Why Are We Doing This?

ALIGNING PAYMENT WITH PATIENT-CENTERED CARE AND VALUE-BASED PAY Craig Hostetler MPCA Annual Conference August 5 th, 2013 Why Are We Doing This? Why Take the Risk? Our stakeholders wanted something better Patients Payers Providers & support staff Recruitment getting harder Increased pressure Transparency and accountability increasing Payment moving from volume to value 1

Policy Environment Policy Environment in Oregon Legacy of innovation Oregon Health Plan Legislature has worked well together Oregon Health Authority Created in 2009 Led by nine-member board Consolidates most state health care programs: Public Health, Oregon Health Plan, Healthy Kids, employee benefits, public-private partnerships Purchasing power to affect cost, quality, access 2

Coordinated Care Organizations Oregon s version of ACOs for Medicaid Key elements: PCMH Needs to address access and quality Local control Coordination Health equity Metrics/performance measures Global budgets (pmpm) & shared savings Value-based pay the burning platform Pressure from State State knows our clinics well Questions our value for enhanced rate Pressure to align more with value-based payment reform Become part of local solution: Include enhanced rates in CCO global budget Pressure from CMS FQHC wrap not part of CCO global budget CMS wants wrap growth < 3.4% New patients counted against growth limit Exceptions: NAP Federally initiated service expansions Change in Scope 3

National Pressure Medicaid Directors questioning value of enhanced reimbursement CMS is asking same question of BPHC CMS and Medicaid Directors want: Alignment with value-based pay, and/or Movement away from FFS Pressure way up in the last 12 months Partnering with Medicaid Pressure on the Current Payment System Health care cost increases not sustainable State budget deficit in Oregon Reformed health system needs as its foundation: Primary care Prevention Wellness 4

Starting the Conversation with Medicaid Our missions are aligned Payment reform should make primary care more effective Value-based pay makes sense Must account for behavioral and socio-economic barriers Let s work together on a bridge to value-based pay Adjusting/Stratifying for Patient Complexity Not adjusting could increase disparities Hong et. al., Relationships Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings, Journal of the American Medical Association, 9/8/10. Chien et.al., Do Physician Organizations Located in Lower Socioeconomic Status Areas Score Lower on P4P Measures?, Journal of General Internal Medicine, 12/13/11 Paying for health homes in the safety net Long A., Phillips K., Hoyer D., Payment Models to Support Patient- Centered Medical Home Transformation: Addressing Social, Behavioral, and Environmental Factors, Qualis Health, 8/11. Not adjusting could penalize safety net Tyo et. al., Methodological Challenges for Measuring Primary Care Delivery to Pediatric Medicaid Beneficiaries Who Use CHCs, American Journal Of Public Health, 2/13. APM Model 5

Alternative Payment Methodology States have Alternative Payment Methodology (APM) option APM must pay at least as much as PPS FQHCs/RHCs can keep PPS or transition to APM Goal and Intent 2010: PCMH clinics asked OPCA for methodology to better align with model Current reimbursement is a barrier to medical home transformation Provider team retention issue Goal of APM: De-link payment from the traditional, face-to-face, patient-provider encounter Building the Will to Transform 6

Removing the Biggest Barrier Provider satisfaction and patient outcomes started improving, BUT Providers were becoming dissatisfied Providers still have F2F visit targets Additional PCMH responsibilities lengthening their day Basic APM Construct Convert PPS into a bundled, pmpm rate CCO will pay a pmpm rate comparable to any primary care provider State will pay a pmpm wraparound based on prior year s wraparound payments PCPCH payments, Pay for Performance or other bonus payments are separate Oregon s APM Process Fall 2010 Initial meetings between CHCs, OPCA and state November 2010 Board and full membership engaged Spring 2011 MCO engaged Spring 2011 June 2012 Model developed Laura Sisulak, Curt Degenfelder, Don Ross, CHCs 7

Oregon s APM Process, cont d June 2012 SPA submitted to CMS September 2012 SPA approved March 1, 2013 Go Live APM Budget-neutral Includes: Physical health services Mental health services after one year Dental services Will be more difficult, but intended to be carved in Inpatient care/prenatal/deliveries carved out All sites, all patients (managed care and open card) Three-year commitment from both parties Change in Scope process - similar to PPS Oregon PPS Change in Scope Pretty Robust PCMH Implementation EMR ongoing costs Change in patient mix Provider mix fluctuation Services mix fluctuation, including enabling services that don t require a F2F visit Addition of services out of scope 8

APM, cont d Clinics to provide: Process and outcome data to the state Touches with the patient Demographic data will be collected OCHIN has been an outstanding partner State/CCO to provide total patient cost info Aligning with other state reform efforts (e.g., PCMH, CCO) CHCs join based on readiness MOU with the state is key 9

APM, cont d Attribution To be developed and paid on current users for Day 1 18 month look back Add patients through F2F visit with licensed professional Thorough intake: Medical history Problem Rx list At minimum Next Steps with APM March 1, 2013 was our go live Submit/analyze quarterly data Track financial impact Add clinics to pilot Add mental health (and eventually dental) 10

Non-Visit Based Care We re re-imagining how the medical home would be structured if we eliminated the incentive to crank visits What Have We Learned? Lessons Learned Framing conversation with Medicaid critical APM took longer than we expected Attribution issue Competing priorities for state We need to get a lot better with data: Tracking Reporting Using A good offense can be more effective than a good defense, but you need both 11

Elements of Risk We Shouldn t Underestimate CHC work for each patient may increase while payment remains the same Transparency in data (cost, quality and access) shortens bridge to value-based pay Little time remains to adjust for behavioral and socioeconomic barriers Elements of Risk We Shouldn t Underestimate, cont d Oregon s focus on shortterm cost-cutting It s alarming Everything else appears secondary Our data needs to be cleaner yesterday Must focus on showing CHC value in a managed care and ACO/CCO environment Social Determinants 12

Game, Set and Match Bridging to value-based pay must take psychological and socioeconomic complexities into account Focusing Adjustments on What Matters Social circumstances 15% Genetic predisposition 30% Environmental exposure 5% Health care 10% Behavioral patterns 40% Source: McGinnis J.M., Williams-Russo P., Knickman J.R. The Case for More Active Attention to Health Promotion, Health Affairs 2002;21(2):78-93. Medicare Readmission Penalties Reasons: Many safety-net providers not penalized Denver Health Need to hold all hospitals accountable for the same outcomes Medicare gave grants to these hospitals No adjustment for social determinants 13

Does This Sound Familiar? We all should target the same outcomes, period. Providers need to be held accountable, not given excuses. Psycho-social characteristics show up in medical complexity, so it would be double counting. If clinic X can meet the health outcome benchmarks without adjustments, why can t they all? Addressing Naysayers Target the same outcome and: Safety net clinics need more time & resources Clinic choices without psycho-social adjustments: Improve/add services Limit seeing complex patients To hold providers accountable: Stratify patients Hold providers accountable for patients with similar barriers Addressing Naysayers, cont d Stratified patients Same high blood pressure or glucose readings Different psycho-social barriers Producing outcomes through fundraising Deal with the Devil BUT, we need to get our house in order 14

What Can We Do? Taking Charge Value perceptions of CHCs Cost, quality and ACCESS (CHC focus on quality vs. access) Complete/share complexity research and link to cost studies Research issue nationally Determine three-five SDOH to standardize and collect Most impact on PCMH work and health outcomes Standardize and collect data on enabling services Develop ROI nationally Payment reform Develop payment strategy for state Advocate for risk adjustments beyond medical Determine payment methodologies to support continuation of enabling services in CHCs Current Research Cost comparisons: CHC vs. non-chc (All Payers) In process Complexity comparisons: CHC vs. non-chc 500 charts reviewed Looking for chart notes that would indicate: Social and environmental circumstances Enabling services delivered 15

Preliminary Results CHC patients have more extreme barriers Higher SPMI Homelessness Unstable social situations CHC patients have higher rates of chronic conditions CHCs invest more in supporting social issues Housing, access to food, linking to other benefits (food stamps, alcohol & drug services) CHC patients have less of a social support network CHCs invest less in wellness Nutrition takes a back seat when patients are homeless Coordinated Care Organizations Designing incentive programs No ability to risk adjust for social determinants of health Community Advisory Councils Will they have teeth? Short-term cost reduction vs. system transformation Provisions of SB 1522 CCOs to account for psychological & social barriers Quality measures Payment All providers to meet same outcomes For providers treating complex patients: Measurement/payment stratified for extra time & resources required 16

Get Our House in Order Get clean data Bring up low performers Work With Your PCA Data to promote and improve CHC value Research Payment reform PCMH has to be about transformation Questions 17

Thank You Craig Hostetler Oregon Primary Care Association 503-228-8852 x 227 chostetler@orpca.org 18