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ACO Impacts on the Dental Marketplace

Dr. Jeffrey Sulitzer - InterDentMatt Sinnott - Willamette Dental Group

September 29, 2015

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Overview

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The Problem … industry context

The Challenge … significant cost reduction with quality improvement

A Solution … systems of care, e.g., accountable care organizations (ACO’s)

Implementing ACO Relationships … key building blocks

Key Success Factors

Effective Solutions

Patient Protection and Affordable Care Act

Integrated Health Management

Re-distribution of Accountability and Risk

Health Analytics and Business Intelligence

Mobility, Telemedicine, Virtual care and the de-location of Healthcare

Support CMS Triple Aim

Macro Trend Implications for the Industry

ACO will change the coordination of care - Shift from “sick care” towards a true “health care”.

Cost of Care Savings Programs that “promote accountability for a patient service delivery.”

Exhibition of improved MLR management and delivers better outcomes

Competitive investment in HIX

Enabled by rapidly evolving technology - broadband, social computing, “anything-as-a-service”

Experiments with “virtual care” models and telehealth will continue to proliferate

Reform will reduce overall health industry profits Only the most efficient ACOs will survive Successful ACOs will need to find ways to improve

efficiencies and coordination of care

Patient Centered Medical Homes (PCMH) Value-based benefit products offered by ACOs Provider pay-for performance, outcomes-based contracts

and evidence-based practices

Enhance delivery & technology for reduced

administrative costs

Provide Access to information and the revamp portals.

Develop Health 2.0 strategy

Evaluate ACO models and provide Business strategy and Operational services

Leverage the power of the “Cloud” – platform based

outsourcing

Stratification and management of At Risk

Population

Meet CMS requirements Increase patient satisfaction Reduce medical costs while increasing provider satisfaction Delivering on better outcomes

Healthcare Industry Macro Trends and Implications

Transformation in Healthcare :Optimized initiative will have significant positive bottom line impact, but organizations need to embark on a set of transformational initiatives to adapt to the changing healthcare industry tends

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The Problem … possible systemic failure

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The US is poised for systemic failure without radical transformation

Source: www.cms.gov

• The size of the federal budget deficit is unsustainable

• The annual increase in the Medicare budget is unsustainable

• The percentage of healthcare spending to GDP is unsustainable

• State Medicaid programs are unsustainable

• The continued transfer of costs to employers and consumers is unsustainable

Source: The Transformation of America’s Hospitals, The Governance Institute, Kaufman, Hall & Associates, Jan 17, 2012

Revenues and Primary Spending, by Category, Under CBO’s Long‐Term Budget Scenarios

Source: CBO’s long term budget outlook, August 2010

0.0

5.0

10.0

15.0

20.0

25.0

2000 2005 2010 2015 2020 2025 2030 2035

% of GDP

Other Non‐Interest spending

Medicare, Medicaid and Exchange Subsidies

Social Security


The Problem … is global

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As healthcare trends are global, cost concerns are not unique to the US, but the US has a much higher healthcare spend than most other countries

North America

17% of GDPEurope

10% of GDP

East and Central Asia6.5% of GDP

South America and Caribbean6.7% of GDP Pacific

7% of GDP

South Asia4% of GDP

1) Personalized medicine and technological advancements2) Aging population and rising costs3) Evidence-based and preventive medicine4) Medical tourism 5) Demand driven consumer centric model6) Global pandemics and treatment of infectious diseases7) Environmental challenges8) NGOs treating diseases that plague poor countries

Global Mega Trends

11.7

10.1 9.6 9.5 9.08.7

4.6

2.5

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Per

cen

tag

e

Healthcare Spending as a % of GDP

Source: :www.data.worldbank.org; www.Hbr.org ; http://www.logica.com/we-are-logica/media-centre/thought-pieces/2012/healthcare-challenges-and-trends/

*Netherlands,France, Germany,Switzerland,Denmark

Healthcare trends are global. Costs will continue

to grow..

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The Challenge – cost reduction plus quality improvement

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The industry must significantly reduce the per person annual average cost over the next five years to slow or arrest the growth in total healthcare expenditures … and there are areas of opportunity:

Source: www.ibisworld.com, “Healthcare Consultants in the US February 2012”

Estimated waste in US healthcareSource: Healthcare Analytics, Thomson Reuters (data as of: 2009) Estimated waste in US healthcareSource: Healthcare Analytics, Thomson Reuters (data as of: 2009)

$0B $50B $100B $150B $200B $250B $300B $350B

Avoidable Care

Un-coordinated care

Hospital Inefficiencies

Administrative Inefficiencies

Fraud and Abuse

Unnecessary Care

Note: The light blue bar represents the minimum estimated waste and the total bar represents the maximum estimated waste

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A History of Systems of CareThe industry has recognized the value of ‘systems of care’. There have been several attempts in the past at creating systems of care to drive value and accountability

Dr. Michael ShadidManaged Care PioneerStarted rural farmers’ health plan in Elk City, OK

1929

Enlisted Drs. Donald Ross and H. Clifford Loos to provide comprehensive services for 2,000 workers and their families. Start of the first commercial HMOEnrollment grows to 12,000 workers + 25,000 dependents at a cost of $2.69 PSPM, first capitation contract

Cigna bought Ross-Loos Medical group in 1980

Dr. Paul Elwood coined the phrase “health maintenance organization”

1954

Formed the first Independent Practice Association (IPA). Accepted capitation payments from subscribers and paid affiliated independent physicians and hospitals according to value-based fee schedule.Developed Peer review processes and monitored quality of care

1971

c. 1968

Nixon administration announces new national health strategy: the development of HMOs

1973

HMO act becomes law. $375M federal funds earmarked to develop HMOs

1996

HMOs become “managed care”; enrollment continues to grow through 80s & 90s. By 1996 there are over 600 HMOs with 65M members

President Obama signs Patient

Protection and Affordability Care Act (PPACA) into

law mandating Accountable Care

Organizations (ACO)

2011

1933Dr. Sidney Garfield provides similar services to Henry J. Kaiser for his workers at Grand Coulee Dam. During WW II, Kaiser expands this model to all his workers across all of his factories. After the war, Kaiser Permanente is formed covering 500,000 people

1938

2003

Pay for Performance (or Value Based Purchasing) is a payment mechanism for paying when certain quality measures are met

2007

Elliott Fischer, MD (Dartmouth Institute for Health Policy and Clinical Practice) and Glenn Hackbarth (Medicare Payment Advisory Commission) jointly coin the term “accountable care organizations”

Dr. Sidney Garfield started providing medical care on a prepaid basis for 5,000 workers on a aqueduct construction site.

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ACOs – Accountable Care Organizations

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Population

Health

Population

Health

Patient Experience

Patient Experience

ACOACO

CostsCosts

One proposition that is universally accepted is that greater coordination is needed among physicians and hospitals across the continuum of care in order to reduce costs and improve outcomes.

ACO is a network of physicians, specialists and provider organizations, that are collectively accountable for the quality and cost for a defined patient population.

Affordable Care Act (ACA) of 2010, part of the new healthcare reform legislation, gives healthcare organizations an opportunity, and a financial incentive to create Accountable Care Organizations (ACOs).

In sharp contrast to the current system which provides “sick care”, ACOs will move towards a true “health care”.

The core principles of ACOs are predicated on Institute for Healthcare Improvement's (IHI) Triple Aim

1. Improving the patient experience of care (including quality and satisfaction);

2. Improving the health of populations; and3. Reducing the per capita cost of health

care.


Types of ACOs present in the US Healthcare System

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ACOs offer a path to reaching the goals of Triple Aim … there are about 50M individuals in some form of an ACO like arrangement in the public and private sectors

CMS- Pioneer ACO Program- Shared Savings Program- Advanced Payment Program

Medicaid- Arkansas- Colorado- Connecticut- New Jersey- New York- Utah- Vermont- Wyoming- 27 other states are considering

or have pilots in effect

IDNs

MSGs

PHOs

IPAs

MSG = Multi Specialty GroupsPHO = Physician Hospital Organizations

IPA = Independent Practice AssociationsVPO = Virtual Physician Organizations

IDN = Integrated Delivery Network

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ACO Models

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The major lever of an ACO is the use of financial bonuses that groups can receive if they meet quality and cost benchmarks. ACOs can be structured with varying risk/rewards.

Re

wa

rds

Financial Risk

Type 1

Payment Model – FFS, shared savings for quality. No downside risk

Basic IT infrastructure Basic performance reporting Legal entity for contracting,

savings distribution etc.

Type 2

Payment Model – FFS, shared savings for quality with cost targets

Care coordination staff needed Investments in efficiency improvement plans

performance reporting Advanced IT Advanced analytics

Type 3

Payment Model – Risk adjusted/full capitation with bonus for quality

Advanced IT infrastructure incl. HIEs

Complex analytics Advanced care management

protocols Standardization

Financial incentives give providers an incentive to coordinate their patients' care to reduce duplication of services, invest in HIT, finding new way, cheaper, safer ways to do work, and adhere to evidence-based guidelines.


Implementing an ACO – e.g., CMS Shared Savings Model

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Shared Savings Model is one of the two ACO programs sponsored by CMS

Agreement

Setup

Assignment

Analysis & Projections

Benchmark

Operational Setup

Progress Reporting

Performance Measuring

Shared Savings

Providers decide to participate in an ACO and forms a legal entity

ACO provides list of participating providers to the payer

Patients are assigned to the ACO based on their physician

Analyze MedPAR data to determine cost projections

Establish spending benchmark, shared savings, quality and patient satisfaction benchmarks

ACO implements capacity, process, & delivery system improvement strategies e.g., reducing avoidable hospitalizations, coordinating care, health IT, LEAN, utilization management, etc.

ACO publishes progress reports on cost and quality for ACO providers and Beneficiaries

Every year end, total and per capita spending are measured for all patients (regardless of whether they received care from ACO providers)

If the ACO achieves both quality and cost targets, its providers may be eligible to receive a bonus

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ACO CEO

COO CFO CMO CNO CQO CIO

AncillaryProviders

HomeCare Hospital(s) HospiceLong-term

CarePost-Acute

CareSpecialistsPharmacyRetailClinic

People

Payer Partners

Implementing an ACO - a new legal entity

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An ACO requires a new operating model (or business model) that combines the capabilities of payers and providers and therefore requires a new organizational structure.

CMIO

Primary Care Physicians



Implementing an ACO – Business Capabilities Reference Model

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An ACO is a new legal entity that requires a combination of payer and provider capabilities. A reference model is a useful accelerator for evaluating current business capabilities of an organization(s) that wants to become an ACO.

Integrated Care Plan

PatientProvider

Care

Coordination

Analytics &

Payment

Strategy

Decision Support

Health Information Exchange

Health Plan

Administration

Co-branded Products

Front / Back Office Support

Compliance

Quality Reporting

AnalyticsAnalytics

Interoperability

and Workflow

Incentives

Remote Monitoring

Case Managers

Caregiver

Toolbox

Programs

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Implementing an ACO – Business Function View

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The following business functions are required for an ACO to operate … strategies for closing gaps include partnering and outsourcing

Physician, Member , Patient Services

Health & Wellness Member Services Physician Services Patient Activation

-Wellness Programs-Disease Management-Disease Registries

-Benefit Eligibility-Scheduling-WISMO-Medical Necessity

-Prior Auth-Reimbursement-Credentialing

-Health Assessment-Tracking

Payer (Administrative)

Quote to Bill-Product Design-Underwriting-Physician Attribution-Quote Generation-Policy Generation-Enrollment

Provider Management-N/W Management-Physician Contracting

Providers

Arrange Care-Registration-Admitting

Deliver Care-CDS-Care Delivery*

HIM-Transcription-Abstraction-Coding

Finance

Corp Finance Contract Management

Billing & Reimbursement

Pricing P4P (Pay for Performance)

-DSS-Cost Accounting-G/L-Change Master

- ContractManagement System

- Terms and Conditions

- Billing- COB- Exp. Reimb- Payments- Adjustments

- Claim Pricing - P4P- Payment

Distribution

Clinical Integration

EHR/ EMR HIE CPOE eRx Device Integration

Clinical Informatics

EvidenceMedicine

TreatmentProtocols

- Clinical Pathways

- Nursing Protocols

- Order Sets

PersonalizedMedicine

Analytics & Reporting

Health Economics

Quality

Hospital Efficiency

PhysicianPerformance

Physician Efficiency

Pop Health

Investigative Forensics


Implementing an ACO - Process and Org. Implications

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A key success factor is rethinking and redefining how and by whom work is done … use cases are a critical tool for completing this work …

PersonalCare Plan

Plan

Patient/Member/Consumer Experience

CCM High Level Workflow

Consumer

HealthAssessment

and Preferences Care

DeliveryOutcomes

Annual Update or Health Event

- Mail- Web- Call- Appointment- Other..

• Personal elements based on PHR.

• Grouped by: Population and Risk

• Quality Measures• Revised Risk • Care plan

revision• Care plan

completion

• Multi-setting• Multi-

channel interventions

• Identified PatientMember

• Population Risk Based Contracts

• Populations segmented and

• Risk Stratified

ProductDevelopment & Marketing

Scenarios: well, worried well, chronic conditions, complex cases, readmits

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Dental Care Trends - 2006-2012

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-7.0% +5.0% +9.0%

Total Visits U.S Population Practicing Dentist

According to the Health Policy Institute within the ADA, these are some of the trends in dental care in the US from 2006-2012

Source; Marko Vujicic, PhD, Economist and VP, Health Policy Institute, ADA


Dental Care Trends - 2006-2012 continued

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-9.0% +73.9% +19.7%Total Dental Federally Qualified Hospital ERs

office visit Health Centers

According to the Health Policy Institute within the ADA, these are some of the trends in dental care in the US from 2006-2012

Source; Marko Vujicic, PhD, Economist and VP, Health Policy Institute, ADA

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Staying Healthy(70 % Population)

Getting Better(15% Population)

Living with Illness(15% Population)

Health Promotion

through Coordinated

Care

CareManagement

through Coordinated

Care

Case / Population

Health Management

15% Costs

60% Costs

25% Costs

• A typical payor organization incurs about 80% of benefit costs over 30% of the populationconstituted by ill and unhealthy insured lives.

• Payor efforts to move unhealthy insured population segment towards the healthypopulation spectrum by gaining access further along the care continuum can significantlyreduce benefit costs.

• It is also important to minimize benefit costs associated with insured population segmentsuffering with chronic ailments and requiring better management of such medicalconditions to minimize cost of coverage, instead of focusing on acute care alone.

• Wellness and disease management programs can play a vital role in minimizing the benefitcosts and in maximizing return on investment percentage earlier along the care continuum.

PCPAncillary Provider

Care

Home Healthcare

Medication Therapy

MgtSpecialists

SNF and Rehab

Outpatient Care

Acute Stay

Access to care further up the Care Continuum is the key to reducing the costs

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Low Risk Medium Risk High Risk Acute Event Chronic IllnessL

ow

Co

st

Hig

h C

os

t

Complexity of Process High

Decision Support•HEDIS Support•Remote Patient Monitoring

Patient Member Outreach

WellnessUM Services

Care Management

Low

Benefits Cost Arc

• Prior Authorization• Post Service Review• Retrospective Review• Concurrent Review• Appeals and Grievances

Management• MTM (Medication Therapy

Management)

• Chronic Illness• Acute Care• Population

Management• Case Management• MTM (Medication

Therapy Management)

• Transition of Care• Continuity of Care

• SmokingCessation

• Maternity• Healthy Eating• Healthy Lifestyle• Exercise• Lifestyle Support

• Medicare Star ratings• Nurse Training• Communication: - Patient and

Provider Outreach• Post Discharge Calls• Prescription Compliance Calls

Wellness Occasional visits to PCP

Visits to PCP & Specialists

PCP, Specialist(s), Inpatient

Multiple inpt stays + high service use

Medical Management Capability Continuum


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Periodontal Disease

Diabetes Mellitus

Coronary Artery Disease

Risk Factors for Chronic Disease

Juvenile Diabetes

Cardiovascular Disease

Global Influence

Effects all age groups

Effects more than 60 % of the population

The prevalence of severe periodontitis increases with age

On average, approximately 13 % of the population has moderate to severe periodontitis. 4

WHO organization has highlighted Perio Disease as a global burden

Research validates long term relationship of Periodontal Disease with Diabetes Type II and Coronary Artery Disease

Confirming the need to include Periodontal Disease management for DM and CAD. *1,* 2

Between 2002 and 2012, a number of studies were designed to evaluate the effect of periodontal therapy on patients with diabetes mellitus and heart disease.

These studies are important and have been published to assist both the medical professions and the public, as to the potential benefit of controlling another risk factor; periodontal infections

Two significant questions were asked within the aim of these studies: (1.) Does untreated periodontal disease increase health care costs?(2) Does the treatment of periodontal disease decrease health care costs?

1.Vincent E. Friedewald, Kenneth S. Kornman, James D. Beck, Robert Genco, Allison Goldfine, Peter Libby, Steven Offenbacher, Paul M. Ridker, Thomas E. Van Dyke, William C. Roberts ; The American Journal of Cardiology and Journal of Periodontology Editors’ Consensus: Periodontitis and Atherosclerotic Cardiovascular Disease; Published simultaneously in The American Journal ofCardiology and The Journal of Periodontology, July 2009 ; 2009; 80: 1021-1032

2.Lockhart, Bolger, et al., Periodontal Disease and Atherosclerotic Vascular Disease: Does the Evidence Support an Independent Association? A Scientific Statement From the American Heart Association; Circulation; April 18, 2012

Periodontal Disease


Diabetes

Obesity

CardiovascularDisease

Heart AttackStroke

Pre-Term Birth

Low Birth Weight

Systemic Diseases Diabetes

Presence of Periodontal Disease increases risk of poor blood sugar control

Periodontal Disease is an infection which worsens blood sugar control in people with diabetes

Obesity is the number one risk factor for Type II Diabetes Obesity increases insulin resistance like inflammation does Fat cells produce proinflammatory cytokines which directly

change the insulin receptor and prevents insulin from working

Periodontal inflammation also causes the same activities

Cardiovascular Disease

28 of the 36 studies done show that Periodontal Disease is an independent risk factor for cardiovascular disease related events such as Heart Attach and Stroke

The more teeth that are affected by Periodontal Disease, the higher the risk for Cardiovascular Disease

Study done by Beck et al, J Periodontal, 2009 *3 C-Reactive Protein is a protein found in blood whose level is

related to the risk of developing cardiovascular disease

Pre-Term Birth

Periodontal Disease is known to be related to the high incidence of Pre-Term Birth, or better known as Low Birth Weight Babies

Severe Periodontal Disease increased risk of Pre-Term Birth (LBW) by 7.5 fold, adjusted for age, race, tobacco use, prenatal care, hx of bacteremia, (Offenbacher et al, 2001* 4)

The risk for both medically indicated and spontaneous preterm birth is higher for smokers than non-smokers

Study done by Lu and Aliya, Preventive Medicine, 2010 *5 Many epidemiological evidences have proven the

association between smoking and Periodontal Disease, Ojima and Hanioka, Tobacco Induced Diseases, 2010 *6

Oral health is improved through the reduction of chronic inflammation

General health is improved through reduction of chronic inflammation

Savings is achieved through reduction of medical costs

Higher rate of patient satisfaction

Higher rate of provider satisfaction

Better Evidence-based medical/dental outcomes

Dental Treatment

Several studies show that a combination of Scaling and Root Planing (SRP)and systemic Tetracycline antibiotics result in improved periodontal health and improved glycemic control

Reduction in gingival inflammation from SRP alone resulted in significant improvement in glycemic control

Studies show reduction in gingival inflammation alone can have significant positive effect on glycemic control

Kuran et al, J ClinPeriodontol, 2008 *7

Treatment of Periodontal Disease can reduce C-Reactive Protein

Treatment of Periodontal Disease during pregnancy deceases risk of pre-term/LBW delivery by 3 fold to 5 fold, Offenbacher et al, 2001*4

Periodontal Disease and Chronic Inflammation

Advantages of Dental Treatment

Outcomes

Periodontal Disease• Chronic

Inflammation• Effects >65% of the

population • Proven + outcome

when chronic inflammation is reduced

Oral Health - General Health Link

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United Concordia and University of Pennsylvania

Based on dental insurance records, periodontal treatment was provided to14% of subjects with DM, 13.12% with CAD, and 11.5% with a history of CVD.Figure one displays the results of early periodontal therapy for these groups

Aetna and Columbia College of Dental Medicine

Based on the data, medical costs decreased by an average of 11% per month for patients who received one to two periodontal treatments annually to those who received noneFor patients who received three to four periodontal treatments per year, their medical costs were 12% lower

University of Michigan

The study reported “lower medical costs were observed in the group who received prior treatment and maintenance care. Conversely, medical costs were higher in the group who first received treatment during the baseline year. These medical costs differences averaged $10,142 per patient in the baseline year among stroke patients and $1,418 per patient in the baseline year among patients with diabetes.”

Cigna and University of Pennsylvania School of Dental Medicine

Frequency of Periodontal therapy

reduces costs of care

Early Periodontal therapy reduces costs

of care

Proof that Periodontal therapy reduces costs

of care• In the first year of the study, hospital admissions were reduced 61%, physicians visits

were reduced by 41% and the overall cost of medical care was 32% less• Over the 3 year period, the average savings in medical costs was $1,814 annually.

The average reduction in hospital admissions was 33%The average reduction in physicians visits was 13%

Summary of Outcomes of StudiesPeriodontal therapy

reduces costs of care


Oral Health - General Health Link - Diabetes

Physician-Dentist Collaboration Recommended in Diabetes CareDentists can accurately identify patients with diabetes, could provide follow-up care

• Satheesh Elangovan, B.D.S., Sc.D., D.M.Sc., from the University of Iowa College of Dentistry in Iowa City, and colleagues discuss the interrelationships between diabetes and dental conditions, providing insights for both dental and medical professionals.

• FRIDAY, Oct. 31, 2014 (HealthDay News) -- Dentists are uniquely placed to identify patients with diabetes, and those with diabetes who are at risk for complications, according to an article published in the October issue of Clinical Diabetes


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Abstract

• The researchers note that more older people visit a dentist than a primary care physician.

• In 2011, 58 percent of those aged ≥65 years visited a dentist versus 38 percent who visited a primary care doctor.

• Diabetes has several oral manifestations and dentists can potentially identify patients with diabetes who are at risk. Patients could be placed on a recall program as a preventive measure, providing an opportunity for monitoring.

• Periodontal examinations can also be used to identify people with diabetes, with 92 percent accuracy seen in one study involving 506 dental patients. Dentists should also be trained to recognize patients at high risk for diabetes. Dentists and their auxiliary staff can also provide guidance for patients and help them attain glycemic control.

• "With the projected rise in chronic diseases, including diabetes, and the growing shortage of primary care physicians, it is ever more important for dental and medical health care providers to work together closely to tackle this public health crisis," the authors write.


Process #1

CCO Nurse CM refers high risk patient to Capitol dental for emergent or routine care

Dental care is delivered to patient at Capitol Dental and referred back to CCO Nurse CM

Data from dental visit is shared by Capitol Dental clinical team through Community Customer Coordinator

Capitol Dental clinical team identifies high risk patient receiving dental care

Following needed emergent or routine dental care, high risk patient is referred to CCO Nurse CM through Capitol Dental Community Customer Coordinator

CCO Nurse CM enrolls high risk patient into the appropriate CM program and coordinates future dental care with Capitol Dental through the Community Customer Coordination

Process #2

Transforming Care Management Services within ACOs

High Risk Patient diagnosed with :

•Diabetes•Hypertension•Pregnant Patient•Cardiovascular Disease Patient•Patient Using Tobacco•Depression

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Oregon Health Policy Landscape:Medicaid

The Oregon Health Plan (OHP) was launched in 1994 as the managed care delivery system for Medicaid under a Section 1115 Waiver. The creation of the OHP phased out the Physician Care Organization program (a limited benefit

prepaid plan model) in the favor of the full-risk, capitation-based approach.

Oregon Health Policy Landscape:Medicaid

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Oregon Health Policy Landscape: Medicaid

Establishment of Coordinated Care Organizations (CCOs):

CCOs as the delivery system for Medicaid.

Federal Investment:

Federal investment of ~$1.9 billion over 5 years through the Designated State Health Programs (DSHP).

(Year 1:$620 million, Year 2: $620 million, Year 3 $290 million, Year 4: $183 million, Year 5: $183M)

Savings:

Reduce per capita medical trend by 2

%age points. Penalties are significant; ranging

from $145 million for not achieving the second

year goal, to $183 million in Years 4 and 5.

Quality:

CCOs are required to meet quality metrics

with a financial incentive for performance. There

is a requirement by CMS for a 1% withhold for timely and accurate

data submission.

Workforce:

Changes to support the new model of care,

including loan repayment programs for

rural or underserved communities and training for 300

community health workers.

Transparency:

State must publicize data about quality of

care provided by CCOs in the interest of

advancing transparency and providing enrollees

with the information necessary to make informed choices

OHP Medical Benefits:Current OHP benefits are

maintained.

Flexibility in use of federal funds:

Oregon may use Medicaid dollars for flexible services e.g. non-traditional health

care workers. All flexible services have to

be used for health related care.

New Payment Methods:

Work is ongoing related to development of

alternative payment methodologies to

reimburse on the basis of outcomes and quality through shared savings

and incentives.

Oregon Health Policy Landscape: 1115 Medicaid Demonstration

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Oregon was awarded up to $45 million to “test” the CCO model of health system transformation.

• Integrate and coordinate care among primary, specialty, mental and behavioral health, and oral health providers

• Reduce health disparities

• Engage patients and consumers in their own care

• Engage providers in health system transformation

• Improve community health through local partnerships that support promotion and prevention activities

• Implement more effective health care payment models that incent value over volume

• Share information, innovation, and best practices across Oregon’s health care sector

Oregon Health Policy Landscape: CMMI State Innovation Model (SIM) Grant

Oregon shall test model “spread” among state funded (in part or full) healthcare such as Educators (OEBB), Public Employees (PEBB) and Insurance Exchange. As envisioned, a tipping point/ripple effect would impact Medicare Advantage, commercial and self-funded markets.

Oregon Health Policy Landscape: CMMI State Innovation Model (SIM) Grant

OHA

Medicaid Program Integrity

Regulation

Mission

and

Vision

Transformation CenterInnovator Agents

HIT/HIE support

Data and analytics

Provider engagement

Shared Learning

Technical assistance

CCOsCommunity Advisory Councils Clinical Advisory Panels

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Oregon Health Policy Landscape: Beyond Medicaid

Oregon Health Policy Board (OHPB)

Released a report outlining three key strategies to better align Oregon’s health system reform efforts and spread triple aim goals across all markets:

Create system-wide transparency and accountability through a robust measurement framework, including a public-facing health system dashboard, which tracks the effect of ACA implementation and Oregon’s health system reforms.

Established quarterly report which includes dashboards to track quality and implementation.

Move the health care marketplace toward a fixed and sustainable rate of growth.

Creation of workgroup to develop a sustainable rate of growth methodology for the total cost of care.

Improve quality and contain costs by expanding an innovative and outcome-focused primary, preventive and chronic care infrastructure.

Creation of Coordinated Care Model Alignment Work Group including OHA, Public Employee Benefits Board (PEBB) and Oregon Educators Benefits Board (OEBB).

CCO Model

OHP

PEBB

OEBB

Exchange

Medicare

Self Insured

Commercial

By exercising purchaser leverage, the State continues to pursue expansion of the CCO model.

Introduction to CCOs:The Triple Aim Vision

18

Introduction to CCOs:What are they all about?

A CCO is a network of all types of healthcare providers (physical, mental and addictions and dental) who have agreed to work together, in their local

communities, to serve people who receive coverage under the OHP.

Best practices to manage and

coordinate care

Shared responsibility for

health

Transparency in price and quality

Measuring performance

Paying for outcomes and

health

A sustainable rate of growth

Introduction to CCOs: What are they all about?

Integration of Care Siloes Principled Approach

CCO

Medical

Behavioral

(Mental and Addictions)

Dental

NEMT CCO

Benefits and services are integrated

and coordinated

One global budget that grows at a fixed rate

Local flexibility

Metrics: standards for

safe and effective care

Local accountability for health and

budget

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Introduction to CCOs:Statewide Coverage, limited choice

Introduction to CCOs:Accountability Plan

Oregon’s Medicaid Program Commitments to CMS Reduce annual increase in cost of care (the cost curve) by 2 percentage points

Ensure that quality of care improves

Ensure that population health improves

Establish a 1% withhold for timely and accurate reporting of data

Establish a quality pool

Accountability Plan Quality Strategy

State “Tests” for Quality and Access

Measurement Strategy

Quality Pool

Expenditure Review

Evaluation

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Quality Strategy

Quality Assurance

•On‐site reviews

•Quarterly and annual financial reporting

•Complaints and G/A reports

•FWA reports

Quality Improvement

•7 quality improvement focus areas for CCOs

•Contractual requirements

•Transparency

•Financial incentives

State “Test” for Quality and

Access

Annual assessment of statewide performance on 33 metrics in 7 areas:

–Behavioral and physical health coordination

–Perinatal and maternity care

–Reducing preventable re‐hospitalizations

–Ensuring appropriate care is delivered in appropriate settings

–Primary care for all populations

–Reducing preventable and unnecessarily costly utilization by super users

–Discrete health issues (such as asthma, diabetes, hypertension)

Measurement Strategy

Five important sets of metrics:

1. Core performance metrics

2. Metrics and Scoring Committee: Quality Pool Metrics

3. Child Health Insurance Program (CHIP) Core Set

4. Medicaid Adult Core

5. Set Seriously and persistently mentally ill special focus

CMS requirements:

-Quality and Access Measures for Quality Pool

-Transparency: Core measures and Quality Pool measures will be posted on OHA website by CCO

Expenditure Trend Review

2 %age point reduction will be evaluated based on expenditures for:

-All services provided through CCOs;

-Wrap-around payments to FQHCs; and

-Incentives and shared savings payments to CCOs.

The 2 %age point reduction in per capita spending growth measured from a 5.4% annual projected trend. Per capita expenditures cannot exceed

-4.4 percent July 2013 – June 2014

-percent July 2014 – July 2015.

Introduction to CCOs:Accountability Plan

Introduction to CCOs:Quality Pool: Measuring Performance

Incentive

3% withhold of the monthly payments to CCOs, which are put into a common "quality pool."

To earn full incentive payment, CCOs must meet benchmarks or improvement targets on at least 12 of the 17 incentive measures and have at least 60 percent of their members enrolled in a patient-centered primary care home.

Committee uses public process to identify objective outcome and quality measures and benchmarks.

17 metrics in the 7 quality improvement focus areas.

Performance

Annual assessment of Oregon’s statewide performance on 33 metrics, in 7 quality improvement focus areas. Significant financial penalties to the state if quality goals are not achieved:

1. Improving behavioral and physical health coordination

2. Improving perinatal and maternity care

3. Reducing preventable re‐hospitalizations

4. Ensuring appropriate care is delivered in appropriate settings

5. Improving primary care for all populations

6. Reducing preventable and unnecessarily costly utilization by super users

7. Addressing discrete health issues (such as asthma, diabetes, hypertension)

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CCOs are continuing to hold down costs and improve quality. Oregon has stayed within the budget to reduce the growth in spending by 2 percentage points per member, per year.

All CCOs show improvement in some number of measures and 13 out of 16 CCOs earned 100% of their quality pool payments in 2014.

Decreased ED visits. ED visit have decreased 22% since 2011 baseline data.

Decreased hospital admissions for short-term complications

from diabetes. The rate of adult members (ages 18 and older) with diabetes who had a hospital stay because of a short-term problem from their disease dropped by 26.9% since 2011 baseline data.

Decreased rate of hospital admissions

for chronic obstructive

pulmonary disease.

The rate of adult members (ages 40 and older) who had a hospital stay because of chronic obstructive pulmonary disease or asthma decreased by 60% since 2011 baseline data.

Patient-centered primary care home

(PCPCH) enrollment continues to increase. Proportion of members enrolled in a PCPCH has increased 56% since 2011. Additionally, primary care costs continue to increase, which means more health care services are happening within primary care.

Strong improvement to the Screening,

Brief Intervention, and Referral to

Treatment (SBIRT) measure.

Measures the percentage of adult patients (ages 18 and older) who had appropriate screening and intervention for alcohol or other substance abuse. Two CCOs have exceeded the benchmark, a great accomplishment given the statewide baseline of almost zero.

Introduction to CCOs:Early Results

Introduction to CCOs:Early Results

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Introduction to CCOs:What has it meant for DCOs?

Agency Simplification Dental Plan Fragmentation

MCOs

Prior to 2012

CCOs

2012-current

CCOsDCOsDCOs


December 2013~660,000

Estimated ACA Growth

260,000

Jan 1, 20151,028,263

July 2015

1,078,900

Approx. 960,000 through CCOs

August 2012 CCO Go-Live

July 2013 Dental to CCO Integration

commences

July 2014Dental to CCO

Integration concludes

Jan 1, 2014Medicaid Expansion

Actual growth since Jan 1, 2014

419,800

Paving the road while driving on it. Dental plans have contended with both a revolution and an evolution due to the convergence of dental integration and ACA Medicaid Expansion.

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Prior to CCO integration:

Direct Contractor PAHP

Post CCO Integration:

Subcontractor to MCO

CCO Quality Pool

Emphasis on medical and behavioral health

Number of measures in pool is preset and size constraints

Cost/Benefit of additional dental measures in limited pool

No industry standards

Risk Based Subcontractors

From PAHP to MCO

Lack of Delegation Oversight monitoring tools for CCOs

No standardization across CCOs

Conflicts with efforts to achieve CCO MLR

Filling the Gap:

CCO Dental Measures

Two dental inclusive measures do not tell enough

No industry standards

Ad hoc creation of CCO specific measure sets

Variability for dental plans from CCO to CCO

Dental alignment with quality pool metrics

Warm Handoffs

ED Deferral Programs

Chronic Disease Management

Integration into primary care

Limited FootprintOne dental specific measure: Sealants on permanent molar One measure expanded: DHS Foster Kids assessment

Standardized Delegation Work is underway to begin the process of creating standardized delegation oversight tools

Statewide Measure SetThrough collaborative work, a measure set is under development that would represent an “off the shelf” product for CCOs

Evolution not RevolutionEfforts are underway to align dental with ongoing work related to quality pool measures and general integration and coordination.


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Competitive Landscape

• New Entrants • Consolidation of CCOs• Active Purchaser for dental

Programmatic (Operational) Changes

• New metrics• Additional withholds• 2017-19 budget deficit due to federal match drop - Uncertainty for adult dental?• Basic Health Plan through CCOs• 12-months continuous eligibility

Regulatory

• Managed Care Rules – PAHP to MCO• Managed Care Rules – MLR• Managed Care Rules – Grievance and Appeal process• Managed Care Rules – Network Adequacy

Introduction to CCOs:What may the future hold?

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