I/DD Members and DSRIP:
Data Initiatives Promoting Quality
Outcomes for Individuals with
Disabilities
Douglas G. Fish, MD
Medical Director
Division of Program Development and Management
Office of Health Insurance Programs
New York State Department of Health
June 2, 2016
Saratoga, NY
June 2016
Objectives
• Purposes of Measurement Data
• I/DD Subpopulation claims and spend data for in-patient and emergency department
• Total Cost of Care for the I/DD subpopulation
• Lessons from the Health And Recovery Plan (HARP) Behavioral Health Subpopulation
• Potentially Avoidable Complications
• Entering the World of Performance Based Outcomes & Value Based Payments
Source: Intellectual/Developmental Disabilities and DSRIP. NYSDOH DSRIP Website. Published October 2015.
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June 2016
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DSRIP Objectives Explained
Develop
Integrated
Delivery
Systems
Remove
Silos
• DSRIP was built on the CMS and
State goals in the Triple Aim:
 Improving quality of care
 Improving health
 Reducing costs
Enhance
Primary
Care and
Communitybased
Services
Goal:
Reduce avoidable
hospital use –
Emergency
Department and
Inpatient – by 25%
over 5+ years of
DSRIP
Source: The New York State DSRIP Program. NYSDOH DSRIP Website.
Integrate
Behavioral
Health and
Primary
Care
• DSRIP has specific behavioral health
focused projects
• DSRIP’s holistic and integrated
approach to healthcare transformation
provides a template for integration of
behavioral health initiatives into
primary care plans
June 2016
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Different Purposes of Measurement Data
• Data for accountability is different than data for performance improvement and care management
Accountability
Performance Measurement to evaluate
performance, compare providers, enable
consumer choice. Aggregating quantitative
data for external use.
Improvement
Performance Measurement to learn &
improve care process. Aggregating
quantitative data for internal use.
Care Coordination
Sharing of quantitative or qualitative data in
the care for individual patients. No primary
focus on aggregation of data.
June 2016
The Intellectual/ Developmental Disability (I/DD)
Behavioral Health Sub-population
• An estimated 1.5% to 2.5% of the general population has an intellectual or
developmental disability
• I/DD is a lifelong impairment
Significant differences in functional status and abilities
Co-morbidities and co-occurring conditions are common
Over a lifetime, people’s health status change
• Persons with I/DD who enter the Emergency Room are more than twice as
likely to be admitted than the general population
• An estimated 1 in 21 hospitalizations in New York State (NYS) involve persons
with I/DD
Source: Intellectual/Developmental Disabilities and DSRIP. NYSDOH DSRIP Website. Published October 2015.
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June 2016
I/DD vs. General Population Medicaid FFS Claims
and Spend Data – In-Patient Hospitalization 2014
2014 IP Claims per Unique Member (DD vs. NYS
General)
2014 IP Spend per Unique Member (DD vs.NYS
General)
Statewide Average
Statewide Average
Western
Western
Southern Tier
Southern Tier
North Country
North Country
New York City
New York City
Mohawk Valley
Mohawk Valley
Mid-Hudson
Mid-Hudson
Long Island
Long Island
Finger Lakes
Finger Lakes
Central
Central
Capital District
Capital District
0.00
0.50
1.00
General Population Claims per Unique Member
Patient
1.50
Member
DD Claims per Unique Patient
IP Medicaid Claims
* Statewide averages do not include regional duplications
2.00
2.50
$-
$2,000
$4,000
$6,000
$8,000
General Population Spend per Unique Member
Patient
$10,000 $12,000 $14,000 $16,000
DD Spend per Unique Member
Patient
IP Medicaid Dollars Spent
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June 2016
I/DD vs. General Population Medicaid FFS Claims
and Spend Data – Emergency Room 2014
2014 ER Claims per Unique Member (DD vs. NYS
General)
2014 ER Spend per Unique Member DD vs. NYS
General)
Statewide Average
Statewide Average
Western
Western
Southern Tier
Southern Tier
North Country
North Country
New York City
New York City
Mohawk Valley
Mohawk Valley
Mid-Hudson
Mid-Hudson
Long Island
Long Island
Finger Lakes
Finger Lakes
Central
Central
Capital District
Capital District
0.00
0.50
1.00
1.50
2.00
2.50
General Population Claims per Unique Patient
Member
3.50
4.00
Member
DD Claims per Unique Patient
ER Medicaid Claims
* Statewide averages do not include regional duplications
3.00
4.50
$-
$50
$100
$150
General Population Spend per Unique Member
Patient
$200
$250
$300
DD Spend per Unique Member
Patient
ER Medicaid Dollars Spent
$350
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June 2016
Total Cost of Care (TCC) for Medicaid I/DD Claims:
Breakdown by Service Category
Total Cost of Care:
$7.7 Billion for
97,000 individuals
analyzed within the
I/DD system
MSC
3%
Day Services
17%
Intermediate Care Facilities
17%
Non-OPWDD Services
14%
Residential Services
44%
Employment Services
3%
Respite
1%
Other OPWDD
1%
Other LTC
Services
3%
Capitated Programs
2%
Nursing Homes
1%
OSA
1%
Other DOH
1%
Pharmacy
2%
Clinic
2%
Other Acute
Medical
1%
Hospitals
2%
Acute & Primary Care Services: $1.1 Billion
OPWDD Specialty Services: $6.6 Billion
June 2016
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The Medicaid Population
HARP
Total Medicaid population
HIV/AIDS
Developmental Disability (I/DD)
Managed Long Term Care (MLTC)
General population
Depression
& Anxiety
Trauma &
Stressor
Chronic
Conditions
(Diabetes,
Asthma, etc)
SUD
• The total Medicaid population is divided in four
subpopulations and the general population
 I/DD is one of those sub-populations
 Subpopulation arrangements are inclusive of total
cost of care and outcomes are measured at the
level of the whole subpopulation
• There are also bundles (e.g., Depression, Chronic
Conditions)
• General Population
 They can be contracted in the general
population
 Patients in a subpopulation can have one or
more bundles
• Bundles within Subpopulations
 However, for subpopulation contracts bundles
are only used for analytical purposes
 They can be used to help inform analysis on
what is happening within the subpopulation
 But they do not form the basis of any financial,
contractual care arrangement
June 2016
Health And Recovery Plans (HARPs)
 HARPs specialize in serving people with serious behavioral health conditions
 Eligibility is based on utilization or functional impairment
 Enhanced benefit package - HARPs offer all Medicaid Managed Care Plan
(MMC) covered benefits plus access to additional services called Behavioral
Health Home and Community Based Services (BH HCBS), if eligible
 Enhanced care coordination through Health Homes: A Care Manager
 Providers and Plans will work together to assist HARP members
 Performance metrics specific to higher need population and BH HCBS
 VBP can support the goals by making more flexible and performance-based
payments that over time measure what matters to this population, like functional
status improvement on domains such as housing, social stability, and
employment, e.g.
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June 2016
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The HARP Population and the Transition to VBP
Historically, the HARP population has experienced lower quality scores and associated poor
outcomes
• More than 20% of those discharged from general
hospital psychiatric units are readmitted within 30
days. A majority of these readmissions are at
different hospitals.
• Approximately 42% of individuals in a New York City jail
have a substance use disorder and 33% have a serious
mental illness. Of those with a mental illness diagnosis,
50% have a co-occurring substance abuse disorder.
• There is little coordination between inpatient care
and outpatient aftercare, often resulting in these
readmissions.
• The unemployment rate for people with serious
mental illnesses is 85%.
• Only about 20% of adults with mental health
disorders are seen by mental health specialists.
• People who suffer from serious mental illnesses have a
life expectancy that is about 25 years less than the
general population, typically due to poorly managed
chronic conditions.
NYS is developing VBP arrangements specific to this subpopulation with financing and quality measures
designed to improve outcomes, quality of care and functional status. HARP MCOs will contract with
advanced networks of specialty providers for this population.
Source: New York State Department of Health Medicaid Redesign Team. Behavioral Health (HARP, Depression, Bipolar Disorder).Clinical Advisory
Group. NYSDOH DSRIP Website. Published 12 August 2015.
June 2016
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Evidence Informed Case Rates
• Moving from DSRIP to VBP requires rate changes
• Evidence Informed Case Rates (ECRs) are the Health Care
Incentives and Improvement Institute (HCI3) episode
definitions
 ECRs are patient centered, time-limited, episodes of
treatment
 Include all covered services related to the specific condition
All patient services
related to a single
condition
 E.g.: surgery, procedures, management, ancillary, lab, pharmacy
services
 Distinguish between “typical” services from “potentially
avoidable complications”
 Based on clinical logic: clinically vetted and developed based
on evidence-informed practice guidelines or expert opinions
Sum of services (based on
encounter data the State
receives from MCOs)
June 2016
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$250
50%
45%
Total Episode Costs
$200
40%
35%
$150
30%
25%
$100
20%
15%
$50
10%
5%
$-
0%
Episode Name
Costs Included:
Total Cost
% PAC Cost
•
Fee-for-service and MCO payments (paid encounters);
•
Caveat: add-on payments included in some cost data, not in others (GME/IME, HCRA, Capital). Data not yet standardized.
Source: CY2014 Medicaid claims, Real Pricing, Level 5, General Population , Non-duals
Please note: The slide offers preliminary data for illustration purposes. It is anticipated that elements such as volume, or cost, etc. may change slightly as the data
is further developed and refined.
PAC $ Percentage of Total
Millions
Chronic Episodes of the HARP Subpopulation
(CY2014)
June 2016
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$25
50%
45%
Total Episode Costs
$20
40%
35%
$15
30%
25%
$10
20%
15%
$5
10%
5%
$-
0%
DEPANX
BIPLR
ASTHMA
DIAB
PTSD
HTN
SUDS
GERD
Episode Name
COPD
ARRBLK
HF
LBP
Total Cost
% PAC Cost
Costs Included:
•
Fee-for-service and MCO payments (paid encounters);
•
Caveat: add-on payments included in some cost data, not in others (GME/IME, HCRA, Capital). Data not yet standardized.
Source: CY2014 Medicaid claims, Real Pricing, Level 5, General Population, Non-duals
Please note: The slide offers preliminary data for illustration purposes. It is anticipated that elements such as volume, or cost, etc. may change slightly as
the data is further developed and refined.
OSTEOA
CAD
PAC $ Percentage of Total
Millions
Chronic Episodes of the I/DD Subpopulation
(CY2014)
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June 2016
Person Centered, Full Continuum of Care
• Inclusive of all supportive
care relationships across
the spectrum of primary,
acute, long-term support
services, and OPWDD
specialty services
• Disease-oriented care
• Clinically focused
decision making
• Medical model
Full
Continuum
Patient
Centered
Person
Centered
• Non-disease oriented
• Focus on the whole-person
to ensure comprehensive,
continuous and coordinated
care
Health
Measures
• Measures that capture
population-specific outcomes
for physical health
• For example:
• Preventive screenings
• BMI
Source: Kodner, Dennis. Value-Based Purchasing Health Care: Strategic Implications for Vulnerable Populations. The ArthurWebbGroup, Published June 2015.
June 2016
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Examples from HARP and MLTC Subpopulations
• For other subpopulations discussions have broadened from medical and behavioral health
measures to more holistic measurement of quality of life and the social determinants of health
• The pilot phase will be used to further refine and validate quality measures, especially for new
measures
HARP Quality Measures
•
•
•
•
Employment & economic stability
Education
Housing stability
Interaction with the criminal justice
system
• Social connectedness
• Satisfaction
MLTC Quality Measures
• Personal decisions about care
prioritized
• Continuity & stability of care
relationships
• Improvement in ability to self-support
in community
• Participation in community & social
supports
• Satisfaction
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June 2016
CQL Personal Outcome Measures
Under Consideration
• My Self - Who I am as a result of my
unique heredity, life experiences and
decisions. Person-Centered Life
Plans
•
People are connected to support
networks
•
People have intimate relationships
•
People are safe
•
People have the best possible health
•
People exercise rights
•
People are treated fairly
•
People are free from abuse and
neglect
•
People experience continuity and
security
•
People decide when to share
personal information
Measures in bold overlap with group exercise
My Dreams - How I want my life
(self and world) to be.
• People choose personal goals
• People realize personal goals
• People participate in the life of
the community
• People have friends
• People are respected
My World - Where I work, live, socialize,
belong or connect.
• People choose where and with whom
they live
• People choose where they work
• People use their environments
• People live in integrated environments
• People interact with other members
of the community
• People perform different social roles
• People choose services
June 2016
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Stakeholder Driven: I/DD VBP Advisory Group
Meeting #2 Exercise
• Exercise
• Advisory Group divided into four groups
• Brainstormed and discussed:
• “What is the value proposition?”
• “How do we want to be measured?”
• Wrote ideas on sticky notes  Ideas were grouped into thematic
domains  Discussed preliminary findings
• Results indicative of a holistic focus on personal goal attainment, community
participation, meaningful activities, rewarding relationships, quality of life, and
socially desirable endeavors such as employment
See the “Word Cloud” for a thematic, schematic interpretation of results!
June 2016
A Thematic, Schematic Interpretation of Results
The word cloud below is a visual presentation of qualitative data—words with greater prominence are words that
appeared more frequently in the written submissions of the group exercise.
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Questions?
DSRIP E-mail:
dsrip@health.ny.gov
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