Texas Policy Summit on Integrated Health Care

Transcription

1 Texas Policy Summit on Integrated Health Care Advancing Sustainable Integrated Health Care Through Value-Based Payment Thursday, October 19, :00 AM 3:00 PM Royal Sonesta Houston Galleria

2 Setting the Stage: Value-Based Payment from a National Perspective Joan Henneberry, MS Vice President, Health Management Associates Texas Policy Summit on Integrated Health Care October 19, 2017

3 Texas Policy Summit on Integrated Health Care Joan Henneberry, VP HMA s Denver Office

4 CONVERGING FACTORS DRIVING INTEGRATED CARE Costs of Health Care and BH Role Life Expectancy of BH with SMI Health Care Reform Team Based Care

5 Annual Cost of Care Total Population Common Chronic Medical Illnesses with Comorbid Mental Condition Value Opportunities Patient Groups Annual Cost of Care Illness Prevalence % with Comorbid Annual Cost with Mental Condition* Mental Condition % Increase with Mental Condition All Insured $2,920 10%-15% Arthritis $5, % 36% $10,710 94% Asthma $3, % 35% $10, % Cancer $11, % 37% $18,870 62% Diabetes $5, % 30% $12, % CHF $9, % 40% $17,200 76% Migraine $4, % 43% $10, % COPD $3, % 38% $10, % Cartesian Solutions, Inc. --consolidated health plan claims data *Approximately 10% receive evidence-based mental condition treatment

6 WHERE THE MONEY GOES

7 Medicaid Now Pays for Over 1/6 of U.S. Health Care: Spending by Payer in U.S. Health Spending: $3.5 Trillion $1,209 B In $Billions $604 B $719 B 34% $659 B 17% 20% 18% $366 B 11% Medicaid Medicare Private DOD, VA, and CHIP Insurance IHS, Others Note: $587 Billion for Medicaid and $18 Billion for CHIP. Source: HMA estimates, Out of Pocket

8 PER-CAPITA CAPS AND BLOCK GRANTS Impact relevant in EVERY state, whether they expanded or not Current proposal worse for expansion Dramatic reductions in federal support over several years Over time, likely to especially hit those with disability and chronic conditions the hardest. Highcost services could be rationed on a state-by-state basis. Current example: US Territories receive Medicaid Block Grants

9 MEDICAID MANAGED CARE RULE Beginning this year, 42 CFR gives states greater ability to provide direction as to how health plans reimburse providers States may direct an MCO to: Adopt a minimum (or maximum) fee schedule for all providers of a particular service Provide a uniform dollar or percentage increase for all providers of a service in a particular class of providers Participate in an alternative payment methodology program Directed payment process

10 MANAGED CARE PLANS INCREASINGLY MOVING TO VBPS Contract and reward high value care and incentivize further improvement Help improve low value providers where possible Move beneficiaries to higher value providers where possible Discontinue contracts with low value providers where no improvement is deemed feasible

11 WHAT ARE VALUE BASED PAYMENTS? The vision for a transformed delivery system is one that is primarily ready for delivering valuebased care: + Efficient + Effective + Patient-centered Value-based purchasing efforts are: + A variety of alternative payment approaches + Developed in partnership with the clinician community + Provide added incentives to deliver high-quality and cost-efficient care VBPs move beyond Fee For Service to paying for quality and value across a population and allow for multiple providers and staff to contribute to the care An ever increasing number of public and private payers are moving to VBPs J Smith, HMA Idaho

12 WHAT DOES THIS MEAN INSIDE THE CLINICS? Moving from managing schedules to managing populations Building relationships: empanelment and continuity Considering alternatives to the traditional office visit Monitoring operational and access measures as well as clinical outcomes Using teams efficiently Creating incentives with mindfulness to unintended consequences and focusing more on culture as a real long-term driver

13 PHYSICIAN S PERSPECTIVES 80% didn t support a change in reimbursement, yet many do note that the current Federal Fee for Service (FFS) doesn t offer value to those it serves 71% said they would participate in VBP if offered financial incentives Don t want to be held accountable for metrics whose outcomes they can t control 2016 SURVEY OF PHYSICIANS - DELOITTE Concern for no credit for care that has a longer term impact on outcomes improvement such as care coordination and family education Currently majority report that only 10-20% income tied to metrics - anticipate moving to 50% at risk over the decade

14 IF GUARANTEED AN INCREASE IN PAYMENT, WHICH VBP? No Alternative Payment Models Shared Risk Arrangements Bundled Payments 7% 15% Capitation payments 29% 17% 19% 52% Episode-based Payments Shared Savings Arrangements From 2016 Survey of US Physicians, Deloitte Center for Health Solutions

15 HOSPITAL PARTICIPATION IN VOLUNTARY VBPS Three types of Alternative Payment Models No Alternative Payment Models 24% 10% 37% One type of Alternative Payment Model 32% Two Types of Alternative Payment Models From the Financial Leadership Council Survey summary by the Advisory Board, August 18, 2016

16 CONTINUUM OF HOSPITAL PAYMENT OPTIONS Base Rates DSH Base inpatient and outpatient rates Medicaid DSH allotment prescribed by the federal government Hospitals limited by OBRA cap (their hospital specific limit) Adjustment Payments Directed Managed Care Payments Quality Incentive Payments Waiver Flexibility Also known as UPL payments that target funds to specific providers or services Payments capped by class of hospital and service Minimum fee schedule or uniform payment adjustments by class of provider. Must be tied to utilization and be associated with state s overall quality goals Aggregate spend up to 5% of cap rate Must be linked to specific performance metrics (i.e. readmission rate, HACs, ) DSRIP Delivery System Reform Incentive Payments ($ tied to metrics) Uncompensated care payments ($ for Medicaid and UC shortfalls)

17 TO BE SUCCESSFUL WITH VBPS Aim for a staged approach that is operationally feasible and made in consideration of both health plan and provider system capabilities Providers need to assess core capabilities and systems that are critical to succeed under VBP contracts + Clinical integration + Data analytics and connectivity + Care management and coordination + Patient engagement/ wellness programs + Leadership committed to practice transformation Align with upcoming MACRA QPP Develop VBPs that mirror MACRA APMs to provide consistent contracting for providers and increase eligibility for All-Payer APM Option

18 PROVIDERS SHARED IN SAVINGS IN NEW VBPS MODELS IN MEDICAID Colorado s Regional Care Collaborative Organizations: $14 million reinvested into the providers based on a shared incentive pool Oregon s CCOs 4% of budget withheld from CCO budgets $168 million savings distributed All but one of the 16 earned 100 % of the base distribution of the quality pool All CCOs earned a share of the $1.25 million in the challenge pool Vermont s MSSP Saved $14 million in Medicaid in 2014 for the lives in two participating ACOs One earned 100% of possible savings; other earned 85% Total of $3.3 million distributed to the participating ACOs in year 1 based on number of lives and their quality performance

19 PROMISING RESULTS IN NEW VBP MODELS IN MEDICAID Colorado s Regional Care Collaborative Organizations: +$77 million in net savings for Medicaid +Lower ED visits, hicost imaging, hospital readmissions Minnesota s Integrated Health Partnerships Program: +$76.3 million savings in first two years +Exceeded their quality targets +Achieved shared savings Vermont s MSSP +$14.6 million in first year +Both of the state s Medicaid ACOs achieved significant savings +Exceeded their quality benchmarks +Received shared savings distributions

20 WITH VBP SINCE 2011: OREGON S MEDICAID CCOS QUALITY METRICS RESULTS + 33% decrease in hospital readmissions + 29% reduction in hospital admissions for diabetes + Decreased hospitalization for: + Congestive heart failure + Chronic obstructive pulmonary disease (COPD) + Adult asthma + Avoidable ED visits down from 14% to 7% statewide + 4% increase in chlamydia screening + 8% increase in cervical cancer screening + Increased use of developmental screening in the first 36 months of life + Almost 10% improved member satisfaction + 38% increase in adolescent well-care visits + Increased primary care visits and expenditures + 69% Increase in enrollment in patient-centered primary care homes Oregon s Coordinated Care Organizations (CCOs) have global budgets with cost trend cap at 3.4%; 4% withholds for quality incentive pool

21 MARYLAND ALL-PAYER MODEL Only state able to set payment rates for Medicare in addition to regulating the state s market 95% of hospital revenue is in a global budget- fixed annual amount for both inpatient and outpatient, unrelated to number of patients admitted YEAR 1 RESULTS: Quality composite measure preventable conditions improved by 26% Decreased overall per capita Medicare hospital costs by over 1% - saving $116 million All 46 hospitals have signed on

22 RESOURCES ON MACRA AND VBP Centers for Medicare and Medicaid Services (CMS) MACRA Includes links to the quality programs, slide shows, webinars, answers to questions submitted to CMS, proposed rules American Medical Association info on MACRA Network for Regional Healthcare Improvement (NRHI)- collaborative of regional communities originally funded by RWJF for quality improvement efforts, have worked to align quality measures nationally The Health Care Payment Learning & Action Network (LAN) was created to drive alignment in payment approaches across the public and private sectors of the U.S. health care system. APM White Paper:

23 DISCUSSION Comments Questions Joan Henneberry

24 Setting the Stage: Outcomes of Integrated Health Care DSRIP Projects Ellen Breckenridge, PhD, JD, MPH Faculty Associate, The University of Texas School of Public Health Texas Policy Summit on Integrated Health Care October 19, 2017

25 INTEGRATING PRIMARY AND MENTAL HEALTH CARE AT TEN TEXAS COMMUNITY CENTERS October 19, 2017 Ellen Breckenridge Prepared for the Texas Policy Summit on Integrated Health Care This study was funded by the Meadows Mental Health Policy Institute (MMHPI), the Texas Health and Human Services Commission (HHSC), and the Centers for Medicare and Medicaid Services. The findings are those of the authors and do not necessarily represent the official positions of the funders.

26 Context: DSRIP opportunity DSRIP major innovation opportunity for Texas behavioral health centers Our focus: Integrating primary care with CMHC services

27 Process: Chose 10 of 33 eligible CMHCs

28 Structure of integrated care

29 Challenges of integrating 4 CMHCs had unsuccessfully tried to integrate before HARD to do 4 projects non-operational for months because of no PCP Managed care contract delays prevented billing at start Limited Rx, dental, specialty care

30 Successes PATIENTS SERVED BY 10 CENTERS IN 1115(A) MEDICAID WAIVER DEMONSTRATION YEARS 3 & 4

31 Processes All care on same floor Shared treatment planning Morning huddles Warm handoffs On-site lab sample collection Shared health records Usual physical exam room Used team-based care

32 Staff observations on outcomes More holistic care: Triangulating info, especially about effects of psychotropic Rx Improved accuracy of diagnoses; ability to respond to emergent situations Provider peace of mind

33 Patient perceptions of benefits Comfort Convenience and cost Better communication with providers Some - better self-care and health

34 Increases in screening rates BMI 4X Hypertension 4X Smoking 10X Diabetes 78X

35 Health outcomes # patients # screened patients at risk 1286 # patients at risk controlled during integration High Systolic BP 52% High Diastolic BP 57% Patients' Improvement in BP Control While Receiving Integrated Care 35

36 Cost outcomes: Hospital use Fewer hospital encounters Shorter lengths of stay 18 % 32 % 36

37 Cost outcomes: Cost implications Fewer hospitalizations = $1000+ savings / year / patient Shorter stays = $1200+ savings / hospitalization 37

38 Major concerns about sustainability CMHC patient health insurance status 10% 8% Uninsured 20% 62% Medicaid Medicare 38

39 Implications Integrated care improves: Screening rates Health care experiences Health outcomes Resource use 39

40 Future needs Dedicated funding Resources to build information systems for analyses & reporting 40

41 Ellen Breckenridge, MPH, JD, PHD Faculty Associate Management, Policy, and Community Health Department 1200 Pressler Street, RAS E327 Houston, Texas

42 Value-Based Payment for Integrated Health Care in Action: The Center for Children and Women/ Texas Children s Health Plan Heidi Schwarzwald, MD, MPH Chief Medical Officer Pediatrics, Texas Children s Health Plan Texas Policy Summit on Integrated Health Care October 19, 2017

43 THE CENTER FOR CHILDREN AND WOMEN Heidi Schwarzwald MD MPH CMO-Pediatrics Texas Children s Health Plan

44 THE CENTER The Center for Children and Women is a patient and family-centered medical home developed as an innovative, comprehensive, and coordinated primary care practice exclusively for TCHP members (Children and Pregnant Women). First opened in August 2013 and second in November With the joint principles of a patient-centered primary medical home serving as the underpinning for The Center, there is the opportunity to: Keep members healthy Focus on coordinated care Leverage the EMR Eliminate financial disincentives Decrease avoidable ER visits

45 THE CENTER LOCATIONS Southwest Houston: Opened Nov 2014 North Houston: Opened Aug 2013

46 Services Pediatrics Obstetrics/Gynecology Ultrasonography Behavioral Health Speech Therapy Optometry Dentistry Radiology Pathology Pharmacy

47 Team Members Physicians Advance Practice Nurses (APRNs, CNMs) Pharmacists Registered Nurses Medical Assistants Care Coordinators Psychologists Clinical Therapists Social Workers Nutritionists Health Educators Others

48 FY 2017 ACTIVITY 153,533 Patient Visits 40% same day access for Pediatrics and Ob/Gyn 1,416 Deliveries 2

49 BH INTEGRATION IMPROVES TRIPLE AIM Quality of care for patients with chronic illness improved Enhanced satisfaction for patients and providers Spend for those identified with BH issues that were treated decreased by 16% DEPARTMENT NAME

50 PEDIATRIC BEHAVIORAL NEEDS One in five pediatric patients experience mental health issue 7/10 adolescents with depression not receiving care Fewer pediatric psychiatrist available who take insurance Many behavioral health issues can be co-managed by PCP and therapist ADHD/mild depression/mild anxiety Few pediatricians feel comfortable handling on their own DEPARTMENT NAME

51 COST OF BEHAVIORAL HEALTH-PMPM CLAIMS BH Non_BH All Total Paid $402 $122 $152 Acuity Total Paid/Acuity $165 $157 $159 DEPARTMENT NAME

52 INTERDISCIPLINARY BH TEAM 2 Psychologists 6 FTE Mid-level Providers (LCSW, LPC) 2 Psychiatrist 4 Social Workers (LMSW) 5 2

53 THE CENTER BEHAVIORAL HEALTH: MOVE TOWARDS FULL INTEGRATION OF BEHAVIORAL HEALTH IN HEALTHCARE Minimal Coordinated At a Distance Co-located Fully Integrated

54 BH Integration = Access to Care

55 JUST IN TIME CARE BH services 7 days a week 30% of BH appointments occur outside traditional hours

56 BH GROWTH YEARLY TRENDS

57 TELEHEALTH INCREASES ACCESS Telehealth = 7% of Psychiatry encounters Contributes to 100% psychiatry template utilization

58 BH Integration = Engagement in Care

59 Center BH Patient All TCHP BH patients Center BH patients = 8.1% of all TCHP patients receiving BH services

60 PERCENTAGE OF BH MEMBERS AS PROPORTION OF TOTAL MEMBERSHIP TCHP The Center

61 RIGHT CARE / RIGHT PLACE - BEHAVIORAL HEALTH Behavioral Health Integration Increases Engagement in Underserved Communities

62 BH Integration = Innovation in Care

63 RIGHT CARE / RIGHT PLACE / RIGHT COST BEHAVIORAL HEALTH 88% of ADHD medication managed by PCP vs. 60% for TCHP overall PCP Medication Management Psychiatry Formal Consult Role BH Clinician Assessment and Therapy Social Worker- Resources Patient

64 BH INTERVENTION IN OB/GYN Percent of Women Social Workers Clinical Therapist Provider Utilized Psychologist Psychiatrist No Behavioral Health

65 BH Integration = Improvements in Care

66 RIGHT CARE / RIGHT PLACE / RIGHT TIME BEHAVIORAL HEALTH ADHD stimulant initiation 95 th Percentile ADHD continuation/maintenance 95 th Percentile 7 Day psychiatric hospitalization follow-up 75 th Percentile 30 Day psychiatric hospitalization follow-up 50 th Percentile

67 CENTER SAVINGS ON ER & INPATIENT ER Inpatient 2,000 No Visit 3,000 No Visit 1,800 1,600 2,500 ER Visits / 1,000 Members 1,400 1,200 1, Visited Center Annualized Savings $1.6M IP Days / 1,000 Members 2,000 1,500 1, Visited Center Annualized Savings $6.5M *Data is for the Incurred Period April 2016 through March

68 IN THE COMMUNITY Flu Vaccines Back to School Zika Prevention Houston Storm Relief Voter Registration Car Seat Training 6

69 Value-Based Payment for Integrated Health Care in Action: Panel Discussion Joan Henneberry, MS, Vice President, Health Management Associates (Moderator) Ernest Buck, MD, Chief Medical Officer, Driscoll Health Plan Lisa Kirsch, MPAff, Senior Policy Director, Dell Medical School Heidi Schwarzwald, MD, MPH, Chief Medical Officer Pediatrics, Texas Children s Health Plan Dawn Velligan, PhD, Director, Division of Community Recovery, Research and Training, and Henry B. Dielmann Chair, Department of Psychiatry, UT Health San Antonio Texas Policy Summit on Integrated Health Care October 19, 2017

70 Health and Human Services Commission (HHSC) Value-Based Purchasing Roadmap Andy Vasquez Deputy Associate Commissioner for Quality and Program Improvement Texas Health and Human Services Commission Texas Policy Summit on Integrated Health Care October 19, 2017

71 Facilitated Discussion Groups & Lunch Texas Policy Summit on Integrated Health Care October 19, 2017

72 Facilitated Discussion Facilitator: Jeff Stys, Strategic Decision Associates Texas Policy Summit on Integrated Health Care October 19, 2017