Employer Breakout Session Payment Change in Ohio: What it Means for Employers

Transcription

1 Employer Breakout Session Payment Change in Ohio: What it Means for Employers Moderators Jeff Biehl, Health Collaborative of Greater Columbus Frank A. Johnson, Maine Health Management Coalition

2 Who is leading Ohio s Payment Reform Initiatives? Ohio Health Transformation Greg Moody, Director Governor s Office of Health Transformation 3

3 One of the reasons... 4

4 The Governor s Council on Payment Innovation Convene health care purchasers, providers, plans and consumer advocates to prioritize and coordinate multi-payer health care payment innovation activities statewide Received federal State Innovation Model (SIM) grants to design and test payment models across multiple payers Provide access to medical homes for most Ohioans Use episode-based payments for acute medical events Prioritize state activities that enable payment innovation: Coordinate health sector workforce and training programs Coordinate HIT/HIE infrastructure Report and measure health system performance Support regional payment innovation 5

5 The State s Health Care Payment Innovation Partners 6

6 Ohio s Payment Innovation Goal 7

7 OHT Plan Leverages PCMH Ohio s PCMH sites as of October practices 8

8 OHT Roll-out of Comprehensive Primary Care Initiative CPCi: Comprehensive Primary Care Initiative Roll-out begins in SW Ohio; will be replicated statewide 9

9 Comprehensive Primary Care Initiative (CPCi) Payment reform initiative based on PCMH in Southwest Ohio Multi-payer PCMH: approximately 75 practices, 11 payers Medicaid Commercial Medicare Common (harmonized) Metrics Patient Experience Quality of Care Utilization and Costs Common Approach to Payment Patient Experience Shared Savings with Practices 10

10 Center for Medicare and Medicaid Innovation s CPC Program 11

11 CPCi Care and Health Outcome Metrics Surveys Pt Experience (CG CAHPS) Claims Care Coordination Unplanned Readmit ACSC Admits Overall ACSC Admits: COPD ACSC Admits: CHF Electronic Health Records BP Control Smoking Screening, Rx Breast Ca Screening CRC Screening Flu Vaccinations Pneumovax A1C Poor Control LDL Management CHF Management Falls Screening Depression Screening Med reconciliation 12

12 CPCi Utilization and Cost Metrics Costs Total Cost PMPM Total Prescription PMPM Inpatient PMPM PCP Cost PMPM Specialist Cost PMPM Emergency Department PMPM Utilization Hospital Discharges/1,000 Hospital Days/1,000 ED Visits/1,000 PCP Visits/1,000 Specialist Visits/1,000 13

13 CPCi Shared Savings Approach If the region spends less than projected, Medicare will share the savings 14

14 Why Medical Homes AND Episodes? If the region spends less than projected, Medicare will share the savings Medical homes provide the foundation for total cost/quality accountability Population-based accountability transcends delivery system Large long-term impact: prevention and chronic disease management Requires providers to fully transform business model away from FFS Requires significant provider capabilities and commitment Episodes nested within total cost of care for more specific accountability Patient-centered design around the patient journey through the delivery system Faster to impact: clear and specific opportunities to improve Stages business model transition away from FFS for specialists and hospitals Faster to scale, independent of market structure or capabilities Fit with other models Both models implemented agnostic of provider structure, can be carved out or carved in for ACO or capitation 15

15 What is an Episode of Care? Definition FAQs: Episodes of care include all the care related to a defined medical event (e.g., a procedure, an acute exacerbation of a chronic condition), including the care for the event itself (e.g.,procedures, professional claims, pharmacy), any pre cursors to the event (i.e.,diagnostictests, pre operative visits), and follow up care (e.g., follow up visits, medications, rehab, readmissions). They are built from the perspective of a patient journey through the health system, providing a more comprehensive view of care involved in treating a condition for a patient. For a given episode type, a principal accountable provider is defined who is held accountable for both the quality and cost of care delivered to the patient for the entire episode. 16

16 Who is the Principal Accountable for an Episode of Care? 17

17 Retrospective Thresholds Reward 18

18 Episodes Selection in the First Year of Rollout: 2015 Episode Principal Accountable Provider (PAP) Perinatal Physician/group delivering the baby Asthma (acute exacerbation) Facility where trigger event occurs COPD (exacerbation) Facility where trigger event occurs Percutaneous Coronary Intervention (PCI) For acute: facility where PCI performed For non-acute: physician Total Joint Replacement Orthopedic surgeon performing replacement 19

19 Variations PERINATAL 20

20 Variations TOTAL JOINT REPLACEMENT 21

21 Variations ASTHMA ACUTE EXACERBATION 22

22 And the Patient s Journey 23

23 Where the Value Lies 24

24 What Does this Mean for Employers? A Healthier Workforce and Lower Costs Where employers manage their own risk pools (self-insured), they can implement strategies that share benefits with providers, who increasingly are incented and able to provide more value-based care Lake Health Primary Care PCMH/Care Coordination initiative November

25 Before We Move On... Have we provided you understandable information about Ohio s Health Transformation initiatives? Is anything unclear? Can you begin to see ways that employers, as purchasers of health care benefits and services, might relate to these initiatives? 26

26 Next Up: Asthma Case Study At your tables, read case study and discuss: What can employers, as health care purchasers, do to improve this episode of care to achieve better health outcomes and lower costs? (30 minutes) What action items can you take back to your workplace Monday to move toward paying for value (vs. volume) (20 minutes) Tables report out ideas and 1-2 key action items (20 minutes) References: Catalyst for Payment Reform: Payment Reform Check-Up GUROO.com: Reference Asthma Care Bundle 27

27 CPR s Payment Reform Check-Up 28

28 GUROO s Asthma Care Bundle 29

29 Thank You! For more information contact: Rita Horwitz RN, Director Business Development & Operations