National Initiative for Asthma Reimbursement

2015 2016 2017 Green & Healthy Homes Initiative. All rights reserved. National Initiative for Asthma Reimbursement Achieving Reimbursement for Environmental Health Services November 16, 2017 A recording of this webinar can be found here: https://attendee.gotowebinar.com/recording/5722649446588761602

Webinar Logistics To join: 1. Open the calendar invitation you received after registering for the webinar. 2. Click the Join URL when it's time to start. 3.If using a telephone,* dial in and enter the Audio Pin provided in the GoToWebinar control panel. *We recommend using a phone to avoid echo problems If you are experiencing difficulties in joining the webinar, please email Kevin Chan (kchan@ghhi.org) www.ghhi.org 2

Agenda Introductions Overview of EPA Indoor Environments Division Overview of GHHI Introduction to Center for Health Care Strategies Overview of the National Initiative for Asthma Reimbursement Overview of Business Development Technical Assistance Services Q&A www.ghhi.org 3

Introductions Welcome from Executive Sponsors Ruth Ann Norton President & CEO Green & Healthy Homes Initiative Tracey Mitchell, RRT, AE-C Environmental Protection Specialist Environmental Protection Agency www.ghhi.org 4

Protecting Public Health and the Environment through Health Care Collaboration and Reimbursement of Preventive Asthma Control Strategies Tracey Mitchell, RRT, AE-C U.S. Environmental Protection Agency Indoor Environments Division 5

EPA s Role in Asthma Agency Mechanisms Regulatory Measures Research Guidance Development Outreach & Education Partnerships; Leveraging systems IED Asthma Program Aim Get environmental controls into all elements of asthma management. Health care Housing Schools Community Systems, with a special focus on EJ

Asthma Program History at a Glance: 1990-Present 7

Environment Plays a Critical Role in Asthma Control Federal asthma guidelines recognize environmental trigger reduction as a critical component of comprehensive asthma care. * The evidence base demonstrates that in-home environmental interventions are effective at improving asthma control in children and adolescents. NHLBI. Guidelines for the Diagnosis and Management of Asthma (EPR-3). 2007. https://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines CDC. The Guide to Community Preventive Services. 2005. https://www.thecommunityguide.org/ 8

Evolution of IED s Asthma Program Sustainable Financing Science, Policy & Practice in Place 9

Federal Agencies Working to Expand Access to In-Home Asthma Care Services

EPA Supports High Value, In-Home Environmental Interventions Meeting Communities Where They Are

Synthesize and Spread Learning: Understanding How to Secure Sustainable Financing AsthmaCommunityNetwork.org/Financing 12

Introductions The GHHI National Initiative for Asthma Reimbursement Team Brendan Brown Senior Associate Project Lead Lead, data & evaluation Michael McKnight VP, Policy & Innovation Overall portfolio manager Kiersten Sweeney Social Innovation Specialist Site lead Kevin Chan Social Innovation Specialist Site lead Andrew Olson Social Innovation Specialist Lead, health policy & funder relations Cooper Sutton Lead, data & evaluation www.ghhi.org 14

Overview of GHHI GHHI has a long history of working towards healthy housing for all. 2017 EPA-supported Technical Assistance Providing technical assistance to support comprehensive asthma interventions 2016 National Lead Summit Launched concept paper on addressing leadpoisoning through Social Impact Bond 2016 Robert Wood Johnson Foundation Award expands Pay for Success portfolio to 11 asthma projects including state governments 2015 Social Innovation Fund Award Award expands to 6 national sites to advance asthma Pay for Success across private business models 2015 EPA Asthma Award Proud recipient of EPA s National Environmental Award in Asthma Management 2009 Becomes GHHI Expand scope and scale to break the link between unhealthy homes and unhealthy families nationally 1986 Founded Parents Against Lead became the Coalition to End Childhood Lead Poisoning www.ghhi.org 15

Overview of GHHI Breaking the link between unhealthy homes and unhealthy families to improve health, economic, and social outcomes. Source(s): Philanthropy Government Private-sector System Single intake system Comprehensive assessment Coordinate services Integrated interventions Cross-trained workers Shared data GHHI $ Outcomes Lead-hazard reduction Asthma-trigger control Household injury prevention Energy efficiency Weatherization Housing rehabilitation Accomplishments 98% reduction of lead poisoning in Maryland 35 pieces of legislation passed 25 GHHI-designated sites across the country Over $300 million raised Over 500,000 integrated healthy homes, lead hazard reduction, and energy efficiency units in partnership with HUD www.ghhi.org 16

Overview of GHHI GHHI leads development of 12 asthma-focused Pay for Success projects with healthcare and service provider partners across the country. Feasibility ongoing Chicago-Presence Health Houston-Community Health Choice Philadelphia-Health Partners Plans Rhode Island-State Medicaid Funders of asthma PFS feasibility studies: Post-feasibility transition Buffalo-YourCare Health Plan Grand Rapids-Spectrum Health Houston-UnitedHealthcare Memphis-Le Bonheur Children s Hospital New York City-Affinity Health Plan Springfield-Baystate Health Transaction structuring Baltimore*-Johns Hopkins Medicine Salt Lake County-U. of Utah Health Plans *GHHI is the service provider in the Baltimore PFS project. GHHI is a technical services provider on all other projects. www.ghhi.org 17

About the Center for Health Care Strategies Non-profit policy center dedicated to improving the health of low-income Americans www.ghhi.org 18

Goals of the National Initiative for Asthma Reimbursement The National Initiative for Asthma Reimbursement has three main goals, which we will work toward simultaneously. 1 Increase the number of home visiting programs providing comprehensive asthma (including environmental remediation of asthma triggers) interventions. 2 Increase the number of health plans serving Medicaid populations and/or state Medicaid programs that reimburse for these comprehensive services. 3 Increase the use of standardized environmental management & health outcomes metrics for evaluation (EMHOME) www.ghhi.org 20

Community Clinical Providing a Continuum of Healthcare from the Clinic into the Home There is a strong evidence base for the efficacy and efficiency of comprehensive asthma interventions that provide environmental health services. Based on a review of the evidence base, the NIH s National Asthma Education and Prevention Program recommends four components of effective asthma care. Four components of asthma care Medications Assessment and monitoring Patient education Control of environmental factors Asthma programs use a community-based element to reinforce clinical interventions and also address environmental triggers for the patient and family. Research shows that environmental control should be performed in a comprehensive manner using a multi-trigger, multicomponent approach. Ex: Mold remediation, ventilation, removal of carpets and dust sinks for dust mites and allergens, integrated pest management Although the evidence shows that comprehensive interventions can improve asthma outcomes, the healthcare system does not traditionally pay for these types of services. www.ghhi.org 21

Overview of the National Initiative for Asthma Reimbursement The National Initiative for Asthma Reimbursement seeks to advance evidence-based comprehensive interventions through three support services. 1 Business development technical assistance 2 Reimbursement technical assistance 3 Environmental Management & Health Outcomes Metrics for Evaluation (EMHOME) system www.ghhi.org 22

Overview of the National Initiative for Asthma Reimbursement There are three discrete opportunities within the National Initiative for Asthma Reimbursement Business Development Technical Assistance Goal: Develop and implement asthma home visiting programs that provide or are seeking to provide comprehensive environmental health service Timeline: Each cohort (5 sites) will receive 8 months of technical assistance. Cohort 1 (2018) will run from January 15 September 30, 2018 Eligibility criteria: 2 partners willing to participate: a health care entity & a service provider Interest in delivering environmental health services Key Dates Nov 8: RFP released Dec 15: Applications due 8p ET Jan 22: Public award announcement Business Development Technical Assistance Cohort Timeline Cohort year 2018 2019 2020 TA sites per cohort 5 sites 5 sites 5 sites www.ghhi.org 23

Overview of the National Initiative for Asthma Reimbursement There are three discrete opportunities within the National Initiative for Asthma Reimbursement Reimbursement Technical Assistance Goal: Increase Medicaid funding for these comprehensive environmental health service interventions. Timeline: Each cohort will receive up to 8 months of technical assistance Eligibility criteria: Operational program that includes environmental health services Established partnership with healthcare entity Key Dates: Dec 18: RFP released Jan 8 (4p ET): Informational webinar Jan 15: Proposals due at 8p ET Reimbursement Technical Assistance Cohort Timeline Cohort year 2018 2019 2020 TA sites per cohort 2 sites 4 sites 4 sites Projects that successfully complete the business development phase will be encouraged to apply for the Reimbursement phase in the following year. www.ghhi.org 24

Overview of the National Initiative for Asthma Reimbursement There are three discrete opportunities within the National Initiative for Asthma Reimbursement EMHOME System Goal: Convene and manage the Asthma Outcome Metrics Working Group to develop Environmental Management & Health Outcomes Metrics for Evaluation (EMHOME) system Key Dates: Feb 7: Convene working group Aug 2018: Final working group meeting Sept 2018-20: Collect data & report Components: The full working group will convene monthly from February August 2018 Topical sub-groups will be formed for each area of expertise, including: Outcomes Coordination of care Control of environmental factors and comorbid conditions Assessment & monitoring of asthma severity and control Patient education for self-management Medication adherence compliance Intervention cost and billing www.ghhi.org 25

Overview of Business Development Technical Assistance Services GHHI will provide technical assistance to the five selected sites across eight different areas with specific planned deliverables. Technical assistance areas: 1. Project planning 2. Stakeholder analysis 3. Data management 4. Operations planning 5. Payer engagement 6. Benefit-cost analysis 7. Evaluation design Deliverables Operations plan Data management plan Benefit-cost analysis to determine ROI Evaluation plan Business plan 8. Business plan www.ghhi.org 27

Overview of Business Development Technical Assistance Services Business Development Timeline Activities 00 Project selection (5 sites) 01 Project planning 02 Stakeholder analysis 03 Data management 04 Operations planning 05 Payer engagement 06 Benefit-cost analysis 07 Evaluation design 08 Business plan Project timeline (Cohort 1, Jan Sept 2018) Jan Feb Mar Apr May Jun Jul Aug Sept 00 01 02 03 04 05 06 07 08 Site visits www.ghhi.org 28

Example Technical Assistance Services Types of technical assistance provided by GHHI. 1 Payer Engagement 2 Asthma costs vary by medical need stratification $, Plan average annual claims spending per enrollee Data Analysis for Defining a Target Population www.ghhi.org 29

Example Technical Assistance Services Types of technical assistance provided by GHHI. 3 4 Operations Planning Benefit-cost analysis Process flow design Subpopulation economic projections $ thousands per enrollee, (log scale) 16.00 14.00 12.00 10.00 8.00 6.00 4.00 2.41 3.30 2.00-14.83 10.32 4.34 3.45 IP - Adult IP - Pediatric ED - Adult ED - Pediatric Savings per enrollee Service cost Subsidy Total cost www.ghhi.org 30

Overview of Business Development Technical Assistance Services GHHI will assess six core areas to produce an assessment of the business plan created collaboratively through the technical assistance deliverables. Technical The evidence for the program s ability to produce the desired outcomes for the defined population and geography. Sociopolitical The stakeholder ecosystem and its ability to affect project success. Economics The case for the business model, cost structure, revenue streams, economics on a unit basis, and assessment of scalability. Payment mechanism Institutional, legal, policy, and regulatory issues related to the ability of a payer to reimburse for services. Operational The project team s capacity to implement the program, scale it effectively, and maintain operational excellence throughout. Capital availability The ability to support the capitalization of the program either internally or with external partners. In the final business plan we determine the strengths and weaknesses of the project on a scale of 1-5 for each of these categories, given the project partners, parameters, and the plans in place. http://www.greenandhealthyhomes.org/sites/default/files/ghhi%20-%20determining%20the%20feasibility%20of%20pay%20for%20success%20projects.pdf www.ghhi.org 31

Requirements Eligibility Criteria Overview of Business Development Technical Assistance Services To apply for technical assistance, the applicant must meet a set of eligibility criteria and requirements. Use requested Business Development support for a project that delivers home visiting asthma self-management education, environmental assessment, & environmental control practices aimed at reducing exposures. Have two partners willing to participate as project leaders: one from a health care entity partner and one from a service provider partner. Enter into a Memorandum of Understanding with GHHI for technical assistance services Contribute in-kind hours, estimated at 300-360 hours from each partner, to support the technical assistance GHHI will provide Participate in knowledge-sharing activities and make publicly available all non-confidential documents and tools developed during the agreement period www.ghhi.org 32

Overview of Business Development Technical Assistance Services The Business Development RFP outlines all necessary application materials, submission guidelines, and selection criteria. Application materials Cover sheet Proposal narrative Most recent A-133 audit, if applicable Most recent financial statement Letters of commitment from partner organizations leadership (optional, but recommended) Additional project-related documents, such as program evaluation report (optional, but recommended) GHHI will provide each applicant the opportunity to have a telephone call of no more than 30 minutes with GHHI staff to answer questions about the opportunity. www.ghhi.org 33

Overview of Business Development Technical Assistance Services Important dates and links November 8, 2017: RFP released View application materials here: http://www.greenandhealthyhomes.org/gethelp/national-resources November 16, 2017: Informational webinar for prospective applicants December 15, 2017: Applications due at 8p ET January 22, 2018: Public announcement of awards www.ghhi.org 34

Questions? Ruth Ann Norton President & CEO ranorton@ghhi.org Brendan Brown Project Lead bbrown@ghhi.org Website: http://www.greenandhealthyhomes.org/ Twitter: @HealthyHousing Facebook: GHHInational Instagram: healthy_housing www.ghhi.org 36 2016 2015 Green & Healthy Homes Initiative. All rights reserved.

GHHI project scoring rubric (1/2) Technical Economic Operational Very high feasibility 5 High feasibility 4 Moderate feasibility 3 Low feasibility 2 Very low feasibility 1 Multiple independent, experimental or quasiexperimental studies and/or substantive operational data demonstrating achievement of the planned PFS outcomes with the planned PFS intervention, population, and setting. Multiple studies and/or operational data demonstrating achievement of outcomes related to those in PFS plans. Studies are nonexperimental and/or nonindependent. Intervention may not be as complete as one in PFS plans, but is near complete. Population and setting are similar to those in PFS plans. Plans for an evidencebased intervention aligned with established bestpractices that will be implemented for first time with PFS partners who have been providing similar services for multiple years. Partners have at least demonstrated positive outcomes with self-reported data. Plans for an intervention supported with evidence from other settings or populations with PFS partners who have not provided similar services previously OR plans for a new intervention backed by little to no research with PFS partners who have an established working history. Plans for an intervention backed by no evidence with partners who have no history partnering together or providing similar services. Significant evidence of the full PFS intervention achieving measurable cashable savings, or outcomes that a potential payer values, substantially above all projected PFS intervention and transaction costs with a population and setting similar to those in the PFS plans. Evidence of the PFS intervention, or components of it, achieving some measurable cashable savings, and/or outcomes that a potential payer values, above all projected PFS intervention and transaction costs with a population and setting similar to those in the PFS plans. Evidence of the PFS intervention, or components of it, achieving outcomes associated with cashable savings, or outcomes that a potential payer might value, above at least the projected PFS intervention costs with a population and setting similar to those in the PFS plans. Evidence of the intervention achieving outcomes associated with cashable savings, or outcomes that a potential payer might value, but unclear if savings/value outweigh projected PFS intervention costs. No evidence of the intervention achieving outcomes associated with cashable savings or producing value for a potential payer. Service provider(s) has multiple years partnering to successfully implement and manage performance of the complete PFS intervention with a scale, population, and setting similar to that in PFS plans. Service provider(s) has multiple years partnering to successfully implement and manage performance of most components of PFS intervention at scale or complete PFS intervention on smaller scale, but with necessary capacity and plans to scale and manage performance with planned PFS population and setting. Service provider(s) has multiple years successfully providing related services, but full PFS intervention is a new endeavor. Team has strong plans in place to scale and manage performance in the planned PFS population and setting. Service provider(s) has no experience providing related services, but has plans to scale and manage performance. Significant untested assumptions exist related to PFS operational plans. Service provider(s) has a history of not meeting performance management goals or intervention is completely new and team has weak plans in place to scale and manage performance. www.ghhi.org 38 2016 2015 Green & Healthy Homes Initiative. All rights reserved.

GHHI project scoring rubric (2/2) Payment mechanism Sociopolitical Capital availability Very high feasibility 5 High feasibility 4 Moderate feasibility 3 Low feasibility 2 Very low feasibility 1 Key internal and external stakeholders including pertinent local, state, and federal government agencies have actively demonstrated support of PFS project. Key internal and external stakeholders, including pertinent local, state, and federal government agencies, are educated on and supportive of PFS project. Team is confident that no sociopolitical barriers exist to structuring and launching the PFS transaction. A few key internal and external stakeholders or pertinent local, state, and federal government agencies are educated on and supportive of PFS project. Team is unaware of any sociopolitical barriers to structuring and launching the PFS transaction, but has not confirmed. Team does not know who the key stakeholders are and has made no contact with any to discuss PFS project or some key stakeholders are ambivalent toward PFS project. Potential sociopolitical barriers to structuring and launching the PFS transaction exist. Key stakeholders required to advance project actively expressed disapproval and/or significant sociopolitical barriers to structuring and launching the PFS transaction exist. A clearly defined payment mechanism, including any applicable legislation, that has been used by similar projects exists. A clearly defined payment mechanism exists that has not been used but has been committed to by the necessary parties. A number of viable payment mechanisms exist that are supported but not yet committed to by the necessary parties. A limited number of possible payment mechanisms exist but have not yet been discussed with necessary parties. Few, if any, possible payment mechanisms are readily apparent or have a reasonable chance of being advanced. Strong evidence of capital availability and investment, nationally and locally, from parties with a history of involvement in similar projects and active interest from one or more potential funders. Strong evidence of capital availability and investment, nationally and locally, from parties with a history of involvement in similar projects. Project team has strong relationships with those parties. Some evidence of capital availability and investment, nationally or locally, in related projects. Project team has limited relationships with potential funders. Very little evidence of capital availability and investment, nationally or locally, in related projects. Project team has limited to no relationships with potential funders. No evidence of capital availability and investment in related projects and/or active disinterest found among potential funders in investing in related projects. www.ghhi.org 39 2016 2015 Green & Healthy Homes Initiative. All rights reserved.