health reform in vermont - csg knowledge...

Steve MaierHealth Care Reform Manager

Vermont Division of Health Care Reformsteven.maier@ahs.state.vt.us

1/11/2011 1

Health Reform in VermontTransforming to a High Value and Affordable Health Care System

Vermont Context• 620,000 total population

• 13 Hospital Service Areas define ‘community systems’

• Payers: 3 major commercial+ 2 public

• History of collaboration: multi-partisan and multi-stakeholder

Health Reform in Vermont Transforming to a High Value and Affordable Health Care System

COVERAGE Reform

CARE Reform

INSURANCE Reform

PAYMENT Reform

FINANCING & COST Reform

INFRASTRUCTURE Reform

CARE reforms for all Vermonters include:

Advanced Primary Care foundation (PCMHs + CHTs)

Multi-Insurer Payment Reforms

A focus on prevention (public health health care delivery)

A statewide health information exchange

An evaluation infrastructure to support ongoing improvement

Facilitators & support for a learning health system

CARE Reform =

Vermont’s Administration and Legislature have consistently supported CARE Reform

2003 Blueprint launched as a Governor’s Initiative

2005 Implementation of Chronic Care Model2006 Blueprint codification as part of sweeping

reform legislation2007 Blueprint leadership and Integrated Pilots2008 Community Health Team structure and

insurer mandate2009 Accountable Care Organization Exploration2010 Statewide Expansion

“a program for integrating a system of health care for patients, improving the health of the overall population, and improving control over health care costs by promoting health maintenance, prevention, and care coordination and management.”

VT Act 128 - 2010

VT Blueprint for Healthfor all Vermonters

Health IT Framework

Evaluation Framework

Medical Home

Hospitals

Public Health Programs & Services

Community Health TeamNurse Coordinator

Social WorkersNutrition Specialists

Community Health WorkersMCAID Care Coordinators

Public Health Specialist

Specialty Care & Disease Management Programs

A foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of services

Multi Insurer Payment Reform that supports a foundation of medical homes and community health teams

A health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry

An evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impact

Mental Health & Substance Abuse

Programs

Medical Home

Social, Economic, & Community Services

Healthier Living Workshops

1/11/2011 9

Multi-insurer Payment Reforms

Insurers

•Community Health Teams•Shared costs as core resource•Consistent across insurers•Minimizes barriers

•Patient Centered Medical Home•Payment to practices•Consistent across insurers•Promotes quality

•Fee for Service•Unchanged•Allows competition•Promotes volume

•Based on NCQA PPC-PCMH Score•$1.20 - $2.49 PPPM•Based on active case load

•5 FTE / 20,000 people•$ 350,000 per 5 FTE•Scaled based on population

•Medicaid•Commercial Insurers•Medicare?

0 10 20 30 40 50 60 70 80 90 100

NCQA PCMH Score

Requires 5 of 10 Must Pass Elements

All insurers pay enhanced payment based on a practices score as a patient centered medical home

NCQA PCMH standards and scoring methods are used to score practices as a medical home

Payment changes with each 5 point change in the NCQA PCMH score (score ranges from 0 – 100 points)

Designed to incent ongoing iterative improvement, and to provide a disincentive for moving backwards

1/11/2011 11

Patient Centered Medical Homes

Multi-insurer payment reform

Health Information Infrastructure

Evaluation Infrastructure

Foundation

General population

SubPopulation

Community Health Team

Advanced Model of Primary CareA Foundation for integrated services

Foundation

General population

SubPopulation

Foundation

General population

SubPopulation

Targeted Services

Specialty Care

Disease Management Programs

Case Management

Social Services

Economic Services

Foundation

Targeted Services

Specialty Care

Disease Management Programs

Case Management

Social Services

Economic Services

General population

SubPopulation

Advanced Primary Care PracticesNCQA Criteria for PCMH recognition

Blueprint Central Registry

Patient tracking - Access to searchable and actionable data

Care Management - Use of evidence based guidelines

Patient Management Support - Identify patients with unique needs

Test tracking - Managing results/alerts

Performance Reporting - % of patients meeting various guidelines

NCQA PCMH Points

Average PPPM

Payment

0 0.00

5 0.00

10 0.00

15 0.00

20 0.00

25 1.20

30 1.28

35 1.36

40 1.44

45 1.52

50 1.60

55 1.68

60 1.76

65 1.84

70 1.92

75 2.00

80 2.07

85 2.15

90 2.23

95 2.31

100 2.3917

Priorities

Transformation vs. Research

Don’t interfere with health services …. But

Build a learning health system…

with continuous improvements

Evaluation & Results

Building a Learning Health System

Do meaningful & useful evaluation

Provide data as part of routine operations

Support a broad array of meaningful metrics

Create flexible & dynamic reports

Organize processes & people to use information to make improvements

Data Sources Categories of Measures

Reporting

Central Registry Clinical ProcessesHealth Status

Web basedFlexible & dynamic

Multi-Payer Claims Database Resource UtilizationExpenditures

Standard ReportsWeb based Flexible & dynamic

Chart Reviews Clinical ProcessesHealth Status

Standard Reports

NCQA Scoring Clinical ProcessesPCMH Standards

Standard Reports

Public Health Registries Population levelRisk FactorsGuide planningTrack change

Standard Reports

Patient Handout

Basic Outreach Report

Distributions vs. Averages

Group 1Good Disease

Control

Group 2Intermediate

Disease Control

Group 3Poor

Disease Control

Average = 7.46 Average = 7.36

Burlington Cohort: Total Admission Rate

10AesculapiusCohortAdmission RatePer Thousand:Pre-MedicalHomeImplementation

AesculapiusCohortAdmission RatePer Thousand:Post-MedicalHomeImplementation

Linear(AesculapiusCohortAdmission RatePer Thousand:Pre-MedicalHomeImplementation)Linear(AesculapiusCohortAdmission RatePer Thousand:Post-MedicalHomeImplementation)

Start MAPCP Pilot

Rate of change = 8.4% decrease

y = 0.0609x + 4.804R2 = 0.229

y = -0.0042x + 7.1R2 = 0.0009

Burlington Cohort: ER Visit Rate

Aesculapius CohortER Visit Rate PerThousand: Pre-Medical HomeImplementation

Aesculapius CohortER Visit Rate PerThousand: Post-Medical HomeImplementation

Linear (AesculapiusCohort ER VisitRate Per Thousand:Pre-Medical HomeImplementation)

Linear (AesculapiusCohort ER VisitRate Per Thousand:Post-Medical HomeImplementation)

Start MAPCP Pilot

y = 0.146x + 13.167R2 = 0.2974

y = 0.0135x + 16.164R2 = 0.003

St. Johnsbury Cohort: ER Visit Rate

Corner Medical CohortER Visit Rate PerThousand: Post-CCT

Corner Medical CohortER Visit Rate PerThousand: Pre-CCT

Linear (Corner MedicalCohort ER Visit Rate PerThousand: Pre-CCT)

Linear (Corner MedicalCohort ER Visit Rate PerThousand: Post-CCT)

y = 0.3248x + 41.454R2 = 0.2165

y = -0.5203x + 69.572R2 = 0.4655

Start of MAPCP Pilot

St. Johnsbury Cohort: Total Hospital Admissions Rate

Corner Medical CohortAdmission Rate PerThousand: Post-CCT

Corner Medical CohortAdmission Rate PerThousand: Pre-CCT

Linear (Corner MedicalCohort Admission RatePer Thousand: Pre-CCT)

Linear (Corner MedicalCohort Admission RatePer Thousand: Post-CCT)

Start MAPCP Pilot

y = 0.0784x + 5.6467R2 = 0.2769

y = -0.0417x + 9.6114R2 = 0.0871

*At each site, an active APCP cohort was selected (patients with a visit in the APCP between the start date of the pilot and a defined time period). Monthly rates of ED visits and IP admissions (all cause) for the APCP cohorts were evaluated during two time periods, the 2 years prior to the start of the pilot, and the time period since the start of the pilot. Each chart displays the two different data series and trend lines for the same cohort. The findings suggest a change in gross directionality of hospital encounter volumes, and are suggestive of change with a trajectory that is sustained over time making it unlikely to be a Hawthorne effect. The results are not predictive, but do display early trends with simple linear regression methods.

Vermont MAPCP Preliminary DataTrends in hospital based care per 1000 (pre/post start of MAPCP pilots)*

$200,000,000

$250,000,000

$300,000,000

$350,000,000

$400,000,000

$450,000,000

1 2 3 4 5

IMPACT OF INTEGRATED HEALTH SYSTEM-POTENTIAL COST AVOIDANCE ACROSS TOTAL POPULATION

INCREMENTAL EXPENDITURES WITHOUT INTEGRATED HEALTH SYSTEM

INCREMENTAL EXPENDITURES WITH INTEGRATED HEALTH SYSTEM

Target Population% of VT Population# CHTs

42,1796.7%

126,28620%

316,66250%16

508,1780%25

637,130100%

321/11/2011 27

$4,000,000

$4,500,000

$5,000,000

$5,500,000

$6,000,000

$6,500,000

1 2 3 4 5

IMPACT OF INTEGRATED HEALTH SYSTEM-POTENTIAL COST AVOIDANCE ACROSS TOTAL POPULATION

(000'S)

EXPENDITURES WITHOUT INTEGRATED HEALTH SYSTEM

EXPENDITURES WITH INTEGRATED HEALTH SYSTEM

42,1796.7%

126,28620%

316,66250%16

508,1780%25

637,130100%

321/11/2011 28

Health Care Reform 2010 and BeyondConvergence and Opportunity

Vermont Act 128 – Statewide expansion of medical homes, community health teams, and mandated multi-insurer payment reforms

Affordable Care Act – Comprehensive insurance reforms for increased accountability, lower costs and enhancing the quality of health care (Sections 3502 and 3503)

Multi-payer Advanced Primary Care Practice demonstration –Medicare to join state led multi-insurer payment reforms that support an advanced model of primary care

July2008

Jan2009

July 2009

Jan 2010

July 2010

Jan2011

July 2011

Jan 2012

July 2012

Jan 2013

July 2013

Pilot # 1 St Johnsbury HSA St Johnsbury HSA Expansion

Pilot # 2 Burlington HSA Burlington HSA Expansion

Readiness Pilot # 3 Barre HSA Barre HSA Expansion

Readiness HSA # 4 Rollout

Implementation Phase Demonstration Phase (Medicare?)

42,1796.7%

126,28620%

316,66250%16

508,1780%

637,130100%

Blueprint Integrated Health System - Proposed Expansion

1/11/2011 30

State & Federal PartnershipsExample - Health information & quality infrastructure

National Guidelines & Measures(NIH, Task Force, AHRQ)

Guideline based Data Dictionary

•Clinical process data elements

•Health status data elements

•Aligned measure set

•Aligned answer options

Reporting & Evaluation

• Registry reports

Outreach

Performance

• Claims database reports

Clinical Tracking Systems

•EMR Templates

•Registry visit planners

•Outreach reports

•Interfaces & data transfer

Guideline Based Health Services

•Individual patient care

•Population management

•Coordinated health services

•Emphasis on prevention

Guideline Based QI

•Comparative Evaluation

•Provide reports & data

•Coaching & facilitation

•Shared learning

Learning Health System

Ongoing Refinement

State Led Health Reforms

Federal Funding & Guidance(ONC, CMS)

Future Challenges & Opportunities

COVERAGE Reform

CARE Reform

INSURANCE Reform

PAYMENT Reform

FINANCING & COST Reform

INFRASTRUCTURE Reform

• Health care costs• Maximize benefits to VT of federal reform • Health care workforce • Payment reform – ACOs • Sustainable financing • System design options - one single-payer

option, one public-insurance option, and one other – Dr. William Hsiao, Harvard

1/11/2011 35

Conclusions: We propose the establishment of ethics committees to review all future redisorganizationproposals in order to put a stop to uncontrolled, unplanned experimentation inflicted on providers and users of the health services.

A surrealistic mega-analysis of redisorganization theories

Oxman AD, Sackett DL Chalmers I, Prescott TE. J R Soc Med 2005;98:563-568

Make Time to Listen

Susan W. Besio, Ph.D.CommissionerOffice of Vermont Health AccessVermont Health Care Reform 802-879-5901susan.besio@ahs.state.vt.us

Hunt BlairDirectorVT Healthcare Reform Div.State Health IT Coord.(802) 879-5901hunt.blair@ahs.state.vt.us

Steve MaierHealth Care Reform ManagerVT Healthcare Reform Div.(802) 879-2395steven.maier@ahs.state.vt.us

Diane HawkinsExecutive Staff Assistant (802) 879-5988diane.hawkins@ahs.state.vt.us

Craig Jones, MDDirectorVT Blueprint for Health(802) 879-5988craig.jones@ahs.state.vt.us

Christine OliverDeputy CommissionerVT Banking, Insurance, Securities and Health Care Administration(802) 828-2900 christine.oliver@state.vt.us

Vermont Health Care Reformhttp://hcr.vermont.gov

health reform in vermont - csg knowledge...

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