Designing a Medicaid ACO Program: Insights from Trailblazing States

Designing a Medicaid ACO Program: Insights from Trailblazing States February 11, 2016, 3:30 5:00 pm ET For Audio Dial: 877-830-2582 Passcode: 805070 Made possible by The Commonwealth Fund www.chcs.org

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Agenda I. Welcome and Introductions II. III. Overview of Medicaid ACO Design Considerations Background on Trailblazing Programs Colorado s Accountable Care Collaborative Minnesota s Integrated Health Partnerships IV. Moderated Panel Discussion and Q&A 3

Welcome and Introductions Tricia McGinnis Vice President CHCS Pamela Riley Assistant Vice President Delivery System Reform The Commonwealth Fund Rob Houston Senior Program Officer CHCS Susan Mathieu Accountable Care Collaborative Program Manager Colorado Department of Health Care Policy and Financing Heather Petermann Manager, Health Care Delivery & Payment Reform Minnesota Department of Human Services 4

commonwealthfund.org Pamela Riley Assistant Vice President, Delivery System Reform

About the Center for Health Care Strategies A non-profit health policy resource center dedicated to advancing access, quality, and costeffectiveness in publicly financed health care 6

The Medicaid ACO Learning Collaborative Initiative designed to help states plan and launch their Medicaid ACO Programs through peer-to-peer learning and technical assistance Now in third phase Helped 13 states develop and improve their programs; five of which have already launched Now accepting applications for Phase IV Peer-to-peer learning opportunities Forthcoming Medicaid ACO Resource Center and newsletter 7

Overview of Medicaid ACO Design Considerations Rob Houston Senior Program Officer CHCS www.chcs.org

Program Design Considerations for Medicaid Accountable Care Organizations CHCS issue brief outlining findings from the Medicaid Accountable Care Organization Learning Collaborative Insights on designing a Medicaid ACO model Input from 8 states with active Medicaid ACO programs CO, IL, ME, MN, NJ, OR, UT, VT Download from the CHCS website 9

What are Accountable Care Organizations? Accountable Care Organizations (ACOs) are designed to hold providers accountable for improving health outcomes and controlling costs Key ACO features include: Value-based payment incentives Provider-level financial accountability Robust quality measurement Data sharing and analysis On the ground care management Provider/community collaboration 10

Designing a Medicaid ACO program Evaluate the Current Environment Define Program Goals/ Framework Develop a Structural Model States perform these three steps when designing a Medicaid ACO program While these steps will not be conducted uniformly across states, they do provide a helpful guideline for the process 11

Evaluate the Current Environment Provider readiness Ability to perform ACO financial and care management Market dynamics Managed care? Dominant payers or providers? Existing programs Can ACOs be built on existing efforts? Political factors Where impetus of program originates can influence its formation and attributes 12

Define Program Goals/Framework Think about program goals Should be clear, measurable, and achievable Should address identified problems Define scope of the model Will it be a pilot or statewide effort? Should the program be prescriptive or flexible? Are there any must have structural elements? 13

8 Key Design Questions to Develop a Structural Model 1. Who will lead the ACOs? 2. Whom will the ACOs serve? 3. How will patients be attributed? 4. What services will ACOs provide? 5. How will the payment model be structured? 6. How will quality be measured? 7. How will data be collected and analyzed? 8. How will MCOs be involved (if applicable)? 14

Design Questions Walkthrough 1. Who will lead the ACOs? Providers or payers? Another entity or partnership? 2. Whom will the ACOs serve? Full population or sub-population? Include Medicare-Medicaid enrollees? 3. How will patients be attributed? Retrospectively or prospectively? By utilization or geographically? 15

Design Questions Walkthrough 4. What services will ACOs provide? States have included physical health, behavioral health, long-term supports and services, oral health, pharmacy, non-emergency medical transport 5. How will the payment model be structured? Pay-for performance Shared savings/risk Global or capitated payments 6. How will quality be measured? How many/which metrics will be used? How will metrics be tied to payment? 16

Design Questions Walkthrough 7. How will data be collected and analyzed? Insource or outsource? How will contractors be utilized (if at all)? 8. How will MCOs be involved (if applicable)? Will MCOs be part of an ACO, the ACO itself, or not involved? What responsibilities will MCOs have relative to ACOs and vice versa? 17

A Final Consideration States should be mindful of future iterations when designing their Medicaid ACO program Colorado and Minnesota are currently seeking to update their programs to Version 2.0 in 2017 18

Colorado s Accountable Care Collaborative Program Susan Mathieu Accountable Care Collaborative Program Manager February 11, 2016

Colorado s Accountable Care Collaborative (ACC) Program Regionally-based delivery system for Colorado Medicaid Serves as primary physical health delivery system and the primary platform for Medicaid reform Primary care case management model with a focus on care coordination, practice support, and making available an unprecedented level of data and analytics Desired outcomes of the ACC are based on the Triple Aim ACC Phase I

Developing the ACC Program Created in response to: Unsuccessful experience with capitated managed care 85% in an unmanaged Fee-For-Service (FFS) system Unprecedented economic situation, highest Medicaid caseload and expenditures in state history Desire not to continue to pay for higher volume/utilization Colorado s delivery system reform Governor s agenda, stakeholder input, and budget-savings action Developed prior to the federal Medicare ACO concept ACC Phase I

ACC Program Structure Regional Care Collaborative Organizations (RCCOs) Primary Care Medical Providers (PCMPs) Statewide Data and Analytics Contractor (SDAC) 22 ACC Phase I

Regional (RCCO) Role Achieve financial and health outcomes, accountability and reporting to the State Medical management and care coordination Network development/management Connect clients with medical homes (PCMPs) Offer provider support PCMP Role Person-centered medical homes Coordinated, accessible care SDAC Role Data and analytics Web portal for RCCOs, PCMPs

ACC Successes Iterative pay-for-performance system, strong networks, local connections, and a platform for innovation. Net savings of more than $77 million dollars over the program s first four years Lower rates of exacerbated chronic health conditions such as hypertension (5%) and diabetes (9%) relative to clients not enrolled in the ACC Program 22% reduction in hospital admissions among ACC members with COPD who have been enrolled in the program <6 months, compared to those not enrolled Reductions in high-cost imaging and hospital readmissions ACC Phase I

Next Phase of the ACC Program Colorado is required to re-procure Regional Care Collaborative Organizations in 2017-2018. The Program is being redesigned with the following in mind: System-level integration of administrative entities responsible for physical health and behavioral health Moving to an increasingly whole-person definition of health Closer alignment with LTSS and other delivery systems in the state Moving to more value-based payments Making use of new data / HIT investments ACC Phase II

Minnesota s Medicaid ACOs: Integrated Health Partnerships HEATHER PETERMANN MINNESOTA DEPARTMENT OF HUMAN SERVICES F E B R U A RY 11, 2 0 1 6

Approach to MN Medicaid ACO development Integrated Health Partnership (IHPs) demonstration authorized in 2010 by MN Statutes, 256B.0755 Builds on a long history of reform Define the what (better care, lower costs), rather then the how Allow for broad flexibility and innovation under a common framework of accountability for patient s total cost of care

IHP Model Components Eligible recipients Non-dual, across both FFS and all Medicaid MCO enrollees Attributed using past encounters/claims Provider requirements Voluntary contracts under model options Virtual (shared savings only) and Integrated (negotiated gain/loss sharing) based on size and structure Flexibility in governance structure and care models Payment and quality model Defined core set of services, IHP may elect to include additional services Existing payments persist with gain-/loss-sharing payments made annually based on risk-adjusted TCOC performance, contingent on quality performance Provider supports Data analytics and reporting feedback Learning collaboratives

How do we calculate total cost of care (TCOC)? Performance compares each IHP s base year (year prior to their start) TCOC to their subsequent years risk adjusted and trended TCOC. LOSS: Delivery system pays back a prenegotiated portion of spending above the minimum threshold GAIN: Savings achieved beyond the minimum threshold are shared between the payer and delivery system at pre-negotiated levels

Quality Measurement Performance on quality measures impacts the amount of shared savings an IHP can receive; phased in over 3-year demo Year 1 25% of shared savings based on reporting only Year 2 25% of shared savings based on performance Year 3 50% of shared savings based on performance Core set of measures based on existing state reporting requirements Minnesota s Statewide Quality Reporting and Measurement System Core includes 7 clinical measures and 2 patient experience measures, totaling 32 individual measure components across both clinic and hospital settings IHPs have flexibility to propose alternative measures and methods Each individual measure is scored based on either achievement or yearto-year improvement

IHP Successes: Participant Growth and Savings 400,000 350,000 ACOs = 19 Enrollees = 342,314 Providers = 8,892 300,000 250,000 200,000 150,000 100,000 ACOs = 6 Enrollees = 99,107 Providers = 2,739 ACOs = 9 Enrollees = 145,869 Providers = 4,792 ACOs = 16 Enrollees = 204,119 Providers = 7,328 50,000 0 2013 2014 2015 2016 Enrollees IHPs are helping to bend the cost curve. In 2013 and 2014, they achieved a combined estimated savings of over $76 million compared to trended targets. Through 2014, all participating providers beat their targets and met quality requirements receiving shared savings settlements ranging from $570,000 to over $22 million.

IHP Lessons Learned New partnerships take time to become operational; require resources to develop necessary governance and infrastructure Value flexibility and need for multiple tracks so providers at varying places in their ability and appetite for risk arrangements can participate Interest in stabilizing support for care coordination and data analytic infrastructure (for example through a consolidated prospective payment) Desire to make continued improvements in patient attribution to capture those not accessing primary care Increasing complexity in accounting for overlap in contracting arrangements as use of value based arrangements grows

Questions? To submit a question, please click the question mark icon located in the toolbar at the top of your screen. Answers to questions that cannot be addressed due to time constraints will be shared after the webinar. 33

Panel Discussion

Visit CHCS.org to Download practical resources to improve the quality and cost-effectiveness of Medicaid services Subscribe to CHCS e-mail updates to learn about new programs and resources Learn about cutting-edge efforts to improve care for Medicaid s highest-need, highest-cost beneficiaries www.chcs.org 35