Development of A
Community Health System
To Achieve the Triple
p Aims
Better Care and Lower Cost: High Performing
Communities in American Health Care
Academy Health
June 27, 2010
Jim Hester PhD
Director
Vermont Health Care Reform Commission
Governing the Commons: Act 128 (2010)

“It is
i the
th intent
i t t off the
th generall assembly
bl tto reform
f
the health care delivery system in order to
manage total costs of the system, improve
health outcomes for Vermonters, and provide a
positive health care experience for patients and
pro iders In order to achie
providers.
achieve
e this goal and to
ensure the success of health care reform, it is
essential to pursue innovative approaches to a
single system of health care delivery that
integrates health care at a community level and
contains costs through communitycommunity-based
payment reform.”
2
I Context: VT Health Reform
I.
State: 600,000 population
Regions: 13 Hospital
Service Areas define
‘communityy systems’
y
Payers: 3 major
commercial + 2 public
Collaboration: bipartisan
bipartisan,
multi-stakeholder
Laboratory for health
reform
3
Vermont’s
Vermont
s Reform Strategy
A t 191 (2006) created
Act
t d ‘th
‘three llegged
d stool’
t l’
which balanced
1. Sustainable reduction in uninsured from
y 2010
10% to 4% by
2. Health IT as catalyst for improved
performance
3. Bending the medical cost curve through
d li
delivery
system
t
reform
f
•
Blueprint for Health: Chronic illness
prevention
ti and
d care
4
II. Building a Community
Health System
‘E
‘Every
system
t
is
i perfectly
f tl designed
d i
d to
t obtain
bt i the
th
results it achieves.’
Approach
A
h

System redesign at four geographic levels
1.
2.
3.
4.

Primary care practice level: Enhanced medical
homes
Community health system: ‘neighborhood’
neighborhood for
medical home
State/regional infrastructure and support e.g. HIT,
payment reform
National: Medicare participation
Start in pilot communities, spread statewide
5
Building ‘Systemness’
Systemness
Five key generic functions of a community health
system
1. Service integration across levels and settings
of care
2. Financial
a c a integration
teg at o
3. Governance
Governance:: Provide leadership, and establish
accountability
accou
ab y
4. Information
Information:: Deploy information tools to
pp care,, management,
g
,p
process
support
improvement and evaluation
5. Process improvement:
improvement
p
: Design,
g , implement
p
and improve performance
6
Payment Reform
 Necessary,
but not sufficient element of
reform: must build ‘systemness’
y
 Phase I: Blueprint enhanced medical
home pilots links primary care incentives
to medical home functions
 Phase II : ACO pilot broadens incentives
to community providers
7
Phase I: Community Based
Enhanced Medical Home Pilots

S i C
Service
Coordination
di ti



Patient Centered Medical Home (PCMH) model
New community health team funded by payers
Financial integration: single system of aligned incentives



Sliding care management fee linked to 10 NCQA PCMH criteria
Mandated participation by 3 commercial payers and Medicaid
Medicare: MAPCP demo

IT support: registry
registry, EMR’s
EMR s & interfaces,
interfaces HIE,
HIE all payer
claims data
 Process improvement:
p
training
g and on g
going
g support
pp
 Timeline:


1/10 10% of VT population in 3 pilot communities
7/11 spread state wide to all hospital service areas
8
IMPACT OF INTEGRATED HEALTH SYSTEMPOTENTIAL COST AVOIDANCE ACROSS TOTAL POPULATION
ANNUAL CHA
ANGE IN
HEA
ALTHCARE EX
XPENDITURES
$450,000,000
$400,000,000
INCREMENTAL EXPENDITURES
WITHOUT INTEGRATED HEALTH
SYSTEM
28.7%
$350,000,000
INCREMENTAL EXPENDITURES
WITH INTEGRATED HEALTH
SYSTEM
$300,000,000
$250,000,000
$200,000,000
1
2
3
4
5
508,17
80%
25
637,130
100%
32
YEARS
Target Population
% of VT Population
# CHTs
42,179
6.7%
2
126,286 316,662
20%
50%
6
16
9
Blueprint Pilot Evaluation Data Sources
NCQA Scoring
Chart Review
DocSite Database
Multi Payer claims Data
Public Health Databases
Core Assessments
Expanded Evaluation
NCQA PCMH Standards
Healthcare
Clinical Process Measures
Social
Health Status Measures
Economic
Utilization & Healthcare
Expenditures
Ecological
Population Health Indicators
Health Policy
10
Phase II: ACO Pilot
 Focus
on community health system level
 Translate potential system wide savings
into actual savings
 Capture
C t
partt off shared
h d saving
i tto reinvest
i
t
in local community health system


Transition funding for adjusting to reallocation
Investments in population health
health, primary
care, etc.
11
Goals of The ACO Pilot
 Improve
performance in IHI ‘triple aims’
 Test the ACO concept in a small number
of ‘early adaptor’ community provider
networks that already have key functional
capabilities.
 Have at least one Vermont site in the
national ACO Learning Collaborative and
Learning Network
12
ACO Pilot Status and Next Steps

Th
Three
qualified
lifi d and
d iinterested
t
t d ACO pilot
il t sites
it
identified & participating in National Learning
Network
 Creating all payer model





Th
Three
major
j commercial
i l payers participating
ti i ti and
d
consolidated shared savings pool accepted
Plan for Medicaid participation due 7/10
Planning for Medicare participation 2012
Financial impact
p
model for ACO developed
p for two
sites
Vermont legislation (2010) for 3 pilots by end of
2012
13
III Conclusions
III.

Community health system level is the focal point
of delivery system reform
 Most small and medium sized communities and
care systems
y
will need state/national support for




Defining a common financial framework for all payers
IT support
pp for clinical tools,, p
process improvement,
p
,
information exchange, reporting and evaluation
Technical support and training
Start up funding
14
Conclusions
 Likelihood
Lik lih d
off success off ACO pilots
il t iis
enhanced by key prepre-requisites



Implementation of medical home model,
including primary care payment reform
All payer participation in a common financial
framework
Strong IT support for operations, reporting
and evaluation
 Vermont
is 1212-18 months away from
p
g foundation work for first ACO
completing
pilot
15
The Vision
 Community
Health System responsible for
achieving
g the Triple
p Aims for its p
population
p



Improving its health over time
Ensuring patients have a good experience of
care, when care is needed
M
Managing
i th
the ttotal
t l costs
t off care
16
Resources

V
Vermont
t Health
H lth R
Reform
f




Health reform : http://hcr.vermont.gov/
Information technology: http://www.vitl.net/
Health Care Reform Commission:
http://www.leg.state.vt.us/CommissiononHealthCareReform/defa
ult2 cfm
ult2.cfm
Vermont ACO Pilots
http://www.commonwealthfund.org/Content/Publications/Fund-http://www.commonwealthfund.org/Content/Publications/Fund
Reports/2010/May/The--Vermont
Reports/2010/May/The
Vermont--Accountable
Accountable--Care
Care-Organization--PilotOrganization
Pilot-A-CommunityCommunity-HealthHealth-SystemSystem-toto-Control.aspx
Jim
Ji H
Hester,
t Di
Director,
t 802 828
828--1107,
1107 jhester@leg.state.vt.us
jh t @l
t t t
17