transforming access into outcomes · transforming access into outcomes chris clark, executive...
TRANSCRIPT
10/29/2015
1
Transforming Access into Outcomes
Chris Clark, Executive Director
Why build a State‐Based Exchange?
• Kentucky Ranks at the Bottom in Health Outcomes.Kentucky continues to rank at the bottom in most national health rankings. This includes 50th in smoking, 40th in obesity, 43rd in sedentary lifestyles, 41st in diabetes, 48th in poor mental health days, 49th in poor physical health days, 50th in cancer deaths, 49th in cardiac heart disease, 43rd in high cholesterol, 44th in annual dental visits and 48th in heart attacks.
• Access to health insurance will improve health outcomes
Opportunity
• Unique
• Important
• Visible
• Polarized
• Evolving
• Constrained
Information
Enacted
Interpreted
Evolved
Revolved
10/29/2015
2
Visible
Opportunity
• Unique
• Important
• Visible
• Polarized
• Evolving
• Constrained
Information
Enacted
Interpreted
Evolved
Revolved
Percentage of Uninsured by County 2012
10/29/2015
3
Percentage of Uninsured by County April 15, 2014
8
Impact…
Adults
Elderly & Persons with Disabilities
Parents
PregnantWomen
Children
Extends to Adults ≤138% FPL*
Medicaid Eligibility Historically Medicaid Eligibility Beginning in 2014Limited to Specific Low‐Income Groups
Extends to Adults ≤138% FPL*
*138% FPL = $16,243 for an individual and $33,465 for a family of 4
9
Changing Demographics
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
1 5 9
13
17
21
25
29
33
37
41
45
49
53
57
61
65
69
73
77
81
85
89
93
97
101
105
109
Member Age DistributionExpansion vs. Traditional Medicaid
Traditional Medicaid
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96 100104
Member Recipients Age DistributionExpansion vs. Traditional Medicaid
Expansion Traditional Medicaid
1,279,398Total
Medicaid Members400,427Expansion
10/29/2015
4
How Did We Get Here?KENTUCKY
RANKPOOR MENTAL HEALTH DAYS 50
CANCER DEATHS 50
PREVENTABLE HOSPITALIZATIONS 50CHILDREN IN POVERTY 50
SMOKING 49DRUG DEATHS 48
POOR PHYSICAL HEALTH DAYS 47
OBESITY IN ADULTS 46
UNDEREMPLOYMENT RATE 45PREMATURE DEATH/100,000 44
CARDIOVASCULAR DEATHS/100,000 43PHYSICAL INACTIVITY 42
LOW BIRTHWEIGHT 38DIABETES IN ADULTS 33
LACK OF HEALTH INSURANCE 28
HIGH SCHOOL GRADUATION 22
47th
America’s Health Rankings
2014
Why build a State‐Based Exchange?
12
“HEALTH is a state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity.”
Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June, 1946
WHO, 1946
Definition
10/29/2015
5
Better Care for Individuals
Better Health for Populations
FinancialStewardship
National Quality Strategy
TripleAim
WHAT
14
Key Challenges in US Health Care System
Source: Sam Nussbaum, MD, “Advancing Health Care Quality, Access, and Affordability Through Innovation”
20%OF GDP BY 2021
$700BWASTE ACROSS U.S. SYSTEM
2XCOST PER CAPITA VERSUS
OECD NATIONS
45%CARE INCONSISTENT WITH
RECOMMENDED GUIDELINES
$210BUNNECCESARY SERVICES
3XVARIATION IN HOSPITAL DAYS IN LAST 6 MONTHS OF LIFE
19.6%MEDICARE HOSPITAL
READMISSIONS
$45BANNUAL COSTS FOR
AVOIDABLE COMPLICATIONS
$91BREDUNDANT
ADMINISTRATIVE PRACTICES
Governor Says:
“Let’s Accomplish
before the end of this decade (2019)!”
Goals
Reduce Kentucky’s rate of uninsured individuals to less than 5%
Reduce Kentucky’s smoking rate by 10%
Reduce the rate of obesity among Kentuckians by 10%
Reduce Kentucky cancer deaths by 10%Reduce cardiovascular deaths by 10%Reduce the % of children with untreated dental decay and increase adult dental visits by 10%
Reduce deaths from drug overdose by 25% and reduce the average number of poor mental health days of Kentuckians
Governor’s Health Initiative
10/29/2015
6
16
Overview of Selected Preventive ServicesRelative Increases in number of Medicaid screenings
Pre‐Expansion (2013) vs. Post‐Expansion (2014)
0%20%40%60%80%100%120%140%160%180%200%
Smoking
Obesity-Metabolic
CancerCardio-vascular
DentalMH
Drug & Alcohol
OverallExams
*Based Medicaid Claims Data
17
Adult Tobacco Counseling
2013
2014
2013 2014
406
1,094
Tobacco Use Counseling & Interventions
688More Received
Preventive Services
*Based Medicaid Claims Data
18
Adult Diabetes Screening
2013
2014
2013 2014
784
1,214
Adult Diabetes Screening
430More Received
Preventive Services
*Based Medicaid Claims Data
10/29/2015
7
19
Gestational Diabetes Screening
2013
2014
2013 2014
3,313
3,751
Gestational Diabetes Screening in Pregnancy
438More Received
Preventive Services
*Based Medicaid Claims Data
20
Cancer Screening
Breast CancerScreening
Colorectal CancerScreening
Cervical CancerScreening
Prostate CancerScreening
110% 108%
88%
51%
Relative Increases in number of Medicaid screenings of selected Cancers
Pre‐Expansion (2013) vs. Post‐Expansion (2014)
*Based Medicaid Claims Data
21
Breast Cancer Screening
2013
2014
2013 2014
24,386
51,292
Breast Cancer Screening
26,906More Received
Preventive Services
*Based Medicaid Claims Data
10/29/2015
8
22
Colorectal Cancer Screening
2013
2014
2013 2014
17,164
35,633
Colorectal Cancer Screening
18,469More Received
Preventive Services
*Based Medicaid Claims Data
23
Cervical Cancer Screening
2013
2014
2013 2014
41,613
78,281
Cervical Cancer Screening
36,668More Received
Preventive Services
*Based Medicaid Claims Data
24
Adult LDL‐Cholesterol Screening
2013
2014
2013 2014
80,769
170,514
LDL-Cholesterol Screening
89,745More Received
Preventive Services
*Based Medicaid Claims Data
10/29/2015
9
25
Adult Preventive Dental Visits
2013
2014
2013 2014
73,739
159,739
Preventive Dental Services
85,779More Received
Preventive Services
26
Adults With Alcohol Screening or Counseling
2013
2014
2013 2014
597
1,205
Alcohol Misuse Screening & Counseling
608More Received
Preventive Services
*Based Medicaid Claims Data
27
Annual Wellness Exam
2013
2014
2013 2014
22,290
63,888
Annual Wellness/Physical Exams
41,598More Received
Preventive Services
*Based Medicaid Claims Data
10/29/2015
10
SIM Program OverviewThe Centers for Medicare & Medicaid Services (CMS) State Innovation Model
(SIM) initiative is focused on testing the ability of state governments to use available levers to accelerate health transformation.
Current Future• Uncoordinated, fragmented delivery systems with highly variable quality
• Unsupportive of patients and physicians
• Unsustainable costs rising at twice the inflation rate
• Affordable
• Accessible to care and to information
• Seamless and coordinated
• High‐quality – timely, equitable, and safe
• Person‐ and family‐centered
• Supportive of clinicians
• Provides financial and technical support to states for developing and testing state‐led, multi‐payer health care payment and service delivery models that will impact all residents
• The overall goals of the SIM initiative:
− Establish public and private collaboration with multi‐payer and multi‐stakeholder engagement
− Improve population health
− Transform health care payment and delivery systems
− Decrease total per capita health care spending
Improve health system performance
Improve health system performance
Increase quality of careIncrease quality of care Decrease costsDecrease costsImprove health system
performanceIncrease quality of care Decrease costs
CMS’ Triple Aim Strategy
Source: CMS SIM Round Two Funding Opportunity Announcement Webinar
• Nearly $300 million was awarded to 25 states in December 2012 to design or test innovative health care payment and service delivery models during Round 1 of the SIM initiative.
• Awardee Breakdown
−Model Design Awards: 16
−Model Pre‐Testing Awards: 3
−Model Testing Awards: 6
Round 1 SIM Grant Recipients
• CMMI added more parameters in Round 2 that better correlate with successful statewide health transformation. It also selected Model Test/Model Design applications based on their potential to impact the health of the entire state population.
• In December 2014, more than $660 million was provided to 32 awardees (28 states, three territories, and the District of Columbia) for Round 2.
• Awardee Breakdown:
−Model Design Awards: 21
−Model Testing Awards: 11
Round 2 SIM Grant Recipients
Current Landscape of the SIM ProgramThe Center for Medicare & Medicaid Innovation (CMMI) within CMS awarded states cooperative agreements in two rounds to design and implement strategies for service delivery and payment reform.
Roles State Government May Play in Health Care
State governments play many overlapping roles in influencing the health and delivery of health care services for their population.
Convener
Regulator
Provider
Promoter of Wellness
& Public Health
Purchaser/
Payer
Promoter of Economic
Development
Federal Program
Administrator
10/29/2015
11
Tools in the Toolkit
Care Management
& Coordination
Value‐BasedModels:
PCMHACO
BP/EOC
Community
Partnerships
Advanced
Analytics
ProviderEngagement
& Education
Quality
Strategy &
Alignment
PatientEngagement
& Education
Transition of Care
Strategies
PopulationHealth
Strategies
Effective
Messaging
Clinical Pharmacy
Engagement
Evidence Based
Guidelines
Tele‐Health
&
mHealth
PatientRegistries
EHR&HIE
Components of a SIM Model DesignState Health System Innovation Plan = “Model Design” is the final deliverable for a SIM grant.
State Health System Innovation Plan
(SHSIP)
Health care delivery system
transformation plan
Payment and/or service delivery model
Plan for leveraging regulatory authority
Health Information Technology (HIT)
plan
Stakeholder engagement
plan
Quality measure alignment
Monitoring and evaluation plan
Alignment with state and federal
innovation
Components of a successful Model Design
PHIP Harmonized With kyhealthnow Kentucky will build upon existing health initiatives within the Commonwealth and at a national level in
development of an integrated, comprehensive Population Health Improvement Plan (PHIP).
Drug Overdose/Poor
Mental Health Days
Cancer Oral Health
Obesity
DiabetesTobacco
Cardiovascular Disease
CMS/CDC Required Focus Areas
10/29/2015
12
Kentucky’s Vision of APCD
The Health Data Trust
The vision of the Kentucky Health Data Trust is to improve the HEALTH of Kentucky’s children, families, and
workforce by providing complete and transparent information about health care
utilization and outcomes
WHY ‐ KY Health Data Trust
• The 2014 Foundation for a Healthy Kentucky meeting on Transparency in Health Care concluded that Kentucky should develop and establish an All Payer Claims Database
• Key Recommendations:
A “Public Utility” model to support policymakers, consumers, providers, payers and researchers
Mandated reporting from public and private payers
Consumer engagement and education
Sustainability, data integrity and security
APCD Definition
APCDs are a systematic collection of data from payer sources, providers, and any available disparate source…linked at individual level
APCDs provide information about the cost, effectiveness, performance, and outcomes of health at an individualpatient and population levels
All Payer Claims Databases (APCDs) support Value‐Based Health Care where individuals & organizations can make informed decisions
10/29/2015
13
What's Happening Nationally
Source: www.apcdcouncil.org/state/map
19 states active, 21 planning
Providers
MCO
Behavioral
Health
Consultants
Advisors
Care
Coordinator
Community
Agencies
Lab
Health
Department
Pharmacist
Dietician
HOW
Citizen PortalProvider Portal
EMRWorker’s Portal
External Partner
External Partner
Enterprise Service Bus* Notification Service * Security Framework * Rules Engine * Document Mgmt. *
*Master Data Mgmt. * Data/Fraud Analytics *Kentucky Enterprise Framework
KENTUCKY CITIZEN INFORMATION
M
E
M
S
K
H
B
E
S
U
P
P
O
R
T
P
R
O
G
R
A
M
S
P
U
B
L
I
C
H
E
A
L
T
H
K
H
I
E
Kentucky CHFS’ Vision: Be Data Driven AND Achieve Real Measurable Outcomes
10/29/2015
14
Collaboration with the University of Kentucky
• CHFS engaged UK to begin the planning and design of the Kentucky Health Data Trust
–Leverage current relationships and ongoing research activity across the University
–Utilized Freedman Healthcare as consultants
WHO
Planning and Design Process
Stakeholder Engagement
Gather internal & external stakeholders’ input/concerns
Data Governance Planning
Determine an effective & efficient data governance structure
System Design Assessment
Identify the best KyHDT system design
Critical Requirements & Sustainability
Plan what is needed to drive the KyHDT project forward
HOW
Stakeholder Engagement
10/29/2015
15
Stakeholder Interviews
Internal Stakeholders (28)
DMS, DPH, OHP, DBHDID, OHBHIE, KHIE, DOI, DEI, COT, OET, OATS, OIG, DEHP
External Stakeholders (29)
Hospitals and providers, private insurers (Medical Directors), business and consumer advocates, researchers
Stakeholder Findings: Benefits
Public health surveillance
Quality of care improvement
Health outcomes measurement
Comparisons and trend analyses across populations & providers
Increased transparency of quality and cost
Consumer decision‐making
Stakeholder Findings: Key Priorities
• Protect privacy and PHI
• Data Security must be Robust
• Secure a Sustainable Funding Source
• Data quality is key for ensuring user confidence and adoption of the KyHDT
10/29/2015
16
Stakeholder Findings: Approach
• Phase In – Start small and grow incrementally
• Mandatory data submission model may be more successful
• Governance – Public‐private collaboration, with representation from all key stakeholders
• Data Presentation/Visualization is important for engaging stakeholders to use the data trust
System Design
Build on current expertise and infrastructure at UK and CHFS
CHFS serves as Honest Brokers Intake of Identified information to validate submissions,
generate master data, de‐identify Honest Broker model creates “TRUST” in access to data
UK Team uses encrypted, de‐identified Information following established methodology All HIPAA fields will be encrypted, shifted, and reported
at minimum identifiable levels
Kentucky Health Data Trust
JAN MAR JAN‐JUN
JAN‐JUN JUL‐DEC JUL‐DEC
OCT
OCT‐DEC
System Data Submission Website Phase III Data Intake Prototype Guide Release Deployment Validation
Database Phase I Phase II Phase IV Build/Deployment Data Intake Data Intake Data Intake
Validation Validation Validation
2015 2016 2017
Development TimelinePhase IMedicaid, DBHDID, Vitals, KASPER
Phase IIMedicare, KEHP, Public
Universities
Phase IIIHBE Members, KHIE Clinical Integration
Phase IVCommercial Carriers & Self‐Insured Plans
Legal, Governance, and Technical Planning
10/29/2015
17
Use Case Driven Design
• Kyhealthnow: population health improvement– Impact of access, obesity, substance use and abuse, cancer, cardiovascular, dental care
• Value based payments: efficient and effective care– Comparative effectiveness outcomes by payers, demographics, providers
• Transparency: supports patients and employers evaluating benefit choices and quality of care
Examples
Use Case Driven Design
KY has 2nd Highest Overdose Death Rate Over 1,000 Deaths/Year Driven by High Use of Prescription Opioids
Analysis of Prescription Drug Monitoring Program (KASPER) Data Linked to Payers & Providers to Identify High Risk Patients, Providers, and Evaluate Policy Decisions
Kyhealthnow Benchmarking
Current Data and Reporting
10/29/2015
18
Top Controlled Drugs
Oxycodone Prescribing
ResourcesState Innovation Model (SIM)
http://chfs.ky.gov/ohp/sim/
kyhealthnow
http://governor.ky.gov/healthierky/kyhealthnow/pages/default.aspx
Medicaid Expansion Dashboard
https://tableaui.deloitte.com/views/Dashboard02102015_v9/Cover?:embed=y