Federal Initiatives to Support
State/Community-Based Approaches
to Coordinated Care
ASA-N3C-NYAM Symposium
April 27, 2011
Julianne R. Howell, Ph.D.
Senior Advisor
State HIE Programs
Overview
 Alignment through implementation of the Affordable Care Act
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Strategic Framework on Multiple Chronic Conditions
National Quality Strategy
Federal HIT Strategic Plan
Partnership for Patients
 Themes recurring across multiple initiatives:
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Importance of care coordination
Focus on care transitions
Role of community-based services
Focus on the patient and family caregivers
 Triple Aim: Better care, better health, lower cost
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Multiple Chronic Conditions: A Strategic
Framework December 2010
Source
 HHS Interagency Workgroup with input from public and stakeholders
Overarching Goals:
 #1 Foster health care and public health system changes to improve
the health of individuals with multiple chronic conditions.
 #2 Maximize the use of proven self-care management and other
services by individuals with multiple chronic conditions.
 #3 Provide better tools and information to health care, public health,
and social services workers who deliver care to individuals with
multiple chronic conditions.
 #4 Facilitate research to fill knowledge gaps about, and interventions
and systems to benefit, individuals with multiple chronic conditions.
Multiple Chronic Conditions: A Strategic Framework
http://www.hhs.gov/ash/initiatives/mcc/mcc_framework.pdf
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National Quality Strategy March 2011
Aims
 Better Care: Improve quality, by making health care more patientcentered, reliable, accessible, and safe
 Healthy People and Communities: Improve health of population
 Affordable Care: Reduce cost of quality health care
Six Priorities and Goals to help focus public and private efforts:
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Safer Care: eliminate preventable health care-acquired conditions
Effective Care Coordination
Person- and Family-Centered Care
Prevention and Treatment of Leading Causes of Mortality: prevent
and reduce harm caused by cardiovascular disease
 Support Better Health in Communities
 Make Care More Affordable
National Quality Strategy
http://www.healthcare.gov/center/reports/quality03212011a.html#append
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Partnership for Patients April 2011
Public-Private Partnership to make care safer, potentially save
up to $50 billion
Two Goals of the Partnership:
 Keep hospital patients from getting injured or sicker: decrease
preventable hospital-acquired conditions 40% by 2013 cf. 2010
– Up to $500M from CMS Innovation Center
 Help patients heal without complication: decrease preventable
complications during transition from one care setting to another so
that hospital readmissions will be reduced 20% by 2013 cf. 2010
– Up to $500M available through Community-Based Care Transitions
Program authorized by Section 3026 of ACA
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Illustrative Federal Programs to
Support State/Community Initiatives
 Multi-Payer Advanced Primary Care Practice (MAPCP)
Demonstration
 HITECH
– Beacon Communities
– State HIE Challenge Grants
 Partnership for Patients
– Community-Based Care Transitions Program ACA Section 3026
 State Demonstrations to Integrate Care for Dual Eligible
Individuals
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MAPCP Demonstration Overview
 3-year demonstration open to states
 Medicare will join Medicaid and private insurers in state
health reform initiatives aimed at improving delivery of
primary care
 A multi-payer effort
– Aligns economic incentives
– Reduces administrative burdens
– Provides resources that can be shared across practices
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MAPCP Goals
 Goals include…
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Improve safety, timeliness, effectiveness, and efficiency
Reduce unjustified variation in utilization and expenditure
Increase patient participation in decision making
Increase access to evidence-based care in underserved areas
Contribute to ‘bending the curve’ in health expenditures
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Application Requirements
 Applicant had to be a State agency
 Program operational prior to Medicare participation
 Multi-payer participation
– Medicaid FFS & managed care
– Medicare Advantage
– “Significant” private payer participation
 Specifications to be an Advanced Primary Care Practice
(APCP)
 Evidence of physician support & participation
 Community-based support
 Coordination with state wellness/disease prevention efforts
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Program Attributes
 8 States: ME, VT, RI, NY, PA, NC, MI, MN
– Some projects state-wide; others limited in geographic scope or #
of practices
– APCP requirements vary by state
– Monthly payment to the practice for beneficiaries “assigned” using
a state-specific algorithm
– Some projects involve community health teams
– Some projects include additional payment to state for
administrative/evaluation services
 Some states will launch July 2011; some October 2011
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Eligible Practices
 Geographic range/size of project determined by state
– Regional vs. state-wide
– Planned expansion
 Definition of APCP
– Determined by state
– NCQA-PCMH commonly used (often supplemented by additional
requirements)
 FQHCs participating in some states
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Eligible Beneficiaries
 Reside in the state
– Some states have county restrictions
– Excludes beneficiaries who cross state lines (operational
limitations/impacts)
 Have Medicare A & B
 Covered under traditional FFS Medicare
– Not enrolled in MA or other Medicare health plan
– No restrictions on other categories such as disabled, ESRD,
hospice, etc.
 Medicare must be primary payer
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Payment Rates and Policy
 Monthly payments to APCP generally < $10 per
beneficiary per month (pbpm)
– Exception: Minnesota, which uses clinically risk-adjusted tiers
(range: $0 - $60.81 pbpm; average: $14.43 pbpm estimated
based on historic ACGs)
 Variables determining APCP payment rate:
– Age of beneficiary
– NCQA-PCMH certification status of practice
– Use of independent community teams vs. expecting practice to
provide/contract for community-based care coordination services
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HITECH Act (Health Information
Technology for Economic and Clinical Health)
 Section of the American Recovery & Reinvestment Act
(ARRA) signed into law in February 2009
 Key components of the legislation
– Codifies the Office of the National Coordinator for HIT
– Creates Federal Advisory Committees on HIT Policy & Standards
– Creates Medicare & Medicaid “Meaningful Use” (MU) incentives for
physicians and hospitals to adopt EHRs
– Creates new HIT and HIE (Health Information Exchange) Programs
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State HIE Planning and Implementation grants
Regional Extension Center (RECs) grants
Workforce Training grants
New technology research & development grants
– Increases privacy protections
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HITECH Programs Address Barriers to
Adoption, Meaningful Use, Exchange
Intervention
Barriers
Funds Allocated
Cost of EHR Adoption
MU Incentives
$27.3 B*
Meaningful Use difficult to
achieve for small providers
REC and HITRC
$643M
$50M
Barriers to health information
exchange
HIE Program
Standards & Interoperability
$548M
$64.3M
Lack of trained workforce
Workforce
$118M
Lack of trust, policy framework
Privacy and Security
Need for “real world” examples
of HIT contribution to Health
Care Transformation
Beacon Communities
SHARP
*$27.3 B is high scenario
Addressed across
all Programs
$250M
$60M
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HITECH Programs and Goals: Where Are
We Today?
Regional Extension Centers
58,810 Enrolled Providers
Adoption of EHRs
Workforce Training
84 Community College Partners
Curriculum Available Summer 2011
Medicare & Medicaid incentives
Meaningful Use of
EHRs
21,000 Total providers
State HIE Grants
46 Approved States
10 Challenge Grants
Beacon Communities
Standards &
Interoperability
framework
Security &
Privacy
framework
• Improved individual and
population health
outcomes
• Increased transparency
and efficiency
• Improved ability to
study and improve care
delivery
Exchange of health
information
17 Communities
Research to enhance HIT
4 Awardees
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Key Objectives
 Align HITECH programs and initiatives to accomplish
– Adoption of EHRs
– Meaningful Use of EHRs
– Exchange of information
 Leverage HITECH programs to have a measurable
impact on health care, health, cost
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Improve transitions
Reduce readmissions
Reduce medication errors
Achieve better chronic care outcomes
 Support health care transformation in each state
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Beacon Communities Program
 17 communities selected to demonstrate feasibility and
health care delivery benefits of widespread HIT adoption
and exchange of health information.
 Core Aims:
– Build and strengthen community/regional health IT foundation to
achieve long-term improvements in care quality, health
outcomes, and cost efficiencies;
– Demonstrate that health IT-enabled interventions and community
collaborations can achieve concrete cost/quality performance
improvements;
– Test innovations to improve health and health care
 14 of 17 include a care transitions component
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Beacon Communities
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Beacon Communities’ Transitions
Aims
 To reduce hospital utilization, especially that arising from
errors in transitions
 To use HIT to improve care for individuals with high cost / high
risk chronic conditions (e.g., DM, CVD, etc.)
 To connect local hospital associations with primary and
chronic care settings
 To engineer electronic continuity and care plans, and to
incorporate them into EHRs and HIEs
 To build on initial successes by ongoing learning with other
Beacon Communities and by seeking Community-Based Care
Transitions funding
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Beacon Communities Transitions
Interventions
 Three tiers of IT focus
– Many Communities are using HIT systems to notify PCPs of
hospital and/or ER use
– Some are using HIT to provide hospital discharge information
(e.g., medications, lab values) to next providers (e.g., nursing
homes, FQHCs, PCPs)
– A few are using HIT to facilitate making appointments for quick
follow-up (e.g., PCPs to specialists)
 IT tools are coupled with case management (e.g., selfmanagement coaching, medication reconciliation, care
coordination)
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State HIE Challenge Grants
 Program Goal: provide additional funding to recipients
of State HIE Cooperative Agreements to spearhead
development of technology and approaches focused on
5 “Challenge Themes”:
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Achieving health goals through health information exchange
Improving long-term and post-acute care transitions
Encouraging consumer-mediated information exchange
Enabling enhanced query for patient care
Fostering distributed population-level analytics
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Challenge Theme 2: Improving Long-Term
and Post-Acute Care Transitions
 Requirements
– Identify types of long-term and post-acute care providers to be
included
– Describe technology and policy to achieve timely electronic
exchange of clinical summaries, medication lists, advance
directives and other information most relevant to transitions
– Develop and monitor relevant quality measures
– Identify barriers to timely electronic exchange and how they will
be addressed
 Grantees: Colorado, Maryland, Massachusetts, Oklahoma
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Partnership for Patients: CommunityBased Care Transitions Program
 5 years beginning April 12, 2011; rolling application
process
 Program Goals:
– Improve the quality of care transitions
– Reduce readmissions for high-risk Medicare beneficiaries
– Document measureable savings to the Medicare program by
reducing unnecessary readmissions
 Creates source of funding for effectively managing
transitions from acute to community-based settings
 Eligible entities paid on per-discharge basis for
Medicare benes at high risk of readmission, including
those with multiple chronic conditions, depression, or
cognitive impairment.
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Community-Based Care Transitions
Program: Selection Criteria
 Preference given to Administration on Aging grantees that
– Provide care transition interventions in conjunction with multiple
hospitals and practitioners
– Provide services to medically-underserved populations, small
communities, and rural areas
 Applicants must
– Identify root causes of readmissions and define target population and
strategies for identifying high-risk patients
– Specify transition interventions, including improving provider
communications and patient activation
– Indicate how community and social supports and resources will be
incorporated to enhance beneficiary post-hospitalization
management outcomes
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State Demonstrations to Integrate Care
for Dual Eligible Individuals
 Partnership between Federal Office of Integrated Care and
the Innovation Center
– Testing delivery system and payment reform that improves the
quality, coordination, and cost-effectiveness of care for dual
eligible individuals.
 On April 14, 2011, 15 states awarded contracts for up to
$1million to design new models for serving dual eligibles:
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West: California, Colorado, Oregon, Washington
Midwest: Oklahoma, Michigan, Minnesota, Wisconsin
South: North Carolina, South Carolina, Tennessee
East : Connecticut, New York, Massachusetts, Vermont
 Models will be person-centered and fully coordinate primary,
acute, behavioral and long-term supports and services.
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Further Information
 Websites:
– General http://www.healthcare.gov/
– Innovation Center http://innovations.cms.gov/
– Office of the National Coordinator for HIT
http://healthit.hhs.gov/
 For Questions:
julie.howell@hhs.gov
202-205-8124
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