APPENDIX 3: STATE HEALTH CARE INNOVATION PLAN
1. Provide a Vision Statement for health system transformation.
Washington State aims to achieve better health, better care, at a lower cost with an
integrated health system that provides coordinated services across a continuum of care
settings. Internal and external stakeholders will work together in a unified effort to
transform the current system with strong leadership, shared compromise, and vision for a
better future.
Five key reform transformations will accelerate Washington’s movement from: volumebased to value-based purchasing; fragmented to coordinated care; purchasing costly,
ineffective treatments to procuring evidence-based and cost-effective options; and
management of disease to prevention. These reforms encourage managing costs, improving
patient safety and quality of care, and increasing access to care that is coordinated to meet
the needs of individuals and communities.
Value-Based
Benefit and
Payment Reforms
Delivery Systems
Reforms
Consumer
Engagement
•Public /private payers and providers test, confirm,
and adopt new, common business models that sustain
a strong primary care base and promote the delivery
of value-based, patient-centered care.
•Integrated system where providers respond to
routine reporting that highlights efficient and
inefficient practices, and where consumers,
providers, and payers make informed decisions for
more effective and efficient use of health care
resources resulting in better health outcomes.
•Informed consumers that take greater responsibility
for managing their own health.
Prevention and
Wellness
•Prevention-focused health care and community efforts
aimed at maintaining good health rather than treating
illnesses.
Administrative
Simplification
•Reduction in administrative costs for public and
private entities through timely and efficient
processing of business transactions between
providers, payers, and government.
Value Based Benefit and Payment Reform. Value-based payment is designed to give
healthcare providers adequate resources to deliver efficient, quality care and to remove the
disincentives that exist today for improving quality and efficiency. Payment systems
should be tailored to promote efficient, high-quality care. Episode-of-care payments are
most appropriate for conditions where there is not a problem with overuse of treatment
(e.g., hip fractures and labor and delivery) but where there are opportunities to reduce the
D. Hanig
1
March 24, 16
cost and complications of the treatment. Comprehensive care payments are suitable for
conditions such as chronic diseases where there is concern about unnecessarily high rates
of hospitalizations and specialty care. This payment reform is also considered for
conditions contributing to overuse of certain types of procedures (e.g., heart surgery vs.
medical management of heart disease). Areas of underutilization, such as the delivery of
prevention services with long-term impacts, may be best addressed through fee-for-service
payment.
Washington is keenly aware that setting the right payment amount (i.e., the price) is as
important as using the right payment method. If the amount is too low, providers will be
unable to deliver quality care, and if it is too high, there is no incentive to seek out
efficiencies. Differential price-setting approaches need to be responsive in different regions
and for different providers and services depending on the local market structure.
Delivery Systems Reforms. The ideal health care delivery system is driven by high
performance. This requires a system where a patient’s clinically relevant information is
available to all providers at the point of care and to patients through electronic health
record systems. Patient care should be coordinated among multiple providers, and
transitions across care settings actively managed. Providers (including nurses and other
members of care teams) both within and across settings have accountability to each other,
review each other’s work, and collaborate to reliably deliver high-quality, high-value care.
Moreover, patients have easy access to appropriate care and information, including after
hours; there are multiple points of entry to the system; and providers are culturally
competent and responsive to patients’ needs. There is clear accountability for the total care
of patients. The system is continuously innovating and learning in order to improve the
quality, value, and patients’ experiences of health care delivery. Leadership is a critical
factor in the success of delivery system reform.
Consumer Engagement. Consumers who are actively engaged in their care make choices
that have a significant impact on both costs and outcomes of care. At the individual level,
patient or consumer engagement means involvement in one’s own health and health care
and decisions about one’s treatment. At the community level, consumer engagement
involves participation in decisions about the design, delivery and evaluation of health
services. Engaged consumers can be powerful partners in their own health and health care
and advocates for higher-value health care and a more efficient and effective health care
system.
The current system presents multiple barriers preventing consumers from acting as full
partners in their own care and in playing a meaningful role in improving the quality of local
health care systems. These include difficulty in wading through complicated choices of
services and treatments, getting enough time with harried providers, perceived lack of
consumer expertise, logistical and financial barriers and low levels of organizational
commitment. These barriers are even more acute for consumers of specific racial, ethnic
and socio-economic backgrounds.
D. Hanig
2
March 24, 16
Consumer engagement holds great potential to spur health quality improvements; but, it is
not a silver bullet, since consumers have neither the power nor the skills to transform
health care systems on their own. Change will require a joint effort on the part of many
stakeholders: consumers, providers, employers, payers, insurers, public health, and policymakers.
Prevention and Wellness To maintain global economic competitiveness, reduce
burgeoning health care costs, and ensure that our children have healthy futures, disease
prevention and health promotion must become core objectives for state government.
Although personal responsibility is one factor in attaining wellness, Washington can play
an essential role in reorienting states’ actions toward prevention of poor health outcomes
through three primary avenues: communities, worksites, and schools creating culture of
wellness. State programs and policies should be consistent with wellness goals and public
health messages delivered throughout the state. This includes educating the public about
existing community resources; partnering with community organizations to communicate
information and encouraging healthy lifestyles; promoting civic and personal responsibility
for health; improving access to healthy options in disadvantaged communities; and publicly
sharing their efforts to get healthy.
Creating successful statewide health improvement programs requires three key elements;
1) coordination of activities across multiple state agencies to make everyone’s efforts more
efficient; 2) fully engaging communities how services are delivered locally; and 3) drawing
upon the expertise of public health policy and research experts.
Administrative Simplification Physicians spend a reported 43 minutes per day on
average – the equivalent of 3 hours per week and nearly 3 weeks per year – on
administrative interactions with health plans and not on patient care. Efforts to streamline
and harmonize payment and reporting requirements as basic, straightforward, and
practical prerequisites to eliminating substantial systemic administrative costs are vital to
lowering costs. Reform should encourage the spread of administrative simplification
through the full healthcare delivery “supply chain,” from employer or plan sponsor, to
health plan or plan administrator, to EMR (electronic medical record) or practice
management systems vendor, to medical practice. In addition, policies promoting such
spread should encourage fidelity of adoption in order to maximize harmonization across
payers and care providers.
To drive reform, a decision-making and implementation framework is needed, an
organized infrastructure to promote collaboration and well-informed discussions and
decisions. Together, stakeholders will bring about broad adoption of the common
standards and processes necessary for administrative simplification and cost reduction. By
formalizing a public/private approach between all affected entities, including clearly
defining roles, administrative simplification is more likely to occur with greater
acceleration then if attempted on an ad hoc basis.
D. Hanig
3
March 24, 16
2. Describe population demographic including Medicaid and CHIP populations.
The following tables provide key demographic information, starting with Medicaid and CHIP populations:
Table 1. Medical Assistance Eligible Persons Report - April, 2012
19,539
Adults
Managed
Care
93,840
Total
Eligible
113,379
17,835
Children
Managed
Care
166,699
Total
Eligible
184,534
37,374
Total
Managed
Care
260,539
Total
Eligible
297,913
187
969
1156
39,835
244,374
284,209
40,022
245,343
285,365
AHK - Medicaid CN Optional Children
88
446
534
35,556
143,539
179,095
35,644
143,985
179,629
AHK - Medicaid CN Foster Care and
Adoption Support Children
927
0
927
21,448
30
21,478
22,375
30
22,405
13
58
71
4,442
19,483
23,925
4,455
19,541
23,996
121
0
121
20,554
0
20,554
20,675
0
20,675
Medicaid CN Pregnant Women
7,950
14,401
22,351
307
345
652
8,257
14,746
23,003
Title XXI Non-Citizen Pregnant Women
5,932
0
5,932
95
0
95
6,027
0
6,027
Medicaid CN Family Planning - Post
Partum
25,950
6
25,956
17
0
17
25,967
6
25,973
Medicaid Family Planning -
31,576
0
31,576
4,387
0
4,387
35,963
0
35,963
Medicaid CN Elderly
62,858
945
63,803
2
0
2
62,860
945
63,805
Dual Eligible
61,068
877
61,945
0
0
0
61,068
877
61,945
1,790
68
1,858
2
0
2
1,792
68
1,860
Medicaid MN Elderly
4,117
0
4,117
1
0
1
4,118
0
4,118
Dual Eligible
3,904
0
3,904
0
0
0
3,904
0
3,904
213
0
213
1
0
1
214
0
214
133,220
4,725
137,945
19,296
17
19,313
152,516
4,742
157,258
Dual Eligible
44,744
460
45,204
20
0
20
44,764
460
45,224
Non dual Eligible
88,476
4,265
92,741
19,276
17
19,293
107,752
4,282
112,034
FFS
Medicaid CN Family Medical
AHK - Medicaid CN Mandatory
Children
AHK - Children's Health Insurance
Program (CHIP)
AHK - Non-Citizen Children
Non Dual Eligible
Non Dual Eligible
Medicaid CN Blind/Disabled (SSI
Related)
D. Hanig
4
FFS
March 24, 16
FFS
7,653
Adults
Managed
Care
1
Total
Eligible
7,654
6
Children
Managed
Care
0
Total
Eligible
6
Dual Eligible
4,401
0
4,401
0
0
Non dual Eligible
3,252
1
3,253
6
1,528
0
1,528
1,065
0
463
FFS
7,659
1
0
4,401
0
4,401
0
6
3,258
1
3,259
0
0
0
1,528
0
1,528
1,065
0
0
0
1,065
0
1,065
0
463
0
0
0
463
0
463
1,035
0
1,035
0
0
0
1,035
0
1,035
49
0
49
147
2
149
196
2
198
Medicaid Alien Emergency Medical
431
0
431
0
0
0
431
0
431
Medicaid Refugee Assistance
662
2
664
87
1
88
749
3
752
44,808
0
44,808
5
0
5
44,813
0
44,813
Medical Care Services - Disability
Lifeline
4,117
6,905
11,022
0
0
0
4,117
6,905
11,022
Medical Care Services - ADATSA
4,452
0
4,452
4
0
4
4,456
0
4,456
12
0
12
0
0
0
12
0
12
Involuntary Psychiatric Treatment
267
0
267
16
0
16
283
0
283
Voluntary Treatment - Psychiatric
62
0
62
0
0
0
62
0
62
Total MAA
357,554
122,298
479,852
164,040
574,490
738,530
521,594
696,788
1,218,382
Total MMA less Family Planning
300,028
122,292
422,320
159,636
574,490
734,126
459,664
696,782
1,156,446
1,336
1,473
2,809
121,835
407,426
529,261
123,171
408,899
532,070
Medicaid CN Health Care for Workers
with Disabilities
Dual Eligible
Non dual Eligible
Medicaid CN Women with Breast and
Cervical Cancer
Medicaid MN Others (Pregnant
Women and Children)
Medicaid/Medicare Cost Sharing
(Partial Duals)
Detoxification Services Only
Apple Health (including adults on
children's only programs)
FFS
Total
Managed
Care
Total
Eligible
7,660
Medicaid MN Blind/Disabled (SSI
Related)
FFS
Notes: Adults are persons age 19 and older; children are persons under age 19.
Managed Care persons enrolled in health plans that are paid a monthly capitation rate to service enrolled clients. (Excludes
PCCM and Care Management Enrollments). Total Eligible = sum of Fee For Service and Managed Care Enrolled.
D. Hanig
5
March 24, 16
Table 2. Demographic Characteristics of Nonelderly Adults by Baseline Coverage Type
Insurance Type
Uninsured
Medicaid
Private
N
%
N
%
N
%
Total Nonelderly Adults
729,504
100.0 359,644
100.0 2,990,493
100.0
Health Status
Excellent
Very Good
Good
Fair
Poor
139,566
152,535
281,366
115,272
40,764
19.1
20.9
38.6
15.8
5.6
38,885
48,127
129,784
79,723
63,126
10.8
13.4
36.1
22.2
17.6
938,405
953,633
853,490
196,176
48,788
31.4
31.9
28.5
6.6
1.6
Modified Adjusted Gross
Income (MAGI)
Under 138% FPL
138% - 200% FPL
200% - 300% FPL
300% - 400% FPL
400%+ FPL
336,565
104,775
128,858
77,502
81,804
46.1
14.4
17.7
10.6
11.2
250,676
41,358
37,836
14,655
15,119
69.7
11.5
10.5
4.1
4.2
203,609
177,432
382,294
426,313
1,800,845
6.8
5.9
12.8
14.3
60.2
Age
19 - 24 years
25 - 44 years
45 - 64 years
166,041
360,940
202,523
22.8
49.5
27.8
60,199
173,108
126,337
16.7
48.1
35.1
327,290
1,272,476
1,390,727
10.9
42.6
46.5
Race/Ethnicity
White, Non-Hispanic
Black, Non-Hispanic
Hispanic
Other1
485,473
25,383
144,243
74,405
66.5
3.5
19.8
10.2
225,880
19,177
62,664
51,923
62.8
5.3
17.4
14.4
2,399,999
94,195
147,914
348,385
80.3
3.1
4.9
11.6
Coverage Category
Eligible for Medicaid
72,578
Undocumented Immigrant2
62,603
Other
594,323
9.9
8.6
81.5
359,644
0
0
100.0
0.0
0.0
110,214
67,502
2,812,777
3.7
2.3
94.1
HIU Type3
Single, No Dependents
Single, With Dependents
Married, No Dependents
Married, With Dependents
Kid Only
54.2
9.8
12.3
23.7
0.0
155,051
69,149
32,234
103,210
0
43.1
19.2
9.0
28.7
0.0
746,613
135,852
950,003
1,158,025
0
25.0
4.5
31.8
38.7
0.0
D. Hanig
395,261
71,547
89,837
172,858
0
6
March 24, 16
Uninsured
N
%
Employment Status
Unemployed
Employed - Unidentifiable
Firm Size
Small Firm (< 50)
Employees)
Medium Firm (50 - 500
Employees)
Large Firm (500+
Employees)
Insurance Type
Medicaid
N
%
Private
N
%
350,966
48.1
236,977
65.9
690,764
23.1
143,251
19.6
54,019
15.0
845,583
28.3
139,696
19.1
39,071
10.9
464,333
15.5
37,358
5.1
15,860
4.4
429,505
14.4
58,233
8.0
13,717
3.8
560,308
18.7
Tobacco Use
Yes
No
182,978
546,525
25.1
74.9
106,652
252,992
29.7
70.3
615,704
2,374,789
20.6
79.4
Chronic Condition
Prevalences4
Angina
Arthritis
Asthma
Coronary Heart Disease
Diabetes
Emphysema
Heart Attack
High Blood Pressure
Other Heart Disease
Stroke
7,396
81,621
69,000
10,831
30,615
6,276
14,693
109,075
42,586
7,806
1.0
11.2
9.5
1.5
4.2
0.9
2.0
15.0
5.8
1.1
8,121
75,374
56,267
12,352
38,698
6,191
9,203
85,671
34,158
10,937
2.3
21.0
15.6
3.4
10.8
1.7
2.6
23.8
9.5
3.0
44,501
449,712
239,186
63,998
177,540
21,978
55,630
664,601
170,467
34,006
1.5
15.0
8.0
2.1
5.9
0.7
1.9
22.2
5.7
1.1
Source: Urban Institute (UI) Analysis of Augmented Washington State Database
1) Other includes, among the non-Hispanic population, American Indian/Alaskan Native,
Native Hawaiian/ Other Pacific Islander, and Multiracial
2) Excludes those undocumented immigrants who are eligible for Medicaid through
special programs
3) "Married" includes health insurance units with a married individual even if the spouse
is not within the unit
4) Except for asthma, all prevalences reflect any diagnosis of the disease in question,
regardless how long ago the diagnosis occurred. The asthma prevalence reflects a
current asthma diagnosis.
D. Hanig
7
March 24, 16
Table 3. Demographic Characteristics of Washington Children by Baseline Coverage
Total Children
Uninsured
N
%
56,900
100.0
Insurance Type
Medicaid
N
%
735,611
100.0
Private
N
%
925,276
100.0
Health Status
Excellent
Very Good
Good
Fair
Poor
22,060
9,766
20,060
5,014
0
38.8
17.2
35.3
8.8
0.0
232,504
144,777
297,309
53,066
7,955
31.6
19.7
40.4
7.2
1.1
535,891
239,962
138,577
9,642
1,204
57.9
25.9
15.0
1.0
0.1
Under 138 FPL
16,698
29.3
62.2
48,120
5.2
138 - 200 FPL
200 - 300 FPL
300 - 400 FPL
400%+ FPL
12,595
11,944
9,068
6,594
22.1
21.0
15.9
11.6
120,801
89,666
37,533
30,020
16.4
12.2
5.1
4.1
47,098
146,855
183,576
499,625
5.1
15.9
19.8
54.0
Race /Ethnicity
White, Non-Hispanic
Black, Non-Hispanic
Hispanic
1
Other
38,496
2,430
9,260
67.7
4.3
16.3
368,962
38,800
223,408
50.2
5.3
30.4
693,208
33,616
69,654
74.9
3.6
7.5
6,715
11.8
104,442
14.2
128,798
13.9
35,930
63.1
735,611
100.0
318,460
34.4
2,291
4.0
0
0.0
4,755
0.5
18,679
32.8
0
0.0
602,061
65.1
One Parent
15,051
26.5
332,021
45.1
Two Parents
Kid Only
35,720
6,129
62.8
10.8
360,698
42,892
49.0
5.8
Characteristic
MAGI
457,590
Coverage Category
Eligible for Medicaid
Undocumented
2
Immigrant
Other
HIU Type3
135,854
774,412
15,010
14.7
83.7
1.6
Source: Urban Institute Analysis of Augmented Washington State Database
D. Hanig
8
March 24, 16
1. Other includes, among the non-Hispanic population, American Indian/Alaskan Native,
Native Hawaiian/ Other Pacific Islander, and Multiracial
2. Excludes those undocumented immigrants who are eligible for Medicaid through
special programs
3. "Married" includes health insurance units with a married individual even if the spouse
is not within the unit
4. Except for asthma, all prevalences reflect any diagnosis of the disease in question,
regardless how long ago the diagnosis occurred. The asthma prevalence reflects a
current asthma diagnosis.
3. Describe population health status and issues or barriers that need to be
addressed.
GENERAL HEALTH STATUS TRENDS
Washington differs in a few areas from national statistics. Demographically, the state has
fewer minorities than the national average. Longevity is slightly higher and teen birth rates
are substantially (28%) lower in WA – in part due to robust family planning and sexual
education in the state.
Table 4. Kaiser Family Foundation – State Health Facts
WA
US
Notes
#
%
#
%
Birth Rate
13.4
13.5
Teen Birth Rate per 1,000 Females
26.7
34.3
ages 15-19
White
4.3
5.7
Black
7.8
13.4
Hispanic
4.5
5.5
Total
4.9
6.8
Life Expectancy at Birth
79.7
78.6
Years
Overweight/Obese Children
29.5
- 31.6
% children
Children (19-35 mo.) Immunized
74
75
Child Mortality Rate per 100,000
Children
16
18
ages 1-14
Overweight/Obesity Adults
61.8
- 63.8
Cancer Incidence Rate per 100,000
472.2
- 462.1
Asthma among Adults
9.6
- 8.6
Adults who Visited the Dentist/Clinic
72.1
- 69.7
Violent Crime Rate per 100,000
313.8
- 403.6
-
D. Hanig
9
March 24, 16
Figure 2. Dual Medicare-Medicaid Enrollees by Age Group and Gender: WA, 2007
Male
<45
45-64
65-74
85+
Female
100
80
14%
19%
61%
69%
39%
31%
All Dual
Dual Age
65+
60
18%
51%
40
20
27%
49%
0
Dual Age 1864
Figure 3. Racial Distribution by Enrollment Group: Washington, 2007
100
3%
3%
90
11%
6%
18%
80
3%
6%
70
2%
3%
8%
3%
3%
2%2%
<1%
4%
Other
60
Asian
50
40
77%
30
72%
83%
93%
Black
Hispanic
White
20
10
0
Dual
Dual Age 65+
Dual Age 18-64
Medicare Only
Washington is ranked one of the healthier states in the nation. The United Health
Foundation placed Washington 15th in overall health in 2012 and the state took 10th in the
Commonwealth Fund’s 2011 Child Health Score Card.
D. Hanig
10
March 24, 16
Figure 4. Better than the Nation on Critical Health and Population Measures
30
25
27
20
15
21
20
15
20
18
17
10
US
13
5
WA
10
6
6.8
4.9
0
Living in
Poverty
Children in
Poverty
Medicaid
Uninsured
Uninsured
Children
Infant
Mortality
Washingtonians may be healthier in some areas; they are on par with national trends
in others. Approximately 21% of adults in the 11 counties are living at 200% of the Federal
Poverty Level (FPL) or below. Large imbalances in the distribution of health risk by income
persist in these counties. According to self-report data from the Washington State
Behavioral Risk Factor Surveillance System (BRFSS), low-income adults in priority counties
are at significantly higher risk, with the largest imbalances by income for obesity, tobacco
use, diabetes, and lack of screening for cholesterol, breast cancer, and colon cancer.
D. Hanig
11
March 24, 16
Figure 5. Federally Designated Health Professional Shortage Areas for Primary Care
Washington State struggles to maintain the number of health care providers needed to
serve rural communities and underserved populations. This not only affects access to
routine care, but it also impacts the health of many in our state.
D. Hanig
12
March 24, 16
CHRONIC DISEASE
In Washington, nearly two out of three deaths annually are from smoking and obesityrelated diseases, including heart disease, stroke, cancer, diabetes, and chronic lower
respiratory disease (2009 death data, Washington State DOH Vital Statistics System). It is
not just older people dying from these diseases; almost one-fourth of these deaths are
among people younger than 65. The causes of many of these deaths are related to tobacco
use, poor diet, insufficient physical activity, and alcohol consumption, and they unevenly
impact communities of color, individuals with lower socioeconomic status, and other
underserved sectors of the population. For example, while obesity, diabetes, and
hypertension have increased for all income groups in Washington since 1993, they have
increased more rapidly among people with lower incomes. Smoking rates have decreased
for all income groups in the state since 2000, but these decreases are happening more
slowly in low-income populations.
The state’s Department of Health1 has found that the prevalence of diabetes and the
incidence of melanoma are on the rise, while rates of mortality or incidence of many other
diseases are declining. Death rates for stroke, breast cancer, and lung cancer in Washington
are similar to those seen nationally, while rates of coronary heart disease mortality,
diabetes prevalence, and incidence of invasive cervical and colorectal cancers are lower for
Washington than the nation. Rates of asthma prevalence and melanoma incidence have
consistently exceeded national levels since the 1990s. The following table from the Agency
for Healthcare Research and Quality (AHRQ) shows the prevalence of certain chronic
conditions in Washington State, along with goals for improvement.2
Table 5. Chronic Disease in WA by Health People 2020 (HP2020 Targets)
Measure
HP 2020
Target
Most Recent
Baseline
State
Rate
Data
Year
State
Rate
Data
Year
Definition
Cancer
All cancer deaths
160.6
178.0
2007
196.0
2000
per 100,000 population
Lung cancer deaths
45.5
49.5
2007
57.6
2000
per 100,000 population
Colorectal cancer
deaths per year
14.5
14.9
2007
18.3
2000
Per 100,000 population
Prostate cancer deaths
21.2
24.4
2007
27.5
2000
per 100,000 male population
HIV deaths
3.3
1.6
2007
2.1
2000
per 100,000 population
70.3
2009
72.9
2001
Adults age 65 and over who
received an influenza
vaccination in the last 12
months
Immunization and Infectious Diseases
Flu vaccine - age 65
and over
1
2
90.0
http://www.doh.wa.gov/Portals/1/Documents/5500/CD2007.pdf
Washington
D. Hanig
13
March 24, 16
Measure
HP 2020
Target
Most Recent
Baseline
State
Rate
Data
Year
State
Rate
Data
Year
Definition
Pneumonia vaccine
ever - age 65 plus
90.0
71.3
2009
66.9
2001
Adults age 65 and over who
ever received pneumococcal
vaccination
Flu vaccine for highrisk persons
80.0
39.7
2009
32.2
2003
Percent of high-risk persons
ages 18-64 who received an
influenza vaccination in the
past 12 months
Pneumonia vaccine
ever - high-risk, age 18
to 64
60.0
30.5
2009
22.0
2003
High-risk people ages 18-64
who ever received a
pneumococcal vaccination
13.0
2007
12.3
2000
Suicide deaths per 100,000
population
Mental Health and Mental Illness
Suicide deaths
10.2
Duals have greater prevalence of chronic disease compared to Medicare-only beneficiaries.
And both duals and non-duals served in the state’s Medicaid program show a high
incidence of chronic conditions as depicted in Figures 6 and 7 below:
Figure 6. Number of Chronic Conditions by Enrollment Group: Washington 2007
50
45
40
35
30
25
20
15
10
5
0
Dual
Medicare-Only
None
D. Hanig
1 to 2
3 to 4
5+
14
March 24, 16
Figure 7. Prevalence of Select Chronic Conditions by Enrollment Group: WA 2007
No Chronic Condition
Stroke
Osteoporosis
Heart Disease
Diabetes
Depression
Medicare-only
Congestive Heart Failure
Dual
COPD
Chronic Kidney Disease
Cancer
Arthritis
Alzheimers/Dementia
0
10
20
30
40
50
These profiles highlight the significance of behavioral health, long‐term care and physical
health needs among both elders and working‐age duals, and point to the importance of
efforts to better coordinate health services for this vulnerable population. In just Medicare,
over 50% of beneficiaries have 1 or more chronic conditions. Characteristics of Medicaid
single and dual eligibles show considerable need for improved coordination of care. For
example, one quarter of Medicaid Disabled clients are considered “high risk”. Of these,
nearly 90% receive services from two or more programs, including Long-Term Care (LTC),
Severe Mental Illness (SMI), Alcohol or Drug Abuse (AOD) and Developmental Disabilities
(DD). The state’s predictive modeling database (PRISM) generated the following Venn
diagram showing the overlap of risk factors among high-risk single-eligible Medicaid
disabled clients:
D. Hanig
15
March 24, 16
Figure 8. Venn diagram: Overlap of risk factors among high-risk single-eligible
Medicaid disabled clients
GRAND TOTAL
TOTAL AOD = 7,281
30%
ALL HIGH/MED RISK (Dotted Outline)
= 24,006
Shaded Area Between
Dotted Outline and Circles =
7,052
AOD ONLY = 2,516
29%
10%
AOD + LTC
= 769
3%
AOD + SMI = 2,962
12%
AOD + SMI
+ LTC = 941
LTC ONLY = 2,733
11%
4%
TOTAL LTC
= 6,068
SMI + LTC
= 1,550
25%
6%
TOTAL SMI
= 8,867
37%
DD + SMI + LTC = 24
<1%
SMI ONLY = 2,542
11%
SMI+DD
789
SMI + LTC =
47
<1%
3%
DD ONLY = 1,988
8%
TOTAL DD = 2,941
12%
MOTHERS AND BABIES3
Background: Washington State has seen a downward trend in births in recent years. In
2011, there were 85,494 birth, 86,480 in 2010, and 90,270 in 2008. Medicaid funded over
half (50.4%) of all deliveries, up from 48.5% in 2009.
Birth rates and pregnancy rates
decreased in 2010, especially among women 15-24.
The singleton low birth weight rate
for African Americans has significantly decreased since 1990.
After increasing from the early 1990s through 2006, the preterm birth rate appears to be
declining. SIDS rates decreased from 1990-2005, and remain low. In 2010, 80.2% of
Washington women received prenatal care in the first trimester. First trimester prenatal
care has increased each of the last three years. Smoking just before and after pregnancy
Paragraph cites material from the 2007 DOH Maternal & Child Health Plan. Cathy.wasserman@doh.wa.gov,
polly.taylor@doh.wa.gov.
3
D. Hanig
16
March 24, 16
decreased from 1996 through 2008. In 2010, 20% of women reported smoking in the
three months before pregnancy, using a slightly different definition of smoking. Approximately 95% of new mothers reported ever breastfeeding in 2010. Both initiation of
breastfeeding and breastfeeding at two months postpartum are increasing.
Areas of concern:
Almost 43% of women were either overweight or obese prior to pregnancy in 2010; over
46% of all women gained more than recommended amounts. The singleton low birth
weight rate overall, and among all race and ethnic groups except African Americans, has
increased since 1990. Though not yet statistically significant, rates may be stabilizing.
The Native American infant mortality rate remained high and exceeds the infant mortality
rates of other race and ethnic groups.
Women receiving Medicaid continued to have lower
first trimester prenatal care rates and higher rates of late/no prenatal care than women
who did not receive Medicaid. Smoking rates during pregnancy continued to be
significantly higher for women receiving Medicaid than for women who did not receive
Medicaid.
The unintended pregnancy rate remained high, but in 2010 dropped below 50%
for the first time since we began measuring it in 1996.
Around half of women report not
taking a multivitamin at all in the month prior to pregnancy.
C-Sections. The overall C-section rate in Washington State increased 73%, from 1996 to
2009, one of the biggest increases in the nation. In Washington State C-section rates vary
greatly by hospital and region, from 10 to 39%. The following graph shows the growth in
total C-section rates in Washington State.
Figure 9. Total C-Section Rates: Medicaid and Non-Medicaid Births 1989-2009
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
0.0%
Medicaid
D. Hanig
Non-Medicaid
17
March 24, 16
Of great concern is the correlation between early term C-sections and NICU admissions.
The evidence indicates that early deliveries lead to poorer neonatal outcomes, leading to
our focus on decreasing such deliveries when not medically necessary:
Table 6. C-Sections and NICU Admissions
For C-Sections Conducted at:
The Risk of NICU Admission is:
37 weeks
20.8%
38 weeks
16.5%
39-41 weeks
7.8%
There is considerable regional variation in low risk C-sections unrelated to risk factors,
ranging from 15% - 30% in facilities across the state.
Inductions. The percentage of induction of labor among Washington State hospitals varied
from 3% to 48%, in 2011 (includes both elective and non-elective inductions). Reasons for
the wide variation are the same as for elective deliveries before the 39th week: 1) the
mother requests the procedure; 2) provider decisions (indications for whether and when
to perform inductions of labor and elective inductions of labor are gray areas); 3)
scheduling for convenience reasons. Like inductions, no national labor and delivery
management standards or guidelines exist for whether and when to perform a C-section
once labor has started. Washington State and the Bree have suggested standards that are
now being applied across all hospital and payers. The CMMI/SIM offer a means to more
rapidly apply, train and feedback reports for rapid cycle improvements.
4. Describe health system models “current as is” and “future to be” states, including
the level of integration of behavioral health, substance abuse, developmental
disabilities, elder care, community health, and home and community-based
support services.
CURRENT SYSTEM
Washington State’s current system mirrors the strengths and weaknesses of the U.S. health
care system:
1. Administrative inefficiency. Multiple payers covering different services have distinct
requirements and payment methods, resulting in high administrative costs for providers. A
study4 conducted by the Washington Office of the Insurance Commissioner found that
upward of 40% of health care costs are spent in administrative activities and each primary
care provider must hire more than 4 FTEs to accommodate the administrative burden of
differing payers’ requirements for formularies, prior authorizations and payment methods.
4
http://oic.wa.gov/legislative/reports/SimplificationRpt.pdf
D. Hanig
18
March 24, 16
2. Siloed services. Most services, and especially publicly funded services such as Medicaid,
usually operate in a siloed fashion, with many clients receiving services from different state
agencies without any coordination of care. The division of state and federal responsibilities
for dual eligible Medicare and Medicaid clients compounds this fragmentation further.
Currently, the following programs largely operate through separate delivery and payment
systems:
1. Primary, specialty, rehabilitative and acute care
2. Long-term services and supports
3. Mental health and recovery services
4. Substance abuse prevention and treatment services
5. Diverse range of supports for people with developmental disabilities
Each system has unique performance outcomes and goals that make sense within each
sphere but typically do not hold providers accountable for influencing overall health
outcomes or expenditures. That creates significant barriers in the face of mounting
evidence that the greatest public expenditures and most preventable health outcomes are
associated with individuals who have complex needs that cut across the disciplines
represented by each of the current delivery silos.
Payment is tied to the provision of distinct services, treatments or interventions and
therefore is not oriented to prevention or performance based outcomes. Money saved in
one silo or funding stream due to the intervention by another cannot easily be moved to
incentivize the outcomes desired. As such, there are few incentives for the system to work
together to comprehensively meet complex needs. The result is often uncoordinated
service delivery, where beneficiaries express frustration in accessing necessary services
and navigating across systems of care.
Without a comprehensive, patient-centered orientation to care , it is difficult to identify
whether patients are: 1) getting the care they need; 2) experiencing avoidable emergency
room visits, hospitalizations and institutional stays; 3) knowledgeable about opportunities
to improve health outcomes; 4) accessing preventative care and routine labs; or 5)
experiencing gaps in care or service transitions. Getting this full view is complicated by
separate Medicare and Medicaid funding streams where data systems are not aligned and
cost shifting between fund sources is common.
3. Fee-for-service (FFS). Another key feature is the reliance on fee-for-service (FFS)
payment (described in detail under Question 6 below).
Approximately 1.2 million individuals enrolled in Medicaid receive primary care, other
physical health and limited mental health services purchased by the Health Care Authority
(HCA) through managed care and fee-for-service financing arrangements. Those services
cost the state and federal government approximately $10 billion each biennium. Since July
1, 2012, about 70 percent of all Medicaid enrollees are covered by one of five managed care
plans.
RECENT PROGRESS
D. Hanig
19
March 24, 16
Washington State has made promising progress in the integration of allied services, such as
behavioral health, substance abuse, developmental disabilities, elder care, community
health, and home and community-based support services. The state recently submitted its
Pathways to Health: Medicare and Medicaid Integration in Washington State proposal to
CMS to accelerate integration of these services under §2703 of the Affordable Care Act,
including improved care for dual eligibles. This proposal requires providers serving highrisk populations to identify a lead caregiver and coordinate the care provided.
The state can also point to several successful initiatives to integrate care across systems,
including:
1. Disability Lifeline Program (DL)5: For over two decades, Washington has provided cash
and medical benefits for disabled adults who had not (yet) qualified for SSI or SSDI
disability benefits. In 2010, the Legislature modified the program to transition clients
to a managed care plan – Community Health Plan of Washington – whose network is
largely comprised of FQHCs and RHCs. The new program added onsite behavioral
health coverage or active coordinate to link to behavioral health. Subsequent
evaluation found that the target population, which was at high risk for substance and
mental health problems, showed improvements in behavioral health status as well as
reductions in inpatient days.
2. HB 1738: The Legislature demonstrated its commitment to integrating care across
systems when, in 2011, it passed HB 1738, requiring the Health Care Authority and
Department of Social and Health Services to conduct a community-based process to
more effectively coordinating “. . . the purchase and delivery of care, including the
integration of long-term care and behavioral health services.” The agencies’ report
included concrete steps to purchase health care through MCOs that “. . . compete based
on service, access, quality and price and . . . [through] robust health home functions . . ..”
3. Chronic Care Management (CCM): program provides high-risk clients with enhanced
nurse care management services in five pilot sites across Washington State. Early
results showed reduced inpatient and ER utilization, resulting in net savings of $27
PMPM, as well as longer lifespans and less care in institutional settings.
4. Washington Screening, Brief Intervention, and Referral to Treatment (WASBIRT):
evidence-based public health practice training providers, including primary care, to
conduct routine alcohol and drug screening. Results show more rapid access to
treatment leading to better health outcomes.
 Multipayer Medical Home Project: There are a growing number of efforts in Washington
focused on how to measure and pay for better outcomes. Currently nine clinics across
the state are engaged in medical home projects. Participating providers receive a
PMPM ($2.50) to cover care coordination, expand access to after hours, disease
registries and team management.
5
Unützer, J, et al. Quality Improvement With Pay-for-Performance Incentives in Integrated Behavioral
Health Care, in American Journal of Public Health, April 19, 2012.
D. Hanig
20
March 24, 16
See Appendix A for a more complete list of current Washington State health care system
delivery initiatives.
FUTURE HEALTH SYSTEM
Once implemented, the future health system will have the following characteristics: 1)
evidence based practices, 2) effective management of chronic conditions, and 3) value
based accountable care.
1. Evidence-based Practices: As described in this plan, Washington State has been in the
forefront of states emphasizing rigorous reviews of services and products to assure that
they are safe and effective, including the Bree, the Generics First program and the Health
Technology Assessment Program (HTAP). The project will extend these efforts through the
Bree Collaborative, i.e., developing best practice recommendations; providing training via
the DOH Collaborative Learning program, and modifying payment strategies to support
best practices. The state will also explore changes to help providers and payers lower their
risk of liability exposure by following approved evidence-based guidelines. Using these
approaches, we intend to transform the practice culture in Washington State to provide
care that is supported by research and found to be safe and effective.
2. Effective Management of Chronic Conditions: The Model’s efforts will complement
those of the §2703 Health Home and Dual Eligibles projects. There will be greater
emphasis on primary care, especially medical homes serving people with chronic
conditions. Strengthening primary care, through training, modified reimbursement and
contractual performance metrics, will be critical to achieving the Triple Aim. A key element
of enhanced primary care will be the inclusion of behavioral health services. For example,
building on earlier projects cited above, and consistent with the Pathways to Health
proposal, there will be an expectation for medical services delivery integrated or closely
linked with behavioral health services. Training provided under DOH collaboratives will
include behavioral health screening and intervention and, since the project affects both
private and public payers, training regarding long-term care will focus on screening,
referral and coordination. Primary care practices need not be experts in long-term care
services, but training will develop capacity to screen for unmet needs and refer to
appropriate resources. For clients receiving LTC services, the focus will be on shared
treatment planning and regular communication.
3. Value Based Accountable Care. Typically, ACO’s use primary care as central tools;
however the most successful programs have integrated specialty and hospital care - where
expenditures are highest. Nationally models like the PROMETHEUS, ProvenCare
(Geisinger), Group Health Cooperative (GHC) and Inter-Mountain Care are called out in the
literature along with a promising model in Blue Cross Blue Shield of Massachusetts where
the health care system’s in which financial and clinical goals are aligned. However, these
systems are already highly integrated (and have developed over many years cultures that
support higher-value, lower-cost care) and do not fit situations where PCP and specialist
practices operate independently of facilities. The grant will offer a testing ground where
larger systems do not exist or are not integrated across professional and facility care. The
Model will adapt elements of the Massachusetts BC/BS Alternative Quality Contracts (AQC)
payment model. The AQC can help construct “virtual” ACOs by aligning incentives:
D. Hanig
21
March 24, 16
1. Gain sharing to stabilize spends and trends;
2. Feedback reports to reduce variation
3. Functional integration of systems (e.g., PCP, facility and medications)
4. Incentive payments f for providers achieving quality metrics
This approach has particular resonance for communities that are developing Regional
Health Improvement Collaboratives. Communities, like Whatcom (Bellingham), Yakima,
Thurston, Spokane and Clark (Vancouver) counties are moving to link and coordinate a
wide range of services at the local level where services are delivered. The AQC model
provides a natural vehicle to accelerate these efforts.
As a first step, Washington proposes to adapt the AQC model to pay for integrated services
for births starting with a global budget negotiated with a set of professionals and their
associated hospital(s). Professionals and hospitals that achieve a lower target cost will
receive a portion of the savings.
Providers can receive additional payments upon achieving quality outcomes, such as very
low 37-39 week elective non-medically necessary delivery rates. In 2011-12, Washington
used a similar model (the hospital quality assessment) to pay an incentive based on five
quality targets with four gates. The program demonstrated a significant change in all
quality measures, including a 65% reduction in 37-39 week elective deliveries6.
Payers will agree to a core standard set of quality and utilization measures for the infant
and maternal project and the chronic care medical home as a requirement for participating
in the CMMI project.
The Legislative health care committee chairs have expressed willingness to support
legislative changes, where recommended, to further incentivize providers and facilities to
coordinate efforts. The chairs are currently conducting meetings with stakeholder groups
on this topic.
5. Report on opportunities for or challenges to adoption of Health Information
Exchanges (HIE) and meaningful use of electronic health record technologies by
various provider categories, and potential strategies and approaches to improve
use and deployment of HIT.
Washington State the advantage of being an early adopter of electronic health records and
a health information exchange. In a prescient move, 2009 Legislature passed SB 5501,
establishing a lead agency and process to build a health information exchange. Shortly
after passage, the state received ARRA funding enabling it to proceed quickly in
constructing the Exchange.
The HIE provides centralized shared services, including: Hub for secure exchange of HL7
and X12 transactions; Master Person Index (MPI) to match patient identities; and Provider
Directory. Patient information will be accessed in a secure fashion from decentralized sites.
Over time, the HIE will benefit this project in two ways: 1) assist in the aggregation of
6
http://www.wsha.org/0382.cfm
D. Hanig
22
March 24, 16
patient data to generate timely reports so providers can better coordinate care; and 2)
permit providers to directly query patient data, such as lab results and medications
prescribed by other practitioners, to improve day-to-day care.
Washington has a variety of Health Information Technology (HIT) and Health Information
Exchange (HIE) initiatives in communities and organizations across the state. Electronic
Health Record (EHR) adoption appears to be above average compared to the nation as a
whole, and there is an active interest in Personal Heath Records (PHR). While no
community or organization has met all its HIE needs, there is a significant electronic health
information infrastructure that serves as a foundation for statewide HIE including
Medicaid, Public Health, other state agencies, the Regional Extension Center, the Beacon
Community grantee, the Community College Consortia, and various Federal organizations.
HIE Organization for Washington, OneHealthPort. HCA designated OneHealthPort, a
private sector health information technology management organization, to serve as the
lead HIE organization for Washington. In this role, OneHealthPort is responsible for:
1. Leading initial development of HIE in a manner that will comply with the new State
law (SB 5501 is now part of the Revised Code of Washington, Chapter 41.05);
2. Satisfying the grant objectives of the Federal Health HITECH Act; and
3. Attracting private and public sector stakeholders to invest and participate in HIE.
OneHealthPort is governed by the Foundation for Health Care Quality, a community notfor-profit organization that also plays a key role supporting the efforts of the Bree
Collaborative. The HCA coordinates the work of the public sector and other American
Recovery and Reinvestment Act (ARRA) programs while providing any additional oversight
needed by the Foundation and OneHealthPort.
The architecture is a “thin-layer” model built to harness and leverage the existing HIT/HIE
capabilities in the state. The modest scope of the HIE also enhances sustainability of the
HIE and reduces privacy and security barriers to information exchange. The shared
services to be centralized in the HIE include:
1. Hub for secure exchange of HL7 and X12 transactions
2. Master Person Index (MPI) to match patient identities
3. Record Locator Service (RLS) to find where patient data resides
4. Provider Directory to identify and locate trading partners
5. Standards and conventions to support trusted and efficient exchange
6. Management organization to operate the HIE
The services to be decentralized and offered in the marketplace by other parties include:
1. Data repository for storing patient information
2. Data transformation to edit and translate information
3. Applications for viewing, storing and using information
D. Hanig
23
March 24, 16
Figure 10. HIE Organization for Washington, OneHealthPort
Current State and Gap Analysis of EHR Adoption and Meaningful Use Washington State
has higher adoption rate of EHRs than many other markets (75% of office-based practices
in Washington vs. 57% nationally). Since launching in June 2011, the EHR Incentive
Program has received more than 2,700 Washington registrants. As of June 25, 2012, more
than 2,140 professionals and hospitals have been approved as eligible for more than $104
million in federal incentive payments.
Although EHR adoption rate is relatively high, considerable gaps remain related to the
emerging definitions of meaningful use. The biggest gap in the current structure is the
inability to exchange all required CCD information between these hospitals and the care
provider at the transition of care. 27 of the 50 hospitals within this region are currently
connected and can exchange information, and all physicians have the ability to
electronically receive information from those hospitals as well as reference laboratories
and imaging centers. However, there needs to be a more robust exchange available to
connect those not currently sharing information. Beyond HIE, providers in the region need
help to make better use of their existing EHRs for chronic disease management and quality
measure reporting. Organizations in this region have significantly promoted chronic
disease management, most notably the Washington State Diabetes Collaborative. This
D. Hanig
24
March 24, 16
initiative of the WA DOH provided physicians with tools and guidance to implement best
practices regarding patients with diabetes. The Collaborative has been very successful and
has served as a model for the rest of the country. However, small physician practices
generally have not adopted tools to support disease management or utilized existing
capability in their EHRs. Providers also need to be able to generate and submit reports to
quality monitoring organizations and provide patients with electronic access to their health
information.
6. Describe delivery system payment methods both “current as is” and “future to be”
payment methods.
CURRENT SYSTEM
As noted under Question 4, in Washington State fee-for-service is the predominant
payment method – one that tends to incent volume of care with even when it may not be
necessary. Like all other regions, Washington sees considerable service variation, as
documented by the Dartmouth Atlas and similar studies. The state does have a noteworthy
fully integrated HMO in Group Health Cooperative, which has been able to document gains
in quality and efficiency. However, it is worth noting that even in a system like Group
Health, where incentives are well-aligned, recent research7 indicates that actual physician
practices can reflect community standards – even if those standards lack an evidence basis.
FUTURE SYSTEM
Four years into implementation, we will see wider adoption of non–FFS payment methods
that are tailored to address the particular conditions or patient needs and providing
greater flexibility than the current system. Examples include:
1. Bundled rates for specific conditions or episodes of care. These will all share an
emphasis on combining payment for all stages of treatment (including facility and
outpatient) to strengthen coordinated care and follow-up. All Washington payers (FFS
and managed care) currently pay professionals and hospitals using CPT and DRG
coding, and have some experience paying a global professional fee for prenatal, delivery
of any type and post-natal care. More recently, Washington Medicaid changed the DRG
weights, paying low risk C-sections high risk vaginal rates (effectively lowering the
average payment by nearly $1000 per low risk C-section).
2. Gain-Sharing. In the future, certain episodes of care, such maternity and delivery, will
benefit from gain-sharing. Professionals meeting a defined goal would be given an
enhanced rate for the following year. Professional and hospitals not integrating care
would not gain share. Adapting existing FFS payment systems for this purpose will
achieve our goals while minimizing administrative overhead and changes to existing
contracts.
3. Upfront payments for certain services, such as primary care, to build an infrastructure
capable of employing best practices.
7
http://jama.jamanetwork.com/article.aspx?articleid=1182858
D. Hanig
25
March 24, 16
4. Continued use of FFS and capitated payments for certain episodes of care.
The payment changes will occur under the rubric of contracts modeled after the AQC
contract, as described under Question 4 in this document.
In sum, we expect greater diversity of payment approaches in the future. However, at the
same time, we expect less diversity among payers’ administrative practices. To assure
providers will participate in reformed systems, we expect participating payers to agree to
use the core standard set of quality and utilization measures for the obstetrics project and
managing chronic conditions.
7. Describe health care delivery system performance “current as is” and “future to
be” performance measures.
One of the key features of this proposal is its emphasis on systemic change across many
payers. This distinguishes it from other concurrent initiatives such as §2703 funding for
Health Homes and the Dual Eligibles project – both of which are limited to the Medicaid
and Medicare populations. While these are critical efforts, we recognize it is difficult for
providers to modify their practices for certain payers and not for others. This proposal
addresses that issue by engaging providers and large payers to promote practice
transformation – changes that will also enhance the Health Homes and Dual Eligibles
projects.
CURRENT SYSTEM
Efforts to measure performance in the current system can be described as fragmented, at
best. As is the case nationally, most providers are paid based on the volume of services
delivered rather than on quality or value. Across the system, there are some broader
yardsticks, such as accreditation entities (e.g., JCAHO); but accreditation often reflects
adherence to process requirements, instead of health outcomes. There are some entities –
such as Group Health Cooperative, the Everett Clinic and the Virginia Mason Medical Center,
among others, who have moved beyond the status quo by implementing evidence-based
practices, conducting their own research, and using LEAN methods to promote continuous
quality improvement. In addition, there is growing reliance by purchasers on performance
measures as exemplified by the Puget Sound Health Alliance and the Health Technology
Assessment Program (HTAP), but their direct linkage to payment levels is limited. For
example the HTAP has successfully reduced reliance on unproven or non-beneficial
interventions; but its findings have been applied primarily by state health purchasing
agencies and not widely in the private sector. The Puget Sound Health Alliance has
successfully aggregated claims data to generate provider quality reports; but, until recently,
these were limited to five counties in the metropolitan Seattle area (King, Kitsap, Pierce,
Snohomish and Thurston counties). Beginning in 2013, the Alliance will report statewide,
with quality metrics by county.
In addition, the physician driven, clinically derived quality measurement programs of the
Foundation for Health Care Quality are nationally unique and have been successful for
D. Hanig
26
March 24, 16
years in providing measured, benchmarked feedback to physicians and hospitals statewide.
Many improvements have been, and continue to be documented in the fields of
interventional cardiology, general and pediatric surgery, vascular surgery, spine care and
surgery, and obstetric care. This important work will continue and it will be available to
form the necessary clinical basis of any quality/cost analyses.
FUTURE SYSTEM:
The CMMI grant will have an enormous impact on the use of evidence-, performance-based
measures. The Bree Collaborative and the Puget Sound Health Alliance will be the grant
implementation venues. The Bree currently evaluates the research and selects up to three
episodes of care that are high-cost but low value and then develops recommended
evidence-based best practices. Under the grant, the Bree Collaborative’s role will be
expanded to include payment reforms, such as bundled payments for obstetrics care. The
Collaborative will apply this improvement cycle to other episodes of care, such as
appropriate management of low back pain, potentially avoidable readmissions and
interventional cardiology services. The grant will convene payers, purchasers and
providers followed by rapid, broad adoption through the DOH collaborative learning
programs and payment modifications. These steps will lead to broad adoption of agreedupon performance measures across payers and providers in the state by the end of the
grant period.
The Alliance has extensive experience in aggregating claims data to generate reports
(community checkups) depicting performance of provider organizations. This role will
continue on a broader basis in the future with the Alliance accepting claims data from
payers statewide. The aggregated data will support the development of performance
metrics and related reports.
The following table provides examples of performance measures, a subset of which the
project will employ during the life of the grant. These will be refined during the first six
months of the grant period and are expected to continue in use after the grant expires.
Table 7. Performance Measure Inventory Is this complete?
#
1
2
Measure
Flu Shots
BMI Assessment
3
Breast Cancer
Screening
4
Cervical Cancer
Screening
5
Smoking
Cessation
D. Hanig
Existing Quality Effort Inventory
DOH used CDC funding through Healthy Communities program to provide
outreach to providers to raise awareness of the Medicare obesity screening
benefit. DOH will integrate improvement strategies into provider training through
collaboratives, other initiatives
CHC funds a cancer screening coach through DOH to provide education to
clinics on breast cancer guidelines. Will incorporate into collaborative learning
where there is clinic-level interest.
CHC funds a cancer screening coach through DOH to provide education to
clinics on cervical cancer guidelines. Will incorporate into collaborative learning
where there is clinic-level interest.
One of the Million Hearts Campaign core aims. DOH contracts to provide training
and outreach to providers in the screening and treatment of tobacco users,
27
March 24, 16
#
Measure
6
Depression
Screening &
Follow-up
Readmissions
7
8
9
10
11
Diabetes
Admissions
COPD Admissions
CHF Admissions
Adult Asthma
Admissions
12
Chlamydia
Screening
13
MH Hospital
Follow-up
Elective Delivery
14
15
16
17
Antenatal Steroids
Annual HIV/AIDS
visit
High Blood
Pressure
18
LDL-C screening
19
A1c Testing
20
Antidepressant
Med Mgmt.
Antipsychotic
Adherence
Persistent Med
Mgmt.
21
22
23
CAHPS Survey
24
Care Transition
Record
25
AOD Initiation &
Engagement
Postpartum Care
Rate
26
27
NICU Data
D. Hanig
Existing Quality Effort Inventory
including modification of their clinical systems.
DOH will be incorporating PHQ-9 and other mental health screening tools into
collaborative learning activities.
There are many statewide initiatives including those involving DOH, QUALIS,
WSHA, WSMA, and the Alliance under contract to HCA to improve the safety
and efficacy of transitions across health care settings and reduce admits.
DOH currently provides technical assistance and training to safety net providers
and tribal clinics on asthma upon request and supports several pilot home
visiting programs.
DOH does not currently have a targeted improvement effort underway beyond
on-going consultation and assistance to Take Charge providers and in support of
adolescent health services.
Extensive statewide QI project just concluding. The Governor’s Bree
Collaborative published their final obstetrics care report and recommendations in
August 2012. Since 2009 DOH has sponsored and staffs the quality work plan of
the Perinatal Advisory Collaborative with support from HCA and in collaboration
with WSHA.
Reflects one of the Million Hearts Campaign core aims. DOH provides support
to clinics through collaborative learning to improve measurement and
management of blood pressure, including medication and lifestyle management.
Reflects one of the Million Hearts Campaign core aims - for all patients (not just
those with diabetes).
DOH will be integrating strategies for A1C improvement through collaboratives
and other initiatives.
The Alliance asks providers to track and use the PHQ9 reporting tool to assess
mood.
The HCA uses a statewide set of reports on Red Flags (dose, poly-pharmacy
and adherence) to all CMHCs in WA.
DOH and training partners (WSHA, Qualis, WSMA, the Alliance) are developing
strategies to support more frequent medication reconciliation and monitoring,
particularly in transitions between healthcare settings.
DOH is looking at aligning CG-CAHPS survey strategies with those used by the
Puget Sound Health Alliance to provide clinics with feedback on patient
experience in their practices.
DOH is working with Qualis, WSHA, WSMA, and managed care organizations
under contract to HCA to improve the safety and efficacy of transitions across
health care settings and reduce readmits.
DOH is not currently providing on-going training on prenatal and postpartum
care, but does monitor rates and is very concerned about access issues due to
primary care shortages. DOH sponsors and staffs the Perinatal Collaborative
with support from HCA.
All but two level 3 NICUs (UW and Fort Lewis) report to the VON data set. Ten
28
March 24, 16
#
Measure
28
ED Utilization
26
Brand Generic
Use
Existing Quality Effort Inventory
Level 1-2 NICU report to the FHCQ/OB-COAP
HCA tracks total ED use, low acuity, PRC/Lock-in and narcotic utilization using
the NY University list of non-emergent conditions. The Alliance tracks nonemergent ED utilization with the CA list of non-emergent conditions. The “ER is
for Emergencies” campaign of WSHA, WSMA, and WA-ACEP is implementing
seven target strategies to reduce unnecessary use of the ER.
HCA tracks brand generic use in six drug classes targeting high brand use
providers. The Alliance targets drug four classes publically reporting rates by
clinic.
8. Describe the current health care cost performance trends and factors affecting
cost trends (including commercial insurance premiums, Medicaid and CHIP
information, Medicare information, etc.). Section to be completed by fiscal staff
based on assumptions used in financial modeling
9. Describe the current quality performance by key indicators (for each payer type)
and factors affecting quality performance.
CURRENT QUALITY PERFORMANCE MEASURES
Washington State agencies maintain numerous health care databases for their own
programs, but strong interagency relations allow departments to share and link data
effectively, including:
• Vital statistics records (birth and death certificates);
• Medicaid claims data;
• Washington State employee claims data;
• Claims and chart reviews mirroring the NQF;
• CMS children and adult quality measures.
Washington State currently uses vital records data to monitor statewide all 37-39 week
preterm outcomes through the quality assessment project8, supplemented by individual
hospital data from the Washington State Hospital Association.. Two other JCAHO metrics
(i.e., NTSV C-sections, and Vaginal Births after C-section) are publicly reported by hospital
with peer-to-peer comparisons and statewide goals. By the fourth quarter of 2012,
provider specific peer-to-peer comparisons reporting on OB outcomes will be available for
individual providers on a secured website. These efforts are augmented by the Puget
Sound Health Alliance (the Alliance) with public reporting of clinic variation and will soon
8
http://www.wsha.org/wshaNews.cfm?EID=2012-05-09%2000%3A00%3A00%2E0
D. Hanig
29
March 24, 16
be reporting prescriber data with generic and brand use rates. This grant will allow us to
progress to the next phase of linking professional and facilities outcomes.
The HCA and the Alliance use claims data across public and private programs to produce
predictive modeling and feedback reports to providers. The DSHS PRISM program allows a
provider to view historical claims data (prescription history, hospital and ED use) as well
as a prediction score that categories a client’s risk level. PRISM is a tool to assist providers
and case managers in targeting and prioritizing interventions in medical homes and mental
health clinics.
Claims histories are also used in feedback reports to providers to reduce inappropriate
variation. The power of this approach is demonstrated by the Generics First initiative that
targeted 800 high users of brand name medications. By feeding back prescription
utilization data, generic fill rates rose from 68% to 85% in the Medicaid program. This was
accomplished by targeting only the highest variation providers. At this time only four
prescribers remain statistically variant from their peers. Other feedback reporting includes
ED utilization (over use, low acuity use and narcotic prescriptions), statewide mental
health prescribing history (too much, too many, too young and medication adherence) in
conjunction with the PRISM data.
Many of our payers have similar risk adjustment programs (AP-DRG, DXCG, ETG groupers),
which can mirror the DSHS PRISM predictive modeling. Washington State has found that
providers and case managers are very interested in this data to supplement care decisions.
This grant will allow learnings to be shared across these multiple payers and assist us with
standardizing reporting and integrating these models into the HIT solutions.
Factors affecting quality performance. As discussed above, Washington has been on the
cutting edge for adopting quality performance measures; nevertheless, major barriers
remain. Key factors include:
1. Fragmentation resulting from multiple payers. Providers answer to many payers, many
of which have few or no quality performance metrics. Others employ such metrics but
what is measured and how it is measured can vary among payers.
2. Lack of agreement on what is important to measure. Historically, credentialing
organizations tended to emphasize process measures as proxies for measuring quality.
In recent years, as evidence-based research has expanded, there has been increased
effort to construct measures reflecting that research; however, we are still at an early
stage of developing such measures.
FUTURE QUALITY MEASURES: Quality Improvement in Episodes of Care
Moving from low value/high costs to high/value low cost payments
Obstetrics: There is growing national consensus on what constitutes quality OB outcomes,
spurred by good evidence that elective delivery of pre-term infants can lead to morbidity,
mortality, and higher costs (NICU admissions, infection, re-hospitalization and long term
poor academic performance)9.
Hoffmire CA, et al. “Elective delivery before 39 weeks: the risk of infant admission to the neonatal intensive
care unit”, in Maternal Child Health J. 2012 Jul;16(5):1053-62.
9
D. Hanig
30
March 24, 16
Washington’s recent quality assessment saw a 65% reduction in elective 37-39 week
deliveries across all hospital, achieved due to the efforts of the statewide perinatal
collaborative with the support of the WSHA and other professional associations. Meeting
our statewide goal of less than 5% elective preterm delivers will likely be realized.
In addition, there is now agreement through the Bree and statewide Perinatal Advisory
Committee and by OB COAP members that reductions in elective deliveries including
inductions and primary C-sections can have a positive effect on quality, reduce costs and
improve access to needed services. Washington State has seen a 75% increase in the use of
C-sections over the past decade and a drop in access to VBAC services (from 40% to 15%).
By linking professional and facility care payments we hope to reduce trends in primary Csections by replacing them with higher value lower cost vaginal deliveries. By targeting
prematurity we hope to increase statewide average gestational age thus reducing NICU
admissions and other downstream costs. The central theme is to use evidence-based best
practices based on accurate clinical data -+measurements, quality metrics and payment
reform as an incentive to improve infant and maternal outcomes. This approach to
changing practices is at the heart of our efforts under this grant.
Performance Measures in Managing Chronic Conditions: The medical home offers
better access to primary care, prevention efforts and integrated case management.
Reducing hospitalizations, re-hospitalizations and ED use are all good indicators of the cost
of care reductions, yet may not be indicators of better care. These measures have already
been employed in various pilot projects, such as the Boeing IOCP, and the Multi-Payer
Health Home project. The CMS adult measures offer more process-oriented metrics to
track the health of clients and reduce inappropriate variations in care. In addition, we note
the important link between chronic diseases, mental illness and or substance abuse. At
present, integrated solutions are few and far between. By linking professional and facility
payments we hope to improve effective care transitions for those clients that represent the
5% of the population who spend 50% of the dollars. For this reason Washington intends to
look at new metrics (i.e. episodes of care outcomes) to design, educate and measure the
effectiveness of a medical home. Measures for managing chronic conditions are described
in detail under Question 12 below.
10. Describe population health status measures, social/economic determinants
impacting health status, high-risk communities, and current health status
outcomes and the other factors impacting population health.
The Washington Legislature’s passage of Substitute Senate Bill 6197 in 2006 is an example
of our state’s effort to reduce health disparities. This legislation created a governor’s
interagency council on health disparities, charged with conducting health impact reviews
to determine the extent to which proposed legislative or budgetary actions improve or
exacerbate disparities in health. The interagency council is also required to develop an
action plan to develop policies and strategies that address social factors driving health
disparities. Developing a better understanding of the social and economic determinants of
health is essential to reduce health disparities among Washington State residents. Public
health professionals are partnering with communities and with local and state agencies to
D. Hanig
31
March 24, 16
implement policies and programs designed to address social and economic factors
associated with poor health outcomes.
In 2007, Washington State Department of Health addressed the impact of social
determinates in their statewide assessment of health status, health risks, and health care
services The Health of Washington State.
Factors related to lifestyle. Several important behavioral risk factors for poor health are
more common among people in lower socioeconomic position (SEP) groups. Washington
adults with lower incomes or less education are more likely to smoke, be obese, or eat
fewer fruits and vegetables than adults with higher incomes and more education. Lack of
money and conditions associated with poor neighborhoods can make healthy lifestyles or
ways of living difficult to achieve for people in lower SEP groups. The broader culture also
influences ways of living so that an individual’s risk of illness mirrors that of the population
group to which he or she belongs. For example, in cultures where smoking is culturally
unacceptable for women, women die less often from smoking-related diseases than women
in groups where smoking is socially accepted.
Factors related to medical care. Lack of access to or inadequate use of medical services,
especially preventive services, contributes to relatively poorer health among people in
lower SEP groups. Some research suggests this occurs because health care received by the
poor is inferior in quality or because other factors, such as cultural differences, remain as
barriers to access. People might also need social resources, such as knowledge, wealth,
prestige, and social connections to take advantage of new health-enhancing technologies.
International comparisons suggest that higher medical expenditures do not necessarily
result in better community measures of health, such as life expectancy. This research
suggests that broader social and economic conditions that lead to poor health are more
important for the health of the population as a whole than medical care once a person has
become sick.21 Support for this perspective comes from the 2006 World Health Report,
which shows that the United States ranks first among all 192 member nations in per capita
health care expenditures ($5,711 per person per year in 2003 U.S. dollars) but ranks 24th
in life expectancy.
Income inequality. The distribution of wealth in a society often plays a role in health
disparities. Income distribution is often studied in terms of quintiles or fifths. If income
were evenly distributed across all households in an area, a fifth of all households would
receive a fifth of the total income. In 2000, the wealthiest 20% of Washington households
received almost 50% of the income, while the poorest 20% received less than 5%. A
widening gap between rich and poor might adversely affect the health of all members of
society. This has been demonstrated in the United States. Greater inequality in income
distribution has been linked to WA’s disparities in infant mortality, teen birth rates, as well
as violence and all-cause mortality.
Factors related to the physical environment. Low socioeconomic neighborhoods often
do not have safe parks and trails that provide opportunities for physical activity. They can
also lack access to affordable, healthy foods. In addition, tobacco products and alcohol are
marketed more aggressively in low-income communities. People with lower incomes often
live or work in environments where they are exposed to harmful chemicals and other
toxins. For example, children who live in older or dilapidated housing can be exposed to
D. Hanig
32
March 24, 16
indoor allergens and irritants that provoke asthma and increase its severity. Members of
lower socioeconomic groups are also more likely to work as manual laborers. These jobs
are associated with increased risk of occupational injury or death and exposure to toxic
substances. Low socioeconomic neighborhoods are frequently located near toxic waste
sites and other potential environmental hazards.
11. Describe specific special needs populations (for each payer type) and factors
impacting care, health, and cost.
The Department of Social and Health Services (DSHS) provides $7 billion in services each
biennium to people with needs related to physical, cognitive, or developmental disabilities,
and for people facing challenges related to mental health or chemical dependency. Those
services reach approximately one in five of the people enrolled in Medicaid. DSHS spends
its funds on four main types of activities: 1) community-based services; 2) institutional
services; 3) eligibility, case management and quality assurance; 4) program
support/administration.
DSHS community-based and institutional spending on the populations that are the focus of
this report is organized in four main ways (all numbers are for the 2011-13 Biennium, are
rounded and approximate):
1. Long-term services and supports for people with physical and/or cognitive
disabilities.
$3 billion is appropriated and distributed to providers on a fee-for-service basis for the
following major services:
a. $1 billion for nursing home care for approximately 11,000 people each month.
b. $2 billion to purchase assistance with activities of daily living, such as bathing,
dressing, personal hygiene, and help with mobility, for 44,000 people each month.
$1.4 billion of that provides help in the client’s own home, with the balance provided
in adult family homes or boarding homes.
D. Hanig
33
March 24, 16
Figure 11. Community Based and Institutional Spending: DSHS/ADSA Expenditures,
All Fund Sources 2011-2013 Biennium
Community-Based
Services
67%
$4.9 Billion
Institutions
26%
$1.9 Billion
5%
Program Support
$109 Million
1.5%
Eligibility, Case Management,
Quality Assurance
$383 Million
SOURCE: Aging and Disability Services Administration, March 2012
2. Long-term services and supports for people with developmental disabilities.
$2 billion is appropriated and distributed to providers on a fee-for-service basis for the
following major services:
a. $350 million for state-operated Residential Habilitation Centers, which care for
800 people.
b. $577 million for instruction and support to persons who live in their own homes
in the community.
c. $527 million for activities of daily living assistance similar to what is described
above for long-term care.
d. $330 million in supports that help people live in the community, including
employment, family support and programs to preserve public safety.
3. Supports for people with serious mental health diagnoses.
$1.6 billion is appropriated for the following services:
a. $445 million for state-operated mental health hospitals that serve 2,400 people in a
year.
b. $1.1 billion for community mental health services, purchased through 13 Regional
Support Networks operating as Prepaid Inpatient Health Plans. Community mental
health services reach 129,000 people each year and include outpatient and
residential treatment, crisis and commitment services, crisis stabilization, family
treatment, medication management, peer supports and employment and housing
supports.
4. Supports for people with chemical dependency challenges.
D. Hanig
34
March 24, 16
Approximately $345 million is appropriated for services that reach approximately 40,000
people each year, primarily purchased through DSHS-administered contracts with counties.
The services include: assessment, crisis management, acute and subacute detoxification,
outpatient and residential treatment and criminal justice programs.
The conditions and support needs that are the subject of this report—disabilities, mental
illness, and substance abuse—frequently co-occur. For people who are high medical risk
and not dually eligible for Medicare, almost two thirds have at least one of those additional
risk factors and 28 percent have more than one additional risk. For those who are high risk
and dually eligible for Medicare and Medicaid, 91 percent have at least one additional risk
factor and 31 percent have more than one additional risk.
The current medical system and the systems of support managed by DSHS are not designed
to address that level of complexity. Service planning does not create coordinated
responses to address co-occurring needs. Financing is not aligned to support
comprehensive responses. The current administrative structures have not been charged
with the responsibility or given the authority to be held accountable for addressing such
complexity. More than any other factor, correction of those shortfalls is the driving force
behind the recommendations in this report.
Washington State has made promising progress in the integration of allied services, such as
behavioral health, substance abuse, developmental disabilities, elder care, community
health, and home and community-based support services. The state recently submitted its
Pathways to Health: Medicare and Medicaid Integration in Washington State proposal to
CMS to accelerate integration of these services under §2703 of the Affordable Care Act,
including improved care for dual eligibles. This proposal requires providers serving highrisk populations to identify a lead caregiver and coordinate the care provided.
The state can also point to several successful initiatives to integrate care across systems,
including:
1. Disability Lifeline Program (DL)10: For over two decades, Washington has provided
cash and medical benefits for disabled adults who had not qualified for SSI or SSDI
disability benefits. In 2010, the Legislature modified the program to transition clients
to a managed care plan – Community Health Plan of Washington – whose network is
largely comprised of FQHCs and RHCs. The new program added in situ behavioral
health coverage or active coordinate to link to behavioral health. Subsequent
evaluation found that the target population, which was at high risk for substance and
mental health problems, showed improvements in behavioral health status as well as
reductions in inpatient days.
2. HB 1738: The Legislature demonstrated its commitment to integrating care across
systems when, in 2011, it passed HB 1738, requiring the Health Care Authority and
Department of Social and Health Services to conduct a community-based process to
more effectively coordinate “ . . . the purchase and delivery of care, including the
10
Unützer, J, et al. Quality Improvement With Pay-for-Performance Incentives in Integrated Behavioral
Health Care, in American Journal of Public Health, April 19, 2012.
D. Hanig
35
March 24, 16
integration of long-term care and behavioral health services.” The agencies’ report
included concrete steps to purchase health care through MCOs that “ . . . compete based
on service, access, quality and price and . . . [through] robust health home functions . . ..”
3. Chronic Care Management (CCM): program provides high-risk clients with enhanced
nurse care management services in five pilot sites across Washington State. Early
results showed reduced inpatient and ER utilization, resulting in net savings of $27
PMPM, as well as longer lifespans and less care in institutional settings.
4. Washington Screening, Brief Intervention, and Referral to Treatment (WASBIRT):
evidence-based public health practice training providers, including primary care, to
conduct routine alcohol and drug screening. Results show more rapid access to
treatment leading to better health outcomes.
 Multipayer Medical Home Project: There are a growing number of efforts in Washington
focused on how to measure and pay for better outcomes. Currently some nine clinics
across the state are engaged in medical home projects. Participating providers receive
a PMPM ($2.50) to cover care coordination, expand access to after hours, disease
registries and team management.
12. Describe delivery system cost quality and population health performance targets
that will be the focus of delivery system transformation. Note: cost and population
health targets are being developed as assumptions under the financial modeling.
Once drafted, those will need to be referenced here.
Selection of delivery system cost quality and population health performance targets
Review of metrics relating to deliveries and medical homes finds both national and
consensus definitions from which to build a quality incentive program. Beginning with the
26 core adult measures, several relate to deliveries and all relate to the Medical Home.
Many of these measures currently exist in statewide reports based on vital records (all
births). Other measures are being acquired across hospital systems (e.g. level 3 NICU
supply outcomes data to the Vermont Oxford Network) and several hospitals participate
with the FHQC OB-COAP efforts. Many of the measures are in keeping with Healthy People
2020, National Quality Forum, and the Joint Commission.
Washington will use its reporting to include a disparities analysis to detect those with
greater needs and warp programs around these needs.
Managing Chronic Conditions Performance Targets: will use a subset of the same
quality measures tracked in the Community Checkup reports of the Puget Sound Health
Alliance (drawn from HEDIS indicators). These quality indicators are defined in Table X as
follows:
D. Hanig
36
March 24, 16
Table 8. Chronic Care Medical Homes Quality Measures
#
Quality Measure
Definition
1
Diabetes - HbA1c testing
Percentage of people with diabetes 18 -75 years old
that had a hemoglobin A1c test in the last year.
2
Diabetes - Cholesterol testing
Percentage of people with diabetes 18-75 years old
that had a LDL cholesterol test in the last year.
3
Diabetes - Nephropathy
screening
Percentage of people with diabetes 18-75 years old
that had a kidney-screening test in the last year.
4
Heart Disease - cholesterol
testing
Percentage of people with cardiovascular disease
18-75 years old that had LDL-C screening in the last
year.
5
Heart Disease - cholesterol
lowering medication
Percentage of people with cardiovascular disease
18-75 years old who are prescribed a lipid lowering
therapy in the last year.
6
Depression medication
adherence at 12 weeks
The percentage of people 18 -75 years old of the
measurement year who were diagnosed with a new
episode of major depression, were treated with
antidepressant medication and remained on an
antidepressant drug during the entire 84-day (12week) Acute Treatment Phase.
7
Depression medication
adherence at 6 months
The percentage of people 18 -75 years old of the
measurement year who were diagnosed with a new
episode of major depression, were treated with
antidepressant medication and remained on an
antidepressant drug during the entire 180-day (6
months) Continuation phase.
The Alliance will convene a work group for quality measure assessment and achieve
agreement on a set of measures, including those above and others, particularly targets
already set by the Department of Health, Department of Labor & Industries COHE program,
Medicare STAR ratings, which, for example, Regence has already incorporated. The
Alliance will report these measures in a timely fashion, and the data set for these metrics
will accompany the separate data files constructed for the project evaluation under a data
use agreement similar to those utilized in prior projects. The quality measures will be
aggregated to the practice and facility level and scored as a practice-level composite
reflecting the seven individual metrics. An actuarial firm will perform this calculation on
data submitted to it from health plans and calculate the margin of error using practice data
from the baseline time period. The practice will receive payment if the quality score in each
observation period is within the margin of error at or above the baseline quality score.
D. Hanig
37
March 24, 16
OB and Delivery Performance Targets:
OB and Delivery targets will reflect measures described above, i.e., reducing morbidity,
mortality, unsupported variation in care and costs by reducing elective pre-term deliveries
including inductions and primary C-Sections, and increasing the rate of VBACs. By targeting
prematurity we hope to increase statewide average gestational age, thus reducing NICU
admissions and other downstream costs. The central theme is to use clinically based
evidence, quality metrics and payment reform as an incentive to improve infant and
maternal outcomes.
 Measures: The following table depicts a range of metrics for quality and health
performance for OB and delivery. A subset of these plus other measures will be used in
the project:
Table 9. OB & Delivery Quality Performance Measures
#
Measure
Existing Quality Effort Inventory
1 Elective Delivery
The current Washington Medicaid Quality Assessment
Program uses The Joint Commission elective delivery
measure, which is supported by the National Quality
Forum (NQF) and the Hospital Corporation of America,.
The measure is “patients with elective vaginal
deliveries or elective cesarean sections at >= 37 and <
39 weeks of gestation completed.”
2
Postpartum Care
Rate
3
NICU Data
DOH is not currently providing on-going training on
prenatal and postpartum care, but does monitor rates
and is very concerned about access issues due to
primary care shortages. DOH sponsors and staffs the
Perinatal Collaborative with support from HCA.
All but two level 3 NICUs (UW and Fort Lewis) report
to the VON data set. Ten Level 1-2 NICU report to the
FHCQ/OB-COAP
13. State goals for improving care, population health and reducing health care cost.
Principle Goal: The project’s principle goal is to shift the health delivery system from
reliance on non-empirical standards of care to evidence-based best practices, thereby
improving quality and containing costs.
Change Process: Our goal is attainable through the grant’s change process:
1. Via the Collaborative, sequentially identify episodes of care that are high-volume
and low-value;
2. Develop recommendations for evidence-based best practices;
3. Engage professional organizations and their members through collaborative
learning to broadly adopt recommended practices; and
4. Selectively reform payment methods to support those practices.
D. Hanig
38
March 24, 16
Approach: The model will involve multiple payers including Medicaid (fee for service and
managed care), Medicare (including dual eligibles), private payers (including Premera,
Regence and GHC), and large employers (such as Boeing, Costco, the state and King County).
It will build on our state’s existing collaboratives, the Bree and the Alliance, to engage other
stakeholders, including the state and legislature.
The state has already completed significant work related to specific component areas: (1)
chronic care medical homes (CCMH); and (2) infant and maternal care. The Alliance will be
the lead organization for chronic care medical homes, while the Bree will coordinate
implementation for evidence-based best practices – initially for infant and maternal care
and later, other episodes of care, such as spine surgery and care, hospital readmissions, and
interventional cardiac care. Each organization’s roles and responsibilities are described in
Table 10 below. Participation by payers and providers will be optional; but incentives will
encourage broad participation.
Managing chronic conditions. The Alliance will be responsible for facilitating
implementation of the CCMH across multiple payers. The goal is to focus attention on those
patients with chronic conditions requiring costly care in the public and commercial
coverage in Washington State. In the public programs, this population is described as the
5% of patients who account for 50% of health spending. This initiative will build on past
efforts, such as the Boeing Intensive Outpatient Care Program (IOCP), the Patient Centered
Medical Home Multi-payer Reimbursement project and SB 5394 – Primary Care Health
Homes and Chronic Care Management.
Key elements:
1. Private and public predictive modeling tools to identify patients with chronic
conditions11 and then provide information to help providers manage and coordinate
their patients’ care;
2. Enhanced payment or incentive for CCMH services to fund coordination of care and
data-driven interventions;
3. Integrated behavioral health services;
4. Incentives such as gain-sharing or shared savings;
5. The Alliance will convene the multiple parties to ensure statewide coordination and
stakeholdering towards the use of consistent quality indicators among models,
while ensuring business flexibility for payers; and
6. The plans will agree to secure data reporting for academic evaluation and research
through the Foundation for Health Care Quality (FHCQ) and University of
Washington (UW).
11
Per the ACA and SB 5394: a mental health condition; substance use disorder; asthma; diabetes; heart
disease; and being overweight, as evidenced by a body mass index over twenty-five.
D. Hanig
39
March 24, 16
Payment Reform. Professional and facility services will be integrated using a core set of
statewide quality and utilization measures designed to address the Triple Aim. The state
will accomplish this by adapting an approach like the BCBS of Massachusetts “Alternative
Quality Contracting” (AQC) model which creates an accountable delivery system but does
not require providers and facilities to be part of a single organization. Professionals and
facilities that achieve savings and improve quality will be eligible for gain sharing. An
advantage of this approach is that it integrates better with local initiatives, such as Regional
Health Improvement Collaboratives, that are building community-based approaches to
improving the health of local residents. The project will establish goals enabling providers
who meet additional quality metrics to receive higher payment. This produces a win-win
value proposition where payers have predictable expenditures and providers retain
predictable revenues. In light of our experience, we believe this approach will 1) enable
distinct provider groups to operate in an accountable payment environment and 2)
maximize provider and payer participation in the project. This approach has been
described as a virtual Accountable Care Organization (ACO), without the corporate
structure, for those who are familiar with that model. It is important to note that how
payers reimburse providers may differ and some providers may choose to not participate.
All participating payers will agree to provide core standard claims data in a timely manner.
Core data elements include quality and utilization measures for the infant and maternal
project and chronic care medical home.
Feedback Reports. To strengthen adoption of evidence based best practices, we will share
performance data, and provide secure peer-to-peer feedback reports to providers and
aggregated data to communities. Purchasers, including Medicaid and Boeing, have
experience using such reports. Feedback reports will provide information on infant and
maternal outcomes, as well as prevention and chronic care in medical homes, and will
provide communities with a comprehensive picture of their local health care system.
Feedback reports serve one other purpose: they can be used to identify outliers for
outreach and education.
Obstetrics & Deliveries: As mentioned previously the Bree Collaborative recently
completed its report on obstetrics care12 which recommends developing a new bundled
payment to promote labor and delivery best practices and to eliminate elective deliveries
and reduce elective inductions including primary C-sections.13 The Bree Collaborative will
work on establishing a bundled payment that combines doctor and facility fees and
incentivizes providers and hospitals to provide the most appropriate care to mother and
baby. Since Washington has few integrated systems of care, the project will work with
hospitals and providers to facilitate the establishment of operating agreements enabling
practices to maintain their independence while operating in a more integrated fashion.
12
See http://www.hta.hca.wa.gov/documents/bree_ob_report_final_080212.pdf
See Massachusetts Blue Cross Blue Shield Alternative Quality Contract and Transitioning to
Accountable Care by Harold Miller of the Center for Healthcare Quality and Payment Reform.
13
D. Hanig
40
March 24, 16
14. Describe delivery system models and approaches including how public
health
care entities, such as publicly-supported university hospitals and
faculty
practices will transition to value-based business and clinical models
The Model involves all WA health care providers, including those who practice at public
health care entities, such as publicly-supported university hospitals, critical access
hospitals, rural health clinics, federally qualified health centers, community health centers
and faculty practices, to value based care models. Simply put, public health entities are full
participants in all aspects of the project.
The Model will leverage the collaboratives as vehicles to align payment reform with our
policies, quality initiatives, and evidence based medicine to transform the structure for
service delivery across the state. The modified payment approaches will include 1) bundled
rates for specific conditions or episodes of care; and 2) upfront payments for certain
services to support an infrastructure capable of employing best practices. Bundled
payments will combine payment for all stages of treatment (including facility and
outpatient) to strengthen coordinated care and follow-up. This approach to transforming
payment will work well as all WA payers (FFS and managed care) have experience paying a
global professional fee for prenatal, delivery of any type and post-natal care. The Model
includes gain-sharing for meeting quality measures in episodes of care.
Specific institutions – the University of Washington and the Oregon Health Sciences
University – are actively involved in the Bree Collaborative and similar initiatives and will
have an expanded role in developing evidence-based practices, and in conducting
evaluative research of the Model.
The Model will weave evidence based quality assessment and adoption into the fabric of
our delivery system. Advancing knowledge in areas that need it the most, specifically those
practice patterns that have high rates of variation or high use of services that do not result
in improved outcomes. Further, HCA will work with the Health Care Personnel Shortage
Task Force and WA’s medical schools to integrate the Model’s evidence based best
practices and develop continuing medical education sessions to promote adoption. Since
1999, the DOH has offered Learning Collaboratives for health care providers. These include
in-person training, webinars, and other e-Tools, primary care practice coaching,
community asset mapping and other technical assistance all of which are supported with
pooled funds from federal grants and support from Medicaid health plans. Today, the DOH
partners with Qualis Health and the University of WA Advancing Integrated Mental Health
Solutions (AIMS) Center to support statewide initiatives such as WA Community
Transformation Grant, Beacon Grant, WA State Perinatal Collaborative, and Emergency
Cardiac and Stroke System. DOH can identify how to streamline CQI activities, expand
existing programs and mitigate overlapping initiatives, as well as, facilitate and mobilize
community partners- community health improvement efforts.
The Model prepares the provider for the accountable care future by collecting, aggregating
and providing feedback in performance measures to improve care and lower costs. The
core quality and utilization metrics will be streamlined and aligned with CMS' Physician
Quality Reporting System (PQRS) and Meaningful Use incentive programs to avoid
duplicative processes.
D. Hanig
41
March 24, 16
15. Describe proposed payment and service delivery models.
WA will implement both quality and payment reforms over the life of the project. The
principles of the Model include:
1. Accountability: There is increasing agreement on the need for accountability for
quality and cost across the continuum of care. The consistent provision of highquality care, particularly for chronic conditions, will require coordination and
engagement of multiple health care professionals across different institutional
settings and specialties including: medical, behavioral, developmental disability,
substance abuse, safety net providers, Area Agencies on Aging and long term
services and support providers.
2. Flexibility: The reform must be viable across the diverse practice types and
organizational settings that characterize the WA health care system and be
sufficiently flexible to allow for variation in the strategies that local health systems
use to improve care. One size does not fit all.
3. Aligned Incentives: The reform requires a shift in a payment system that rewards
volume and intensity to one that promotes value (higher value at lower cost),
encourages collaboration and shared responsibility among providers, and ensures
that payers, both public and private, offer a consistent set of incentives to providers.
4. Transparency: With increased providers’ accountability, the reform will present
greater transparency for consumers and community stakeholders. Measures of
overall quality, cost, and other aspects of performance will support the provider’s
clinical decision making and increase consumers’ confidence in the care they are
receiving in their local community.
Features of the Model
1.
Align and Incent Performance Metric Across Payers: The Collaboratives will
engage facilities and professionals to link provider payment to an agreed-upon common
core set of quality and utilization metrics that will define global budget targets. Initially,
they will focus on the areas of obstetrics and managing chronic disease, aiming to increase
use of evidence-based care and reduce overuse of low-value, high cost services at the
professional and facility levels. Payers’ commitment to the Model is predicated on the
flexibility to use their own contracting and payment mechanisms to incentivize common
core quality outcomes and utilization targets. All payers have agreed to adopt a core set of
performance measures and are willing to link those measures to opportunities for
differential gain sharing (based on performance) and increase our current peer-to-peer
comparisons to support improvement. The core quality and utilization metrics will be
streamlined and aligned with CMS' Physician Quality Reporting System (PQRS), National
Quality Forum , Joint Commission and Meaningful Use and other nationally recognized
incentive programs to avoid duplicative processes and improve administrative efficiencies.
To that end, the Model has received full support from the three key agencies in the state: 1)
Qualis Health, which serves as the state’s Quality Improvement Organization (QIO) and
operates the Regional Health Extension Center; 2) the State’s Health Information Exchange,
OneHealthPort; and 3) the federal Beacon Grant in eastern WA.
D. Hanig
42
March 24, 16
2.
Conduct Statewide Data Aggregation and Performance Metrics Reporting: The
Collaboratives will engage health care provider organizations, health insurers and selffunded purchasers to adopt consistent processes for data collection, monitoring cycles, and
use of a core set of quality and utilization metrics to support statewide Provider Feedback
Reports in the areas of obstetrics and managing chronic disease. Successful examples of
such activities are currently active in WA, and address clinical conditions in obstetrics
cardiology, general surgery, vascular surgery, spine surgery and obstetrics. As expansion of
data volume grows, Collaboratives will identify and work local with outlier
practices/processes and support access to local rapid cycle improvement processes.
Hands-on coaching and peer learning opportunities will be provided by the WA
Department of Health (DOH) in coordination with the WA State Medical Association, the
WA State Hospital Association and FHCQ. Publicly reported at the medical group or facility
level, the feedback provides communities with a comprehensive picture of their local
health care system. Publically reported outcomes currently exist and will be enhanced with
this grant.
3.
Build Workforce Capacity to Promote Adoption of Evidence Based Practice
and Performance Metrics: Resources will be allocated to increase internal workforce
capability to adopt evidence based best practice in the areas of obstetrics and managing
chronic disease. Financial grants will be directed to key professional organizations to
champion initiatives among their membership. The Model will fund an expansion of the WA
DOH’s Collaborative Learning Model to bring training to areas typically not seen as viable
ACO venues. DOH’s existing hands-on learning sessions complement toolkits, “how-to”
guides, checklists, and patient decision aids will be used to support evidence based
recommendations. Structured stakeholder education, including conference calls, webinars,
and listservs will provide practical insight to adapt recommendation to various settings.
Recommendations will be incorporated into accredited continuing medical education
programs and medical training programs with support of DOH.
4.
Explore Policy Levers to Secure Adoption of Evidence Based Care: The
Legislature and Governor have voiced the desire to see systemic reform instead of
piecemeal initiatives. “No more pilots” is a refrain that is increasingly heard in WA and
nationally. To this end, the chairs of the Senate and House health care committees support
this grant and are willing to introduce legislation as needed to help the effort succeed.
Using policy levers to support reforms has precedence; in 2007, the Legislature passed SB
5930, linking patient decision aids to liability reform. This first-in-nation program was
designed to lower provider liability risks by better informing patients. Examples of
potential legislation include: setting minimum standards for uniform payer submission of
claims data (encounter/utilization and payment) to a data aggregator; broadening the
statutory role of the Collaboratives; and reducing provider and payer liability to the extent
they employ evidence based practices. Similarly, the Model may explore the State’s
authority to certify integrated care systems, such as ACOs, virtual ACOs, and RHICs to
support professional and facility integration.
D. Hanig
43
March 24, 16
5.
Increase Coordination Among WA Quality Collaboratives. The Model will
strengthen the infrastructure among WA’s federal and state QI grant programs and
initiatives to raise awareness of program activities, share lessons learned, collaborate
around similar goals and promote best use of limited resources. The Model will convene
biannual events targeting state, regional and local quality initiatives. Their purpose is to
identify overlapping efforts and duplication to promote collaboration, share best practices,
advocate for federal and state policy reform, and overall make better use of existing,
limited resources.
The Model is committed to principles that align WA’s strong regional quality collaboratives
such as the Alliance. The Model leverages the success of public/private partnership such as
those pioneered by providers-Group Health Cooperative, Virginia Mason Medical Center,
and by payers – Boeing and Regence’s, Intensive Outpatient Care Program, Premera’s
Global Outcomes Contracts or homegrown initiatives such as Whatcom Alliance for
Healthcare Access, CHOICE, or Central and Eastern Regional Health Improvement
Collaboratives. Networked together, they create a strong infrastructure incorporating
employers, consumers, local health agencies, tribal governments, educational systems,
community service and support organizations, and faith-based organizations.
16. Provide a timeline for transformation.
Timeline for implementation: In the following table, we assume the contract effective date
starts January 1, 2013. The actual start date, however, will be the effective date of the
executed agreement between the State of Washington and CMMI:
Table 10. Implementation Timeline
Timeframe
Actions
1/13 – 3/13
HCA hires project staff, organizes internal functions, develops allocations
3/13
HCA establishes oversight advisory committee for grant project.
2/13 – 4/13
HCA negotiates contractual terms with Alliance and Collaborative.
Contract executed by 6/30/2013
2/13 – 5/13
Informatics tools developed, tested
3/13 – 6/13
Recruitment of collaborative clinics and hospitals
3/13 – 6/13
Bree and Alliance each develop internal work groups and expand their
roles and responsibilities
1/13 – 4/13
Each collaborative devises scope, details of collaborative intervention
6/13
Bree finalizes proposal for modified payment system for obstetrics and
deliveries. Alliance finalizes proposal for broad adoption of chronic care
medical homes (CCMH).
6/13 – 9/13
Bree provides instruction on the modified payment systems. Alliance
starts rollout of CCMH model.
D. Hanig
44
March 24, 16
Timeframe
Actions
7/13 – 6/16
DOH led training, in conjunction with provider groups, is initiated and
continues through grant period
10/13
Modified payment systems go into effect
10/13 – 6/16
Reformed obstetrics and deliveries payment methodology is broadly
adopted, tracking of implementation and reporting on attainment of
performance measures.
1/14 – 6/16
Conduct rapid cycle improvement programs and outcome evaluation.
Bree expands efforts to additional episodes of care, including hospital
readmissions and spine surgery.
1/2013 –
3/2013
Analyze baseline data; discuss grant-funded opportunity with key
stakeholders (providers/provider groups, client advocacy groups, state
agencies, managed care entities, hospitals/hospital associations) for
input, coordination with existing efforts
7/13 - 6/15
Run 36 month collaborative training on quality improvement and cost
efficiencies
2/14 – 6/15
Produce, disseminate evaluation/progress reports
9/14 – 6/15
Conduct program evaluation and disseminate findings/
recommendations

Gross measures of progress:
o Number of episodes of care for which the Collaborative develops
recommended best practices;
o Number of hospitals and medical groups, and other types of providers, that
agree to implement each set of recommendations. Independent review to
verify provider implementation.
o Number of payers that promote adoption through their contracts by citing
recommendations and by employing reformed payment methods. Number of
covered lives affected by those contracts. Independent review to verify
contractual changes
o Attainment of quality measures and patient satisfaction discussed elsewhere
in this document.
17. Review milestones and opportunities. Timeframes start with the date the effective
date of an agreement subsequent to the awarding of the grant.
Table 11. Milestones and Opportunities
Objective
Grant Activities
Milestones
Grant administrative structure.
D. Hanig
45
March 24, 16
Objective
Grant Activities
Milestones
a. Agreement
between state
and CMMI
o HCA and Governor’s Office negotiate 
contract/ agreement with CMMI for
deliverables
Finalized contract
b. Staff
o HCA hires staff required for

implementation – project manager,
contracts manager, data staff, etc.
Sets in place contractual
requirements and reporting
expectations.
Hiring completed
c. Contracts
o HCA contracts with the
Collaborative and the Alliance to
convene work groups, establish
metrics, oversee implementation,
etc.

Contracts executed.
Bree Collaborative
d. Implement
 Collaborative members modify scope of
 Bree Collaborative internal roles
evidence-based Bree duties
defined
interventions,  HCA and FHCQ negotiate contract to
 Contract finalized.
including
implement grant-requirements.
 Legislative proposals submitted to
obstetrics and  Collaborative determines whether any
chairs
deliveries
statutory changes are needed. If so, submit
recommended changes to HC chairs for
2012 Legislative session
 Collaborative puts in place any additional
work groups needed to effect
implementation
e.
 Complete bundled payment design for
obstetrics and deliveries
 Standards established.
f.
 Promote implementation in collaboration
with DOH and professional organizations
and payers
 Training and dissemination activities
initiated
g.
 Implement payment modifications
 Multi-payer contracts with obstetric
and delivery providers and facilities put
in place (due 6 months after grant start)
D. Hanig
46
March 24, 16
Objective
Grant Activities
 Implement reforms for other identified
episodes of care (including hospital
readmissions and spine surgery)
h.
Milestones
 Repeat process employed with
obstetrics and deliveries – i.e., rigorous
review of evidence, develop
recommended best practices, develop
payment modifications as needed, and
facilitate dissemination and adoption.
Puget Sound Health Alliance
i.
Refine role
 Board members modify scope of Alliance’s  Bree Collaborative internal roles
duties
defined
 Alliance and HCA negotiate contract
 Contract finalized and put in place.
 Collaborative determines whether any
 Legislative proposals submitted to
statutory changes are needed. If so, submit
chairs
recommended changes to HC chairs for
2012 Legislative session
 Collaborative puts in place any additional
work groups needed to effect
implementation
j.
Data
aggregation
and reports
 Determine data elements for collection
 Feedback reports finalized and
 Seek and reach agreement on data elements deployed
 Negotiate contracts with payer and
purchasers to submit approved data
elements.
 Collect data on regular schedule
 Aggregate reported data
 Issue feedback reports on regular basis
k. Chronic care
 Convene work groups of payers, purchasers,  Core performance measures defined
medical homes providers and stakeholders
 Agreements to report on measures
 Define core performance measures
finalized.
 Defined data elements required to
 Data collected and reports issued.
implement core measures
 Finalize agreement with providers and
payers on core elements, frequency of
reporting, etc.
 Begin data collection and monitoring of
chronic care medical homes
Data
D. Hanig
47
March 24, 16
Objective
l.
Grant Activities
Improve
a. Review/modify encounter data specs
managed care b. Audit existing submissions; develop
encounter data correction plans
completeness c. Check progress; modify as needed
and accuracy
Milestones
a. Specs update complete
b. Correction plans complete
c. Re-check complete
m. Develop
1. Assess methods used in other states;
1. State of the art assessment complete
method for
emerging methodology
2. Test complete
care transition 2. Test if possible
3. Written recommendations complete
collection
3. Create written recommendations; vet with
consistent with stakeholders
HIE
n. Develop
customer
survey and
focus group
processes
1. Assess methods used in other states;
emerging methodology (CHAPS and focus
group questions)
2. Test if possible
3. Create written recommendations; vet with
stakeholders
o. Promote all
1. For process measures requiring chart-based 1. Standardized collection
payer standard extracting, work with Multipayer groups to
recommendations complete
setting for HIE standardize collection; incorporate into
2. Standardized collection
meaningful use.
recommendations complete
2. Develop methods for standardized data
collection for measures that lend themselves
to EMR data mining, e.g., lab data or medical
record content.
p. Create new and 1. Develop feedback reports, clinical support
combined
tools for QI projects
feedback
2. Test
reports, clinical 3. Put in production
support tools
1. Tool design complete
2. Testing complete
3. Production complete
q. Produce and 1. Teams identified; analysis templates
use disparities determined
analyses
2. Administrative baselines produced
3. Baseline analyses completed; opportunities
identified
4. Incorporate race/ethnicity considerations
into all quality projects, including those
selected for this grant.
5. Targeted QI interventions are designed to
impact at least one under-served population
1. Teams identified; templates complete
2. Administrative baselines produced
3. Baseline analyses completed;
opportunities identified
4. Disparity reports in production
5. Incorporation complete
D. Hanig
48
March 24, 16
Objective
Grant Activities
Milestones
r. Report clusters 1. Develop review summaries for measures
of measures to grouped around
relevant
a. Health homes
clinical,
b. Behavioral health
stakeholder
c. Diabetes
groups
d. OB/Maternal
1. Reporting to relevant review groups:
a. HeathPath Washington Advisory Board
b. TBD
c. Diabetes Collaborative
d. Perinatal Collaborative
s. Review
predictive
modeling and
risk adjustor
1. Develop review of multi-payer risk adjustor
for
a. Health homes
b. Behavioral health
c. Diabetes
d. OB/Maternal
1. Baseline analysis complete
2. Literature review complete
3. Detailed intervention design complete
4. Intervention deployed
5. Re-measurement complete
t. Review health
services
utilization
reports for
disparities
1. Conduct detailed baseline analysis including 1. Baseline analysis complete
disparities
2. Literature review complete
2. Conduct literature review to identify best 3. Detailed intervention design complete
practices and disparities
4. Intervention deployed
3. Define intervention(s)
5. Re-measurement complete
4. Deploy and monitor interventions
5. Conduct re-measurement
PLACEHOLDER
a.
b.
18. Describe policy, regulatory and/or legislative changes necessary to achieve the State’s
vision for a transformed health care delivery system. States are encouraged to describe
their approach to using the broad array of policy levers available to create a statewide
policy context that supports and drives delivery system transformation. This should
also document how proposed multi-payer supported service delivery and/or payment
models fit into this context and how data and evidence will be collected and used to
support the state goals and strategies.
Washington State benefits from having legislative and regulatory authority already in
place that will serve as a firm foundation for implementation of the project. Specifically:
 SB 5930 (2007): Implemented recommendations of the Blue Ribbon
Commission on Health Care Reform which included several initiatives including
patient decision aids for preference sensitive treatments;
 HB 2956 (2010): Established hospital quality incentives that were used, among
other things, to incent the reduction of early inductions.
 SB 5934 (2011): Established statewide standards for chronic care management,
health homes, multidisciplinary health care teams, and primary care. Law
D. Hanig
49
March 24, 16


required state programs to modify managed care contracts to enhance payment
for chronic care medical homes in exchange for meeting performance measures
such as reducing inpatient and emergency department use. Last, the bill linked
chronic care medical homes to the Department of Health’s Collaborative
Learnings for training in best practices.
HB 1311 (2011): Established the Bree Collaborative to identify highly utilized
medical procedures and promote the use of evidence based best practices to
improve health care outcomes and reduce costs.
Puget Sound Health Alliance: the Alliance was not established under statute (it’s
an independent not-for-profit); but is included in annual agency appropriations
for submitting claims data and supporting the Alliance’s operations.
Both the Executive and Legislative branch leadership are fully committed to supporting the
implementation of the grant.14 The grant is sponsored by the Governor’s Office. As noted
above, the chairs of the legislative health care committees have offered to bring forward
legislation in support of the grant, such as:
 Modifications, if needed, to the statute establishing the Bree Collaborative to
accommodate any changes in their scope of authority;
 Consideration of changes to liability statute to provide limited protections to
providers and payers following recommended, evidence-based guidelines; and
 Enhancement of claims reporting and data aggregation efforts under the Puget
Sound Health Alliance. The chairs recognize the possible need for legislation to
enforce timely reporting of claims data for the purposes of this project. Their past
support for systemic reform is reflected in recent legislation they sponsored and
passed, including SB 5934 (chronic care medical homes) and HB 1311 (Bree
Collaborative).
19. Describe any waiver or State plan amendment requirements and their timing to
enable key strategies for transformation, including changes or additions required
to position the Medicaid and CHIP programs to take advantage of broad health
care delivery system transformation.
Implementation of this grant does not rely on approval of a SPA or waiver. However, in
July 2012, the state submitted an 1115 waiver request to modify the payment
methodology for FQHCs and RHCs. Approval of this waiver request would better align
FQHC payment methods with those proposed under this grant application. Currently,
FQHCs are reimbursed using an encounter-based reconciliation process. Implementing
the proposed waiver would allow the state to apply a reimbursement methodology that
would better support the flexibility required for effective chronic care medical homes.
While approval of the waiver request would enhance implementation of this grant, the
absence of waiver approval would not jeopardize implementation of the CMMI grant.
There are two candidates running for Governor this November. Members of their staff have been briefed
on this project and seem generally supportive.
14
D. Hanig
50
March 24, 16
Appendix A: List of Washington State System Reform Initiatives
Following is a list of key initiatives in Washington focused on achieving the “Triple Aim”.
1) Legislative initiatives and state-payer initiatives: following is a list of innovative
initiatives that were supported through legislation.
a) Health Technology Assessment Program (HTAP)
b) Public-private partnership on best practices for reducing non-emergent care in
the ER
c) Prescription drug and therapeutics program
d) Generics First with prescription feedback
e) Advanced Imaging Management (AIM)
f) Administrative simplification
g) Multi-payer Medical Home Project
h) Primary care health homes and chronic care management legislation
i) DOH Primary Care Collaboratives
j) Perinatal Collaborative
k) Hospital Quality Assessment
l) Dr. Robert Bree Collaborative (Bree Collaborative)
m) Workers’ compensation Centers for Occupational Health and Education (COHEs)
2) Community-based initiatives: Washington State has seen dozens of communitybased initiatives to improve quality of care and bend the curve. Some notable
examples include:
a) Foundation for Health Care Quality (FQHC): since 1998, the foundation has led
dozens of evaluations ranging from use of comparison quality standards by
consumers to supporting public health agencies in the surveillance of sudden
health risks, including:
i) Clinical Outcomes Assessment Program (COAP):
ii) Surgical Care and Outcomes Assessment Program (SCOAP):
iii) Obstetrics Clinical Outcomes Assessment Program (OBCOAP):
b) Puget Sound Health Alliance (Alliance): Created by a coalition of businesses,
providers, payers and state agencies, the Alliance focuses on four interconnected
areas to drive change:
i) Performance Measurement and Public Reporting
ii) Performance Improvement
iii) Consumer Engagement
iv) Payment Reform
c) King County Health Reform Planning Team has staged a platform for stakeholder
engagement in state-led activities such as HealthPath Washington and the
Medicaid Health Homes Network.
D. Hanig
51
March 24, 16
3) Provider-based Initiatives: Washington has benefitted from the efforts of
providers who have pioneered high-value health care:
a) Virginia Mason Medical Center: has developed a rich set of initiatives, including
its Marketplace Collaboratives that address the most costly medical conditions
for purchasers.
b) Group Health Cooperative: Based on a cooperative model of delivering health
care, Group Health has 65 years experience fostering innovations, including
advanced medical homes, shared decision-making and comparative effectiveness
research conducted at its research institute.
c) Everett Clinic: The Everett Clinic has pioneered the provision of coordinated and
integrated care in Washington State, including coordinated care for Medicare
beneficiaries.
4) Health Plan Initiatives: Washington health plans have pioneered a variety of
payment innovations that reward providers for quality, affordable health care.
a) Premera Blue Cross has implemented a statewide medical home program with
Providence Health & Services, as well as Global Outcomes Contracts with 12
medical groups and an IPA, covering nearly 100,000 attributed members.
b) Regence has worked with the Governor and the Boeing Company to implement
the Intensive Outpatient Care Program (IOCP), a successful chronic care model
for high-needs patients that uses clinic-based nurses and a redesigned payment
system to share in savings to provide higher quality care, save time and money.
This is a good example of a successful multi-purchaser campaign to change
health care.
5) Regional Health Improvement Collaboratives: Several communities in
Washington State have initiated efforts to strengthen regional integration of
services to improve health quality and outcomes, including:
a) Central Washington Regional Health Improvement Collaborative: Provides a
formal venue to organize planning and action, determine regional priorities, and
guide implementation of interventions and initiatives among collaborating
public and private interests within a specific regional health care market.
b) CHOICE: Located in the South Puget Sound Region, CHOICE is a non-profit
coalition of rural and urban hospitals, practitioners, public health, clinics,
community health centers, behavioral health providers and other partners
dedicated to improving the health of their region.
c) Eastern Washington Regional Health Improvement Collaborative: This
collaborative provides a formal venue to organize planning and action,
determine regional priorities, and guide implementation of interventions and
initiatives among collaborating public and private interests within a specific
regional health care market.
d) Southwest Washington Regional Health Alliance: The Alliance seeks to achieve
better health for the population, better care for individuals and reduced costs.
The goal is to manage resources efficiently and effectively, in collaboration with
local governments (tribal and county), state government, health plans serving at-
D. Hanig
52
March 24, 16
risk, vulnerable populations, hospitals, local providers, other insurers, and, most
importantly, the people served.
e) Whatcom Alliance for Healthcare Access: Located in Bellingham in Whatcom
County, the Alliance connects community members to health care services;
promote system improvements and foster public engagement to develop sound
health care policies.
D. Hanig
53
March 24, 16
Appendix B: PRISM: The Predictive Risk Intelligence System
With support from the Health Care Authority and DSHS Aging and Disabilities Services
Administration, the DSHS Research and Data Analysis Division has developed a web-based
clinical decision support application, called PRISM, which features state-of-the-art
predictive modeling tools and data integration to support care management for high-risk
Medicaid clients. Listed below are some of the key features of the PRISM application.
1. PRISM is an electronic health record for Medicaid enrollees. PRISM contains
comprehensive longitudinal health information supporting care management for
high-risk Medicaid clients.
2. PRISM integrates medical, behavioral health, social service and health
assessment data to provide a comprehensive view of patient risk factors, service
utilization and health outcomes.
3. PRISM uses state-of-the-art predictive modeling to identify patients at greatest
risk of high future medical costs. PRISM also predicts each patient’s likely primary
care provider, and assesses the extent to which emergency department visits are
potentially avoidable. The risk scoring algorithms are based in part on open source
software maintained at UC San Diego and calibrated to Washington State’s Medicaid
client populations by the PRISM team.
4. PRISM is refreshed weekly. Predictive modeling scores for the entire Medicaid
population are recalculated on a weekly basis to reflect changes in patient service
events and patient risk factors.
5. PRISM currently supports more than 600 authorized users. The current
primary user groups include:
a. Medicaid health plans;
b. Regional Support Networks;
c. Area Agencies on Aging providing care management for high-risk patients;
d. HCA and DSHS staff performing care management or program management
functions.
6. PRISM uses robust security measures to protect patient data security and
privacy. PRISM is fully compliant with HIPAA and other state and federal
confidentiality requirements.
7. The PRISM team provides ongoing training and technical support for PRISM
users.
For more information, please contact David Mancuso, or mail to prism.admin@dshs.wa.gov.
D. Hanig
54
March 24, 16