Advancing innovations in health care delivery for low-income Americans Connecting Value-Based Services to Whole Person Care Caitlin Thomas-Henkel, Senior Program Officer The National Council December 6, 2017 2017 Center for Health Care Strategies www.chcs.org @CHCShealth
About the Center for Health Care Strategies Non-profit policy center dedicated to improving the health of low-income Americans
Relevant CHCS Projects CMMI State Innovation Model Partnerships for Healthy Outcomes Complex Care Innovation Lab Transforming Complex Care Innovation Accelerator Program (IAP) for Value-Based Payment (VBP)
Agenda Welcome and Objectives Select State Approaches to Developing Value-Based and Integrated Behavioral Health Care Building Health Care and Provider Partnerships to Address Social Determinants 4
Objectives To provide an overview of select state efforts to integrate behavioral health services in designing whole person care systems. To identify ways that health care and community providers are building partnerships to address social determinants of health (SDOH). 5
Advancing innovations in health care delivery for low-income Americans State Approaches to Developing Value-Based and Integrated Behavioral Health Care 6 www.chcs.org @CHCShealth
Why Value Based Care? Exhibit 1. Health Care Spending as a Percentage of GDP, 1980 2013 18 16 14 12 10 8 6 4 2 0 7 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013 * 2012. Notes: GDP refers to gross domestic product. Dutch and Swiss data are for current spending only, and exclude spending on capital formation of health care providers. Source: OECD Health Data 2015. US (17.1%) FR (11.6%) SWE (11.5%) GER (11.2%) NETH (11.1%) SWIZ (11.1%) DEN (11.1%) NZ (11.0%) CAN (10.7%) JAP (10.2%) NOR (9.4%) AUS (9.4%)* UK (8.8%)
Level of financial risk Alternative Payment Model (APM) Framework Goal is to shift U.S. health care system toward payment models in Categories 3 and 4. In 2016, 18% of Medicaid payments fell in these categories. Category 1: Fee-for-service payments not link to quality/value Category 2: Fee-for-service payments linked to quality/value (e.g., pay-forperformance) Category 3: Alternative payment models built on fee-forservice payment (e.g., shared savings/risk) Category 4: Population-based payment (e.g. global payments) (e.g., traditional FFS, DRGs) 8 Degree of care, provider integration, and accountability Source: Health Care Payment Learning & Action Network (LAN) APM Framework, available at: https://hcplan.org/workproducts/apm-whitepaper.pdf
VBP Approaches Can Vary Based on State BH Service Delivery Model Fee-for-Service 23 Integrated MCO 8 Risk-Based BHO 8 ASO 2 9 SOURCE: Internal CHCS analyses. Note: Focus on specialty mental health services; Includes District of Columbia. Includes announced reforms as of May 2016
Leveraging Medicaid as a Strategic Purchaser Use of managed care for high-need populations; contracting requirements Shifting from paying for volume to paying for value Integrating behavioral health and social service collaborations Aligning quality outcomes to payment 10
State Strategies to Integrate Behavioral Health & Social Services Governance Financing Models Integrated Assessments and Care Teams Data Procurements and Grants Performance Metrics 11
Arizona: Medicaid Transformation Enhanced cross collaboration with behavioral health experts, enrollees, family, and peer support Agency consolidation to improve payment and service delivery Established minimum performance standards including but not limited to:» Increasing access to education resources for members with chronic conditions» Comprehensive care models- Medicaid and non-medicaid funding streams» Require data sharing» Established minimum performance standards including:» Inpatient and emergency department utilization» Hospital re-admissions» Follow-up after hospitalization after 7 and 30 days» Access to primary care and behavioral health providers» Comprehensive diabetes management 12
Arizona: VBP for Behavioral Health 20% of Medicaid MCO payments must be linked to VBP, subject to 1% quality withhold» At least 5% of payments for adults with SMI must be governed by VBP strategies for the contract year» Minimum of 25% of the 5% requirement shall be with an organization that includes primary care providers Plan will lose money if quality measures are not met» Each plan can determine its approach» To date, plans interested in testing bundled payments AZ model is imitated by many other states 13
Indiana: Medicaid Transformation Transition from a care management program to a disease management program focusing on members with chronic conditions (i.e. asthma, diabetes, hypertension, serious emotional disturbance, etc.) Key features:» Increasing payments tied to outcomes to further incentivize the Managed Care Entities (MCEs) to improve the health of the populations served.» Progressively increasing the payment amount withheld and awarding based on outcomes from 2 percent in the first year to 5 percent in year six» Developing behavioral health case management goals, and HEDIS quality measures continue to be important element of performance consideration» Creating individualized and preventative care goals 14
Indiana: Taking a Closer Look Healthy Indiana Plan aim to promote value-based decision-making and personal health responsibility. Healthy incentives for health needs assessment, preventative exams, and prenatal care including the following focus areas:» Tobacco cessation;» Substance use disorder treatment;» Chronic disease management; and» Employment related incentives. 15
Ohio: Behavioral Health Redesign Key features of physical/behavioral health integration:» Moves all Medicaid behavioral health services into managed care (7/18)» Health plans provide comprehensive care coordination by qualified community behavioral health providers» Providers in the new network will include community behavioral health organizations, inpatient hospitals, clinics, and special features of the modernizing Medicaid behavioral health benefits» Modernizing Medicaid behavioral health benefits including: 16 Aligning billing codes to national standards, redefining mental health, pharma management and substance use disorder services as medical services Repricing services (e.g., community psychiatric care, case management, and health home services) Expanding Medicaid Rehab options for people with the highest needs Providing for lower acuity service coordination and support services Including assertive community treatment (ACT) for adults with SPMI and significant support needs (e.g., intensive home based treatment for youth with serious emotional disorders) Recovery support services for individuals with OUD; peer supports
Ohio: Taking a Closer Look Ohio requires its managed care plans to ensure that 50% of its payments to providers are value oriented by 2020 Covering new services for adults with SPMI such as recovery management, supported employment and peer recovery Adopting ASAM Continuum of Care Framework for people with SUD Developing new services for individuals with high intensity service and support needs (e.g. assertive community treatment, intensive home based treatment, residential treatment for substance abuse) Implementation of value-based payment methodology Health plan requirement to reporting provider performance on high cost episodes of care using definitions and measures developed jointly with state 17
Common Themes Across States Community based services Multidisciplinary care teams Improving care delivery through connection, communication, and coordination Identifying individuals with poor health, high-risk, complex conditions, and/or high utilization due to medical, mental health concerns, emotional challenges, family circumstances and other social determinants Aligning outcomes to payment 18
Advancing innovations in health care delivery for low-income Americans Building Health Care and Provider Partnerships to Address Social Determinants 19 www.chcs.org @CHCShealth
Finger on the Pulse Social Interventions Can Lower Costs and Improve Outcomes March 7, 2017 Medicaid managed care executives say plans must tackle social determinants, opioid epidemic October 31, 2017 Oregon saving big from Medicaid expansion April 28, 2016 20
Social Determinants of Health 21 SOURCE: Kaiser Family Foundation. (November 2015). Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. http://kff.org/disparities-policy/issue-brief/beyondhealth-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
Why Integrate Health and Social Services? Health care is only one relatively small component that influences health outcomes. Growing evidence that investments in social services can improve health and lower health costs States are investing in models that link public health, social services, and care delivery:» Accountable Communities for Health programs» High-need, high-cost populations Impact of Different Factors on Risk of Premature Death 22 SOURCE: Kaiser Family Foundation. (November 2015). Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. http://kff.org/disparities-policy/issuebrief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
Data Collection on Common SDOH Domains* by State *Data collected from Medicaid beneficiaries at the individual and/or population levels; data not systematically collected from the entire Medicaid population 23
Medicaid-izing Health Related Social Services Housing* SNAP Education* Criminal Justice* Medicaid Early Childhood* Child Welfare Home- and Community Based Services* Transportation* 24 *Medicaid coverage under certain conditions
Federal Recognition of Supportive Services CMS Informational Bulletin Medicaid Coverage of Housing Related Activities Depending upon the Medicaid authority and demonstration program, states may receive FFP for the following services/service areas:»individual housing transition services»individual housing and tenancy sustaining services»state-level housing related collaborative activities Managed care regulations clarify in lieu of standard, which give plans flexibility under risk contracts to provide alternate services or services in alternate settings 25
State-Level Efforts to Collect and Use SDOH Information ME CA OR WA NV ID UT AZ MT WY CO NM ND SD NE MN WI IA IL KS MO OK AR MS NY MI PA OH IN WV VA KY NC TN SC AL GA VT NH MA RI CT NJ DE MD DC TX LA HI AK FL How are states defining and collecting SDOH? How are states selecting measures How are states using patient- and population-level data What challenges are states facing in capturing SDOH data? 26
Project Overview: Partnership for Health Outcomes Brought together Nonprofit Finance Fund, the Center for Health Care Strategies, and the Alliance for Strong Families and Communities to capture insights on partnerships between community-based organizations (CBOs) and health care organizations, particularly those serving low-income and vulnerable populations. Request for Information Partnership Case Studies Knowledge Sharing
RFI Response: Partnerships Services Over 200 health care related partnerships serving one or more of all 50 US states responded representing a broad range of service areas
RFI Response: Target Populations The populations served by these partnerships were diverse
Diving Deeper: Case Studies From among the over 200 responding partnerships, leaders from four diverse partnerships were interviewed to learn more about what makes them successful.
Lessons Learned: Best Practices
Lessons Learned: Challenges
Capacity-Building Needs While nearly all organizations acknowledged expanding skills and capacities through partnership, partnerships also noted a need for additional support in the following areas:
Factors to Consider in Integrating Behavioral Health and Social Services Assess community based provider capacity Start slowly and assess provider readiness for shifting Engage stakeholders early and often Ensure providers have opportunity to weigh in the model design Provide technical assistance to plans and providers Delineate responsibility clearly and efficiently Align measures with other programs/payers 34
In Sum: Key Opportunities in Delivery System and Payment Reform Use Medicaid purchasing power to move from volume to value at the provider level via MMC contracting (aligning as much as possible with other purchasers) Engage key stakeholders in identifying the win-win-wins that improve quality and reduce costs; then, be sure to share those savings into the future Embrace the momentum on social determinants and integrate public health/prevention/social services with health care, especially for high-need, high-cost members 35
State interest continues to grow, with focus on Supporting upstream investments Payment models tied to risks and costs of managing high-need, highcost Medicaid population Integrating behavioral health and social determinants into VBP Quality measures Strengthening partnerships with community based providers
Visit CHCS.org to Download practical resources to improve the quality and costeffectiveness of Medicaid services Learn about cutting-edge efforts to improve care for Medicaid s highestneed, highest-cost beneficiaries Subscribe to CHCS e-mail, blog and social media updates to learn about new programs and resources Follow us on Twitter @CHCShealth 37