For AUDIO: Dial: Access Code: #

Transcription

1 Welcome to How Payment Reform Approaches Can Address Community Population Health For AUDIO: Dial: Access Code: #

2 Welcome to How Payment Reform Approaches Can Address Community Population Health

3 Welcome & Introduction Lynn Quincy Director, Healthcare Value 1

4 Housekeeping Thank you for joining us today! All lines are muted until Q&A Technical problems? Use the Chat function in the

5 A New Home. March 2015 July 2017.but our work remains the same: consumer focus evidence-based available via website, , phone Introducing the Healthcare Value Hub 5

6 Resources Key studies, curated studies **New** inventory of programs Webinar slides Available at:

7 Agenda Welcome & Introduction Lynn Quincy (Altarum Institute, Healthcare Value Hub) Reform for Population Health Initiative Enrique Martinez-Vidal, MPP (AcademyHealth) Inventory of Social-Medical Models Todd Shimp, MPH (former Healthcare Value Hub Research Assistant) Q &

8 Reform for Population Health Initiative Enrique Martinez-Vidal, MPP Vice President, State Policy & Technical Assistance, AcademyHealth

9 9 How Payment Reform Approaches Can Address Community Population Health July 14, 2017 Enrique Martinez-Vidal Vice President, State Policy and Technical Assistance AcademyHealth

10 Robert Wood Johnson Foundation s Payment Reform for Population Health (P4PH): Overview and Framework

11 11 P4PH Vision and Mission Vision o Community-wide population health will be improved through a more supportive health care payment system. Mission (i.e., P4PH Goals): o o To better understand the systems, context and structures needed to create the conditions for a health care payment system to support community-wide population improvement; and To identify and address barriers and promote promising opportunities. Defining population health: o o Health outcomes of a group of individuals, including the distribution of such outcomes within the group. (Kindig and Stoddart, 2003) For our purposes, the population is geographically-based total community, not a patient panel or payer s covered lives.

12 Analytic Frameworks and Assumptions

13 Determinants of Health Population Health 1 20% Health Care 30% Health Behaviors 40% Socioeconomic Factors 10% Physical Environment - Access to Care - Quality of Care - Tobacco Use - Diet & Exercise - Alcohol Use - Unsafe Sex - Education - Employment - Income - Social Support - Community Safety - Environmental Quality - Built Environment 1. Defined as: Health outcomes of a group of individuals, including the distribution of such outcomes within the group. (Kindig and Stoddart, 2003). Not NOTE: Genetics as a determinant of health has not been included as we consider that facet much less amenable to being influenced by payment reform. Source: County Health Rankings, Population Health Institute, University of Wisconsin-Madison; Magnan, Sanne. "Achieving Accountability for Health and Health Care." Minnesota Medicine (Nov. 2012). 13

14 14 Auerbach s Three Buckets of Prevention Source: Auerbach, J. The 3 Buckets of Prevention. J Public Health Management Practice, 2016, 22(3),

15 Role of Health Care Funding in Addressing SDH Services Alternative Payment Models Community Benefits Operations (e.g., Employment, Procurement and Investment) Performance Indicators (1) Shared Savings (2) Shared Risk (3) Bundled Payment (4) Comprehensive Population- Based Payment (5) Engagement Vehicles Direct Payment Partnering w/fin Institutions (CDCs, CFDIs) Direct Workforce (i.e. Social Workers, CHWs) Community Benefit Investments Contracting with CBOs Contracting with Non-Health Care Government Agencies Collaborations Engagement Enablers Conceptual Leadership Cross-Sector Consensus Building and Strategic Alignment Transparency Engagement Enablers Operational Data Collection (Environmental Scan) Data Analysis/Measurement (Evidence Generation and ROI) Data Infrastructure Collaborations Convenings Communication Practice Transformation Trusted Convener Housing Food Security Social Determinants of Health (Community Resources) (6) Education Employment Transportation Healthy Behaviors Neighborhood and Built Environment 1. Financial Bonus for meeting quality / cost targets 2. Upside risk only 3. Upside and downside risk 4. Episodic or condition-specific billing 5. Capitation / Global Budgets 6. Components from Healthy People 2020

16 P4PH Activities: Issues and Barriers

17

18

19 19 Health System SDH Investment: The Why and the How Why Motivating Factors (Examples) Mission Driven External Policy Driven Business Case ROI/Evidence Nuts n Bolts (Examples) How Misaligned economic motives Rate-slide for managed care entities Wrong-pocket problem Structuring a risk-based contract State policies and contracting levers

20 20 Health System SDH Investments: Motivating Factors Type of Health Care Entity Motivating Factors Medicaid Managed Care Organizations (MCOs) - State policies and contracting levers - Low-income populations more impacted by social factors Commercial Plans - Some are mission-driven - MACRA Hospitals - Community Benefit Requirements - Financial incentives (federal; state; self-identified) Safety-Net Providers - See health beyond health care more integrated with social services Clinical Providers - Growing recognition that they can t treat everything medically - Part of a larger networks operating under certain financial incentives

21 21 Barrier Domains/Elements That Have Risen to the Top Trusted Environment/Convener Data and Population Metrics Care Delivery Integration of Community and Clinical Resources Payment and Financing 21

22 Trusted Environment/Convener Issues Who is the entity? How is that entity selected? How are all multi-sector community partners identified? How much time and energy should be spent on establishing governance? How are collective decisions made? What is the management structure? Barriers The right convener for the community Governance vs. interventions Financing the convener and the interventions Internal workforce capacity Accountability and transparency Knowledge of local environment

23 Data and Population Metrics Issues How to get started of collecting, analyzing, and sharing? What are the key components of data sharing partnership? Who should receive, analyze, house, and report out data/information? What problems are communities trying to solve using the data? Screening and referral system When should organizations build versus buy their own tools and programs? Barriers Data Measures Data Sharing Standardization ( semantic normalization ) Financing the infrastructure/maintenance/use

24 Multi-sector Care Delivery Issues Need to understand how health care and social services currently are delivered across the partners/community? Key providers? What are the key care delivery interventions to undertake? How will social services be integrated and coordinated with clinical services? How can you ensure the quality/capacity of social services? What are the desired shared outcomes/goals? Should social services organizations be financially at risk for performance? Barriers Accountability Power dynamics Everyone at the table Social service sector capacity/quality

25 Payment and Financing Issues Alignment of financing from core operational dollars, community benefit dollars, and premium/provider reimbursement dollars Can/should health care sector partners be held responsible for individuals and activities outside its four walls? Can/should health care sector partners be held responsible for individuals outside a health care provider s patient panel or payer s enrollees? How can the reimbursements for non-clinical interventions flow between health care sector partners and non-health care sector partners? Sustainability (i.e., for convener and interventions) Evidence (i.e., value proposition) Barriers Business Case/Return on Investment (ROI) Accountability Education for all partners to understand

26 Lessons Learned

27 Lessons Learned: Trusted Environment/Convener Build trust in each other and the convener Recognize all partners diverse viewpoints/perspectives, regardless of power Identify common interests Find and foster a community voice/ownership of the efforts Exhibit adaptive leadership qualities Demonstrate effective communication practices Utilize community organizing principles Separate form (who is convener) from function (what convener does)

28 Lessons Learned: Data and Population Metrics Ground efforts to collect and use data within a shared understanding across partners of mutual goals Use available data as an acceptable starting point Stay pragmatic and realistic when establishing partner expectations Identify the most effective data platform for collective use Develop standardized data definitions Establish a governance process for data collection, sharing, and analysis Identify target population that leads to short-term results (i.e., lowhanging fruit)

29 Lessons Learned: Multi-sector Care Delivery Start small - Identify practical interventions and data collection activities o Builds trust and demonstrates proof of concept Continued engagement ensures commitment and leadership Credible data collection and analysis is critical for intervention s proof of concept SDH assessments are critical to understand individual needs and link with community services Involve local community partners in key decision-making Engage all payers can help shift care coordination to be seen as a utility for total community

30 Lessons Learned: Payment and Financing Use existing provider payment models as a jumping off point o Need to increase signal strength and reduce noise Leverage other funding and financing sources o o Recognize other funding sources may be collectively used/multiple investors Medicaid financing changes are under exploration/ development Evidence o o Identifying positive ROI may be possible with a few population health interventions Using qualitative data and storytelling to illustrate the value in reinvestment and rebalancing of funds Intervention Savings o o For some interventions/ populations, initial savings may be substantial, but with fixed costs, savings will be not be continual Sites, always looking to control costs, will seek to titrate interventions and move individuals to less expensive/dependent support to diminish intervention costs

31 31 Lessons Learned: History of Innovation Shapes Readiness to Move Upstream Commitment to Multi-Sector Collaborations o Collective impact (e.g., AF4Q, RWJF s Bridging for Health, United Way, Re-Think Health) o Governmental initiatives (e.g., ONC s CHP Learning Program, CMMI s AHCs) Commitment to Data Acquisition, Analysis and Use o RHIOs; RWJF s DASH; ONC s CHP; APCDs; Camden Coalition Experience with Care Delivery Transformation o CMS / HHS Initiatives (e.g., CPC+, PCMH, other CMMI & HRSA projects) o IHI Quality Improvement o Evidence-based Community Strategies (e.g., AHRQ-certified Pathways model; Housing First) Participation in Alternative Financing Efforts o CMS Financial Alignment Demonstrations o Medicare Advantage o State Medicaid MCOs/Innovative Medicaid Models (MN s ACOs; OR s CCOs) o CMMI s State Innovation Model (SIM) grants 31

32 32 Lessons Learned: Enabling Factors Provide Foundation for Moving Upstream Having a sole or dominant market player o This can result in increased accountability for community s total cost of care. o Investment calculation: Covered population = large proportion of community. Having a mechanism to transfer healthcare premium resources (savings) to other sectors (e.g., The Vermont Green Mountain Care Board) Addressing care delivery improvements presently o Pre-cursor / concurrent development for success of community strategies (may be underappreciated) Understanding success begets success and can create challenges 32

33 33 Overall Lessons Learned APMs rarely directly reimburse non-clinical, SDH-related support services - hard to move from Auerbach s Bucket 2 to Bucket 3. Other financing sources (e.g., community benefit dollars, grants, and reserves) more commonly used to support SDHs. Three streams: Internal organizational level (operations)/external-facing organizational level (community benefit)/service provider level (APMs). Alignment is needed across the three streams (in addition to other potential financing sources other sectors including community development). The Why (motivation) is as important to understand as the How.

34 34 Other Resources P4PH Website P4PH Bridging the Divide Four-Part Blog Series The Sweet Spot in Health Care and Public Health by Karen Hacker Using Data Sharing to Bring Collaborators Together by Rick Gundling Supplementing Payment Reform to Promote Needed Investments in Population Health by Tricia McGinnis Addressing the Elements in the Room by Enrique Martinez-Vidal Sites for Evidence SIREN Evidence Library at UCSF: WA State Institute for Public Policy Benefit Cost Results: Healthcare Value Hub s Inventory of Programs Targeting Complex Patients:

35 Inventory of Social-Medical Models Todd Shimp, MPH Former Research Assistant, Healthcare Value Hub

36 Resources on Programs Targeting Complex Patients The Better Care Playbook Supported by the Robert Wood Johnson Foundation, Commonwealth Fund, John A. Hartford Foundation, Peterson Center on Healthcare, and The SCAN Foundation The Commonwealth Fund Briefs on high-cost, high-need patients The Center for Health Care Strategies Briefs and a list/map of programs

37 An Inventory Programs Targeting Complex Patients 98 programs from 35 states and DC Excludes case-management only Common features Identify and target high-cost patients using data, medical histories, and interviews Team-based care Integration of social services either by referral or direct involvement Variety in extent and nature of service coordination, ranging from physical colocation to telemedicine Electronic Health Records and data Mostly grant funded Intervention groups often see improvements in utilization of services Cost savings are still a challenge Lots of interest from payers and providers

38 An Inventory of Programs Targeting Complex Patients Sample Profile Hub Easy Explainer

39 Questions for the panelists? Use the chat box or to unmute, press *6 Please do not put us on

40 Resources Key studies, curated studies **New** inventory of programs Webinar slides Available at:

41 Thank You! Enrique Martinez-Vidal Todd Shimp Robert Wood Johnson Foundation Join us Friday, Sept. 15 th for our next Webinar featuring Elisabeth Rosenthal, author of An American Sickness, illuminates our dysfunctional medical market. Questions? Contact Lynn Quincy at or visit us at HealthcareValueHub.org with any questions