STATE OF TENNESSEE NASHP s 30 th Annual State Health Policy Conference 10/25/2017 Timeline of Tennessee Health Care Innovation Initiative 2012 2013 2014 2015 2016 2017 1210 Stakeholder Meetings 16 Partnerships & Procurements 2 Grants Vision Taskforce Governors Kickoff Planning Tennessee Health Care Innovation Initiative 115 SIM Design 237 Episodes 375 337 CCT PCMH Training SIM Testing 146 Evaluation Select Program Milestones report PCMH and Health Link contracting contracting PCMH and Health Link start performance period results Enhanced respiratory care ECF Choices starts Nursing facility quality 2apps
Tennessee s Three Strategies Source of value Strategy elements Examples Primary Care Transformation Maintaining a person s health overtime Coordinating care by specialists Avoiding episode events when appropriate Patient Centered Medical Homes Tennessee Health Link for people with the highest behavioral health needs Care coordination tool with Hospital and ED admission provider alerts Encouraging primary prevention for healthy consumers and coordinated care for the chronically ill Coordinating primary and behavioral health care for those with the highest BH needs Episodes of Care Achieving a specific member objective, including associated upstream and downstream cost and quality Retrospective Episodes of Care 75 episodes designed by 2020 Wave 1: Perinatal, joint replacement, asthma exacerbation Wave 2: COPD, colonoscopy, cholecystectomy, PCI Long Term Services & Supports Provide long-term services and supports (LTSS) that are high quality in the areas that matter most to members Quality and acuity adjusted payments for LTSS services Value-based purchasing for enhanced respiratory care Workforce development Aligning payment with value and quality for nursing facilities (NFs) and home and community based care (HCBS) Training for providers 3 75 episodes of care will be designed and implemented over 5 years Design year & wave 2013 1 2014 2 2015 2016 3 4 5 Episode Perinatal Asthma acute exacerbation Total joint replacement COPD acute exacerbation Colonoscopy Cholecystectomy PCI - acute PCI non acute GI hemorrhage EGD Respiratory Infection Pneumonia UTI - outpatient UTI inpatient ADHD CHF acute exacerbation ODD CABG Valve repair and replacement Bariatric surgery Breast biopsy Breast cancer, medical oncology Breast cancer, Mastectomy Otitis media Tonsillectomy Non-emergent depression Anxiety Design year & wave 2016 6 2017 7 8 Episode Skin and soft tissue infections Neonatal (Age 31 weeks or less) Neonatal (Age 32 to 36 weeks) Neonatal (Age 37 weeks or greater) HIV Pancreatitis Diabetes acute exacerbation Spinal fusion Spinal decompression (without spinal fusion) Femur / pelvic fracture Knee arthroscopy Ankle non-operative injuries Wrist non-operative injuries Shoulder non-operative injuries Knee non-operative injuries Back / Neck pain Acute Seizure Syncope Acute gastroenteritis Pediatric acute lower respiratory infection Colposcopy Hysterectomy GI obstruction Appendectomy Hernia procedures Design year & wave 2018 9 10 2019 11 Episode Conduct disorder Lung cancer (multiple) Colon cancer Female reproductive cancer Liver & pancreatic cancer Drug dependence Sickle cell Renal failure Other major bowel (multiple) Hepatitis C GERD acute exacerbation Kidney & urinary tract stones Hemophilia & other coag. dis. Rheumatoid arthritis Schizophrenia (multiple) Bipolar - chronic Bipolar acute exacerbation PTSD Anal procedures CAD & angina Cardiac arrhythmia Depression acute exacerbation Pacemaker / Defibrillator Dermatitis / Urticaria Updated June 20, 2017
Primary Care Transformation Progress Patient Centered Medical Homes 29 Organizations 250,000 Members Enrolled Additional 41 organizations joining by January 2018 Tennessee Health Link 21 Organizations 64,000 Members Enrolled Admission, Discharge and Transfer (ADT) Data Feeds Hospitals representing 30% of TN licensed beds reporting in real time. Almost all hospitals planning to begin submitting data within a year. 5 Estimated Savings From Perinatal Episode $7,200 $7,000 Analysis of Risk-Adjusted Cost Trend, Perinatal Episode CY 2014 CY 2016 $6,893 $7,100 $6,800 $6,600 $6,693 $6,469 $6,598 $6,400 $6,200 $6,000 CY 2014 CY 2015 CY 2016 Projected Actual Estimated adjusted episode cost for CY 2016, based on 3% annual increase (Projected) Estimated adjusted episode cost for CY 2016, based on MCO reports with 6 months claims run-out (Actual) Total Estimated Savings = $11,065,302 = $156,844,747 = $145,779,445 6
Results: Estimated episodes savings of $14.5M Comparison of Projected and Actual Avg. Risk-Adjusted Episode Cost, CY 2016 Episode Type Projected Actual Estimated Savings per Episode Percent Number of Valid Episodes Total Estimated Savings Total - - - - 45,188 $14,548,603 Perinatal $7,100 $6,598 $502 7.1% 22,090 $11,065,302 Acute Asthma Exacerbation Total Joint Replacement $1,249 $1,067 $182 14.6% 12,939 $2,358,909 $12,855 $11,878 $977 7.6% 460 $449,608 Cholecystectomy $4,653 $4,591 $61 1.3% 2,110 $129,452 Colonoscopy $1,112 $1,082 $30 2.7% 2,929 $87,366 COPD $2,390 $2,253 $136 5.7% 4,116 $561,376 Acute PCI $9,376 $9,284 $92 1.0% 416 $38,279 Non-acute PCI $6,926 $8,033 -$1,107-16.0% 128 -$141,689 7 Results: Episode Quality Measures Quality Measures CY 2015 CY 2016 Perinatal HIV Screening ( 85%) 88.3% 87.7% Group B Streptococcus Screening ( 85%) 85.9% 94.0% C-Section Rate ( 41%) 31.6% 30.6% Acute Asthma Exacerbation Follow-up visit with physician ( 43%) N/A 29.6%* Patient on appropriate medication ( 82%) N/A 60.3%* Cholecystectomy Hospitalization in post-trigger window ( 10%) 0.8% 1.0% COPD Follow-up care within post-trigger window ( 60%) 45.1% 46.7% Acute Percutaneous Coronary Intervention (PCI) Hospitalization in post-trigger window ( 10%) 1.0% 0.7% Non-Acute Percutaneous Coronary Intervention (PCI) Hospitalization in post-trigger window ( 10%) 0.0% 1.6% Green text = positive movement Red text = negative movement Black text = movement of <1% *There was a coding change to these quality metrics so results are not comparable across years. 8
Results: Long Term Services and Supports Nursing facilities Enhanced Respiratory Care 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Resident with Choices in menu, meal time, bath/shower option, sleep/wake times and room decor 50% 30% 10% 10% 2014 2015 16 2016 2016 17 Antipsychotics Prevalence (Clinical Measure): 30% 35% Hundreds 30% 25% 20% 15% 10% 5% 0% 2013 2014 2015 2016 TN National 50% FY 2014 15 (Baseline) FY 2015 16 FY 2016 17 Vent Weaning Chronic Vent Trachael Suctioning Number of Weans: 2015 2016 : 132 2016 2017 : 150 9 Lesson Learned: Alignment is challenging National carriers have national strategies that are difficult to align with state specific strategies. Providers rejected downside risk in commercial market. Tennessee is challenged to maintain its design with 2,824 of pages of specifications and 565,162 lines of claims codes, currently. Other states have chosen less prescriptive requirements. In the past 4 years, we have held over 1,200 with stakeholders. 10
Lessons Learned: Quality measurement still needs improvement Claims data is the easiest date source for a payer but does not always measure what you want. Electronic Health Records are not great sources of standardized clinical quality data. HEDIS measures are designed for measuring health plans, and do not always adapt well to provider level measurement. Adjusting for patient risk is a frequent concern of providers. Long term outcomes are outside the window for action. 11 Lessons Learned: Statewide innovation is achievable It helps to start from a strong foundation of successful management of Medicaid. Recognize that innovation is going to cause disruption and problems. Evaluation should be ongoing. Innovation is a great recruiting tool. 12
THANK YOU More information: http://www.tn.gov/tenncare/section/health care innovation Email: Brooks.@tn.gov