SECTION i. PROJECT NARRATIVE BACKGROUND. transforming the health care delivery system in Illinois and serves as the foundation of this

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1 SECTION i. PROJECT NARRATIVE BACKGROUND The Illinois Alliance for Health Innovation Plan 1 (Innovation Plan) is a blueprint for transforming the health care delivery system in Illinois and serves as the foundation of this proposal. It is the culmination of a $2 million Model Design award from the Center for Medicare & Medicaid Innovation (CMMI). Early in 2013, Governor Pat Quinn established the Alliance for Health (Alliance), made up of health policy makers, health care providers, insurers, payers, public health professionals, unions, businesses, and community health advocates. Through unprecedented cooperation among more than 80 stakeholder organizations, the Alliance reached consensus on five objectives to achieve the Triple Aim : 1) Create comprehensive, integrated delivery systems, with payment reforms to support them; 2) Ensure they offer additional supports and services for people with specific needs; 3) Enhance public health efforts focusing on environmental and social factors that negatively affect large segments of the population; 4) Ensure an adequate workforce with the appropriate education, training and compensation; 5) Expand the State's leadership role in promoting continuous system improvement in public health and health care systems. This application is informed by the intense work over the past six months to begin implementing as many of the Innovations as possible, including the Medicaid 1115 waiver. The new Governor s Office of Health Innovation and Transformation (GOHIT) was established to manage State efforts and lead the public-private partnership needed to transform the health and health care systems recommended in the Innovation Plan pg%20WEB% pdf 1

2 Part 1: Plan for Improving Population Health The overarching goal of Illinois Plan for Improving Population Health (Plan for Pop Health) is to consider the health outcomes of the entire population and focus on reducing health disparities. This will be done by leveraging and enhancing existing State infrastructure to implement innovative approaches and further integrate population health strategies into the health care delivery system. Population health strengthens health care delivery systems by focusing on the social determinants, environmental and societal factors. Illinois legislatively mandated State Health Improvement Plan (SHIP) and its Implementation Coordination Council (SHIP ICC) will be used and informed by existing State data infrastructure. A revised State health assessment and Illinois Plan for Pop Health will be completed by January 2016, and the monitoring of CMS Core Measures and the implementation of public health strategies will be integrated into the health delivery system as proposed in the Innovation Plan. The Illinois Department of Public Health (IDPH) appoints a planning team every five years to lead a state health assessment and publish a SHIP. IDPH will lead the development of the plan in collaboration with GOHIT and the Alliance. Stakeholders on the planning team will reflect the racial, geographic and ethnic diversity of the state and will include the public and private sectors. The SHIP establishes priorities and strategies for health status and public health system improvement, with a focus on prevention. Upon completion of the SHIP, the Governor appoints an Implementation Coordination Council (Council). The Council will monitor the implementation of the Plan for Pop Health by engaging with all public health system partners to address social determinants of health. 2

3 Each of the 89 local health departments engages in a local IPLAN process, a community health assessment conducted every five years. Projects such as We Choose Health, Illinois Community Transformation Grant, demonstrated that communities across the state have broad-based coalitions to improve the health of their communities. Evidence-based approaches, both clinically and community-based, will be shared and implemented. The Plan for Pop Health will utilize the existing SHIP indicators. SHIP data includes: 1) infection data using the National Health Safety Network (NHSN); and 2) AHRQ Preventable Quality Indicators, which are analyzed to show preventable hospitalizations and ED visits for chronic diseases by hospital and community. The various population health datasets, such as the Behavioral Risk Factor Surveillance System (BRFSS), the Hospital Discharge Dataset, I-Query, and PopHealth, will be key resources for tracking performance on CMS Core Measures and for monitoring overall population health. Essential to the use of these resources will be: increasing interoperable health information technology and analytic capacity, enhancing mechanisms for efficient data sharing, and creating new population level data sets by integrating available data sources. These resources are discussed in greater detail in the Health IT and Monitoring/Evaluation sections of this proposal. These databases, and other data resources, will contribute to assessing the impact of enacting the coordinated care model statewide and among multiple payers and populations. The Plan for Pop Health will support the implementation of evidence-based clinical interventions recommended by the U.S. Preventive Services Taskforce and community interventions recommended by the Community Preventative Services Taskforce, Community Guide. 3

4 Tobacco use, diabetes, and obesity and their underlying social determinants are key drivers of poor health outcomes and rising health care costs. Performance improvement related to these three priority areas will be tracked. Team-based health care will foster redesigned workflows for patient care and referral management, better transitions of care, and increased family and patient involvement. BRFSS is an ongoing survey of Illinois adults statewide that provides information on health behaviors and preventive practices related to the leading causes of death and disability in the state. Model Test funds will be directed towards BRFSS data collection enhancements to provide timely and reliable data on the health of subpopulations. Model Test funds will also help support youth related data collection (e.g. Illinois Youth Tobacco Survey). IDPH has spearheaded development and use of PopHealth in six community health centers, and will use this tool to further electronic reporting of quality measures and real-time quality improvement activities. IDPH publishes a Hospital Report Card which includes the NQF and AHRQ Quality Measures and tracks CDC National Health Safety Network HAI data. A Public Health Data Map displays maps public health conditions of interest, like diabetes, asthma, and hypertension. IDPH will establish Regional Public Health Improvement Hubs (Regional Hubs) to assist local communities by linking to community interventions and to provide technical assistance in selecting evidence-based interventions. The Regional Hubs will include communities, providers, local health departments, health plans, local businesses and coalitions. They will encourage hospitals and health systems to collaborate on community health interventions. The Plan for 4

5 Pop Health will also ensure that Regional Hubs increase information to health care providers about availability of, and linkage to, community-based health, human, and social services. The Innovation and Transformation Resource Center (ITRC) will also be established to provide technical assistance to integrated delivery systems, Pilots, and Regional Hubs. This ensures there is access to granular population health data to monitor the success of transformation efforts related to clinical care and population health. The ITRC will work with IDPH to support community capacity development to conduct needs assessments, certifications, and monitoring and support of community-based services. Part 2: Health Care Delivery System Transformation Plan Illinois providers face a daunting number of performance measures and payment arrangements, many of which do not align across payers. This creates significant administrative burdens and impedes health system transformation. Providers do not have the resources to redesign their models of care around the incentives of an individual payer. Illinois recognizes the need to provide technical assistance to the State agencies and providers that will implement the innovations under the Model Test and the need for a centralized source for reporting, analytics and rapid cycle evaluation. To support them, GOHIT will establish the Innovation and Transformation Resource Center (ITRC) to assist providers and health plans to implement innovative techniques and best practices in models of care and technology, particularly for populations with specific needs. The ITRC will collect, validate and integrate data for advancing evidence-based care and new payment methodologies. 5

6 Shortly after taking office in 2009, Governor Pat Quinn recognized the need to transform the state s health care system, and Medicaid in particular, to focus on wellness and prevention and providing care in the most community-integrated setting possible. After settling Olmstead lawsuits in 2011, the governor signed bipartisan Medicaid reform legislation requiring that at least half of Medicaid clients be served in risk-based, coordinated care systems by To lead and direct the transformation, Governor Quinn created GOHIT through an executive order in January GOHIT has established an extensive framework for interagency collaboration, resource coordination and stakeholder engagement to advance the progress of the Innovation Plan, including the reform of Medicaid through an 1115 waiver. The graphic in the Operational Plan illustrates the leadership structure for the Innovation Plan, including the Alliance Executive Committee made up of the state agency leaders, the Steering Committee made up of leaders from 80+ stakeholder organizations, and five work groups that make recommendations on implementing the five objectives. Medicaid innovations and State group health insurance participation It is essential to understand the profound changes in Medicaid, which serves 3.1 million people, over the past three years. In 2013, Illinois elected to expand Medicaid eligibility under the Affordable Care Act. As a result, more than 400,000 new clients will enroll in the first year of expansion. Illinois expects there will be a reasonable degree of movement between Medicaid and commercial insurance purchased in the Healthcare Marketplace. Starting in 2010, Illinois Medicaid has been focused on moving clients into coordinated care. The first step was to create a pilot with traditional managed care organizations to manage the 2 6

7 care of the non-dual seniors and persons with disabilities. Unlike most states, which started their managed care programs with families and children, Illinois started with the population that was most expensive and most vulnerable to poor quality from unmanaged care. This portion of the initiative has been expanded to all the major population concentrations in the state. And, over the course of the last year, has been further expanded to include 130,000 dual-eligibles through participation in the Medicare Medicaid Aligned Incentive initiative. At the same time, the state realized that traditional MCOs did not always have expertise to deal with particularly kinds of vulnerable patients. As a result, Illinois began implementing the following programs in 2013 to accelerate the development of integrated delivery systems and reformed payment models in Medicaid: Care Coordination Entities (CCEs). CCEs are provider-driven entities that have developed models of care designed around the needs of targeted high-risk, high-need populations. Accountable Care Entities (ACEs). In August 2013, the State issued a request for proposals for ACEs to serve the Family Health Plan and/or Newly Eligible Medicaid populations. Like the CCEs, ACEs are provider-driven entities, but aimed at a larger and less targeted population. They must provide a wide range of services to enrollees, including primary and specialty care, mental health and substance use disorder treatment and long-term care. CountyCare (Cook County). This program was designed to build from the base established by the Cook County early expansion Medicaid 1115 Waiver and to leverage Cook County Health and Hospital System s (CCHHS) role as a provider, plan, and payer. Illinois State group health insurance program is another promising area for innovation. The program serves more than 360,000 enrollees, a number that is expected to remain 7

8 relatively steady through the end of 2018, the final Model Test Year. The group health insurance program is administered by the Department of Central Management Services (CMS) through contracts with six managed care health plans, three Medicare Advantage plans and one statewide self-insured medical plan administrator. CMS will participate in the current Alliance work group process to facilitate the inclusion of integrated delivery systems in the health plans available to those enrolled in the State group health insurance program. The Illinois Innovation Model Test Specific integrated delivery systems will serve as Model Test Pilots and will be identified through an application process during the pre-implementation year. They will encompass broad geographic and demographic diversity in the populations covered. In their applications, integrated delivery systems will be evaluated on both their current state of progress toward, and their ability to achieve during the Model Test period, the following characteristics: 1. Organization/Governance: Comprised of and governed by its participating providers; 2. Health homes: Primary care and behavioral health, that meet Federal criteria; 3. Integrated care model: Based on community needs assessment, broad service array; 4. Member centric: Designed to make it easier and more effective for them; 5. Cultural and linguistic competency: works cross-culturally and linguistically; 6. Connectivity: Ability to securely exchange actionable clinical data in a timely fashion; 7. Continuous quality improvement and best practice development: Contributes to and participates in data collection, aggregation, analysis and reporting from multiple sources; 8. Financial plan: costs for target population reduced to equal/exceed pilot funding; 9. Multi-payer: direct contract with the State, commercial plans and Medicare; and 8

9 10. Provider incentives: Distributes outcomes-based payments, rewards efficiency. Engaging providers in system transformation and stakeholder commitment The Alliance has a three-pronged strategy for engaging providers in the development of comprehensive integrated delivery systems and the work necessary to achieve true health system transformation: 1) Inclusion of statewide provider organizations on the Alliance Steering Committee and the recruitment of individual provider entities participating on the Alliance work groups; 2) The Pilot criteria, which calls for provider inclusion in the governance and decision-making structure of integrated delivery systems; 3) Collaboration with commercial health plans to promote the essential components of integrated delivery systems in their existing provider networks and to incentivize those provider networks to acquire the workforce, IT and operational resources necessary to become integrated delivery systems. Illinois approach for the Innovation Model Test has received five letters of intent to participate as Pilots from developing integrated delivery systems and nine letters of participation from health plans to participate in the multi-payer approach to the Model Test. These organizations will all participate in the work groups to align quality metrics for reformed payment structures across payers and expand the integrated delivery system innovations to increasing numbers of Illinois residents across multiple payers throughout the Model Test. Part 3: Payment and Service Delivery Model Illinois is particularly ripe for developing the kind of innovations proposed in the Model Test. In the last four years, Illinois Medicaid (as described in the previous section) has been deeply engaged in a bold initiative to re-engineer the overall care delivery system for its clients. The State group health insurance program has begun exploring the redesign of its plan offerings 9

10 to promote innovative delivery models. Commercial health plans have strongly indicated their commitment to core innovations that are incorporated in our Model Test. By the end of 2016, the integrated delivery networks developed through participation in the Pilots, will have begun covering Medicare enrollees and be ready to begin contracting with commercial health plans. Illinois Model is designed to ensure that patients moving between Medicaid and commercial coverage experience minimal disruptions in care and have access to the same effective, highly integrated delivery networks regardless of their health insurance coverage. Payment model and composition of Model Test Pilot Sites The payment reforms that will be utilized by the Pilots are designed to support integrated delivery systems with varying degrees of experience in system integration and accelerate their progress toward transformation, reduce administrative complexity and encourage commercial health plan participation. The Pilots are expected to use alternative payment methodologies for provider compensation to achieve the best possible health outcomes for each patient. The Pilots will have the flexibility to choose which payment methodologies they implement. The ITRC will evaluate the methodologies utilized by the Pilots for their effectiveness in achieving the Triple Aim. The ITRC also will provide technical assistance and training to support the adoption and dissemination of successful alternative payment methodologies. Tested payment reforms will include: Patient-Centered Primary Care Home (PCPCH) payments; Bundled payments, including case rates, fee-for-service (FFS) with risk-sharing, and episode payments; Risk and gain-sharing arrangements; Service agreements aligning incentives for specialty and primary care physicians; 10

11 Quality bonuses or other performance incentives; and Coverage of non-medical services. This may include bonuses for stable housing, removing allergens from the home of an asthmatic person or helping individuals with disabilities prepare for employment. The ITRC will serve as the nexus to evaluate, support and accelerate the most promising care delivery practices and payment model components to ensure that they are adopted not only by the integrated delivery systems participating as Pilots, but to all integrated delivery systems and health plans that now comprise the Alliance for Health and will increase participation in the Innovation Model throughout the course of the Model Test period. Of the anticipated six Pilots, at least two will be chosen to serve the city of Chicago in Cook County. At least one will be chosen to serve rural areas in the downstate counties. Other Pilots will serve a wide range of geographic areas and comprise a demographic profile that reflects the state as a whole. In their applications to participate as Pilots, integrated delivery systems must demonstrate the capacity to serve a minimum volume of people, adjusted to reflect population density of the geographic areas they serve. One anticipated Pilot for Cook County will serve at least 115,000 residents at the beginning of the Model Test. Other Pilots operating in Cook and the collar counties will serve at least 40,000 people and those operating in downstate counties will serve at least 20,000. Initially, Pilots are anticipated to include primarily Medicaid enrollees, and will steadily expand the number of residents they care for and expand to those covered by multiple payers beginning in Test Year 1 and steadily through the end of Test Year 3. Annual Cost and Quality Targets 11

12 Realistic measures and targets, including both quality and value metrics, will be set during the pre-implementation period for each Pilot based on the current Alliance work group process. Pilots will be required to demonstrate how they will achieve cost savings over the Test period. Quality metrics will incorporate HEDIS measures and those already established for Medicaid care coordination programs, including well-child and adolescent well-care visits, medication management for people with asthma, and frequency of prenatal care. Examples of value metrics are ambulatory care follow-ups after an emergency department visit or inpatient discharge, and inpatient psychiatric 30-day readmission rates. Through the work of the Integrated Delivery System Reform subcommittee, on which health plans and providers participate, the Model Test will align the Pilot measures and targets with commercial health plan value-based payment structures. The ITRC will monitor and report regularly on the number of people served and on progress toward cost and quality goals. This will drive the evolution of the Model into one that is serving at least half of the residents in the state by the end of the Model Test period. Part 4: Leveraging Regulatory Authority Illinois is leveraging its regulatory authority to advance the five objectives of the Innovation Plan in support of testing the Model. To promote the development of integrated delivery systems (Plan objective #1), ACEs were created by statute in 2013, (Public Act ) as a new model for Medicaid. Similarly, Public Act allows Cook County to apply to the Illinois Department of Insurance for a Health Maintenance Organization (HMO) license, to offer its CountyCare plan to a broader population than Medicaid. 12

13 In the area of workforce (Plan objective # 4), Illinois has passed legislation to improve the effectiveness and efficiency of the health care workforce. The community health worker advisory board (HB5412) will develop recommendations for the certification process of community health workers. Clinical psychologists who have met specific training requirements can now prescribe controlled substances (Public Act ). A three-year pilot program for certified nursing assistants to also become certified medication aides (SB 2958) has been created. Telehealth services can be covered by insurance as if the services were rendered onsite (SB647). Dentists, with the appropriate training, can administer the flu vaccine to individuals 18 years of age and older. (Public Act ). These laws expand the scope of practice, and allow Illinois residents in rural areas to receive better access to health care. Illinois Certificate of Need (CON) process is designed to ensure access to necessary health services. The Health Facilities and Services Review Board is in the process of determining whether alternative care models, which will streamline the CON process in order to ensure timely approvals, denials and appeals can be established, via administrative rule, and/or by legislation. The newly developed rules will address the need for services, facility size, staffing, payer mix, travel time, patient transfer, emergency care, and contractual relationships. The Illinois Department of Insurance (IDOI) ensures that health insurance plans are meeting or exceeding federal requirements for network adequacy. IDOI carefully reviews the plan design for each health plan offered through Get Covered Illinois (state-federal marketplace) to ensure that the plan design is not discriminatory toward people with certain health conditions. In the second open enrollment period, Illinois residents will have 504 plans 13

14 to choose from the Marketplace, which provides a competitive combination of value, quality and choice. Illinois has also adopted new maximum out-of-pocket rules. Part 5: Health Information Technology Plan Illinois has invested significant resources in health information technology as a powerful strategy to achieve the Triple Aim. The Innovation Plan leverages these initial investments to accelerate the adoption of health IT among a wide range of health providers and incentivize them to use IT to achieve clinical integration and improve population health. Governance and current state of health IT adoption/use The ILHIE Authority is, by statute 3, the governance structure for the statewide health information exchange (ILHIE). An appointed Board, representing a diverse range of health care stakeholders, and five ex-officio members representing health and human service agencies, govern the ILHIE Authority. The Alliance includes a Data and Technology Work Group, which was established to guide development of the Model Test health IT infrastructure, policy, and governance, will leverage the ILHIE and the health IT progress of the providers connected to it. All activities will be overseen by the GOHIT Health Data and Technology Director. At the end of 2013, the Illinois electronic health records (EHR) adoption rate in the ambulatory setting was 58.7%, above the national average of 48.2%. 4 In the inpatient setting, the adoption rate was 66.8%, significantly higher than the national average of 59.4% ILCS 3860/. 4 Hsiao CJ, Hing E. Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, NCHS Data Brief, no 143. Hyattsville, MD: National Center for Health Statistics Charles D, Gabriel M, Furukawa MF. Adoption of Electronic Health Record Systems among U.S. Non-federal Acute Care Hospitals: , ONC Data Brief, no. 16. Washington, DC: Office of the National Coordinator for Health Information Technology. May

15 More than 3,150 individual providers in 250 health care entities use the ILHIE Direct secure messaging service. More than 80% (165) hospitals use the ILHIE Public Health Reporting service for lab results, syndromic surveillance and immunization data. In addition, 36 health care organizations, two regional HIEs, and one border-state HIE have on-boarded or are in the process of on-boarding the ILHIE service for query-based exchange of EHR. Health IT capacity, however, remains limited among community behavioral health providers, long-term care providers, and home- and community-based care settings and in some physician specialties and rural areas. This has created challenges to effective care coordination that the Model Test proposal will address through significant training and technical assistance. Policy levers to accelerate standards-based, interoperable technology The ILHIE promotes adherence to national technical standards for EHR and HIE through its on-boarding process, policies and data sharing agreements signed by all connected entities. All are aligned with standards advanced by the ONC and CMS to promote interoperability. Contracts executed between the State and each Medicaid ACE require ACE network providers to use Direct secure messaging to securely share clinical information, adopt certified EHRs, and connect to the ILHIE to share clinical data. Additionally, the State requires eligible hospitals and professionals participating in the EHR Incentive Programs to submit public health meaningful use measures using the ILHIE Public Health Reporting service. To facilitate integrated, coordinated care, Pilots will be required to meet specific criteria for integrated delivery systems, which include use of a bundle of IT clinical integration tools. The Model Test will leverage existing ILHIE infrastructure, including the service that allows providers to retrieve individual patient records (continuity of care documents) from all 15

16 connected data sources. The ILHIE is developing a system of real-time data alerts for members of the care team, which will be made available statewide. The service provides prescription medication fill status for Medicaid enrollees to members of the care team. Notices of admissions and discharges to primary care providers and care coordinators will be added, followed by notification for laboratory orders and results. Using data and analytics, telehealth and remote monitoring to improve care Illinois is also home to a federally-funded PCORI project called CAPriCORN 6, which received $7 million to accelerate clinical data standardization and capture longitudinal information on one million patients by September The Alliance is working with the CAPriCORN leadership to leverage the substantial progress being made on semantic interoperability, a common data model for disease-specific analytics and patient identification. Upon conclusion of the CAPriCORN project, it is expected that an extension of this work will be incorporated into the ITRC, funded through the Model Test, to advance the ITRC s analytics support. Telehealth and remote patient monitoring are critical tools used to enable care coordination, address disparities and improve outcomes. The integrated delivery systems in the Model Test will test the use of e-consults, telehealth and remote monitoring, and the payment model innovations will allow providers to invest in the IT infrastructure necessary to support them. The State currently provides technical assistance to Medicaid ACE providers that are connected to or will connect to the ILHIE. This assistance includes a health IT readiness assessment, a tool to support the on-boarding process, and on-site support from ILHIE technical staff. During the pre-implementation year, the ILHIE will expand its technical assistance

17 program to enable Pilot participants to increase adoption of certified EHRs and use nationallyrecognized HIE standards. Illinois also has two highly successful Regional Extension Centers (RECs) with extensive expertise in assisting Medicare and Medicaid providers to adopt EHRs and use them effectively to coordinate patient care. The RECs will provide additional support to Model Test participants to support their development of advanced health information technology infrastructure. Federal investments in IL for interoperable health/human service IT infrastructure More than 20,000 eligible professionals and 180 hospitals 7 participating in the Medicare and Medicaid EHR incentive programs have received more than $1 billion in federal investment for the adoption and meaningful use of interoperable EHRs. 8 Illinois used its ONC-awarded State Health Information Exchange Cooperative Agreement funding to develop the ILHIE Master Patient Index (MPI), which currently contains 6.3 million distinct records. The ILHIE and Illinois MMIS already interface to support the MPI. Additional data interfaces between the two will be established to support continued progress in Medicaid transformation. To further promote interoperability across state agencies, the State created the Framework for Healthcare and Human Services. The Framework is a multi-agency collaborative, coordinating the use of technology and shared data across Illinois federally funded healthcare transformation initiatives. Through the Framework governance body, the State has committed to utilize the MPI across Illinois health and human services enterprise. 7 Registration Detail: Centers for Medicare & Medicaid Services, EHR Program Registrations by State and Program Type as of April 30, Payment Detail: Centers for Medicare & Medicaid Services, Combined Medicare and Medicaid Payments by States through April 30,

18 Integration of public health IT systems in Plan for Pop Health The Regional Hubs will connect to the ILHIE Public Health Reporting infrastructure, which facilitates the aggregation of structured health data from provider sites throughout the state. The fully developed public health IT infrastructure will facilitate evidence-based population health strategies and the continuous improvement envisioned in the Plan for Pop Health. Leveraging of health IT to implement common quality and cost measures across payers The ITRC will facilitate reporting of common quality and cost measures across payers and providers. The Model Test will leverage federal quality initiatives and certified EHR technology functionality to increase adherence to standard quality measures and reporting. Engaging long-term care, behavioral health providers and patients Illinois will develop a common care IT platform during the pre-implementation year that includes all relevant data necessary and is accessible to all members of the patient care team. The common care platform will leverage the ILHIE services already in use by behavioral health and long-term care providers, and the Medicaid ACE requirements for connectivity across provider networks to expand the adoption of health IT among long-term care and behavioral health providers. ILHIE services, in particular, the ILHIE Direct secure messaging service are being leveraged to address current limitations and lack of financial incentives available to providers to adopt EHRs and HIE technology across the care continuum. The common care platform will produce portable care plans that can be accessed, shared, and updated by all members of the patient care team. In the most innovative settings envisioned by the Model Test, the patient will be an integral member of the care team. Meaningful Use requirements that facilitate patient access to health information will be leveraged to spur such innovations. 18

19 Part 6: Stakeholder Engagement Illinois process of convening stakeholders to help accelerate state-wide health transformation builds upon a strong foundation. Advisory councils and committees that met over the past several years in the context of larger health system transformation formed the basis for the State s network of engaged stakeholders that was tapped and utilized even more deeply to develop collaboratively the State s Alliance Innovation Plan. Since then, the network has been called upon to engage via work groups that are currently meeting through the end of 2014 for the dual purpose of developing the Alliance implementation plan and informing implementation details for Illinois proposed 1115 Waiver. Stakeholder engagement around the Model Test implementation will be firmly rooted in and modeled after these preceding processes. The Alliance work structure includes state leaders, legislators, and representatives from relevant agencies, project consultants, provider organizations, consumer advocates, unions and business leaders. The structure was designed to: 1) focus on collaborative planning; 2) allow for productive and meaningful dialogue; 3) involve a broad group of stakeholders representing different types of organizations; 4) create checks and balances; 5) create an open and inclusive process, and 6) ensure state-wide representation. A variety of committees, teams, staff and workgroups helped develop the Alliance process and contributed to content development for the Alliance Innovation Plan. The structure included: 1) a Core Team of state leaders and project consultants (Health Management Associates); 2) a Steering Committee that includes legislators, model representatives, state agencies, population health advocates, provider organizations, consumer advocates, unions and business leaders; 3) a State Executive 19

20 Committee that includes the Governor s Office and relevant State agencies; 4) Representatives from the three platform models: Provider Model, Provider Plan Model, Provider-Plan-Payer Model; 5) Staff workgroups: Delivery System and Payment Reform Data, and Policy, and; 6) Population Health Task Force. Engagement through the workgroup structure was augmented by input and discussion that took place via stakeholder engagement forums, town hall meetings, key informant meetings, and comments set up through the Alliance s website. This process and the need for long-term management and coordination of this work across state agencies led to the January 2014 creation of the GOHIT. Currently, to flesh out details necessary to implement the Alliance Innovation Plan and the proposed 1115 Waiver, GOHIT is convening stakeholders through five work groups: Services and Supports; Integrated Delivery System Reform; Data and Technology; Workforce, and Public Health Integration. The work groups are comprised of health care providers/systems; commercial payers/purchasers; state hospitals and medical associations; community-based and long term support providers, and; consumer advocacy organizations. These include stakeholders that participated in the Alliance planning process as well as additional stakeholders who either have joined this open process of their own volition or have been recruited by the State as we seek to ensure broader geographic representation and deeper penetration into underserved communities. We currently have more than 290 entities represented on the work groups and their subcommittees. Many of these stakeholders have made firm and meaningful commitments to partner with the state in testing the Innovation Model in various ways, including but not limited to: participating as an integrated delivery system pilot; accepting innovation funding and conditions; sending and receiving data to the ITRC; utilizing the health IT service bundle for 20

21 care; participating in technical assistance activities; aligning other work with related state initiatives, etc. (See Letters of Participation and Support appendix) On-going stakeholder commitment will be facilitated by the addition of a Community Engagement Specialist staff person in GOHIT to coordinate at least quarterly meetings to report on progress of Model Test implementation as well as any necessary committee meetings. This new staff person will also ensure the maintenance of regular communication between meetings, including through webinars and the interactive website, and the coordination of forums, town hall meetings, and key informant meetings. All of this will mirror the structure outlined above and in greater detail in Illinois Alliance Innovation Plan. Part 7: Quality Measure Alignment Illinois recognizes the importance of aligning quality metrics. Achieving consensus around specific metrics used to measure progress and ensure accountability is essential for stakeholder buy-in and participation in the Model Test. Creating a standard set quality metrics will reduce provider reporting burden, ensure that the strongest quality measures are in use, and give consumers the confidence to compare provider quality from public sources. The measure set can eventually be used for annual reporting by providers, and for health plans to evaluate provider quality and create tiered products. To help streamline and coordinate quality measures the Alliance convened stakeholders early on to begin the discussion; they quickly reached consensus on the importance of standardizing metrics across health plans to access shared savings. Shared savings can help providers focus not only on specific measures, but on the total cost of care and can be used to prevent providers from withholding needed services to achieve targets. Current public and 21

22 private payers offer pay-for-performance programs with a wide variety of components, measures, targets, timing, types, and amounts of payment. Standardizing pay-for-performance programs will minimize administrative burden and clarify treatment protocols across insurers for both doctors and patients. The following are consensus recommendations by health plan and provider members of the Alliance. Value Metrics: should be standardized among plans and payers as much as possible for similar populations and should be: Broad in scope but focused for providers through choice of a small and manageable subset that are tied to financial incentives; Measured at the practice level by aggregating performance from multiple payers and plans; Periodically and jointly evaluated by plans, providers, other stakeholders, Medicaid and other payers to determine which parameters can maximally impact practice transformation and value of care and should therefore be tied to financial implications; Facilitate rapid cycle improvement efforts at the practice level through frequent feedback to providers; Transition from process and even clinical outcomes measures to health status, functional status and overall care experience, with appropriate risk adjustment. Quality Parameters: should be aligned among health plans and payers for similar populations and should: Be measured in uniform fashion; Include global cost of care as well as preventive measures, management of chronic disease, member functionality and member satisfaction; Minimize administrative burden and allow focus on highest yield outcomes; and Be aggregated on a multi-plan, multi-payer basis so that they are statistically significant and provoke provider action. 22

23 The Alliance Integrated Delivery System Reform Work Group members represent government agencies, hospitals, medical associations, employer associations, medical groups, health plans and consumer advocacy groups. The work group is tasked with establishing a standard set of quality measures and targets for which providers can earn financial incentives. They began meeting in June 2014 and will use their expertise to reach cooperative agreement regarding quality metrics alignment within the first quarter of the planning period. While the Work Group will establish the final set of metrics, they will likely include the following: Adult Quality Metrics, such as: controlling high blood pressure, tobacco use and advice to quit, depression screening, body mass index assessment of healthy weight, comprehensive diabetes care, timeliness of prenatal care, breast and cervical cancer screening, and influenza vaccination rate in adults age 65 and older. Child and Adolescent Quality Metrics, such as: Immunization for adolescents, well-child visits and adolescent well-care visit, weight assessment and counseling for nutrition and physical activity. Measures and targets will be aligned with prevailing commercial pay-for-performance programs. These metrics will be used by the integrated delivery system pilots during the Testing Phase. The same pay-for-performance programs will be applied to Medicaid managed care payment initiatives, including ACEs, CCEs and Medicaid MCOs. Policy and data issues related to their implementation are being identified and solutions defined. Commercial MCOs will be encouraged to offer a shared savings program and utilize the uniform set of measures for nonpilot providers. These metrics will be incorporated into the Plan for Pop Health. With the assistance of the ITRC, Regional Hubs and in consultation with the SHIP Implementation 23

24 Coordination Council, the metrics eventually will shift from process and clinical outcomes to health status, functional status, and overall care experience. Part 8: Monitoring and Evaluation Plan Expanding the State s leadership role in promoting continuous quality improvement in public health and health care is one of the five objectives of the Alliance Innovation Plan. To that end, GOHIT will establish a partnership with one or more academic institutions during the preimplementation year to create and operate the Innovation and Transformation Resource Center (ITRC), funded through this proposal and supplemented with funding designated for technical assistance to Medicaid providers and health plans through the 1115 Medicaid waiver. In order to measure the impact of the innovations, the Model Test evaluation will establish a group of control sites selected on the basis of their similarity to pilots on as many dimensions as possible. The basic mode of evaluation will be a comparison of changes between the Pilots and the control sites over the test period. The evaluation will be designed to accommodate certain potential pilots that are outliers by virtue of their large size and the socioeconomic status of the population they serve. The State anticipates that integrated delivery systems will submit proposals to participate as Pilots. It is further expected that there will be up to six Pilots to ensure adequate diversity of geographic areas and covered populations. It is anticipated that Medicaid CCEs and ACEs will be among the integrated delivery systems that apply to become Pilots, which will contract with the State and receive funding to support and enhance their ability to meet and develop the characteristics 1-10 throughout the Model Test period. 24

25 The ITRC will collect, validate and integrate data provided by participating Pilots and health plans. The ITRC will build, maintain, and continually update a database consisting of historically isolated data sources and create a database management system and data analytics capability for empirically identifying and assessing the causes of successful healthcare transformation across populations and payers. The ITRC will utilize university expertise to provide rapid cycle evaluation and integration of the most transformational health reform efforts on behalf of Medicaid, Medicare, and commercial populations. A HIPPA-secure environment with unique identifiers will be used to harmonize data input from multiple collection points for identifying and replicating best practices across payers. The ITRC will start with the collection of data from the Medicaid program, group health insurance program for state and university employees and retirees, and data voluntarily provided from health plans participating in the Alliance initiatives. Medicare data will be added upon federal approval. This work, along with that of the CAPriCORN project, will provide the foundation for Illinois movement to develop an all payer claims database (APCD) or alternative data infrastructure to achieve cost and quality accountability, transparency, population health planning and evaluation of care effectiveness and outcomes. The Alliance Innovation Plan recommended the development of an APCD and proposing legislation to establish one in Illinois. Although activities funded through the Model Test will support this effort, given the expected length of time to create the APCD by statute, establish policies for data collection across all payers and begin collecting data, it was determined that this could not be accomplished in time for the Model Test, so funding directly for creation of an APCD is not included in this proposal. The 25

26 Alliance Data and Technology Work Group will convene stakeholder discussions on this issue, monitor the progress of the ITRC and its ability to provide sufficient resources for statewide cost, quality, population health and effectiveness data analysis, and make recommendations regarding the APCD or alternative infrastructure. Patient experience and population health performance The Medicaid agency has historically conducted limited scope surveys of client services. However, such surveys can be expanded to more broadly consider the service recipients experience under various innovation models. These client and service level records will then be compared against qualitative and capacity characteristics of various service plans to identify effective providers and plans, as well as effective or unique approaches to dealing with costly health conditions and hard to reach recipients. Last, the population health data will be used measure success or failure against existing and trending medical standards. Geographic data will be used to identify contributing factors such as inadequate provider access or transportation to providers, or the effect of potentially positive initiatives such as workforce development and placement into medically underserved areas. The ITRC will use trend analysis to determine what types of plans and payment methodologies can be effectively replicated to broader populations statewide. The resulting best practices will be deployed by the technical assistance infrastructure within the ITRC to support the success of the Pilots and all other integrated delivery systems. Illinois also will obtain the services of a professional evaluator through an application process during the pre-implementation year. The evaluator will work in close collaboration with the ITRC and potentially be co-located in the ITRC. In addition, GOHIT will have a 26

27 designated staff person responsible for reporting to CMS on the progress of the Model Test and working with the evaluator to ensure compliance with all measurement requirements. Illinois proposes to use the following outcome measures to monitor the impact of the Model: Population health 1. Days of physical health not good (i.e. fair/poor) in past 30 days 2. Days of mental health not good (i.e. fair/poor) in past 30 days 3. % of adults who are overweight or obese 4. % of adults who have ever been told by a doctor that they have diabetes 5. % of adults who have been told by a doctor that they currently have asthma 6. # of deaths due to diseases of the heart per 100,000 population 7. % of individuals who participated in >150 minutes of aerobic activity per week 8. % of adults who are current smokers Health care delivery system transformation 1. Twelve Child and Adolescent HEDIS Measures already used in Medicaid programs 2. Two Adults Access to Preventive/Ambulatory Care HEDIS Measures 3. Five Preventive Screening for Women HEDIS Measures 4. Four Maternity-Related HEDIS Measures 5. Twelve Chronic Condition/Disease Management HEDIS Measures 6. # of nurse practitioners per 100,000 residents 7. # of community health workers working in Model Test pilot sites 8. Active primary care physicians per 100,000 population 9. % of physicians retained in State from undergraduate/graduate medical education 27