New York State Department of Health Innovation Initiatives

Transcription

1 New York State Department of Health Innovation Initiatives HCA Quality & Technology Symposium November 16 th, 2017 Marcus Friedrich, MD, MBA, FACP Chief Medical Officer Office of Quality and Patient Safety NYSDOH

2 2 NYS DOH As of March 2017

3 3 Outline Discuss the State Health Innovation Plan Describe how NY State is transforming primary care Discuss population health approaches to quality Describe how payment reform models will have an impact

4 New York State Health Innovation Plan (SHIP) 4

5 5 New York State Health Innovation Plan (SHIP) Core Objectives: 80% of the state s population will receive primary care within an advanced primary care setting, with a systematic focus on population health and integrated behavioral health care 80% of the care will be paid for under a value-based financial arrangement

6 6 New York State Innovation Themes: Redesigning primary care Population health management Pay for value, not volume

7 NYS Transformation Efforts 7 NYS initiatives NYS payer initiatives CMS initiatives Federal law SIM/APC Practices & Providers

8 Primary Care Transformation through Advanced Primary Care (APC) 8

9 9 Primary Care Transformation Model APC criteria was designed with intention that this would be best solution for NYS needs Verifiable progress over time Transition to performance Building capacity for VBP payments Transforming with technical support Align transformation programs under NYS PCMH program But complexity in the setting of multiple primary care transformation programs has been an ongoing challenge

10 10 Why align with PCMH (NCQA PCMH 2017)? Accelerating the transition toward delivering value and succeeding in new payment models for all practices in NY State Opportunity to simplify a complicated landscape and reduce confusion Why create a distinct NYS PCMH? A NYS PCMH program considers several state-specific components including investments in Health IT, Behavior Health integration, rigorous Care Coordination, Population Health, and the potential for multi-payer support Accelerating the transition toward value-based payment is a priority for NY

11 NYS PCMH builds on APC/PCMH 2017 by converting 12 Electives into Core without asking the practices to do more NYS PCMH criteria compared to PCMH 2017 Changes compared to NCQA PCMH Elective Core Achieves recognition (approx.) Additional Core criteria represent fundamental building blocks in the areas of: Behavioral Health integration More rigorous Care Coordination Health IT capabilities VBP arrangements Population Health Providers would then complete 4-7 elective criteria to earn 7 additional credits 1 PCMH 2017 NYS PCMH Continuation of TA vendor activities 1 From an NCQA point of view, the practice will have then completed NCQA's 40 Core criteria and earned 25 Elective credits (18-19 credits depending on if VBP is upside only or full risk earned from completing the 12 Elective criteria that were converted to Core for NYS PCMH, plus 6 additional credits). Source: NCQA PCMH 2017

12 Detail: Proposed 12 new core criteria Behavioral health Code CC9 KM4 CM3 Criteria Works with behavioral healthcare providers to whom the practice frequently refers to set expectations for information sharing and patient care Conducts BH screenings and/or assessments using a standardized tool. (implement two or more) A. Anxiety B. Alcohol Use Disorder C. Substance Use Disorder D. Pediatric Behavioral Health Screening E. PTSD F. ADHD G. Postpartum Depression Applies a comprehensive risk - stratification process to entire patient panel in order to identify and direct resources appropriately Care management and coordination CC8 CM9 CC19 Works with non-behavioral healthcare specialists to whom the practice frequently refers to set expectations for information sharing and patient care Care plan is integrated and accessible across settings of care Implements process to consistently obtain patient discharge summaries from the hospital and other facilities KM11 Identifies and addresses population-level needs based on the diversity of the practice and the community (Demonstrate at least 2) A. Target pop. health mgmt. on disparities in care B. Address health literacy of the practice C. Educate staff in cultural competence Health IT VBP AC8 AC12 CC21 TC5 QI19 Has a secure electronic system for two-way communication to provide timely clinical advice Provides continuity of medical record information for care and advice when the office is closed Demonstrates electronic exchange of information with external entities, agencies and registries (may select 1 or more): RHIO, Immunization Registry, Summary of care record to other providers or care facilities for care transitions The practice uses an EHR system (or modules) that has been certified and issued an ONC Certification ID, conducts a security risk analysis, and implements security updates as necessary correcting identified security deficiencies The practice is engaged in Value-Based Contract Agreement. (Maximum 2 credits) A. Practice engages in up-side risk contract 1 1 A value-based program where the clinician/practice receives an incentive for meeting performance expectations but do not share losses if costs exceed targets. Source: 2017 NCQA PCMH

13 SIM/APC NYS PCMH Timeline NCQA Initial Proposal 9/8/2017 New TA Contracts Begin 2/1/2018 NYS DSRIP Practices need to complete PCMH 2014 Level 3 (or APC Gate 2) 3/31/ Sep Oct Nov Dec 2018 Feb Mar Apr 2018 Today 1/31/2018 SIM Grant Year Ends 4/1/2018 Proposed Launch for NYS PCMH Continued Discussions with NCQA Update SIM Operational Plan 9/11/ /30/ /1/ /30/2017

14 APC Recruitment Status 11/06/17 County Boundary Region Boundary 2,439 Proposed 994 Engaged 436 Enrolled 17.88% Complete Statewide Region Proposed 1 Engaged 11 Enrolled 10% Complete Region 2 Region 5 0 Proposed 5 Engaged 20 Enrolled Region Proposed 9 Engaged 30 Enrolled 11% Complete 289 Proposed 200 Engaged* 13 Enrolled 5% Complete Region 6 70 Proposed 0 Engaged 2 Enrolled 3% Complete Region Proposed 22 Engaged 19 Enrolled 15% Complete Region 4 1,070 Proposed 556 Engaged* 215 Enrolled 20% Complete *For purposes of those medical practices considered engaged, OQPS is adopting PTTS figures as entered by TA contractors with exception of NYeC and NYC Reach which reflects their originally proposed goals for practices to be enrolled within a region. This is due to their use of linking engagement to pre-identified lists of practices that are involved in past or current TA activities but may not accurately reflect reasonable expectations of enrollment. Region Proposed 201 Engaged* 125 Enrolled 25% Complete

15 Other Transformation Efforts: SHIN-NY Health IT Infrastructure 15 Home Care Agency Community Hospital Medical Center Clinicians RHIO KEY = Transmission of Clinical Patient Information Primary Doctor s Office Reference Laboratory Nursing Home

16 The SHIN-NY Core Services 16 Since March 2015, all RHIOs must provide the following Core Services to Participants 1. Statewide Patient Record Lookup 2. Statewide Secure Messaging (Direct) 3. Notifications (Alerts / Subscribe and Notify) 4. Provider & Public Health Clinical Viewers 5. Consent Management 6. Identity Management and Security 7. Public Health Reporting Integration 8. Lab Results Delivery No charge for these services beyond initial setup SHIN-NY Value Studies, Whitepapers, Videos and other Resources:

17 SHIN-NY Progress 17 v v v As of March 31 st, 2017

18 NY State All Payer Database (APD): 18

19 NY State All Payer Database (APD): 19

20 NY State APD: 20

21 21 New York State Innovation Themes: Redesigning primary care Population health management Pay for value, not volume

22 22

23 23 Sepsis in New York State Approximately 50,000 patients are diagnosed with severe sepsis or septic shock each year - Almost 30% of adults, 9% of children, die in the hospital Early detection coupled with appropriate interventions can improve the chances of survival for patients with sepsis

24 24 NY State Sepsis Improvement Goals Increase the capacity of clinicians in NY State to recognize and treat sepsis Reduce adverse outcomes Decrease variation for sepsis mortality between hospitals

25 25 Department Actions Created Sepsis Advisory Group Developed a data dictionary Data collected quarterly, 70 variables, including treatment, severity, comorbidities, and discharge including 3 hour and 6 hour bundles for adults (used NQF-500 as a guide) Convened a group of clinical advisors from different pediatric subspecialties (critical care, ER, academics) to develop an 1 hour bundle for pediatrics Data collection started Q2, 2014 Hospitals have the ability to correct data Audit of data Increasing alignment with CMS SEP-1

26 26 Quarterly Data Reports from/to Hospitals Hospitals to DOH/IPRO Quarterly reported severe sepsis and septic shock cases, up to 2 months after closure of quarter Including all transfer cases DOH/IPRO to Hospitals Quarterly performance report includes Demographics Protocol exclusions Protocol implementation Treatment variables Treatment bundles (25 th /75 th percentile benchmark, all hospitals) Time Zero, transfers

27 27 Evidence-Based Interventions for Sepsis Adults Interventions recommended within first 3 hours include o o o Measurement of blood lactate level Obtain blood cultures prior to antibiotics Administer broad spectrum antibiotics Interventions recommended within first 6 hours include o o o Fluids Vasopressors Re-measure blood lactate level Pediatrics: Interventions recommended within first hour include o o o Parenteral (IV) Fluids Obtain blood cultures Administer broad spectrum antibiotics 3-Hour Bundle Helps direct appropriate care and provide early treatment 6-Hour Bundle Only for patients with septic shock 1-Hour Bundle

28 28 Sepsis Care Improvement Initiative Partners NYS DOH Office of Quality and Patient Safety External Academic Partners New York State Hospitals and Clinicians Sepsis Care Improvement Initiative Sepsis Advisory Work Group GNYHA HANYS

29 29 First Annual Public Report Describes the quality of care and outcomes for patients treated for severe sepsis/septic shock at NYS hospitals in 2015 Data reported for 170 hospitals First report of its kind in the nation

30 30 Adult Performance Measures in Report % of patients (18 years or older) receiving care using the hospital s sepsis protocol 2016 Q Q2 74% 85% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % of patients (18 years or older) who received all the recommended treatments in the 3-hour early management bundle % of patients (18 years or older) who received all the recommended treatments in the 6-hour early management bundle 2016 Q3 55% 2014 Q2 42% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2016 Q3 36% 2014 Q2 23% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

31 31 Outcome Measures in Report Crude adult (18 years and older) in-hospital mortality rate Crude pediatric (0 to 17 years) in-hospital mortality rate Note: More variability due to significantly smaller numbers of pediatric patients and lower mortality rate Adult risk-adjusted mortality rates (RAMR) Accounts for patient demographic factors, sepsis severity, and chronic conditions Adjustment is necessary to compare rates across hospitals

32 Percentage 32 Adult Outcome Measure in Report: Adult In-Hospital Mortality 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 30.2% 30.4% 30.6% 32.0% 28.4% 27.9% 27.3% 28.0% 26.4% 25.4% 20.0% 10.0% 0.0% 2014Q2 2014Q3 2014Q4 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 Quarter

33 Percentage 33 Pediatric Outcome Measures in Report: Pediatric In-Hospital Mortality 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 6.8% 10.0% 11.5% 15.3% 8.8% 6.5% 8.6% 9.5% 6.8% 10.5% 5.0% 0.0% 2014Q2 2014Q3 2014Q4 2015Q1 2015Q2 2015Q3 2015Q4 2016Q1 2016Q2 2016Q3 Quarter

34 34 Adult Outcome measure: Risk Adjusted Mortality Rates per Hospital This figure shows the RAMR and 95% confidence interval for each hospital in the sepsis public report. Blue represents high performers (lower than expected deaths). Gold represents low performers (higher than expected deaths).

35 35 Results of Analyses After adjusting for patient factors, the odds of dying are 21% less for adult patients for whom a protocol was initiated at the hospital compared to patients for whom a protocol was not initiated. 27% less for adult patients who receive all of the recommended treatments within three hours compared to patients who do not receive all of the recommended treatments. 26% less for adult patients who receive all of the recommended treatments within six hours compared to patients who do not receive all of the recommended treatments

36 In-hospital mortality (%) In-hospital mortality (%) In-hospital mortality (%) 36 Publication Results Crude in-hospital mortality (%) and predicted risk of in-hospital mortality adjusted for covariates across a range of time after protocol initiation for completing the 3-hourt bundle (Panel A), receiving broad-spectrum antibiotics (Panel B), and completing the initial IV fluid bolus (Panel C) for a typical patient, Error bars represent 95% confidence intervals. A B C 35 Crude Risk adjusted 35 Crude Risk adjusted 35 Crude Risk adjusted Time to complete the 3-hour bundle (hrs) Time to administration of antibiotics (hrs) Time to complete the inital IV fluid bolus (hrs) Seymour CW, Gesten F, Prescott HC et al. N Engl J Med May 21

37 37 Next Steps Focus on Quality Improvement Variation in mortality rates = Opportunity to improve and save lives Data collection improvement & alignment with CMS Analysis to evaluate relationship between protocol adherence measures, specific interventions, patient/care characteristics and outcomes in adults and pediatrics

38 38 Other Population Health Activities: Cardiac Services: Disease specific reports e.g. Acute Myocardial Infarctions Stroke: Risk-adjusted outcomes, updating designation Office Based Surgery: Adverse Events Database redesign

39 39 New York State Health Topics: Redesigning primary care Population health management Pay for value, not volume

40 40 New York Medicaid s State s Value Based Payment (VBP) Goal 40

41 41 SIM/APC Commercial VBP Payment Goals Enrollment Year 1 Year 2 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 APC Continuous improvement Progress against Capabilities and measures Commitment Satisfy minimum enrollment requirements Activation 6-month milestones Readiness for care coordination 12-month milestones Improved quality and efficiency Material improvement against select APC core measures Financial sustainability Savings sufficient to offset investments Measurement/ verification Gate Gate Gate Practice transformation support Technical assistance for practice transformation (1 or 2 years) Grant-funded, ~$12,000 per APC site, per year of support Financial support during transformation Payer-funded, ~$X PMPM Ends when care coordination payments begin Value-based payment Care coordination payments Payer-funded, ~$Y-Z PMPM, risk adjusted Continuation of care coordination payments Payer-funded, contingent on yearly practice assessment Outcomes-based payments Bonus payments, shared savings, risk sharing, or capitation, gated by quality on core measures

42 CMS Medicare VBP Payment Goals 42

43 Goal: Alignment of Public and Commercial Models 43 Payment Model Design Attribution Measurement

44 Example: APC Primary Care measure set 44

45 45 Summary: Building a sustainable primary care model for the future Population health management and improvement is key Payment for value, not volume, to drive change Building a High Performing Health System in New York

46 Thank You! 46

47 For more information: 47 Contact Website: Direct contact: