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.

MAKING THE MOST OF PAYMENT REFORM

WELCOMEApril 18,2014

This webinar will begin promptly at 1pm EDT

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 Hospital-Acquired 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

http://www.rand.org/pubs/technical_reports/TR841.html

Making the Most of Payment ReformPayment 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

• 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

Medicaid Policies & Payment Reforms, State Legislatures

11

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

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 State Employee Salaries and BenefitsTaxes and Revenues

Education Infrastructure Corrections/ Public Safety

29 13 13

6912

Source: NCSL survey of state legislative fiscal offices, fall 2013.

Medicaid Expansion

State Structures for Health Insurance Marketplaces/Exchanges

NCSL Data: April 1, 2014

The “New Coverage Gap”

• 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

Payment Reform: Federally Supported Opportunities

•Risk based managed care•Non-risk care management•ACOs (CCOs, RCCOs, ACEs)•Health homes• Integrated primary care and behavioral health

19

Triple Aim – Better Care, Better Outcomes, Lower Cost – Medicaid Payment and Delivery System Reforms

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

http://kff.org/medicaid/

State-Based Medical Home Initiatives

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

WI

MI

WV

SC

GA

FL

UTNV

ND

SD

AR

INOH

KY

TN

MS

DE

RI

NJ CT

MA

HI

Medical home activity (45 states and Washington, D.C.)

Making medical home payments (29 states)

Payments based on provider qualification standards (27 states)

AK

As of August 2013

Source: NASHP

http://www.nashp.org/

State Innovation Models InitiativeTypes 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.

• Privacy issues• Fraud and abuse• Market concerns (anti-trust)• Network adequacy and patient satisfaction • Do new payment methods improve value?

Legislative Concerns With Payment Reform Activities, Some Examples

Contact:Melissa Hansen

[email protected]

For More Information

http://www.ncsl.org/documents/health/PaymentRTK13.pdf

mailto:[email protected]



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.

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

[email protected]

202-331-4606

Resources

http://www.nachc.com/state-policy.cfm

mailto:[email protected]

MONICA BHAREL, MD, MPHBOSTON HEALTH CARE FOR THE

HOMELESS PROGRAM

Payment Reform: Experiences from the Field

A Framework for Preparing for Health Care Reform at your Program

Clearly defining the issueHaving data and knowing the factsUsing the data to be involved early in processUnderstanding that change is hardWorking collaborativelyBe willing to be in it for the long run

Current situation Future possibility

Volume incentives

Fragmented payment

Accountable Care

Vuln

erab

le

popu

lation

s

Accountability for defined population

Pay for value

Comprehensive and transparent care

Fragmented delivery

Inconsistent quality


Clearly defining the issueHaving data and knowing the factsUsing the dataUnderstanding that change is hardWorking collaborativelyBe 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

50

PER CAPITA PERSONAL HEALTH CARE EXPENDITURES, 2009

NOTE: District of Columbia is not included.SOURCE: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2011.

State

NATIONAL AVERAGE

https://www.cms.gov/NationalHealthExpendData/05_NationalHealthAccountsStateHealthAccountsResidence.asp

The Increasing Costs of Health Care Squeeze Out Other Public Spending Priorities

51

MASSACHUSETTS STATE BUDGET, FY2001 VS. FY2011

SOURCE: Massachusetts Budget and Policy Center Budget Browser.

STATE SPENDING (BILLIONS OF DOLLARS) FY2011FY2001

+$5.1 B(+59%)

-38% -33%

-15%

-23%

-13%

-50%

-11%

-$4.0 B(-20%)

Health Care Coverage(State Employees/GIC;

Medicaid/Health Reform)

PublicHealth

MentalHealth

Education Infrastructure/Housing

HumanServices

LocalAid

PublicSafety

http://browser.massbudget.org/

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 AJPH 2013

18

10

37

26

4

6

23

0 10 20 30 40Diabetes

Ischemic HD

HTNAsthma/COPD

Cirrhosis

HIV

Hep C

Ch

ron

ic C

on

dit

ion

Percentage

BHCHP PCC Patients versus members of the PCC Plan

Bharel et al, AJPH 2013

Diagnostic and Other Characteristics StatewideBHCHP

Patients*Number 426,768 3,998DxCG Score 1.5 3.4Both Mental Health & Substance Use 10% 51%Asthma or COPD 6% 24%Diabetes 6% 15%Hospital Discharges Per 1,000 129 859ED Visits Per Person 1.1 4.2Average Annual Cost $6,679 $20,925

*Medicaid-only BHCHP patients enrolled in the PCC plan.

Total Annual Expenditures by Expenditure Group for BHCHP Users with Medicaid in 2010

Users (N=6,493) Expenditures ($149 million)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

25.0%

1.4%

25.0%

6.5%

25.0%

18.6%

15.0%

25.5%

10.0%

48.0%

Total Annual Expenditures by Expenditure Group for BHCHP Users with Medicaid, CY 2010

90 – 100% (650 users)

75 – 90% (974 users)

50 – 75% (1,623 users)

25 – 50% (1,623 users)

Lowest 25% (1,623 users)

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.


Clearly defining the issueHaving data and knowing the factsUsing the data to be involved early in

processUnderstanding that change is hardWorking collaborativelyBe 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

2006

• Comprehensive Health Reform: shared individual and state government, responsibility for access

2007

• Despite a recession, Massachusetts succeeds at having the lowest rate of uninsured in the nation

2012

• Chapter 221 passed with focus now on cost containment while providing high quality care

2013

• One Care Program begins to coordinate care for dual eligible patients (both Medicaid and Medicare)

2014

• Primary Care Payment Reform beings to coordinate behavioral health and primary care services in a global payment to primary care practices

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

Collaborator Issue

Local community organizations

Academic medical centers

MedicaidExecutive Office of

Health and Human Services

Elected Officials

Special populationAttribution of care

issueMedical respite

needsBH integration

needs

Using the data to advocate

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

Payment Reform and Health Care for Homeless Individuals

Collaborations: who else is a stakeholder?

Neighborhood hospitals and academic medical centers

State MedicaidState Legislators/local politicians Consumer advocacy groupsOther organizations caring for special

populationsNational advocacy groupsShelter alliancesAnd more….

Mission Statement:

Photos courtesy of J O’Connell

Provide and assure access to quality health care for all homeless individuals and families in the greater Boston area.

QUESTIONS AND ANSWERS

For more informationwww.nhchc.orgwww.nachc.orgwww.ncsl.org

http://www.nhchc.org/

http://www.nachc.org/

http://www.ncsl.org/

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