South Carolina
Healthy Outcomes Plan
(HOP)
SCDHHS Perspective
Tripp Jennings, MD, FACEP
System Vice President, Palmetto Health
Medical Director, South Carolina Dept of Health and Human Services
SCDHHS Mission:
To purchase the most health for
our citizens in need at the least
possible cost to the taxpayer.
SCDHHS Vision:
Be a responsive and innovative
organization that continuously
improves the health
of South Carolina.
Components of Proviso 33.34
Healthy Outcomes Plan (HOP)
Hospital Transparency and DSH
Graduate Medical Education (GME)
OB/GYN & Telemedicine
Optional State Supplementation (OSS)
• Health system does a poor job
prioritizing who is in need of services
• Once identified, individuals who are
poor or living with disabilities
generally enter a system not designed
to meet their needs
• Proviso 33.34 addresses the root
causes of these problems
Proviso 33.34
 Outcome of the General
Assembly passed FY 2014
budget
 State-based plan to improve
health while increasing value
and transparency
Project Scope
Incentive program to participating
hospitals and primary care safety net
providers, designed to improve health
outcomes and reduce system costs
through better coordinated care of the
uninsured, chronically ill, high-utilizers
of emergency department services.
Healthy Outcomes Plan
IDENTIFY
FIND
ASSESS
MANAGE
Prioritize people
in need
Outreach
PAM, GAIN-SS
Develop care
plan
Healthy Outcomes Plan
Start:August 1, 2013
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After weeks of collaborating with stakeholders,
SCDHHS released the Healthy Outcomes Plan
guidelines and application.
Marked the first time funding may only be accessed if
hospitals and primary care safety net providers serving
the uninsured collaborate and adhere to health
improvement initiatives outlined in the proviso.
Hospitals and their partners will propose service
delivery models to improve case management /
coordinated care for chronically ill, uninsured, high
utilizers of emergency department (ED) services.
HOP is one of the largest process improvement efforts
that Medicaid has undertaken to effectively integrate
the Triple Aim into our delivery systems.
Healthy Outcomes Plan
Preliminary Guidelines Criteria
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Targeted Outcomes
Strategic Measures (Care, Cost, & Health Metrics)
Measurement Periods
Target Population
Targeted Conditions
Patient Eligibility and Program Inclusion
Patient Eligibility for Health Affordability Programs
Social Determinants of Health Assessment
Patient Care Plans
Quality and Cost Transparency
Plan Evaluation Matrix
Collaboration
“Model” Collaborative Partners
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Hospital(s)
FQHCs/FQHC look-a-likes
RHCs
Free Clinics
Community Health Centers
DHEC
DMH
DAODAS
Welvista/Pharmacies
Physicians
Benefit Bank
Housing Services
Transportation
Food Supports
Healthy Outcomes Plan
IDENTIFY
FIND
ASSESS
MANAGE
Prioritize people
in need
Outreach
PAM, GAIN-SS
Develop care
plan
Next Year
Legislative Funding
Purpose
Proviso 33.34
FY 13/14
Proviso 33.26
Proposed
FY 14/15
Rate Increase
$35M
$35M
Rural Hospital DSH Payment (100%)
$20M
$25M
Primary Care Safety Net – FQHC
$5M
$8M
FQHC – Capital Needs
$2M
$4M
Primary Care Safety Net – Free Clinics
$2M
$2M
Primary Care Safety Net – Innovative Care
$5M
$5M
Rural Provider Capacity – Telemedicine
$8M
$10M
Care Coordination – Alcohol/Drug Services
n/a
$2M
$77M
$91M
Total
Note: The FY 14/15 budget is not finalized, and there is a House and Senate version.
Healthy Outcomes Plan
HOP Comparative Enrollment, Assessments and Care Plans
As of April 30, 2014
140%
120%
Enrollment Target
100%
80%
60%
40%
20%
0%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46
Enrolled
PAM
GAIN
HOPs
Care Plan
Draft Sept data
Where We Are Going
DSH Waiver
Current DSH
• Inflexible
• Retrospective
Future DSH: DSH Waiver
• Flexible
• Less prescriptive
• More innovative
• Proactive
• Prospective
• Stakeholder input essential on DSH waiver
• CMS approval (comprehensive)
Overview
Introducing Healthy Connections Checkup
• What is Checkup?
• Healthy Connections Checkup is a Medicaid limited benefit
program. This program was previously called “Family Planning”.
• Who is Eligible for Checkup?
• Men and Women in South Carolina with an income at or below
194% FPL who are ineligible for any other Medicaid program.
• Why the New Name?
• Beginning Aug. 1, 2014, Healthy Connections Checkup will include
benefits that enable a more holistic and comprehensive provision of
not only Family Planning and Family Planning-related services, but
also new preventive health screenings.
• The new name helps communicates the enhancement in addition to
the importance of preventive health care for the eligible
population.
Enhancement
Enhanced Benefit for Healthy Connections Checkup
• Enhancement
• Update the benefit structure for the current Family Planning-Only
benefit category to include a comprehensive biennial (once every
two years) physical examination and screenings/labs recommended
by the U.S. Preventive Services Task Force
• Goals
• Enable providers to make informed decisions regarding the
selection of an appropriate contraceptive method
• Promote the utilization of preventive health care in order to
improve health outcomes for families in South Carolina
• Expected Outcomes
• Regular preventive screening of members
• Identification of health problems that may negatively impact
members in this eligibility category
• Strong referral network to connect members to systems of care
New Screenings
Behavioral & Mental Health screenings
Cholesterol abnormalities screening
Diabetes screening
Hepatitis C virus infection screening
Obesity screening and counseling
Breast cancer screening (mammography)
Abdominal Aortic Aneurysm screening
Colorectal cancer screening
Lung cancer screening for smokers
*Please refer to the U.S. Preventive Services Task Force guidelines
(Grade A & B) for preventative screening standards. Screenings vary
by age, gender and risk factor.
Cards
Healthy Connections Checkup Cards
Thank You
Tripp Jennings, MD, FACEP
@trippjennings
Proviso 33.34 Sec A(1), C, D –
Medicaid Accountability and
Quality Improvement
Initiative
Proviso 33.34
33.34. (DHHS: Medicaid Accountability and Quality Improvement Initiative) From
the funds appropriated and authorized to the Department of Health and Human
Services, the department shall implement the following accountability and quality
improvement initiatives:
(A) Healthy Outcomes Initiative - Upon approval of the Centers for Medicare and
Medicaid Services (CMS), the Department of Health and Human Services shall
make available to participating hospitals up to a $35,000,000 aggregate rate
incentive effective October 1, 2013. This incentive shall be directly linked to a
hospital's participation in initiatives designed to reduce system cost and
increase health outcomes.
To improve community health, the department may explore various health
outreach, education and patient wellness and incentive programs. Working
with Kershaw Health and its LiveWell Kershaw program, the department may
pilot diabetes, smoking cessation, weight management, and heart disease
interventions to identify the potential to offer such interventions as models
for other hospitals to pursue. These initiatives may include, but are not
limited to:
Proviso 33.34
1. entering into a Memorandum of Understanding (MOU) with selected
primary health care and other providers to co-manage chronically ill
uninsured high-utilizers of emergency room services; and
2. participating in price and quality transparency efforts initiated by the
department.
In designing these initiatives the department shall receive public input, and
make the final determination of the initiative design. The department shall,
no later than August 1, 2013, publish the manner in which participation in
these initiatives will correspond with incentives. If at the end of the state
fiscal year the department determines that this program is not generating
cost savings or increasing health outcomes the department may retract this
incentive in part or full.
(B)
Disproportionate Share (DSH) Payment Accountability - Upon approval of
CMS, in order to increase accountability for money reimbursed to hospitals
under the DSH program and to improve outcomes for the uninsured,
hospitals shall:
Proviso 33.34
1. submit claims-level data for all individuals receiving uncompensated care;
and
2. obtain a patient attestation to determine whether or not the individual
receiving uncompensated care has access to affordable health insurance or
does not have other means to pay for services.
(C)
Rural Hospital DSH Payment - Upon approval of CMS, Medicaid-designated
rural hospitals in South Carolina shall receive full coverage of
uncompensated care as part of the State's Medicaid Disproportionate Share
(DSH) program. Funds shall be allocated from the existing DSH program and
shall not exceed $20,000,000 total funds. Rural Hospitals are ineligible for
this increased coverage should they not participate in reporting and quality
guidelines published by the department and outlined in the Healthy
Outcomes Initiative in the Fiscal Year 2013-14 Appropriations Act. These
guidelines shall be published no later than August 1, 2013.
In addition to the requirements placed upon them by the department, rural
hospitals must actively participate with the department and any other
stakeholder identified by the department, in efforts to design an alternative
health care delivery system in these regions.
Proviso 33.34
(D)
Primary Care Safety Net - The department shall develop a methodology to
reimburse safety net providers to provide primary care, behavioral
health services, and pharmacy services for chronically ill individuals that do
not have access to affordable insurance. Qualifying safety net providers are
approved, licensed, and duly organized Federally Qualified Health Centers
(FQHCs, entities receiving funding under Section 330 of the Public Health
Services Act, and FQHC Look-A-Likes), Rural Health Clinics (RHCs), Free
Clinics, other clinics serving the uninsured, and Welvista. No FQHC and
FQHC Look-A-Likes operating under a management agreement or operated
by a Chief Executive Officer who is not an employee of the entity is eligible
to receive funds allocated by this proviso.
The department shall allocate at least $5,000,000 for baseline funding to
FQHCs as defined in paragraph (D), at least $2,000,000 for documented
capital needs for FQHCs as defined in paragraph (D), at least $2,000,000 for
baseline funding for Free Clinics, and at least $5,000,000 for innovative care
strategies for qualifying safety net providers.
Proviso 33.34
The department shall consult with the SC Primary Health Care Association to
determine the entities with the most critical capital needs. From the
aforementioned $14,000,000, Welvista shall receive at least an additional
$600,000.
To be eligible for funds, qualifying providers shall be required to provide the
department patient and service data to assist in the overall improvement of
the state's health quality and when appropriate safety net providers must
enter into a MOU with hospitals to co-manage chronically ill uninsured highutilizers of emergency room services. Participants in this program shall
submit evaluations of effectiveness annually to the department.
(E)
Rural Provider Capacity - The department shall incentivize the development of
rural physician coverage and capacity building through the following
mechanisms:
1. the department shall leverage the Graduate Medical Education program
and develop a methodology to improve accountability and increased
outcomes for the State's GME and Supplemental Teaching Payments
investment by January 1, 2014; and
Proviso 33.34
2. the department shall develop a program to leverage the use of teaching
hospitals to provide rural physician coverage, expand the use of Telemedicine,
and ensure targeted placement and support of OB/GYN services in at least
four (4) counties with a demonstrated lack of adequate OB/GYN resources by
July 1, 2014.
3. during the current fiscal year the department shall allocate $4,000,000 to
the MUSC Hospital Authority for telemedicine.
(F)
Community Residential Care Optional State Supplement - The department
shall establish policies and procedures to include establishing a facility rate
per eligible beneficiary at $1,500 per month for recipients and providers who
meet the requirements for the enhanced maximum OSS payment; establish
eligibility criteria; and establish a methodology for increasing the personal
needs allowance.
Proviso 33.34
The department will revise the net income limit to accommodate the change
in the maximum OSS facility rate. A total of at least $12,000,000 shall be made
available for this rate increase. The facility rate shall increase a minimum of
$100 per month per eligible beneficiary. All current recipients shall remain
eligible for the supplement during the fiscal year and nothing contained
herein may conflict with or limit existing regulations.
In addition, the department will establish Quality of Care Standards and other
requirements for facilities licensed as a Community Residential Care Facility
and participating in the OSS program and Medicaid Waiver services.
(G) The department shall publish quarterly reports on the agency's website
regarding the department's progress in meeting the goals established by this
provision.
Proviso 33.34
Stakeholders:
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SCHA
SCORH
SCPHCA
SCMA
DAODAS
DHEC
DMH
SC Legislative
representation
AccessHealth
Welvista
ORS
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SCCEP
Family Connections
SC EMS Association
SC American Case
Management
Association
SC Free Clinics Assoc.
The Duke Endowment
Health Plans
Governor’s Original Six
Foundation
Proviso 33.34
Disproportionate Share Hospital (DSH)
Payments
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SCDHHS will commit to spending 100% of the
October 1, 2013-September 30, 2014 DSH allotment
Approximately $474.5M; an increase of $17.3M
Greater accountability in use of Medicaid DSH
Increased transparency in patients served, health
pricing and health quality
Proviso 33.34
Healthy Outcomes Initiative
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All hospitals that participate and submit a proposed
plan will receive 100% of their calculated DSH payment
for October 1, 2013-September 30, 2014
SC-designated non-rural DSH hospitals that choose not
to participate will receive 90% of their calculated DSH
payment for October 1, 2013-September 30, 2014
Per Proviso 33.34, all SC Medicaid-designated rural
hospitals must participate in the Healthy Outcomes
Initiative and submit a plan to receive full coverage of
their uncompensated care
Rate Increase
Rate Increase
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All hospitals will receive a 2.75% rate increase ($35M)
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SCDHHS will submit appropriate State Plan
Amendment for CMS approval
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Graduate Medical Education will not be impacted by
increase
Applies to both Medicaid inpatient and outpatient
hospital services