Department of Vermont
Health Access
The Vermont Approach to Building an
Integrated Health System
Creating “Accountable Care Partners”
Based on Shared Interests
State Health Research and
Policy Interest Group Meeting
June 11, 2011
Richard Slusky
Director, Payment Reform
Department of Vermont Health Access
Department of Vermont
Health Access
H.202: Universal and Unified Health
System: “The Path to Single Payer”
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Delivery system reform
Payment reform
Integrated health information technology
Multi-payer claims data base
Health insurance exchange
Financing Plan
Green Mountain Board
Department of Vermont
Health Access
State Role: Designing & Promoting New
Payment Methods
Phase I – Blueprint for Health
Financing
Payment Reform
Fee for Service (Volume)
Medicaid
Medicare
BlueCross
MVP
Cigna
Self Insured
PPPM # 1 - NCQA Score
Standards
Delivery System Reform
Advanced Primary Care
NCQA Standards
Patient Centered Care
Access
Communication
Guideline Based Care
Use of Health IT
Advanced Community Support
Shared Costs
Community Health Teams
MCAID CCs
SASH Teams
Department of Vermont
Health Access
Multi-insurer Payment Reforms
Phase I – Blueprint for Health
•Medicaid
•Commercial Insurers
•Medicare
Insurers
•Fee for Service
•Unchanged
•Allows competition
•Promotes volume
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•Patient Centered Medical Home
•Payment to practices
•Consistent across insurers
•Promotes quality
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•Based on NCQA PPC‐PCMH Score
•$1.20 ‐ $2.49 PPPM
•Based on active case load
•Community Health Teams
•Shared costs as core resource
•Consistent across insurers
•Minimizes barriers
Department of Vermont
Health Access
Multi-insurer Payment Reforms
Patients with 2+ Chronic Conditions
Phase II – PCP/Specialists
•Medicaid
•Commercial Insurers
•Medicare?
Insurers
Payment based on reduction
in total cost of care, avoidable services, quality performance,
patient engagement +
• PCP/specialist partnership
• Equal payment to PCP/Specialist
• Includes all payers
• Promotes coordination /collaboration
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• Community Health Teams
• Shared costs as core resource
• Consistent across insurers
• Minimizes barriers
Department of Vermont
Health Access
Phase II
Blueprint and PCP/Specialists
Financing
Payment Reform
Delivery System Reform
Advanced Community Support
Medicaid
Medicare
BlueCross
MVP
Cigna
Self Insured
Community Health Teams
MCAID CCs
SASH Teams
Specialized Services
Fee for Service (Volume)
PPPM # 2 - Outcome,
Quality, and Patient
Centered Measures
Hospitals
Specialty Care
Targeted Services
Mental Health Services
Substance Use Services
Family Services
Social Services
Economic Services
Long Term Care
Nursing Homes
Department of Vermont
Health Access
Payment Based on Shared Interests:
PCPs & Specialists
Adjustable outcomes based payment – ongoing refinement
Decreased FFS
Continue current FFS
Total new FFS + $PPPM > baseline FFS
Baseline
Measure results
Measure results
First shared interest
$PPPM payment
Second shared interest
$PPPM payment
6 mo
12 mo
Adjust Payment
Dials
Phase III
Integrated Medical & Social Svcs
HEALTH CARE
PROVIDERS
INCLUDED
Level 5 Cost based
payments grants
Public Health
Safety-Net Programs
EXAMPLES OF
COST REDUCTION
OPPORTUNITIES
Better Management
of Complex and
Low-Income Patients
Level 4
Global (ACO)
Other Specialists
Greater Efficiency &
Improved Outcomes
for Inpatient Care
Level 3
Bundled
Major Specialists
(Cardiology,
Orthopedics, Etc.)
Improved Outcomes
and Efficiency for
Major Specialties
Primary
FQHC’s
Care
Practice
Reduction in
Preventable ER
Visits & Admissions
Primary
FQHC’s
Care
Practice
Appropriate Use of
Testing/Referral
Primary
Care
FQHC’s
Practice
Prevention &
Early Diagnosis
Level 2
FFS,
CHT’s,
PMPM
Hospitals
© 2010 Center for Healthcare Quality and Payment Reform, Network for Regional Healthcare Improvement
Department of Vermont
Health Access
State Role: Fostering the Use of
Accountability Measures
Four Dimensions of Performance Measurement
• Reduction in growth of total cost of care
• Reduction in avoidable services:
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ED visits
Inpatient admissions/readmissions
Imaging
Laboratory tests
• Improvement in adherence to quality performance standards
– Process measures
– Outcome measures
• Improved patient experience and engagement
Department of Vermont
Health Access
State Role: Designing and Promoting Data
• Vermont Information Technology Leaders
(VITL)
• Medicity (Gathering/Organizing)
• Onpoint (Gathering/Organizing)
• University of Vermont (Analyzing)
• Docsite (Reporting)
Department of Vermont
Health Access
State Role: Supporting a Continuum of
Care and the Role of Medical Homes
• Primary & specialty care providers share common
goals & interests
• Encourages provider relationships as “Accountable
Care Partners”
• Incentive to help patients be followed in a medical
home
• Incentive for well coordinated health services
(communications, transitions)
Department of Vermont
Health Access
State Role: Supporting a Continuum of
Care and the Role of Medical Homes
• Incentives are balanced and payment is optimized by
collectively improving quality, prevention, control of
costs
• Patient centered not organization centered (payment
follows patients)
• Incentive to meet needs & engage patient in ongoing
care
• Levels out the roles of primary & specialty care
(equal payment for coordinated and effective care)
Department of Vermont
Health Access
State Role: Supporting a Continuum of
Care and the Role of Medical Homes
• Builds on established (and successful) payment
methodologies in the Blueprint (Quality based on
NCQA score, CHTs in place)
• Builds on established measurement capabilities
• Does not require new organizations or administrative
entities
• Promotes shared interests across all providers within a
practice (in addition to promoting shared interests across
primary and specialty care)
Department of Vermont
Health Access
State Role: Supporting a Continuum of
Care and the Role of Medical Homes
• Payment based on goals that are shared by most / all
stakeholders (patients, families, providers, insurers,
businesses)
• Payment streams & methods are applicable in any
financing system (multiple payers, private & public,
single payer)
Department of Vermont
Health Access
State Opportunities for ACO/ACP
Development
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ACO
FFS Payment
Shared Risk
Retrospective Attribution
of Patients
Requires Organizational
Structure
65 Quality Measures]
Requires 50% of PCP’s
to meet meaningful use
criteria
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ACP
FFS & Enhanced Payment Based
on Value
Initial Upside Only –
Performance Risk Increases as
FFS is Reduced
Prospective Attribution Based on
Historical Usage
No New Org Structure Required
Measures Four Dimensions of
Performance
Requires Data Submission in
Several Formats Based on
Provider Capabilities