WELCOME April 18,2014 This webinar will begin promptly at 1pm EDT MAKING THE MOST OF PAYMENT REFORM This activity is made possible by grant number U30CS09746 from the Health Resources and Services Administration, Bureau of Primary Health Care. Its contents are solely the responsibility of the presenters and do not necessarily represent the official views of HRSA. PRESENTERS • Host: Sabrina Edgington, MSSW, Program and Policy Specialist, National Health Care for the Homeless Council • Melissa Hansen, MPH, Program Principal, National Conference of State Legislatures • DaShawn Groves, MPH, Assistant Director, State Affairs, National Association of Community Health Centers • Monica Bharel, MD, Chief Medical Officer, Boston Health Care for the Homeless Program OVERVIEW The role of the state in payment reform State efforts and health center engagement The Boston HCH Program experience HEALTH CENTERS AND PAYMENT REFORM • In expansion states, health centers are expected to absorb many newly eligible beneficiaries. • Many high cost health system users with complex health needs will now have coverage. BALTIMORE HEALTH CARE FOR THE HOMELESS PROGRAM TRIPLE AIM Improved health (outcomes) Improved quality (patient satisfaction) Reduced cost MANY PAYMENT MODELS BEING TESTED • • • • • • Global Payment ACO Shared Savings Program Medical Home Bundled Payment Hospital-Physician Gainsharing Payment for Coordination • Hospital Pay-for Performance • Payment Adjustment for Readmissions • Payment Adjustment for HospitalAcquired Conditions • Physician Pay-for-Performance • Payment for Shared Decision making Source: Schneider, E., Hussey, P., and Schnyer, C. (2011). Payment Reform: Analysis of Models and Performance Measurement Implications. http://www.rand.org/pubs/technical_reports/TR841.html Making the Most of Payment Reform Payment Reform and State Legislatures Introduction: Payment Reform & State Legislatures • History of reforms – Private market reforms – Medicare activities – State activities • Payment reform efforts have accelerated in last few years for multiple reasons Medicaid Policies & Payment Reforms, State Legislatures • Improving Medicaid value is at the top of some legislative agendas (over 520 Medicaid related bills filed) • Driven by a number of factors: • • Continual pressure on state budgets; Health reform: challenges and opportunities; • Reforms aimed at better care, better outcomes, lower cost – provides potential for bipartisan efforts (payment reform) 10 Legislative Role in Payment Reform Efforts • Purchaser of health care – Medicaid, state employers, other programs • Purse strings and policymaking – Infrastructure (e.g. HIT) – Regulatory levers (state agencies) • Convening key stakeholders • Focus on Medicaid reform 11 Factors to Consider Budgetary pressures ACA: challenges and opportunities Federally support for payment reform Pressure on State Budgets Revenues are expected to meet estimates, but growth is expected to taper off. Spending is generally on target. Year end-balances generally have improved. Despite stabilizing fiscal conditions, uncertainties persist. Top Fiscal Issues for 2014 Legislative Sessions Medicaid/ Health Care Taxes and Revenues Education Infrastructure Source: NCSL survey of state legislative fiscal offices, fall 2013. State Employee Salaries and Benefits Corrections/ Public Safety Medicaid Expansion State Structures for Health Insurance Marketplaces/Exchanges NCSL Data: April 1, 2014 The “New Coverage Gap” Payment Reform: Federally Supported Opportunities • Medicaid (examples) – Health Homes for Enrollees with Chronic Conditions – State Innovation Models Initiative • Medicare (examples) – Medicare Shared Savings Program – Medicare Value-based Purchasing Program • Federal Employees Health Benefit Program (examples) – Office of Personnel Management Support for Patient-Center Medical Homes 18 Triple Aim – Better Care, Better Outcomes, Lower Cost – Medicaid Payment and Delivery System Reforms •Risk based managed care •Non-risk care management •ACOs (CCOs, RCCOs, ACEs) •Health homes • Integrated primary care and behavioral health Sources: • Kaiser Commission on Medicaid and the Uninsured, Medicaid in a Historic Time of Transformation: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014, October 2013, available at http://kff.org/medicaid/ • Joan Henneberry joined Health Management Associates 2013 19 State-Based Medical Home Initiatives NH VT WA AK MT ND MN OR NY WI ID SD MI WY PA IA NE OH NV IL UT CO CA KS MO IN WV VA KY NC TN AZ OK NM SC AR MS HI TX AL GA LA FL As of August 2013 Medical home activity (45 states and Washington, D.C.) Making medical home payments (29 states) Payments based on provider qualification standards (27 states) Source: NASHP ME MA RI NJ CT DE MD State Innovation Models Initiative Types of Awards Workforce Demands of New Payment and Delivery Models Models New or Expanded Roles for: – Nurses – Behavioral Health Specialists – Community Health Workers – Social Workers – Peer Specialists – Pharmacists – Health Coaches Mandated Coverage for Telehealth Services Becoming a Key Stakeholder • Track payment reform efforts in your state (or local area). • Establish and maintain a relationship with legislator(s) representing your area(s). • Get involved in collaborative efforts. • Self assessment of capacity (infrastructure, HIT, workforce). • Be clear, concise in communications. Legislative Concerns With Payment Reform Activities, Some Examples • • • • • Privacy issues Fraud and abuse Market concerns (anti-trust) Network adequacy and patient satisfaction Do new payment methods improve value? Contact: Melissa Hansen Melissa.Hansen@ncsl.org For More Information http://www.ncsl.org/documents/health/PaymentRTK13. pdf Making the Most of Payment Reform DaShawn Groves, MPH Assistant Director, State Affairs National Association of Community Health Centers Overview • State Developments on Payment Reform Impacting Health Centers –Missouri (Health Homes) –Minnesota (ACOs) –Oregon (APM Development) • Successfully Engaging in Payment Reform –Considerations for PCAs –Key Capabilities for Health Centers –Key Steps • Resources Missouri • First Section 2703 Health Homes for Chronically Ill State Plan Amendment (SPA) targeting safety-net providers • 18 Health Centers • Eligible chronic conditions include: – Asthma – Diabetes – Heart disease – BMI >25 – Development Disabilities • State pays $58.47 PMPM • Performance measures outlined in SPA • Developing shared savings methodology Missouri: Lessons Learned –Be involved from early stages –Set clear, simple goals –View 2703 as a “safe” opportunity to leverage federal funds and take a step towards capitation Minnesota (FUHN ACO) • Part of a three-year Medicaid payment reform demonstration • Ten urban health centers located in Minneapolis and St. Paul • Paid on PPS basis • Total Costs of Care targets include: – Inpatient – Outpatient – Professional – Ancillary – Some mental health and chemical health services • Savings – 1st 2% will be retained by state – 98% will be split equally between the state and FUHN Minnesota (FUHN ACO) • Keys to Success –Appropriate program governance –Access to population health management technology –Inclusion of performance management coaches –Enhancing care coordination Oregon • Health centers asked PCA for methodology to better align to PCMH model • Delinks payment from a face-to-face visit • Convert PPS into a capitated bundled payment –Includes: • Physical health services • Mental health services after one year • Eventually Dental services • Able to receive incentive payments • Three-year commitment from both parties Oregon: Lesson Learned • Hard to keep all the balls in the air –APM implementation and refinement –Bridging towards value-based pay –Practice transformation • • • • • Data collection Patient engagement Population management Access Team-based care • Clinics face many demands Successfully Engaging in Payment Reform Considerations for PCAs Considerations for PCAs • Keep a Pulse on the Broader Payment Reform Environment • Build Support for Delivery System Transformation as a Primary Goal of Payment Reform • Secure Input in Payment Reform Design • Encourage Innovation among Leading Health Centers • Facilitate Development of Health Center Capacity for Participation. Key Capabilities for Health Centers Analytic Capabilities 1. Document the Value of Enabling Services • coding in billing systems • enabling services in EHR/PM templates 2. Assess Impact of Social Determinants • Define and capture social determinants Analytic Capabilities (continued) 3. Use Data for Design, Monitoring, and Evaluation • • Develop data partnerships/ strategies to secure data – inpatient – specialty care – long-term care – ancillary data Use data robustly: prospectively as well as retrospectively Operational Capacities • Leadership and Appetite for Innovation • Sophisticated use of Health Information Technology • Partnership Capabilities Key Steps for PCAs and Health Centers Key Steps • Robust understanding of payment reform efforts in the state and local environment • Ensure a clear, shared vision of organization’s role in achieving the Triple Aim. • Critically assess current operations and capabilities. • Work collaboratively with other health centers, stakeholders, and partners to accelerate transformation. Resources Publications: • Health Center and Payment Reform: A Primer • Health center Payment Reform: State Initiatives to Meet the Triple Aim, State Policy Report #47 www.nachc.com/state-policy.cfm Contact Info: DaShawn Groves. MPH dgroves@nachc.org 202-331-4606 Payment Reform: Experiences from the Field MONICA BHAREL, MD, MPH BOSTON HEALTH CARE FOR THE HOMELESS PROGRAM A Framework for Preparing for Health Care Reform at your Program Clearly defining the issue Having data and knowing the facts Using the data to be involved early in process Understanding that change is hard Working collaboratively Be willing to be in it for the long run A Framework for Preparing for Health Care Reform at your Program Clearly defining the issue Having data and knowing the facts Using the data to be involved early in process Understanding that change is hard Working collaboratively Be willing to be in it for the long run Current situation Future possibility Accountability for defined population Inconsistent quality Accountable Care Fragmented delivery Pay for value Fragmented payment Volume incentives Comprehensive and transparent care A Framework for Preparing for Health Care Reform at your Program Clearly defining the issue Having data and knowing the facts Using the data Understanding that change is hard Working collaboratively Be willing to be in it for the long run U.S. Health Care Expenditures are Rising Massachusetts Spends More on Health Care than Any Other State PER CAPITA PERSONAL HEALTH CARE EXPENDITURES, 2009 NATIONAL AVERAGE State NOTE: District of Columbia is not included. Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2011. SOURCE: 50 The Increasing Costs of Health Care Squeeze Out Other Public Spending Priorities MASSACHUSETTS STATE BUDGET, FY2001 VS. FY2011 STATE SPENDING (BILLIONS OF DOLLARS) FY2001 FY2011 +$5.1 B (+59%) -$4.0 B (-20%) -15% -13% -11% -23% -38% Health Care Coverage (State Employees/GIC; Medicaid/Health Reform) SOURCE: 51 Massachusetts Budget and Policy Center Budget Browser. Public Health -50% -33% Mental Health Education Infrastructure/ Housing Human Services Local Aid Public Safety How does this compare to homeless individuals in Massachusetts? Lack of data tracking homeless individuals Starting point becomes obtaining data Boston Homeless Cohort: Mental Health and Substance Use AJPH 2013 All (N=6,494) Mental Illness 4,384 (68%) Schizophrenia 1264 (19%) Bipolar Disorders 1889 (30%) Depression 3068 (47%) Anxiety 2627 (40%) Substance use disorders 3890 (60%) Alcohol use disorder 2628 (40%) Drug use disorder 3118 (48%) Co-occurring mental illness and substance use 3135(48%) Boston Homeless Cohort: Selected Chronic Physical Conditions 23 Chronic Condition C Hep 6 HIV 4 sis o h r r Ci /C a m h Ast AJPH 2013 26 OPD 37 HTN 10 HD c i m e Isch tes e b a Di 18 0 10 20 Percentage 30 40 BHCHP PCC Patients versus members of the PCC Plan Diagnostic and Other Characteristics Statewide Number 426,768 1.5 DxCG Score Both Mental Health & Substance Use 10% 6% Asthma or COPD Diabetes 6% 129 Hospital Discharges Per 1,000 ED Visits Per Person 1.1 $6,679 Average Annual Cost BHCHP Patients* 3,998 3.4 51% 24% 15% 859 4.2 $20,925 *Medicaid-only BHCHP patients enrolled in the PCC plan. Bharel et al, AJPH 2013 Total Annual Expenditures by Expenditure Group for BHCHP Users with Medicaid in 2010 Total Annual Expenditures by Expenditure Group for BHCHP Users with Medicaid, CY 2010 100% 10% 90% 80% 15% 48.0% 70% 60% 90 – 100% (650 users) 25% 75 – 90% (974 users) 50% 40% 50 – 75% (1,623 users) 25% 25.5% 25 – 50% (1,623 users) 30% Lowest 25% (1,623 users) 20% 10% 18.6% 25% 0% Users (N=6,493) 6.5% 1.4% Expenditures ($149 million) Health Care Utilization and Housing Studies in New York, Seattle and Chicago have found that housing homeless individuals can decrease use of services including: Emergency department Hospital inpatient Detoxification services Am J Public Health. Apr 2004, JAMA. Apr 1 2009, JAMA. May 6 2009. A Framework for Preparing for Health Care Reform at your Program Clearly defining the issue Having data and knowing the facts Using the data to be involved early in process Understanding that change is hard Working collaboratively Be willing to be in it for the long run Long History of Reform in Massachusetts 1997 • Medicaid 1115 waiver to expand Medicaid, including MCO development • Comprehensive Health Reform: shared individual and state government, responsibility for access 2006 • Despite a recession, Massachusetts succeeds at having the lowest rate of uninsured in the nation 2007 • Chapter 221 passed with focus now on cost containment while providing high quality care 2012 • One Care Program begins to coordinate care for dual eligible patients (both Medicaid and Medicare) 2013 • Primary Care Payment Reform beings to coordinate behavioral health and primary care services in a global payment to primary care practices 2014 One Care: Medicaid Plus Medicare • October 2013 • MA launched program to integrate care and align financing for dual eligible patients • Interdisciplinary Care Teams develop patient care plans and covered services include primary care, BH, specialty care, dental, vision ,medications and long term care. • March 2014 • 9,722 members have enrolled • Payments remain fee-for-service with a supplemental payment for care coordination and management Primary Care Payment Reform Initiative (PCPRI) • Chapter 221 requires transition of Medicaid patients from fee-for-service to alternate payment methods with 80% transformation by July 2015 • PCPR is an alternative payment program where primary care providers are held accountable for cost and quality of care using a BH integration model and patient centered medical home. • Payments are risk adjusted per member per month global payments • Goal of delivery system to increase care coordination and care management, improve access to primary care, integrate BH and practice population management Using the data to advocate Collaborator Local community organizations Academic medical centers Medicaid Executive Office of Health and Human Services Elected Officials Issue Special population Attribution of care issue Medical respite needs BH integration needs A Framework for Preparing for Health Care Reform at your Program Clearly defining the issue Having data and knowing the facts Using the data to be involved early in process Understanding that change is hard Working collaboratively Be willing to be in it for the long run Payment Reform and Health Care for Homeless Individuals Opportunities Flexibility in clinical design Flexibility in outreach model Behavioral health and primary care integration Coordination across the health care system Challenges Change is hard Uncharted territory Attribution of patients Risk adjustment is not adequate Taking on risk at provider level Want clinical staff to remain blind to insurance type A Framework for Preparing for Health Care Reform at your Program Clearly defining the issue Having data and knowing the facts Using the data to be involved early in process Understanding that change is hard Working collaboratively Be willing to be in it for the long run Collaborations: who else is a stakeholder? Neighborhood hospitals and academic medical centers State Medicaid State Legislators/local politicians Consumer advocacy groups Other organizations caring for special populations National advocacy groups Shelter alliances And more…. A Framework for Preparing for Health Care Reform at your Program Clearly defining the issue Having data and knowing the facts Using the data to be involved early in process Understanding that change is hard Working collaboratively Be willing to be in it for the long run Mission Statement: Provide and assure access to quality health care for all homeless individuals and families in the greater Boston area. Photos courtesy of J O’Connell QUESTIONS AND ANSWERS For more information www.nhchc.org www.nachc.org www.ncsl.org THANK YOU FOR YOUR PARTICIPATION Upon exiting you will be prompted to complete a short online survey. Please take a minute to complete the survey to evaluate this webinar production.