Transcript Douglas Fish

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Framework for a Value-Based Payment Strategy for
Children’s Health Care in New York
Douglas Fish, MD
Medical Director
Division of Program Development and Management
Office of Health Insurance Programs, NYSDOH
October 19, 2016
2
October 2016
Agenda
1.
Recap: Medicaid Redesign Team (MRT) and Delivery System Reform Incentive
Payments (DSRIP) Program
2.
DSRIP Program and Children’s Healthcare
3.
Moving Towards Value-Based Payment (VBP)
4.
Transforming Children’s Healthcare through VBP
5.
Challenges Ahead and the Promise of Innovative Approaches
6.
Q&A
October 2015
October 2016
Recap: MRT & DSRIP Program
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October 2016
MRT Recap:
How our transformation initiative started and what we have accomplished in
relation to children’s healthcare.
October 2016
4
October 2016
Initiatives in the MRT
• In 2011, Governor Andrew M. Cuomo created the Medicaid Redesign Team (MRT).
 Made up of 27 stakeholders representing every sector of healthcare delivery system
 Developed a series of recommendations to lower immediate spending and propose
reforms
• Major reforms included cost control; global spending cap; care management for all,
Patient Centered Medical Homes (PCMH), and Health Homes (HH).
• Notable Children and BH Initiatives Stemming from the MRT:
 Expansion of Collocated BH and Primary Care (PC)
 Expansion of HH to Children
 Expansion of Home and Community Based Services for Children
 Children’s Workgroup
 HH Children’s Workgroup
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October 2016
DSRIP Program Recap:
Our DSRIP Program objectives, principles, and the program’s current status.
October 2016
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October 2016
DSRIP Program Objectives
 DSRIP objectives are aligned with the objectives of BH Organizations
Develop
Integrated
Delivery
Systems
Remove
Silos
 DSRIP was built on the Center for Medicare
and Medicaid Services’ (CMS) and the
State’s goals towards achieving the Triple
Aim:
 Better care
 Better health
 Lower costs
Enhance PC
and
Communitybased
Services
Goal:
Reduce avoidable
hospital use –
Emergency
Department (ED)
and Inpatient – by
25% over 5+ years
of DSRIP
Integrate BH
and PC
 To transform the system, DSRIP will focus
on the provision of high quality, integrated
primary, specialty and BH care in the
community setting with hospitals used
primarily for emergent and tertiary level of
services
Source: The New York State DSRIP Program. NYSDOH Website. & New York’s Pathway to Achieving the Triple Aim. NYSDOH DSRIP Website.
Published December 18, 2013.
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October 2016
The Real Goals of DSRIP Mean a Transformed
System
• We need a future system where we think more broadly, on a community basis,
where all of the systems that impact an individual’s well being are coordinated
• We could measure the outcomes that society cares about, moving beyond health
care metrics
 Workforce
Availability
 Community
Engagement
Quality of Life
Mortality
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October 2016
Where We are Now
Performing Provider Systems (PPS) have transitioned from planning to implementing projects.
Focus on Infrastructure
Development
Focus on System/Clinical
Development
Focus on Project
Outcomes/Sustainability
We are here
DY0
DY1
DY2
DY3
DY4
DY5
Q1|Q2|Q3|Q4
Q1|Q2|Q3|Q4
Q1|Q2|Q3|Q4
Q1|Q2|Q3|Q4
Q1|Q2|Q3|Q4
First payment made for
outcomes tied to Domain
2 P4P measures.
Based on MY3 data and
Quarterly Report and DY3
Q2 report.
Payment tied to Domains 2
& 3 is predominately P4P.
Based on MY4 Data and
MY5 data for the DY5 Q4.
Measurement Year (MY)
2 begins. Data collection
for Domain 3 P4P*
measures begins.
Submission/Approval
of Project Plan
• PPS Project Plan valuation
• PPS first DSRIP payment
• PPS submission and approval of
Implementation Plan
• PPS submission of first quarterly
report
MY 3 begins. Data
collection for Domain 2
P4P measures begins.
First payment made for
outcomes tied to Domain
3 P4P measures. Based
on MY2 data and
Demonstration Year (DY)
2 Q2 report
Source: Based on Independent Assessor Project Approval and Oversight Panel Presentation. Nov 9 – 10, 2015. NYS DSRIP Website
* P4P = pay for performance
October 2016
DSRIP Program and
Children’s Healthcare
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October 2016
PPS DSRIP Projects that Impact Children’s Healthcare
DSRIP Project Organization
Domain 1:
Organizational Components
Domain 2:
System Transformation
3.a.i: Integration of
primary care
services and
behavioral health
Domain 3:
Clinical Improvement
Domain 4:
Population Health
3.a.ii: Behavioral
health community
crisis stabilization
services
3.d.ii: Expansion of
asthma homebased selfmanagement
programs
3.d.iii: Evidence
based medicine
guidelines for
asthma treatment
4.a.i: Promote
mental, emotional,
and behavioral wellbeing in
communities
4.a.iii: Strengthen
mental health and
substance use
infrastructure across
systems
4.d.i: Reduce
premature births
Source: New York State DSRIP Project Toolkit. NYSDOH DSRIP Website.
3.f.i: Increase
support programs
for maternal & child
health
October 2016
DSRIP Health Outcomes for Children
• DSRIP’s healthcare transformation will likely have the greatest effect on children in
Medicaid, as avoiding poor health outcomes throughout childhood will lead to a lifetime of
improved health
• The move from hospital-based care to home and community-based care will have a
noticeable effect on this population by avoiding unnecessary hospitalizations and ER
visits throughout childhood and into adulthood
• Unnecessary hospitalizations will be reduced by DSRIP programs that emphasize
proactive management of high risk children through early detection
• The progression from healthcare and behavioral health silos to integrated delivery
systems will give children access to a higher performing continuum of care and integrated
behavioral health benefits within their respective PPS networks
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October 2016
Opportunities for Children’s Mental Health
DSRIP Projects
Children’s mental health
project opportunities
Projects highly relevant to
children
Projects related to Mental
Health
For projects in the overlapping area, children’s mental health providers
are the most valuable providers to PPS
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October 2016
Children’s Health and DSRIP – Metrics
 Below is just a small sample of some of the metrics on which the PPSs will be measured.
 Children’s Health Providers will be vital to ensuring these metrics are met:
Domain 3 – Clinical Improvement Metrics
Measure Name
3.a – Behavioral Health
Follow-up care for Children Prescribed ADHD
Medications
Measure Steward
NQF1#
Source
Measure Type
DY22 & DY3
P4R3/ P4P4
NCQA5
0103
Claims
Process
Reporting
Performance
0576
Claims
Process
Reporting
Performance
Follow-up after hospitalization for Mental Illness NCQA
DY4 & DY5
P4R/ P4P
Screening for Clinical Depression and follow-up
Adherence to Antipsychotic Medications for
People with Schizophrenia
3.d - Asthma
PDI7 # 14 Pediatric Asthma
Asthma Medication Ratio
CMA
0418
Medical Record
Process
Reporting
Performance
NCQA
1879
Claims
Process
Performance
Performance
AHRQ6
NCQA
0638
1800
Claims
Claims
Outcome
Process
Performance
Performance
Performance
Performance
Medication Managed for People with Asthma
3.f - Perinatal
PQI8 # 9 Low Birth Weight
Well Care Visits in the first 15 months
Childhood Immunization Status
Lead Screening in Children
NCQA
1799
Claims
Process
Performance
Performance
AHRQ
NCQA
NCQA
NCQA
0278
1392
0038
Claims
Claims
Medical Record
Medical Record
Outcome
Process
Process
Process
Performance
Reporting
Reporting
Reporting
Performance
Performance
Performance
Performance
1. National Quality Forum 2. DSRIP Year, 3. Pay for Reporting 4. Pay for Performance, 5. National Committee for Quality Assurance, 6. Agency for
Healthcare Research and Quality , 7.Pediatric Discharge Indicator 8. Pediatric Quality Indicator
Source: DSRIP Measure Specification and Reporting Manual: Measurement Year 1. NYSDOH DSRIP Website. Published February 25, 2016.
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October 2016
DSRIP Health Outcomes for Children: An Example
Today
Child in
Medicaid with a
chronic health
condition
After DSRIP
Engagement
Delivery
Outcome
Intermittent
care provided
by separate
providers, as
necessary
Unnecessary
ER visits &
hospitalizations
in childhood
Unnecessary
ER visits &
hospitalizations
throughout
adulthood
Care managed
by a
coordinated set
of integrated
providers
Preventive
healthcare
provides the
resources the
child requires
Integrated care
follows through
adolescence
into adulthood
=
Unnecessary strain on
the child, the family,
and the healthcare
system
=
Value to the child, the
family, and the
healthcare system
October 2016
Moving Towards Value
Based Payments (VBP)
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October 2016
Reforming the Payment System and Moving from
Volume to Value
Value Based Payments (VBP)
An approach to
Medicaid
reimbursement that
rewards value over
volume
An approach to
incentivize providers
through shared
savings and financial
risk
A method to directly
tie payment to
providers with quality
of care and health
outcomes
A component of
DSRIP that is key to
the sustainability of
the program
 HH care management payments will be part of VBP arrangements
 VBP will ensure DSRIP transformation efforts remain successful
VOLUME
VALUE
VOLUME
Source: New York State Department of Health Medicaid Redesign Team. A Path Towards Value Based Payment, New York State Roadmap
for Medicaid Payment Reform. NYSDOH DSRIP Website. Published March 2016.
VALUE
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October 2016
VBP Implementation Timeline
June 2016 – June 2018
June 2016 – October 2016
July 2015 – January 2017
July 2015
Pilot Sites
Regional Bootcamps
Subcommittee and Clinical Advisory Groups
Roadmap finalized; 2016 update submitted to CMS
October 2016
Transforming Children’s
Healthcare through VBP
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October 2016
VBP Strategy
Our vision for how Children’s healthcare will fit in the world of VBP.
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October 2016
Different Levels of Value Based Payments
In addition to choosing which integrated services to focus on, the MCOs and PPS can choose different levels of
VBP:
Level 0 VBP
(Base line State
goal)
FFS with bonus
and/or withhold
based on
quality scores
Level 1 VBP
(only feasible after experience with
Level 0)
FFS with upside-only shared
savings available when outcome
scores are sufficient for PCMH /
Advanced Primary Care (APC), FFS
may be complemented with PMPM
subsidy)
Level 2 VBP
Level 3 VBP
(only feasible after experience with
Level 1)
(only feasible after experience with
Level 2)
FFS with risk sharing (upside
available when outcome scores
are sufficient)
Prospective capitation PMPM or
Bundle (with outcome-based
component)
• Goal of ≥80-90% of total MCO  provider payments (in terms of total dollars) to be captured in Level 1
VBPs at end of DSRIP Year 5
• 35% of total managed care payments (full capitation plans only) tied to level 2 or higher
Source: New York State Department of Health Medicaid Redesign Team. A Path Towards Value Based Payment, New York State Roadmap for Medicaid Payment
Reform. NYSDOH DSRIP Website. Published March 2016.
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October 2016
VBP Levels:
Upside and Downside Risk-Sharing Arrangements
Quality Targets
% Met goal
> 50% of
Quality
Targets Met
Level 1 VBP
Level 2 VBP
Upside Only
Up - and downside when
actual costs < budgeted costs
Level 2 VBP
Up - and downside when
actual costs > budgeted costs
50% of savings returned to VBP
contractors
Up to 90% of savings returned
to VBP contractors
VBP contractors are
responsible for up to 50%
losses
<50 % of
Quality
Targets Met
Between 10 – 50% of savings
returned to VBP contractors
(sliding scale in proportion with %
of Quality Targets met)
Between 10 – 90% of savings
returned to VBP contractors
(sliding scale in proportion with
% of Quality Targets met)
VBP contractors responsible
for 50-90 % of losses (sliding
scale in proportion with % of
Quality Targets met)
Quality
Worsens
No savings returned to VBP
contractors
No savings returned to VBP
contractors
VBP contractors responsible
for up to 90% of losses
Source: New York State Department of Health Medicaid Redesign Team. A Path Towards Value Based Payment, New York State Roadmap for Medicaid Payment
Reform. NYSDOH DSRIP Website. Published March 2016.
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October 2016
Today: >25% of Medicaid Spend is in VBP Level 1 or Higher
Per Survey, VBP Baseline of Levels 1 - 3 for CY 2014: 25.5%*
VBP Level 3
9.1%
VBP Level 2
14.0%
VBP Level
Total Spending
Spending or %
$ 22,741 M
FFS
FFS 63.2%
VBP Level 0
VBP Level 1
2.5%
VBP Level 0 Quality
VBP Level 0 No Quality
VBP Level 1
VBP Level 2
VBP Level 0
11.3%
VBP Level 3
*Includes Mainstream, MLTC, MAP, and HIV SNP plans.
$ 14,372 M
63.2%
$ 2,576 M
11.3%
$ 2,036 M
9%
$ 539 M
2.4%
$ 567.5 M
2.5%
$ 3,172 M
14%
$ 2,062 M
9.1%
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October 2016
VBP Arrangements
• Arrangement Types*
 Total Care General Population (TCGP)
 Integrated Primary Care with Chronic Bundle (IPC-CB)
 Maternity Bundle
 Health and Recovery Plans (HARP)
 HIV/AIDS
 Managed Long Term Care (MLTC)
TCGP
Maternity
Bundle
IPC-CB
*Arrangements do not yet include Dually Eligible members
• Two VBP implementation subcommittees were created to focus on:
 Social Determinants of Health (SDH) and CBOs
 Advocacy and Engagement
HARP
HIV/AIDS
MLTC
 The full recommendations that came from these Subcommittees are available in the DOH VBP
Resource Library:
https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_library/index.htm
October 2016
Two Types of VBP Arrangements Envisioned
1. In Integrated Primary Care – Chronic Episodic Bundled Arrangements
• For children seen more typically in general health care settings
• Explicit in the connection between health, chronic conditions, and BH
care
2. Pediatric Special Needs Subpopulation – Total Cost of Care
• Highest need children in specialty care environments (e.g. voluntary
foster care agencies (VFCA), residential treatment facilities, etc.)
• Inclusive of all costs of care; maximum incentive for
coordination/integration of care across all settings
• Designation to follow child across various modes of care (e.g. from
VFCA to home)
Note: The Children’s Subcommittee/CAG is convening on October 20 and will decide on a proposed
structure for the children’s arrangements.
Source: New York State Department of Health Medicaid Redesign Team. A Path Towards Value Based Payment, New York State Roadmap for Medicaid
Payment Reform. NYSDOH DSRIP Website. Published March 2016.
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October 2016
Clinical Advisory Groups:
How measures are determined for VBP arrangements.
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October 2016
Selecting and Refining Quality Measures is an Ongoing
Process
Start
End of year:
evaluation
results
reported back
to CAG
Clinical
Advisory
Group (CAG)
selects
measures
During the process:
• Lists get refined and reduced to those
measures that really matter (specific to
VBP arrangement)
OQPS reviews
measures
• Key outcome measures
• Measures that are key to DSRIP success
• Nationally standardized key process
measures
• Focus on outcomes will increase as
outcome measures mature
Start of
measurement
VBP
Workgroup
sets
measures
• Pilots are essential to test feasibility and
relevance of measures
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October 2016
CAG Composition
Each CAG is comprised of
leading experts and key
stakeholders throughout NYS
healthcare delivery system,
spanning Upstate and
Downstate regions. Their
scope includes development
of quality measures for all
VBP arrangements.
Medical
Centers
Providers
State
Agencies
Universities
CAG
Clinical
Experts
Medical
Societies
Health
Plans
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October 2016
CAG Current Status
CAG Name
Status
Maternity Care
Pending in the VBP Workgroup to be Finalized (Went through Public
Comment Period)
Chronic Care: Heart Conditions & Diabetes
Draft Report Completed
Chronic Care: Pulmonary Conditions
Draft Report Completed
Behavioral Health (BH): HARP
HARP Draft Report Completed. The CAG reconvened and is in the process of
reviewing the quality measures with OMH (went through public comment
period). The reports will be posted soon.
BH: Substance Use Disorder, Trauma and
Stressor, Depression and Anxiety
BH Chronic Episodes Draft Report Completed; will undergo public comment
period in mid-October
HIV/AIDS
Pending in the VBP Workgroup to be Finalized (Went through Public
Comment Period)
Managed Long Term Care (MLTC)
Draft Report Completed
Intellectually/Developmentally Disabled (I/DD)
Four meetings completed; draft in progress
Children’s Health CAG/Subcommittee
To Be Convened on October 20th
CAG Reports with all quality measures, as well as the definitions of the VBP arrangements, will be posted in the VBP
Resource Library.
October 2016
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Confirmed Children’s Health Subcommittee / CAG
Members
Co-chairs
Jeanne Alicandro, MD
Medical Director Managed
Care
IPRO
[email protected]
NYS DOH Sponsor
Kate Breslin
President and CEO
Schuyler Center for Analysis &
Advocacy
[email protected]
Lana Earle
Deputy Director
Division of Program Development and Management
Office of Health Insurance Programs
[email protected]
Member
Organization
Member
Organization
David (Tucker) Slingerland
Family Physician / VP of Strategy at Hudson Headwaters
Senior Vice President, Medical Services, The New York Foundling
Dr. David Appel
Pediatrician / Montefiore
Joseph R. Saccoccio, MD,
MPH, FAAP
Pat Tursi
CEO, Elizabeth Seton Pediatric Center
Roslyn Murov, MD
Senior Vice President, Mental Health Services, The New York
Foundling
Richard Soden, OD, FAAO
Director of Health Care Development, SUNY College of
Optometry
David Goldstein, PsyD
Vice President Child Health & WellBeing , JCCA
Jeffrey Kaczorowski, MD
Senior Advisor to the Children's Agenda
Lisa B. Handwerker, MD,
FAAP
Medical Officer, The Children's Aid Society
Lauren Tobias
DOH
David Collins, LMSW
Assistant Vice President, Programs & Policy, The Children's Village
Donna Bradbury, MA,
LMHC
Matthew B. Perkins, MD,
MBA, MPH
Associate Commissioner, Division of Integrated Community
Services for Children & Families
Medical Director, Division of Integrated Community Services
for Children & Families
Vice Chair for Public Psychiatry, Department of Child and
Adolescent Psychiatry
Alan Mucatel
Executive Director, Leake and Watts
Bill Baccaglini
Executive Director, The New York Foundling
Sr. Paulette LoMonaco
Executive Director, Good Shepherd Services
Beth Finnerty
President and CEO, Cardinal McCloskey Community Services
Jennifer F. Havens, MD
James Purcell
CEO, Council of Family and Child Caring Agencies
October 2016
3131
Confirmed Children’s Health Subcommittee / CAG
Members , continued
Member
Organization
Member
Organization
Alda Osinaga, MD
Division of Program Development and Management, OHIP
Rahil Briggs
Director of Pediatric Behavioral Health Services
David Oakley
Counsel, Phelps & Phillips, LLP
Clyde Comstock
CEO, Hillside Family of Agencies
Dr. Diane Ferran
Senior Director, Clinical Quality Improvement, CHCANYS
Maria Morris-Groves
Adolescent Women and Children's Services, OASAS
Phyllis Silver
President, Silver Health Strategies / Executive Director,
Partnership for Quality Care
Audrey LaFrenier
COO, Northern Rivers Family of Services
Norbert Goldfield, MD
Medical Director, 3M Health Information Systems
Fern Zagor
CEO, Staten Island Mental Health Society
John Kastan
Chief Program Officer, The Jewish Board of Family and
Children's Services
Joseph A. Stankaitis, MD,
MPH
Chief Medical Officer, YourCare Health Plan
Chad Shearer, JD, MHA
Director, UHF Medicaid Institute
Tony Fiori
PHP Coalition (public health insurance plans)
Mary McCord, MD, MPH
Director of Pediatrics, Gouverneur Health Services (Gotham)
Clinical Professor of Pediatrics, NYU
Sean Doolan, Esq.
Hinman Straub
Deborah Rosen, LCSW
Managing Director of Strategic Partnerships at Hillside Family of
Agencies
Maria Cristalli
Chief Strategy and Quality Officer, Hillside Family of Agencies
David Woodlock*
President and CEO, Institute for Community Living (ICL)
Bill Gettman
President and CEO, Northern Rivers
Dr. George Askew
Deputy Commissioner of Family and Child Health
Ellen Breslin
Administrative Director, Renaissance Addition Services, Inc.
Dawn Lewis
COO, Sheltering Arms
Dodi Meyer
NY Presbyterian
Benard Dreyer
NYU, Bellvue, President of American Academy of Pediatrics
Dr. Kallana Manjanuth
Albany Medical Center
Juliette Price
Albany Promise
Alex Okun, MD
Medical Director, New Alternatives for Children
Susan Beane, MD
VP, Medical Director at Healthfirst
Lauri Cole
NYS Council for Community Behavioral Healthcare
Nina Dadlez
Assistant Medical Director of Pediatric Quality, The Children's
Hospital at Montefiore
October 2016
Challenges Ahead and the
Promise of Innovative
Approaches
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October 2016
Challenges Ahead
• Providers, PPS, VBP contractors will continue to face various challenges in their
care management efforts, including:
 Data exchange/integration is still work in progress, yet critical to support practice reform and
VBP
 Data systems are vital to success, as they underpin decision making, performance
measurement, resource allocation, and more.
 Difficulties exist in identifying and engaging certain patient populations for more targeted
care interventions (e.g., underutilizing patients)
 The lack of automated notifications to the right teams regarding major health events (e.g.,
admission, discharge, missed appointment, medication fill status) impedes coordinated care.
 Limited referral capabilities prevent providers from maximizing utilization of health resources,
namely Community Based Organization referrals
 Building lasting relationships among Health Homes, their networks and DSRIP will be key.
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October 2016
Innovative Approaches to Care Delivery
 The system transformation focus of DSRIP will benefit children by expanding access to home and
community-based care, improving integration between children healthcare providers, and
making preventive care a priority
Implementation of Electronic
Health Records / Qualified Entities:
Ensures all child healthcare providers
can access complete health records
Move toward VBP:
Recognizes that for system for
transformation to occur, there needs
to be a move toward paying for
outcomes
Integration of primary care and
behavioral healthcare:
Improves recognition and provides a
comprehensive approach to
addressing behavioral health issues
Emphasis on preventive care in
Domain 3 & 4 Projects:
Results in better care and
identification of needs from infancy to
adolescence (e.g. perinatal, asthma,
behavioral health)
Investment in Home & Community
Based Services and HHs for
children:
Provides expanded and targeted
services to improve health outcomes
of children
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Questions
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Additional Information:
DOH Website:
http://www.health.ny.gov/health_care/medicaid/
redesign/dsrip/
Contact Us:
DSRIP Email:
[email protected]