Breaking Down Financial Silos

to Address Social Determinants

of Health: Balanced Portfolio

Model and Vermont Experience

Jim Hester

jhester@alum.mit.edu

MPHA Annual Meeting

November, 2017

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Theme

• The health care system is in the early stages of a

major transformation to deliver Triple Aims

outcomes, particularly improved population health

• The determinants of health imply that improving

population health requires integrating clinical

services with public health and community based

interventions targeted on upstream determinants

• The proposed financial model for improving health

has a community integrator managing a balanced

portfolio of interventions financed by diverse

funding vehicles

Patient CenteredCare

Coordinated SeamlessHealthcare System 2.0

• Patient/person centered

• Transparent cost and quality performance

• Accountable provider networks designed around the patient

• Shared financial risk

• HIT integrated

• Focus on care management

and preventive care

Population

Health

● Healthy population centered

● Population health focused strategies

● Integrated networks linked to community resources capable of addressing psycho social/economic needs

● Population-based reimbursement

● Learning organization: capable of rapid

deployment of best practices

● Community health integrated

● E-health and telehealth capable

• Episodic health care

• Lack integrated care networks

• Lack quality & cost performance

transparency

• Poorly coordinated chronic care management

Acute Care System 1.0

US Health Care Delivery System Evolution

CommunityHealth System 3.0

Health Delivery System Transformation Critical Path

Episodic Non-Integrated Care

indow of Opportunity: Integrating Financing of Population Health into Delivery System ReformHalfon N. et al, Health Affairs November 2014

Inventory of Financing Vehicles

Necessary, but not sufficient building blocks

Public financing:

single sector

Multi-sector programs

Value based payment for clinical services

Global Budget: eg, Vermont

• Shared savings

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Growing Inventory of Financing Vehicles

Innovative funding sources

Hospital• community benefit

• Investments: Dignity, Trinity, Dartmouth-Hitchcock

Community development, e.g., CDFI (AHEAD)

Social capital, e.g., social impact bonds

Foundations: Program Related Investments (PRI)

Employers e.g. subscription, employee benefits

Prevention/wellness trusts

Transaction fees for brokering deals

5Window of Opportunity: Integrating Financing of Population Health into Delivery System

Building a Balanced Portfolio

No silver bullet – need to

Balance portfolio in terms of

Spectrum of time horizons for impacts

Level of evidence/risk: test innovative interventions

Scale

Build business case and close on specific transactions

Aggregate and align financing streams

Manage and leverage private and public investment to achieve greater impact

MPHA 2017 Priorities

Access to Healthy Affordable Food

Promoting a Healthy Built Environment

Promoting Community Health Integration

Safeguarding Universal Public Health

Protections

Advancing Economic Justice

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8

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Key Functions of an AHC

A community centered entity responsible for improving the health of a defined population in a geographic area by integrating clinical services, public health and community services

Convene diverse stakeholders and create common vision

Conduct a community health needs assessment and prioritize needs

Build and manage portfolio of interventions

Monitor outcomes and implement rapid cycle improvements

Support transition to value based payment and global budgets

Facilitate coordinated network of community based services

Structure of an Accountable Health

Community

The AHC is made up of

Backbone organization for governance structure and

key functions

Intervention partners to implement specific short,

intermediate, and long term health-related

interventions

Financing partners who fund specific transactions

Challenges

Implementing all payer value based

payment

Identifying and capturing savings across

sectors

Creating and sustaining backbone org.

Operational measures of population health

for payment

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Building a High-Performing Health System for Vermont

11/30/2017 12

Big Goal:Integrated Health

System able to achieve the Triple Aim

All-Payer Model (Next Gen-type ACO):• Way to pursue goal of integrated

system for certain services and providers.

• Enables Medicare, Medicaid, and Commercial payers to align value-based payments for health care.

Medicaid Pathway:• Way to pursue goal of integrated

system for services and providers outside of All-Payer Model.

• Enables Medicaid to align value-based payment models with All-Payer and ACO design.

Complementary Delivery System Reform and Care Delivery Transformation Efforts, including…• Blueprint for Health (multi-payer

patient-centered medical homes)• Community Health Teams (CHTs)• CHT Extensions – Hub & Spoke,

Support and Services at Home (SASH)• Regional Governance (Unified

Community Collaboratives)• Provider Learning Collaboratives• Accountable Communities for Health

Vermont SIM GrantPopulation Health Workgroup

Charge: resource for the other working groups: payment models, performance reporting, service coordination

- ways to incorporate population health principles

- how to improve the health of Vermonters

Priorities: Measures of population health eg ACO payment

Identify innovative financing options for paying for population health and prevention

Identify and support exemplars of effective community-focused interventions. Accountable Health Communities (Prevention Institute)

Delivery System Transformation

Create single payment model for all payers Primary care: Blueprint for Health Phase 2

Statewide ACO (One Care)

All payer population based budget: Medicare/Medicaid waiver, St J pilot

Integrate Blueprint for Health and ACO’s Regional unified community collaboratives

Unified reporting system

Accountable Community for Health Evolution: ACO to AHC to TACO

integrated medical, behavioral health, public health and community services

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Health IT Framework

Evaluation Framework

Advanced

Primary

Care

Hospitals

Public Health

Programs & Services

Community Health Team

Nurse Coordinator

Social Workers

Nutrition Specialists

Community Health Workers

Public Health Specialist

Extended Community Health Team

Medicaid Care Coordinators

Senior Support Teams

Addiction (“Spoke”) Teams

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 this 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

Social, Economic, &

Community Services

Healthier Living

Workshops

Advanced

Primary

Care

Advanced

Primary

Care

Advanced

Primary

Care

Multi-Insurer Payment Reform Framework

11/30/2017 1616

Department of Vermont

Health Access

11/30/2017 16

Transition to a Community Health Focus

Current

PCMHs & CHTs

Community Networks

BP workgroups

ACO workgroups

Increasing measurement

Multiple priorities

Transition

Unified Community Collaboratives

Focus on core ACO quality metrics

Common BP ACO dashboards

Shared data sets

Administrative Efficiencies

Increase capacity

• PCMHs, CHTs

• Community Networks

• Improve quality & outcomes

Community Health Systems

Novel financing

Novel payment system

Regional Organization

Advanced Primary Care

More Complete Service Networks

Population Health

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Department of Vermont

Health Access

Proposed Payment Modifications

Current Proposed

Targeted Payment Composite Payment

Single Component – based on

NCQA PCMH score. Practice

Control

Base Component – participation in UCCs,

and NCQA recognition on 2011 standards.

Practice Control

NCQA Component – rescore is discretionary

but rewarded. Practice Control

Quality Component – HSA results on a set of

core measures. Interdependencies

Utilization Component – HSA results on total

utilization index. Interdependencies

Incentives for NCQA recognition, a

high score on standards, and access to

CHT staff.

Incentives for sustained practice quality, access

to CHT staff; and coordination with others to

improve service area outcomes

VT CMS All Payer Waiver

Creates aligned global budget payment models for Medicare, Medicaid and commercial payers based on Next Gen ACO models

Providers organized into an ACO network

Builds on Blueprint for Health and encourages connections to community resources ($51 million CMS investment)

Creates explicit incentives for improving population health

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Integrating Health Into Payment

Three tiered measures and goals

Total population

Attributed population for ACO

Interim processes

Based on VDH Statewide Health Improvement Plan

Substance abuse disorder

Suicide

Prevalence of chronic disease: COPD, diabetes and hypertension

Access to primary care19

VT Accountable Health

Community InitiativePhase I (Prevention Institute)

Created template for assessing national

and Vermont based initiatives

Identified national exemplars and lessons

learned

Identified potential ACH sites within VT

Phase II: peer learning ACH program for

2016, 2017

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Resource

“Towards Sustainable Improvements in

Population Health: Overview of Community

Integration Structures and Emerging

Innovations in Financing”

Hester JA, Stange PV, Seeff LC, Davis JB,

Craft CA

CDC Health Policy Series, January 2015

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Backbone Organization’s Aggregation and Alignment of Investments and Reinvestments

% of Partner Incentives Reinvested

Return on Investment

Social Determinants of Health Interventions

Community Financial

Commitment

Grant Funding

Capture Savings and Reinvest

Medical/Social Services Coordination Interventions

Risk Behavior Management Interventions

Backbone organization

Wellness Fund

Balanced portfolio of interventions funded viasocial capital performance contracts existing payment for services