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Lessons Learned: The Government Healthcare Transformation Journey

Craig Rhinehart’s BlogInsights from NASHP Conference in AtlantaTrick or Treating for State Healthcare Innovation Treatshttp://craigrhinehart.com

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Barbara Wirth, MD MSProgram Manager

National Academy for State Health Policy

The Government Healthcare Transformation Journey

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Lyn Hohmann, MD PhD MBAMedical Director

Island Peer Review OrganizationDepartment of Health

The Government Healthcare Transformation Journey

Barbara Wirth, MD, MSIBM Health and Social Programs Summit

Arlington, VA October 20, 2014

Medical Homes and Shared Resource Teams:

State Initiatives Impacting Healthcare Delivery

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NASHP27-year-old non-profit, non-partisan organization

Offices in Portland, Maine and Washington, D.C.

Academy members

Peer-selected group of state health policy leaders No dues—commitment to identify needs and

guide work

Working together across states, branches and agencies to advance, accelerate and implement workable policy solutions that address major health issues

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Where do we want to go?

Background Image by Dave Cutler, Vanderbilt Medical Center (http://www.mc.vanderbilt.edu/lens/article/?id=216&pg=999)

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Patient Centered Medical Homes

Key model features:•Multi-stakeholder partnerships•Qualification standards aligned with new payments•Practice teams•Health Information Technology•Data & feedback•Practice Education

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Graphic Source: Ed Wagner. Presentation entitled “The Patient-centered Medical Home: Care Coordination.” Available at: www.improvingchroniccare.org/downloads/care_coordination.ppt

99PCPCC 2013

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WA

OR

TX

CO

NC

LA

PA

NY

IA

VA

NE

OK

AL

MD

MT

ID

KS

MN

NHME

AZ

VT

MOCA

WY

NM

IL

WIMI

WV

SC

GA

FL

UTNV

ND

SD

AR

INOH

KY

TN

MS

DE

RI

NJ CT

MA

HI

Making medical home payments (30)

Payments based on provider qualification standards (28)

Payments based on provider qualification standards, making payments in a multi-payer initiative (18)

Participating in MAPCP Demonstration (8: ME, MI, MN, NY, NC, PA, RI, VT)★

Participating in CPC Initiative (7: AR, CO, NJ, NY, OH, OK, OR)

Medicaid PCMH Payment ActivityAK

★ ★

★

★

★

★

★

★

As of June 2014

SOURCE: National Academy for State Health Policy. “Medical Home and Patient-Centered Care.” Available at: www.nashp.org/med-home-map.

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Care Coordination Payments in Multi-Payer Medical Home Initiatives

State Initiative Per member per month range

Adjusted for Patient

Complexity or Demographic

Adjusted for Medical

Home Level

Lump Sum Payment

Financial Incentive Based on Quality

TOTAL (n=9) $1.20 - $79.05 7 3 2 6

Maine* $6.95 - $7.00 ▲

Maryland $3.51 - $11.54 ▲ ▲ ▲

Massachusetts $2.10 - $7.50 ▲ ▲ ▲

Michigan* $4.50 - $6.50 ▲ ▲

Minnesota $10.14 - $79.05 ▲

North Carolina $2.50 - $5.00 ▲ ▲

Pennsylvania $2.10 - $8.50 ▲ ▲ ▲

Rhode Island $5.00 - $6.00 ▲

Vermont $1.20 - $2.39 ▲

* Michigan: Payments to Provider Organizations; pass-through to practices that employ care coordinators. Maine: Commercial insurer PMPM rates unavailable.

Medical Homes vs. Health Homes

Medical Homes• Designed for everybody• Primary care provider-led• Primary care focus• No enhanced federal

Medicaid match

2703 Health Homes• Designed for eligible

individuals with a serious mental illness and/or specific chronic physical conditions

• Primary care provider is key, but not necessarily the lead

• Focus on linking primary care with behavioral health and long-term care

• Eight-quarter 90 percent federal Medicaid match

• Significant increase in financial support to providers

Expanding Medical Home Capacity through Multi-disciplinary Teams

Key model features:•Practice teams—often shared among practices•Payments to teams and qualified providers•Teams are based in a variety of settings •Community developed, teams vary from region to region

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Whose on the team?

• New or Expanded Roles for:• Nurses• Behavioral Health Specialists• Community Health Workers• Social Workers• Peer Specialists• Pharmacists• Health Coaches

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Shared Support Teams

RIIA

MTME

NY

AL

OK

MN

NC

MI

VT

Making Payments to Shared Support Teams

Pursuing similar models through State Innovation Model Grants

MD

ID

IL

PA

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Michigan

MaineAlabama

Shared Community Care Team SnapshotScope Payer(s) Payment Strategy Core Team Composition

Alabama: Patient Care Networks of Alabama

4 networks, 170,000 eligible patients.

Medicaid (Health Home SPA)

Networks receive $9.50 PMPM for each Health Home patient

Must include clinical director or medical director, clinical pharmacist, chronic care clinical champion (nurse), care managers (nurse or social worker)

Maine: Community Care Teams

10 care teams,130,000 eligible patients.

Medicaid (Health Home SPA), Medicare, private plans, some self-insured employers including state employees.

Teams receive $129.50 PMPM for Medicaid Health Homes; $2.95 Medicaid non Health Home; $2.95 PMPM for Medicare; $0.30 PMPM for privately insured.

Must include part-time clinical leader; team composition based on each entity’s care management strategy

Vermont: Community Health Teams

14 teams; 514,000 eligible patients.

Medicaid, Medicare, private plans, some self-insured.

Teams receive $350,000 for 5 FTE team; costs divided proportionately among payers

Staffing structures are flexible; most include nurse care managers, behavioral health specialists/social workers, health coaches, panel managers, and tobacco cessation counselors

New York: Adirondack Region Medical Home Pilot Pods

3 pods, 106,000 eligible patients.

Medicaid, Medicare, private plans, some self-insured employers including state employees.

Pods receive $7 PMPM payment to providers who contract with pods for support services. Average payment to pod approximately $3.50 PMPM.

No specific staffing requirements; structures vary across pods.

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Patient Care Networks of Alabama

• Four new 501(c)(3) organizations• Support Patient 1st Medicaid providers • Focus on high risk, high acuity patients• Providers who partner with networks receive

$1.60 - $2.10 PMPM + $1 PMPM from Patient 1st • Total PMPM rate for Patient 1st patients in

network areas decreased by 7.7% vs. 0.6% for the rest of the state, after 1st 6 months  • 3 network areas had a 15% decrease in their ER Use vs. non-

network areas that had a 2 % during same time (http://medicaid.alabama.gov/news_detail.aspx?ID=6608)

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Maine Community Care Teams

• Multi-payer support: PMPM varies by payer• Community care teams based in wide variety of

organizations• Support providers meeting “NCQA Plus”

including:• Behavioral health integration• Population risk-stratification and management• Team-based care• Connection to community resources

• Focus on High Costs utilizers aka “Super Utilizers”

• No outcome data available

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Vermont Blueprint for Health: Community Health Teams

• Statewide, multi-payer support • Provider reimbursement tied to NCQA PCMH

recognition and CHTs help practices meet NCQA PCMH recognition

• CHTs focus on public health helping patients engage in preventive services and adopt healthier lifestyles

• Specialized care coordinators added to teams to care for elderly patients and substance abusers added

• 2013 Vermont Annual Report found that people cared for in PCMH + CHT setting had favorable outcomes vs. comparison groups including reductions in annual expenditures, more than offsetting payer investments in PCMHs and CHTs

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Adirondacks Regional Pods

• Three “pods” in upstate NY supported by a central entity (Adirondack Health Institute) • Regional, Multi-payer support

• Workforce shortages was primary reason for development of PCMH initiative

• Support affiliated practices and smaller independent practices in region

• PMPM reimbursement passed through by providers• From 2006 to 2007 the region lost 24 PCPs. Since the

pilot began, primary care has stabilized and grown; total costs of care has been trending downward for commercial payers and Medicaid (http://www.adkmedicalhome.org/wp-content/uploads/2013/10/Dennis-Weaver-Medical-Home-Summit-Presentation.pdf)

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Key Takeaways

• Team-based care is a key feature of a medical home• Meeting medical home criteria, including team-based

care, is hard work for practices—particularly small & rural practices

• Shared community-based support teams offer providers of all types the opportunity to participate in value-based health care delivery models

• Community-based teams can extend their reach by leveraging social, public health and other services

• Community based teams provide infrastructure for ACOs

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Please visit:• www.nashp.org• www. nashp.org

/med-home-map• www.nashp.org

/state-accountable-care-activity-map

• www.statereforum.org

Contact:bwirth@nashp.org

For More Information

Transforming The Medicaid Health care system In New York State

Lyn Karig Hohmann, MD, PhD, MBA (IPRO)Division of program Management and Development

Office of health Insurance ProgramsNYS Department Of Health

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o In 2010 Medicaid reform was not on the agenda.

o Program was stuck in neutral, reform derailed by a harsh political climate and a deep recession.

o In 2011, Governor Cuomo changed the game by creating the Medicaid Redesign Team (MRT).

o The MRT developed a multi-year action plan – we are still implementing that plan today.

Where We Were:

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Cost Control: Reduced Medicaid’s annual spending growth rate from 13% to less than 1%.

Global Spending Cap: Introduced fiscal discipline to an out of control government program; focus on transparency with monthly report on spending.

Care Management for All: Expanded existing and created new models of improved primary/coordinated care that will both improve outcomes and lower costs, moving Medicaid members from fee-for-service to managed care.

PCMH and Health Homes: Investments in high-quality primary care and care coordination through major MRT reforms such as Patient Centered Medical Homes and the creation of Health Homes.

Major MRT Reforms Implemented

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At its core, MRT was about trying to ensure that the Medicaid program was financially sustainable.

After years of out of control cost growth the state budget was no longer able to afford Medicaid driven budget problems.

MRT and its approach to cost containment was to launch many initiatives simultaneously with the goal being to both generate immediate cost savings while also launching multiple systemic reforms designed to generate future cost savings.

To date, the MRT fiscal impact has been staggering – billions of dollars have been saved.

Where We Have Been: Fiscal Impact of MRT

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Total Medicaid Spending Over Time (SFY 03-13)

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NYS Statewide Total Medicaid Spending (CY2003-2013)

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

# of Recipients

4,267,573

4,594,667

4,733,617

4,730,167

4,622,782

4,657,242

4,911,408

5,212,444

5,398,722

5,598,237

5,792,568

Cost per Recipient

$8,469 $8,472 $8,620 $8,607 $9,113 $9,499 $9,574 $9,443 $9,257 $8,884 $8,504

*Projected Spending Absent MRT Initiatives was derived by using the average annual growth rate between 2003 and 2010 of 4.28%.

Calendar Year

2011 MRT Actions

Implemented

Projected Spending

Absent MRT

Initiatives *

Excluded from the 2013 total Medicaid spending estimate is approximately $5 billion in "off-line spending (DSH, etc.)

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NYS Statewide Total Medicaid Spending per Recipient

(CY2003-2013)

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

# of Recipients

4,267,573

4,594,667

4,733,617

4,730,167

4,622,782

4,657,242

4,911,408

5,212,444

5,398,722

5,598,237

5,792,568

Cost per Recipient

$8,469 $8,472 $8,620 $8,607 $9,113 $9,499 $9,574 $9,443 $9,257 $8,884 $8,504

Calendar Year

2011 MRT Actions

Implemented

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MRT: Development of Health Homes

Care management for high cost, high risk Medicaid Members

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NYS Medicaid Health HOmes• New Medicaid program from the ACA• Care management model that supports coordination of care across medical,

behavioral health and social needs. • Health Home services include:

comprehensive care management, health promotion; transitional care including appropriate follow-up from inpatient to other

settings, patient and family support, referral to community and social support services, use of health information technology to link services.

• New York State's Health Home eligibility definition is as follows:Two (2) chronic conditions; or One (1) single qualifying condition (HIV/AIDS or SMI)

• State has specific metrics to measure the impact of Health Homes

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NOTE: Health information technology is a key component of Health homes!

• New York State has invested heavily in HIT infrastructure through development of RHIOs with HIEs, partnership with NYeHealth Collaborative with the SHIN-NY, and support of electronic medical records within the Patient Centered Medical Home projects.

• Health Homes were required to implement electronic clinical care management records exchangeable with down stream care management agencies and to connect with the local RHIO’s HIE for exchange of medical/clinical information.

BUT: Connectivity to the NYS DOH through the Health Home portal on the NYS Health Commerce System was generally by file transfer, not real time, and not user friendly. The limitations forced policy, rather than responding to policy. New York Department of Health needed a connectivity solution to meet the

growing needs of the Health Home Program….

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The DOH with its partner agencies - OHITT, OMH, OASAS, AI and several Health Homes and MCOs - participated in a series of end-user innovation workshops to develop key IT concepts and capabilities for the Health Home program, from which came the Health Homes Analytics Platform (the Portal).

These Health Home workshops focused on defining use cases and supporting workflows. The use cases were the basis for the Health Home system and portal concepts and capabilities.

Building the concept ….

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Identification … Assignment … Outreach …

Consent …

Referral …

Care Planning … Care Coordination …

Performance Mgmt ...

NY Health Homes Use NY Health Homes Use CasesCases

Conceptual Solution Architecture

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The Department decided to build a flexible and scalable architecture with robust data, analytics, and care management capabilities.

The goal was to deliver a solution which supports interoperability across systems, users and business functions – allowing for the collection, use and sharing of information critical to the processing, monitoring, and coordinated care of the program.

Based on assessment of best in class, the decision was made to built using Cúram Software on the Medicaid Data Warehouse and linked with Salient for analytic capability.

Within the portal will be an optional Care Management Lite component, similar to RHIOs that provide a portal to access EMRs.

90:10 Federal funding has been approved through the APD process.

Initial goal was to use this capability for Health Homes now and other state care management programs over time.

Building the concept….

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Medicaid Data Warehouse

InformationSources HH-PF

HH-MR HH-CI

Health Homes Portal Facility

sync

Health HomesMaster Records

Health HomesCare Intelligence

InformationConsumers

Health Homes Analytics Portal (HHAP)Health Homes Analytics Portal (HHAP)Conceptual Solution Architecture Capabilities

OperationalSystems(e.g., Care

Mgmt Lite)

HH-IS• Service Bus• Data Staging / Integration• Data Quality• Data Harmonization

• Portal• Security• Privacy• Audit & Logging

• Person Master• Provider Master• Relationship Mgmt• Data Stewardship

• Care Metrics• Analytics / Reporting• Predictive Models• Text Mining

• Claims & Encounters

• Provider Sources (e.g., CMART, Card Swipe)

• Criminal Justice

• Social Services

• RHIOs

• DOH• MCO• Lead HH• Downstream

Care Mgmt Provider

• Clinicians• Community• Patient /

Family• RHIOs• Care

Planning• Care

Coordin-ation

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Salient Analytics

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Health Home Analytics Portal

Then came the NYS Delivery system Reform Incentive Payment Program (DSRIP)

• DSRIP is the culmination of the MRT action plan.• DSRIP creates the opportunity to fundamentally restructure delivery to achieve

the system we need while also ensuring its long term sustainability.• The health care delivery system we have is a direct result of how we purchase

and regulated health care services. DSRIP changes that.• The NYS Waiver Amendment to the State Partnership plan has been approved

for $ 8 billion to implement changes in the NYS Medicaid delivery system.• $ 6.42 billion will be used for the DSRIP program• Other dollars will go to stabilize the safety net system, support

infrastructure development for Health Homes and be investments in long term care workforce and enhanced behavioral health services.

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NYS DSRIP Program: Key Goals

o Transformation of the health care safety net at both the system and state level.

o Reducing avoidable hospital use and improve other health and public health measures at both the system and state level.

o Ensure delivery system transformation continues beyond the waiver period through leveraging managed care payment reform.

o Near term financial support for vital safety net providers at immediate risk of closure.

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DSRIP Program Principles

Better care, less cost

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NYS DSRIP Plan: Key Components

o Key focus on reducing avoidable hospitalizations by 25% over five years.

o Statewide initiative open to large public hospital systems and a wide array of safety-net providers.

o Payments are based on performance on process and outcome milestones.

o Providers must develop projects based upon a selection of CMS approved projects from each of three domains.o Key theme is collaboration! Communities of eligible providers

are required to work together to develop DSRIP Project Plans.

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DSRIP is Performance based…..• Performing provider systems need access to information about their population in order to

understand how the system needs to change to meet these needs. • Performing provider systems need access to data to monitor how they are meeting their process

and outcome metrics. • The state needs a robust platform to exchange real time data with the Performing Provider

Systems to ensure they are acting on most current data. • The state needs a robust platform that will allow them to maximize the benefits of the robust

analytics of the Salient system that we use in conjunction with the Medicaid Data Warehouse (MDW) and to share these analytics with the Performing Provider Systems.

• The portal must have the capability for PPSs to enter either directly or through the SHIN-NY and RHIOs’ HIE platforms.

• The portal must be secure, capable of role restrictions/permissioning, be flexible and expandable.

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Medicaid Analytics Performance Portal (MAPP)

• Based on the service capability of the already in process Health Home Information Portal, the Department of Health in conjunction with various technology staff and consultants determined that this portal would be able to provide the service needs for both Health Homes and DSRIP.

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What is MAPP

o MAPP: Medicaid Analytics Performance Portal

o MAPP supports both Health Homes and DSRIP performance management technology needs

o MAPP Technology:

o Serve as retail front-end to the Medicaid Data Warehouse for PPS / Health Home community

o Robust dashboard capabilities provided by Salient

o Online tools available in portal technology to support DSRIP

o Health Homes Business and Care Management Functionality

o Data management and analytics to drive performance

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MAPP High Level Conceptual Diagram

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Role:-Insurance Risk Management -Payment Reform -Hold PPS/Other Providers Accountable-Data Analysis-Member Communication-Out of PPS Network Payments-Manage Pharmacy Benefit-Enrollment Assistance -Utilization Management for Non-PPS Providers-DISCO and Possibly FIDA/MLTCP Maintains Care Coordination

Role: -Care Management for Health Home Eligibles -Participation in Alternative Payment Systems

Role: -Be Held Accountable for Patient Outcomes and Overall Health Care Cost-Accept/Distribute Payments -Share Data -Provider Performance Data to Plans/State-Explore Ways to Improve Public Health -Capable to Accept Bundled and Risk-Based Payments

How The Pieces Fit Together: MCO, PPS & HH The DSRIP Vision: Five Years in the Future

*Mainstream, MLTC, FIDA, HARP & DISCO

Supported by the data and analyticscapabilities of MAPP.

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Subscribe to our listserv: http://www.health.ny.gov/health_care/medicaid/redesign/listserv.htm

We want to hear from you!DSRIP e-mail:

dsrip@health.ny.gov

‘Like’ the MRT on Facebook:

http://www.facebook.com/NewYorkMRT

Follow the MRT on Twitter: @NewYorkMRT

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Q&A

Craig Rhinehart

Dr. Barbara Wirth

Dr. Lynda Karig Hohmann