primary care in the new normal part 2: managing the full

Primary Care in the New NormalPart 2: Managing the Full Continuum of Care Under a Total Cost of Care APM

Ohio Association of Community Health CentersDate

ZOOM GUIDELINES

▪ All participants aside from our panelists are muted

▪ A recording of this session will be made available to all registrants after the meeting has ended

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• To share with fellow attendees, please change your chat recipients to “All panelists and attendees”

3

OBJECTIVES

1. Assure recognition of the national nomenclature that categorizes alternative payment models.

2. Increase appreciation for how different categories of alternative payment models can be synergistic.

3. Foster the development of clinical and care management models of care that improve patient experience, patient outcomes and reduce low-value health care utilization and cost.

4. Enhance a vision of Ohio CHCs working together to successfully pursue value-based payment

4

SHARED STAKEHOLDER THINKING

Improve health care access

Focus on population health, high value

care, and improving patient outcomes

Increase provider satisfaction and

strengthen the primary care workforce

Incent innovative team-based care

models

Reduce potentially avoidable inpatient and ED utilization

Expense neutrality for payers, revenue enhancement for primary care providers

For Public Release

The framework situates existing and potential APMs into a series of categories.

APM Framework Nomenclature

5

For Public Release

CMS and State Payment Improvement Initiatives

Delivery System Transformation

Payment System Transformation

Payment Reform without Practice

Transformation doesn’t

change outcomes.

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CHOOSING A PAYMENT STRATEGY THAT UNDERWRITES BETTER

PATIENT OUTCOMES

A Bigger Piece of the Cake (Market Share)

Preserving Revenue• Fee-for-

service PPS or Capitated APM

Icing on the Cake• CM fee • PCMH• P4P • Shared

savings• Partial

capitation for non-PCP services

9

NEW THINKING: PERHAPS THE STEPS ARE OUT OF ORDER

Copyright © 2020 Health Management Associates, Inc. All rights reserved. PROPRIETARY and CONFIDENTIAL

Prov

ider

Fin

anci

al R

isk

Provider Integration and Accountability

Fee For Service

Incentive Payments

Pay for Performance

(P4P)

Bundled/Episodic

PaymentsUpside Shared Savings

Two Way Shared Savings

Partial Capitation

Full Capitation

Cat 2: FFS w/ payment linked to quality and

value

Retrospective Payments

Provider at Risk

Prospective Payments

Cat 3: APM built on FFS Cat 4: Population-based payments

Cat 1: FFS w/ no link to quality

Cost-based Contract

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THE QUESTIONS FQHCs ARE ASKING

Can’t I just keep living on the first floor (or go back to the basement)?

Can I wait for the elevator?

How badly can I get hurt if I fall climbing the stairs?

Is this the only set of stairs and if so, can I skip some steps?

Do I really have to make it to the top?

Does the railing go to the top?

Should I hold someone’s hand on the way up and if so, who’s?

11Medical Home Network | ©2020 All Rights Reserved | Proprietary & Confidential

Medical Home Network ACO: Enhancing Patient Care, Driving Value & Improving Outcomes

Enables members to drive cultural transformation & advance an integrated, practice-level model of care

Medical Home Sites

hospitals

566

183Care Managers

136k

PCPs

117

patients

6

MHN ACO, LLC established in 2014

• 11 FQHCs

• 3 Hospital systems

• Wholly provider-owned entity

• Unique egalitarian governance model

• Delegated for Care Management

• At Risk for Total Cost of Care

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LAN CATEGORY 2A: THE HEALTH HOME PROGRAM

Required CM Services

Comprehensive care management

Care coordination

Health promotion

Comprehensive transitional care

Individual and family support

Referral to community and support services

Payment is for 6 components of “health home” care coordination services and NOT direct treatment

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Medical Home Network:

The Impact of Delegating Care Management to Practices

Medical Home Network | ©2020 All Rights Reserved | Proprietary & Confidential

LAN CATEGORY 2A: DELEGATED, NCQA CERTIFIED CARE MANAGEMENT

Reassessment

Identify & Stratify

Engage & Connect

Moderate & High Risk

Plan & Support

Follow Up & Reassess

Risk

Transition to

Low-Risk Reevaluation

in Response to

Triggers

Health Risk

Assessment

(HRA)

Care Plan

Comprehensiv

e Risk

Assessment

(CRA)

Medication

Reconciliation

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A Consistent and Accountable Model of Care

© 2020 All Rights Reserved Proprietary Confidential

Medical Home Network:

Driving Health Outcomes by Reducing Adverse Social Drivers of Health

MHN OUTCOME 37.4% reduction in total social risk factors impacting health

Source: Jones A, et al., J Community Med Public Health Care 2017, 4: 030. Evaluation criteria: Most recent HRAs for

ACO members with 12+ months continuous enrollment and minimum of 2 HRAs at least 30 days apart.

Social Risk Factor Reduction of High Risk and Medium Risk Adults in Care

Management

3,315 members, July 2014 – June 2018

Social Risk FactorInitial

HRA

Latest

HRA

%

Change

Predictive of

Future Cost

and/or

Utilization*

Total Social Factors 11,124 6,963 -37.4%

Rates overall health as Fair or Poor 2,019 1,578 -21.8% ✓

Difficulty making appointments 685 396 -42.2% ✓

Difficulty getting to appointments or filling

prescriptions

1,396 885 -36.6%✓

Untreated Depression 1,172 511 -56.4%

Untreated Drug/Alcohol Use 304 156 -48.7% ✓

Difficulty securing food, clothing, or housing 1,717 868 -49.4% ✓

Currently homeless or living in a shelter 126 68 -46.0% ✓

Difficulty paying for meds 1,000 270 -73.0% ✓

Does not feel physically or emotionally safe at

home

213 143 -32.9%

Refused Smoking Cessation program 607 226 -62.8%36


© 2020 All Rights Reserved Proprietary Confidential16

MHN uses AI to identify the rising health risk population

RISK STRATIFICATION

Whole-person care, with dynamic daily AI risk stratification

BUILDING ON A PROVEN MODEL: 37.4% reduction in total social risk factors impacting health1

Untreated depression | Difficulty securing food, clothing or housing | Difficulty paying for meds | Difficulty making appointments or filling prescriptions | Untreated drug / alcohol use | Etc.

Dynamic, daily AI health risk stratification

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Real-Time Connect Alerts & Communication

AI / Machine Learning

Warm Handoffs

Ambulatory Visits

Hospital Relation-

ships

Patient Engagement

TRANSITIONS OF CARE WORKFLOWS


The Results21% Decrease in 30-day the Readmission Rate


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19

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CARE COORDINATION WORKFORCE DEVELOPMENT

MHN GOAL: MHN wanted to support the development of a capable, professional, practice-level care coordination workforce

INTERVENTION: MHN created a care coordination certification program

THE OUTCOME: MHN’s care coordination certification program standardizes the care coordination role and equips staff to meet the demands of working with challenging populations.

EDUCATION

CLINICAL▪ Diabetes▪ Asthma▪ Heart Failure▪ COPD▪ Obesity▪ Myocardial

Infarction

BEHAVIORAL▪ Depression &

Anxiety▪ Homelessness▪ Trauma Informed

Care▪ Substance Abuse▪ Suicide

Prevention ▪ Domestic

Violence

MOTIVATIONAL INTERVIEWING▪ Techniques to engage

patients in decision-making and in their care

▪ Training to effectively work with patients on behavior change and therapy compliance

CERTIFICATION PROCESS

1. Attend MHN trainings and 10-12 education sessions2. Participation in facilitated group discussion3. Complete self-study and pass written test4. Validate competency using live simulation with patient actors


CATEGORY 2C: PAY FOR PERFORMANCE

• Choose a set of metrics that has direct financial implications for the health plan (premium withhold, member auto assignment)

• Understand the magnitude of potential financial impact on the health plan

• Agree on a manageable number of metrics

• Choose metrics that you can impact (room for improvement, access to timely information, able to impact with CM and/or clinical model)

• Agree on attribution methodology

• Gauge current performance vs. target performance

• Require at least monthly updates to a provider portal that allows identification of patients out of compliance with the metric

• Agree on a hybrid approach to measuring performance or at least a reconciliation and appeal mechanism

• Negotiate tiered payment based on improvement and attainment

• Negotiate a payment potential adequate to engage PCPs

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CATEGORY 2C: PAY FOR PERFORMANCE

✓ Start the program in year one using statewide benchmark as baseline

✓ Do not be subject to outcomes for members being transferred to the provider from other PCPs when it is too late to impact performance

✓ Do not let your payment be held hostage to total plan performance

✓ Avoid replacement of P4P as assume category 3 or 4 APMs

✓ Try not to allow P4P costs be counted as a cost in category 3 or 4 APMs when there is a separate source of revenue (i.e. premium withhold)

✓ Don’t allow plan to terminate the APM mid year

✓ Agree on detailed terms before signing a contract

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Improvement and attainment of performance targets

Attainment Goal (75th percentile) 80%

Improvement Goal over Baseline 5%

Baseline Score Performance Target

FQHC #1 40% 42%

FQHC #2 60% 61%

FQHC #3 90% 80%

APM QUALITY METRICS EXAMPLE OF PERFORMANCE TARGETS

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APM QUALITY METRICS EXAMPLE: CT PCMH+ PROGRAM

1. Maintain Quality points are awarded if a Participating Entity's (PE's) 2018 rate is greater than or equal to its 2017 rate.2. Improve Quality points are awarded for a PE's 2018 improvement trend over 2017 on a sliding scale based on the participating entities improvement trend.3. Absolute Quality points are awarded for a PE's ability to reach 2018 Absolute Quality targets.4. DNQ (Does Not Qualify) values occur when a denominator count is less than 30.

Quality Measures

Maintain

Quality

Improve

Quality

Absolute

Quality

Quality

Points

Points

Possible

Adolescent Well-Care Visits 1.0 1.0 1.0 3.0 3.0

Avoidance of Antibiotic Treatment in Adults

with Acute Bronchitis 1.0 0.0 0.0 1.0 3.0

Developmental Screening in the First Three

Years of Life 1.0 1.0 1.0 3.0 3.0

Diabetes HbA1c Screening DNQ DNQ DNQ 0.0 0.0

Emergency Department Usage 1.0 1.0 0.0 2.0 3.0

PCMH CAHPS 0.0 0.0 0.0 0.0 3.0

Prenatal Care DNQ DNQ 0.0 0.0 0.5

Postpartum Care DNQ DNQ 0.5 0.5 0.5

Well-child Visits in the First Months of Life 0.0 0.0 0.0 0.0 3.0

Total Points 9.5 19.0

Aggregate Quality Score (Total Quality Points/Total Possible Points) 50%

CATEGORY 3A: APM WITH UPSIDE GAINSHARING; DISCUSS AND AGREE ON

• Define population eligibility types for inclusion • Attribution methodology• Minimum attributed membership• Service inclusion• Accounting for cost of the care management fee and

Category 2 APM funds • Basis for the benchmark spend (percentage of

premium, historical spend)• Annual trending of the benchmark spend• Frequency of resetting the benchmark spend

25

DECISION: SERVICE ACCOUNTABILTY

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Primary Care

Provider

Specialty Care

Outpatient Hospital Care

and ED

Inpatient Hospital

Acute CarePharmacy

Long Term Acute

Hospital Care

Inpatient Rehab

Hospital Care

Skilled Nursing

Facility Care

Post Acute and LTC Bundling

Total Cost of Care Bundle

Ambulatory Care Acute Hospital Bundling

Ambulatory Care Services

▪ What bundle of services can I manage and what do I want to be accountable for now versus over time?

CATEGORY 3A: APM WITH UPSIDE GAINSHARING

• Risk adjustment methodology• Individual stop loss• Split of savings between payer

and provider• Savings corridors if any (minimal

and maximum savings ratios)• First dollar savings• Claims runout/IBNR• Quality parameters and

performance targets for accessing savings

• Impact of quality score on savings

• Multi-payer alignment

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CATEGORY 3B OR 4: RISK MITIGATION STRATEGIES

• Demonstrate ability to generate shared savings before progressing to shared risk

• Assure panel size is enough to minimize the impact of statistical variation in performance

• Negotiate a minimal loss ratio (MLR)

• Negotiate stop loss and risk corridors

• Consider clinical and financial integration with non-PCP partners

• Take risk only for services you can reasonably impact

• Build an adequate reserve pool

• Take a multi-payer approach

• Act now as if you were taking capitated risk

28

CALCULATION OF A CAPITATED FQHC APM

(PPS Rate in Baseline Year) x (# of Billable Encounters for Empaneled Medicaid Members in Baseline Year)

# of empaneled Medicaid Member Months in Baseline Year

= PER MEMBER PER MONTH APM RATE*

*Rate is inflated annually by current trend rates; broken into State and MCO portions

30

• Market share

• Geographic coverage

• Network performance across the continuum of care

• Preferential MCO relationships

• Single signature

• Willingness and ability to assume financial accountability

CREATING IPA CONTRACTING LEVERAGE

Delivery System Transformation

Payment System Transformation

Payment Reform without Practice

Transformation doesn’t

change outcomes.

3232

FRAMEWORK FOR CREATEING A SUCCESSFUL CLINICALLY

INTEGRATED NETWORK

Governance and

Committee Structure

Practice Transformatio

n and Care Management

Work Force Development

Communication &

Connectivity

Care Management

Platform, Analytics and

Reporting

Patient Engagement

Value-Based Payment

7 Key Building Blocks to Population Health and Value-based Care

© Copyright Medical Home Network 2009-2020 | All Rights Reserved | Proprietary & Confidential

Clin

ical

Co

mm

itte

e

Behavioral Health Workgroup

Transitions of Care Workgroup

ED Utilization Workgroup

Quality Workgroup

Specialty Care Workgroup

Care Management Workgroup

Complex CM Workgroup

Pharmacy Work Group

3333

Highly Engaged Clinical Committee and Workgroups


Use Of E-consult System To Meet Specialty Care Needs

34

3434

Recommendation: Explore use of an e-consult system to meet patient specialty care needs.


3535

CONNECTIVITY, DATA ANALYTICS AND TIMELY REPORTLY


Primary Care in the New NormalPart 3: A Menu of National FQHC Models and the Ohio Selection Process

Ohio Association of Community Health CentersDate

primary care in the new normal part 2: managing the full

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