with other health centers,
stakeholders, and partners to accelerate transformation.
Resources
Publications:
• Health Center and Payment Reform: A Primer
• Health center Payment Reform: State Initiatives to Meet the
Triple Aim, State Policy Report #47
www.nachc.com/state-policy.cfm
Contact Info:
DaShawn Groves. MPH
[email protected]
202-331-4606
Payment Reform: Experiences
from the Field
MONICA BHAREL, MD, MPH
BOSTON HEALTH CARE FOR THE HOMELESS
PROGRAM
A Framework for Preparing for Health Care Reform
at your Program
 Clearly defining the issue
 Having data and knowing the facts
 Using the data to be involved early in process
 Understanding that change is hard
 Working collaboratively
 Be willing to be in it for the long run
A Framework for Preparing for Health Care Reform
at your Program
 Clearly defining the issue
 Having data and knowing the facts
 Using the data to be involved early in process
 Understanding that change is hard
 Working collaboratively
 Be willing to be in it for the long run
Current situation
Future possibility
Accountability for
defined population
Inconsistent
quality
Accountable Care
Fragmented
delivery
Pay for value
Fragmented
payment
Volume
incentives
Comprehensive and
transparent care
A Framework for Preparing for Health Care Reform
at your Program
 Clearly defining the issue
 Having data and knowing the facts
 Using the data
 Understanding that change is hard
 Working collaboratively
 Be willing to be in it for the long run
U.S. Health Care Expenditures are Rising
Massachusetts Spends More on Health Care than
Any Other State
PER CAPITA PERSONAL HEALTH CARE EXPENDITURES, 2009
NATIONAL AVERAGE
State
NOTE:
District of Columbia is not included.
Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2011.
SOURCE:
50
The Increasing Costs of Health Care Squeeze Out
Other Public Spending Priorities
MASSACHUSETTS STATE BUDGET, FY2001 VS. FY2011
STATE SPENDING (BILLIONS OF DOLLARS)
FY2001
FY2011
+$5.1 B
(+59%)
-$4.0 B
(-20%)
-15%
-13%
-11%
-23%
-38%
Health Care Coverage
(State Employees/GIC;
Medicaid/Health Reform)
SOURCE:
51
Massachusetts Budget and Policy Center Budget Browser.
Public
Health
-50%
-33%
Mental
Health
Education
Infrastructure/
Housing
Human
Services
Local
Aid
Public
Safety
How does this compare to homeless individuals
in Massachusetts?
 Lack of data tracking homeless individuals
 Starting point becomes obtaining data
Boston Homeless Cohort:
Mental Health and Substance Use
AJPH 2013
All (N=6,494)
Mental Illness
4,384 (68%)
Schizophrenia
1264 (19%)
Bipolar Disorders
1889 (30%)
Depression
3068 (47%)
Anxiety
2627 (40%)
Substance use disorders
3890 (60%)
Alcohol use disorder
2628 (40%)
Drug use disorder
3118 (48%)
Co-occurring mental illness and
substance use
3135(48%)
Boston Homeless Cohort:
Selected Chronic Physical Conditions
23
Chronic Condition
C
Hep
6
HIV
4
sis
o
h
r
r
Ci
/C
a
m
h
Ast
AJPH 2013
26
OPD
37
HTN
10
HD
c
i
m
e
Isch
tes
e
b
a
Di
18
0
10
20
Percentage
30
40
BHCHP PCC Patients versus members of the PCC Plan
Diagnostic and Other Characteristics Statewide
Number
426,768
1.5
DxCG Score
Both Mental Health & Substance Use
10%
6%
Asthma or COPD
Diabetes
6%
129
Hospital Discharges Per 1,000
ED Visits Per Person
1.1
$6,679
Average Annual Cost
BHCHP
Patients*
3,998
3.4
51%
24%
15%
859
4.2
$20,925
*Medicaid-only BHCHP patients enrolled in the PCC plan.
Bharel et al, AJPH 2013
Total Annual Expenditures by Expenditure Group for
BHCHP Users with Medicaid in 2010
Total Annual Expenditures by Expenditure Group
for BHCHP Users with Medicaid, CY 2010
100%
10%
90%
80%
15%
48.0%
70%
60%
90 – 100% (650 users)
25%
75 – 90% (974 users)
50%
40%
50 – 75% (1,623 users)
25%
25.5%
25 – 50% (1,623 users)
30%
Lowest 25% (1,623 users)
20%
10%
18.6%
25%
0%
Users (N=6,493)
6.5%
1.4%
Expenditures ($149 million)
Health Care Utilization and Housing
 Studies in New York, Seattle and Chicago have found that
housing homeless individuals can decrease use of
services including:



Emergency department
Hospital inpatient
Detoxification services
Am J Public Health. Apr 2004, JAMA. Apr 1 2009, JAMA. May 6 2009.
A Framework for Preparing for Health Care Reform
at your Program
 Clearly defining the issue
 Having data and knowing the facts
 Using the data to be involved early in process
 Understanding that change is hard
 Working collaboratively
 Be willing to be in it for the long run
Long History of Reform in Massachusetts
1997
• Medicaid 1115 waiver to expand Medicaid, including MCO development
• Comprehensive Health Reform: shared individual and state government,
responsibility for access
2006
• Despite a recession, Massachusetts succeeds at having the lowest rate of
uninsured in the nation
2007
• Chapter 221 passed with focus now on cost containment while providing
high quality care
2012
• One Care Program begins to coordinate care for dual eligible patients (both
Medicaid and Medicare)
2013
• Primary Care Payment Reform beings to coordinate behavioral health and
primary care services in a global payment to primary care practices
2014
One Care: Medicaid Plus Medicare
• October 2013
• MA launched program to integrate care and align financing for
dual eligible patients
• Interdisciplinary Care Teams develop patient care plans and
covered services include primary care, BH, specialty care,
dental, vision ,medications and long term care.
• March 2014
• 9,722 members have enrolled
• Payments remain fee-for-service with a supplemental payment
for care coordination and management
Primary Care Payment Reform Initiative (PCPRI)
• Chapter 221 requires transition of Medicaid patients
from fee-for-service to alternate payment methods with
80% transformation by July 2015
• PCPR is an alternative payment program where primary
care providers are held accountable for cost and quality
of care using a BH integration model and patient
centered medical home.
• Payments are risk adjusted per member per month
global payments
• Goal of delivery system to increase care coordination and
care management, improve access to primary care,
integrate BH and practice population management
Using the data to advocate
Collaborator
 Local community




organizations
Academic medical
centers
Medicaid
Executive Office of
Health and Human
Services
Elected Officials
Issue
 Special population
 Attribution of care
issue
 Medical respite needs
 BH integration needs
A Framework for Preparing for Health Care Reform
at your Program
 Clearly defining the issue
 Having data and knowing the facts
 Using the data to be involved early in process
 Understanding that change is hard
 Working collaboratively
 Be willing to be in it for the long run
Payment Reform and Health Care for Homeless Individuals
 Opportunities




Flexibility in clinical
design
Flexibility in outreach
model
Behavioral health and
primary care integration
Coordination across the
health care system
 Challenges






Change is hard
Uncharted territory
Attribution of patients
Risk adjustment is not
adequate
Taking on risk at provider
level
Want clinical staff to
remain blind to insurance
type
A Framework for Preparing for Health Care Reform
at your Program
 Clearly defining the issue
 Having data and knowing the facts
 Using the data to be involved early in process
 Understanding that change is hard
 Working collaboratively
 Be willing to be in it for the long run
Collaborations: who else is a stakeholder?
 Neighborhood hospitals and academic medical







centers
State Medicaid
State Legislators/local politicians
Consumer advocacy groups
Other organizations caring for special populations
National advocacy groups
Shelter alliances
And more….
A Framework for Preparing for Health Care Reform
at your Program
 Clearly defining the issue
 Having data and knowing the facts
 Using the data to be involved early in process
 Understanding that change is hard
 Working collaboratively
 Be willing to be in it for the long run
Mission Statement:
Provide and assure access to quality
health care for all homeless individuals
and families in the greater Boston area.
Photos courtesy of J O’Connell
QUESTIONS AND ANSWERS
For more information
www.nhchc.org
www.nachc.org
www.ncsl.org
THANK YOU FOR YOUR
PARTICIPATION
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