Tennessee Health Care Innovation Initiative More information available at: http://www.tn.gov/hcfa/strategic.shtml State Innovation Model grant 2 1
State Innovation Model (SIM) funding Last week the Centers for Medicare and Medicaid Innovation (CMMI) made available Round 2 State Innovation Model funding. CMMI will fund up to 12 Model Test states with approximately $20-100 million grants per state over 4 years. The grant period will begin January 1, 2015 and run through December 31, 2018. This funding will help us achieve our goal of paying for outcomes and for quality care, rather than for the amount of services provided value-based care instead of volume-based. The state is working collaboratively with hospitals, medical providers, and payers to work towards meaningful payment reform. By working together, we can make significant progress toward sustainable medical trends and improving care. We would like your support for our application due July 21 st! The Tennessee Health Care Innovation Initiative met with over 180 different groups from across the state in more than 160 meetings between Feb. 2013 and April 2014 Includes providers, payers and other stakeholders Focus on population-based care (preventative) and episodebased care (acute) Three technical advisory groups focused on three initial episodes: total joint replacement, asthma, and labor and delivery Plan to add new episodes every six months The State Innovation Models Initiative provides funding for states to develop and test state-based models for multi-payer payment and health care delivery system transformation with the aim of improving health system performance for residents of participating states. States with Round 1 SIM Grants SIM Testing SIM Pre-Testing SIM Design 3 State Innovation Model (SIM) funding Existing Commitment to Payment and Delivery System Reform Enhancements the SIM grant will support Overall Episodes State of TN, payers, providers, employers, and the federal government are committed to moving from volumebased care to value based care. State commitment to multi-payer (including commercial) episodes of care, including additional waves of episodes every six months. SIM funding will allow greater collaboration, alignment, and stakeholder input. Greater support for making changes to episodes over time based on provider feedback. Primary Care TennCare PCMH Multi-payer (including commercial) PCMH test in selected sites Health Homes Long-term Care State committed to align payment with value/quality for Nursing Home facilities, members receiving enhanced respiratory care, and strengthening integration and coordination for Dual Eligibles. TBD 4 2
State Innovation Model funding 5 : Wave 1 This month, Principal Accountable Providers began receiving their first information only episodes of care cost and quality reports for perinatal, acute asthma exacerbation, and total joint replacement. Provider reports were released from the three TennCare MCOs (Amerigroup, BlueCare, and UnitedHealthcare Community Plan). Blue Cross Blue Shield of Tennessee commercial networks also released reports for fully insured and state employee members, TennCareSelect, and CoverKids. Providers will begin receiving reports for UnitedHealthcare s commercial network for fullyinsured members later this summer, and Cigna will be reaching out to targeted providers within its network on an ongoing basis. In total over 1,700 reports were released to over 500 unique providers. The best way for quarterbacks to discuss the specifics of their own episodes is to talk to the insurance companies that are implementing episodes of care. Below are the appropriate contact numbers for providers to use: Amerigroup 615-316-2460 Blue Cross Blue Shield of Tennessee 1-800-924-7141, Option 4 Cigna 615-595-3756 UnitedHealthcare 615-372-3509 6 3
Avg. adj. episode cost ($) # of episodes Commendable cost ($) Your avg. cost ($) Number of episodes Share factor 8/13/2014 Delivery System Reform: Reporting Quarterbacks will receive quarterly report from payers: Performance summary Total number of episodes (included and excluded) Quality thresholds achieved Average non-risk adjusted and risk adjusted cost of care Cost comparison to other providers and gain and risk sharing thresholds Gain sharing and risk sharing eligibility and calculated amounts Key utilization statistics Quality detail: Scores for each quality metric with comparison to gain share standard or provider base average Cost detail: Breakdown of episode cost by care category Benchmarks against provider base average Episode detail: Cost detail by care category for each individual episode a provider treats Reason for any episode exclusions Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013 [1. Asthma] A. Episode Summary 1 Overview Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29 2 Cost of care (avg. adj. episode cost) comparison YOUR GAIN/ RISK SHARE You are eligible for gain sharing Commendable Acceptable Not acceptable Less than $1,000 $1,000 to $1,750 > $4000 $1,750 +$10,391.80 Your episode cost distribution (risk adj.) Quality metrics 80 not linked to gain sharing 64 60 1. Repeat acute exacerbation 43 37 within 30 days 40 28 22 21 18 20 Below $500- $833- $1167- $1833- $2167- Above $500 $833 $1167 $1500 $2167 $2500 $2500 Distribution of provider average episode cost (risk adj.) 2,000 1,500 1,000 [Period: Start/end dates of period] x x Your avg. cost: $911.80 Providers base avg. cost: $1,242.20 1,000 910.80 233 50% 3 Episode cost summary 4 Episode quality and utilization summary Your average episode cost is commendable You achieved selected quality metrics Provider Quality metrics Gain share Met Parameters You You base average linked to gain sharing standard standard 1. Total cost across episodes $235,796.00 $317,301.09 1. Follow-up visit w/ physician 61% 55% 233 235 2. Total # of included episodes 2. Patient on appropriate 77% 70% medication 3. Avg. episode cost (non adj.) $1,012.00 $1,350.22 4. Risk adjustment factor* (avg.) 0.90 0.92 $910.80 $1,242.20 5. Avg. episode cost (risk adj.) Provider You base average 5% 8% 500 0 Percentile of providers You Commendable Acceptable Not acceptable Preliminary draft of the provider report template for State of TN (for discussion only) All content/ numbers included in this report are purely illustrative 7 State Innovation Model funding Primary Care Reform 8 4
9 TennCare PCMH Model Goals Reduced non-emergency ED use Reduced preventable hospitalizations Reduced readmissions Increased adherence to preventive care Increased pharmacy adherence Reduced duplication Improved health and patient experience Specialists Patients & families PCP Ancillaries (e.g., outpatient imaging, labs) Community supports Hospitals, ERs 10 5
Health Home Model Our SPMI members have higher rates of asthma, congestive heart failure, COPD, coronary artery disease, diabetes, hypertension, and stroke as compared to non-spmi TennCare members and these members have over twice as many Emergency Department visits (1,936 visits per 1,000) as compared to other TennCare members (891 visits per 1,000). As defined by CMS, a Health Home provides six specific services beyond the clinical services offered by a typical primary care provider. Comprehensive care management Care coordination Health promotion Comprehensive transitional care Individual and family support services Referral to community and support services Providers can only receive 2 years of enhanced payment for each Health Home enrollee. 11 State Innovation Model funding 12 6
QuILTSS Quality Improvements in Long-Term Services and Supports (QuILTSS) is a TennCare value-based purchasing initiative to promote the delivery of high quality LTSS. It focuses on performance measures that are most important to people who receive LTSS and their families the things that most directly impact the member s experience of care. Creation of a new TennCare LTSS payment system (aligning payment with value/quality) for NFs and certain core Home and Community Based Services based in part on performance on specified measures. Stakeholder Input Process Included: Community Forums o 18 sessions between October 24-November 4 o Over 1,200 participants 290 Consumers 831 Providers (388 NF and 443 HCBS) Online Survey One-on-One Meetings with Key Stakeholders Comprehensive report available at: www.lipscomb.edu/transformaging/tareport 13 7