OHPB DRAFT Coordinated Care Organization (CCO) Proposal OMA Summary and Analysis December 15, 2011 Bryan Boehringer Courtni Dresser OMA Government Relations
Overview CCOs established and implemented to provide a stronger focus on: primary and preventive care evidence-based services, more effective management of care Intent is to move the health care system from fragmentation to organization and delivering the right care in the right place at the right time to patients who are fully engaged 9
Key Elements of a CCO Global Budget that includes all eligible Medicaid funding, and for dual eligibles, Medicare funding State will submit demonstration proposal to CMS on aligning and integrating Medicaid and Medicare benefits and financing in April 2012 Global Budget should allow flexibility to support innovation and investment in evidence based care Metrics for health outcomes, quality and efficiency 10
Key Elements of a CCO, continued Patient-centered primary care homes Coordination of care across categories of care and funding streams Patient engagement 11 Aligning incentives that reward providers and beneficiaries for achieving good outcomes
Several Forthcomings Executive Summary of Plan Existing Market Environment and Industry Analysis Target Population, Population Characteristics and Health Status, Current Delivery System for Target Population Financial Projections for Greater System Efficiency and Value Potential for shared savings with Medicaid and Medicare Health Management Associates, (HMA) using Milliman Data is looking for Evidence Based Solutions 12 Alternative Dispute Resolution
CCO Certification Process OHA will develop administrative rules and criteria for applications and release a Request for CCO Applications rather than competitive bidding process or RFP process Applications will build on CMS Medicare Advantage process OHA will review applications in collaboration with CMS 13 OHA will certify CCOs
CCO Criteria Governance structure will vary by community To be certified as a CCO, OPHB recommends 14 the CCO demonstrate: How individuals who bear the financial risk make up the majority interest of the Governing Board How major components of health delivery system are represented How consumers are represented How the Governing Board composition represents community needs and goals of transformation
CCO Criteria CCOs are required to form Community Advisory Councils (CACs) (HB 3650) OHPB recommends that at least one member of CAC serve on Governing Board OHPB also recommends establishing a Clinical Advisory Panel (CAP) to assure best clinical practices CCOs will need to develop and show how these groups work with and influence the Governing Board OHPB also recommends a Community Needs Assessment that includes health equity issue and health disparities. 15 OHA is directed to standardize the assessment so they can collect comparative data.
Patient Rights and Responsibilities, Engagement and Choice OHPB recommends patients be actively engaged partners in design and implementation of their care plans 16 CCOs will need to demonstrate: How they are going to encourage patient participation to be active partners in their healthcare How they will engage members in culturally appropriate ways How they will educate members to navigate the CCO How they will encourage wellness, prevention and healthy lifestyle choices
Delivery System: Access, patient-centered primary care homes, care coordination and provider network requirements Patient-Centered Primary Care Homes (PCPCHs) OHPB recommends that CCOs demonstrate: How the CCO will partner with or implement a network of PCPCHs How the CCO will require contracted partners to communicate and coordinate care with PCPCHs using electronic health technology 17 How the CCO will incentivize and monitor transitions in care and coordination of care between the partners
Delivery System: Access, patient-centered primary care homes, care coordination and provider network requirements, cont d OHPB recommends that CCOs demonstrate (cont d): How the PCPCH delivery system ensures that members receive integrated and person-centered care How member will be informed about access to nontraditional providers, if available. (including personal health navigators, peer wellness specialists, and community health workers) 18
Delivery System: Access, patient-centered primary care homes, care coordination and provider network requirements, cont d Care Coordination OHPB recommends that CCOs show: How they will coordinate care in the absence of full health information technology capabilities How providers will develop partnerships to access and coordinate with social and support services How they will educate members about care coordination and the responsibilities of each in the process of communication 19
Delivery System: Access, patient-centered primary care homes, care coordination and provider network requirements, cont d Care Coordination OHPB recommends that CCOs show: Evidence-based or innovative strategies to ensure coordinated care, especially for members with intensive needs including: Assignment of responsibility and accountability, individual care plans, culturally and linguistically appropriate communication How it will ensure a network of providers to serve members health care and service needs, meet access-to-care standards, and allow for appropriate choice for members How it will build on existing provider networks and transform them into a cohesive network of providers 20 How it will work to develop formal relationships with providers, community health partners, and state and local government support services in its service area(s)
Delivery System: Access, patient-centered primary care homes, care coordination and provider network requirements, cont d Care Integration Mental Health and Chemical Dependency Treatment: HB 3650 requires OHA to renew contracts with providers of residential chemical dependency treatment until the provider enters into a contract with a CCO, but no later than July 1, 2013 Oral Health: By July 1, 2014, each CCO must to have a formal contractual relationship with a dental care organization OHPB recommends shared accountability to align financial incentives for costeffectiveness and to discourage cost shifting 21 Hospital and Specialty Services: Access to hospital and specialty services will be required Agreements should be established that include: o the role of PCPCHs o processes for requesting hospital admission or specialty services o performance expectations for communication and medical records sharing o processes for admission or discharge and after-hospital follow up appointments OHPB recommends the CCO demonstrate how hospitals and specialty services will be accountable to achieve successful transitions of care
Health Equity and Eliminating Health Disparities OHPB recommends that CCOs identify health disparities associated with race, ethnicity, language, health literacy, age, disability, gender, sexual orientation, geography, or other factors in their service areas as part of their community needs assessments OHPB recommends that the OHA Office of Equity and Inclusion assist in identifying standard components (e.g., workforce) that CCOs should address in the assessment to ensure that all CCOs have a strong and comparable set of baseline data on health disparities 22
Payment Reform OHPB recommends that CCOs demonstrate how their payment methodologies promote the following principles: Reimburse providers on the basis of health outcomes and quality measures instead of volume; Hold organizations and providers accountable for the efficient delivery of quality care; Limit increases in medical costs; Promote prevention, early identification and intervention of conditions that lead to chronic illnesses; Provide comprehensive coordination or create shared responsibility across provider types and levels of care, using such delivery systems such as PCPCHs; and Utilize evidence-based practices and health information technology to improve health and health care 23
Payment Reform, cont d CCOs will have flexibility in the payment methodologies they choose to use However, OHPB recommends that CCOs be encouraged to rely on previously developed and tested payment approaches where available Efforts to create incentives for evidence-based and best practices will be expected to increase health care quality and patient safety and more efficient use of health care services 24 CCOs will need to build network capacity and restructure systems and workflows to be able to respond effectively to new payment incentives
Health Information Technology (HIT) Communities will be expected to adopt technology gradually depending upon their starting point HITOC recommendations: Meaningful use of Electronic Health Record (HER) Participation in a Health Information Exchange that allows all providers to exchange health information o All providers register with a Health Information Service Provider (HISP) or o Be a member of a Health Information Organization (HIO) CCOs should leverage HIT tools to transform from a volumebased to value-based delivery system 25
Global Budget Methodology Entire Medicaid population included (currently 78% in MCOs) All Medicaid funding streams included Dental to be added by 2014 26
Global Budget Rate Development CCOs will be accountable for care costs but not enrollment growth Build off of current capitation rate methodology Will still have some add-on payments outside of capitated portion for physical, mental and dental health CCO capitation rate setting would combine the information provided by organizations seeking CCO certification with a method similar to the lowest cost estimate approach OHA took in setting rates for the first year of the 2011-13 biennium Modified Lowest Cost Approach: CCOs would submit a completed Base Cost Template using internal cost data that is representative of a minimum base population and the benefit package in effect as of January 1, 2012 Initially, OHPB recommends that CCO global budget amounts be established for one year 27 Eventually, OHPB recommends that stakeholders and OHA explore the possibility of establishing global budgets that could be enacted on a biennial or multi-year basis
Global Budget Rate Development, cont d OHPB Rate Setting Timeline: 28 Finalize CCO definition/scope and process Release CCO estimated cost submission process document Collect comments on estimated cost submission process document Make final changes to estimated cost submission process Release of CCO case cost template Release Notice of Intent to contract as CCO Collect base cost template Review and certification of CCO rates Conduct final review of CCO capitation rates Submit CCO capitation rates to CMS Submit contracts to CCOs
Global Budget Rate Development, cont d Blended Funding for Individuals who are Dually Eligible for Medicare and Medicaid OHA & CMS will develop Medicare portion of the rates OHPB recommends that three-way contracts with CMS maintain current Medicare Advantage rates in the beginning Gradually incorporate savings to be shared among all parties as a result of CCO efficiencies 29
Global Budget Rate Development, cont d Quality Incentive Payments Initially used to ensure adequate performance and create a data baseline Eventually, metrics will be used to determine exceptional performers who qualify for incentive rewards 30
Accountability OHA required to be an active partner with CCOs in transformation Must provide: accurate data, learning collaborative, best practices, technical assistance, admin simplification CCO Accountability Triple Aim: better health, better care, lower costs Responsible for outcomes, quality and efficiency measures (public process w/stakeholders) 31
Accountability, cont d CCO Measurement and Accountability Plan Technical Advisory Group of experts to develop metrics Metrics will be phased in and include: minimum standards and targets for outstanding performance core standards and developmental measures to encourage experimentation Shared Accountability for Long-Term Care Because long-term care is excluded, shared financial accountability 32
Financial Reporting Requirements to Ensure Against Risk of Insolvency OHA, DCBS and Insurance Commissioner set up process and determine who will receive reports Use National Association of Insurance Commissioners (NAIC) form State actuaries will track financial solvency as enrollments change Factors used to gauge solvency will be the status of the risk-bearing entity, reinsurance, risk reserves, medical loss ratio, organizations size and risk characteristics, enrollment levels, organizational liability, operating budget, administrative expense, real property, investments and executive compensation 33 CCOs required to outline administrative expenses relating to provision of services under its CCO contract and administrative expenses relating to the CCO s contracts for other populations including Medicare, PEBB, OEBB, and other commercial insurance
Financial Reporting Requirements to Ensure Against Risk of Insolvency, cont d OHA Monitoring and Oversight Quality, access and financial monitoring for root cause analysis to develop improvement strategies Monitoring financial solvency and if needed act to restore solvency or identify and prevent threats to solvency in the future If no remedy, pull license and liquidate assets to meet financial obligations 34 Public Disclosure of Information CCO will be subject to public disclosure like a licensed insurer OHA and DCBS will create new licensure category for CCOs Organizational characteristics will be disclosed (corporate status, MCO or MHO status, other state contracts, Medicare contracts, commercial contracts and other administrative or management contracts) Corporate assets and financial management will be public
CCO Implementation Plan Transition strategy that is flexible and provides incentives financial incentives enrollment incentives flexibility in service delivery and administration Prepaid managed care health services organizations will be used in areas where CCOs have not been certified. Contracts will be modified to incorporate elements of HB 3650 35
CCO Implementation Timeline Dec. 14, 2011 Jan 3, 2012: Public comment period on Draft CCO Implementation Proposal Dec. 20, 2011: Interim legislative hearing Jan. 10, 2012: Oregon Health Policy Board meeting: Review and discuss next draft of CCO Implementation Proposal Jan. 11 Jan. 18, 2012: Public Comment Period on Draft CCO Implementation Proposal Jan. 18 Jan. 20, 2012: Interim legislative hearings Jan. 24, 2012: Oregon Health Policy Board meeting: Approval of final draft CCO Implementation Proposal Feb. 1, 2012: Delivery of Draft CCO Implementation Proposal to Legislature March 2012: If Legislature approves, apply for required permissions to CMS March 2012: OHA implementation preparation 36 July 2012: Potential first CCOs certified and enrolling members
Next Steps for OMA Engagement Prepared comments Solicitation of comments from Members Testifying at Joint Health Care Committee on 12/20 Submit comments to OHPB Ongoing: OMA staff meeting with legislators regarding OMA's comments on proposal 37
38 OHA Medical Liability Work Plan
OHA Medical Liability Work Plan Work required by HB 3650 Allen Kachalia, M.D., J.D. and Michelle Mello, J.D. Ph.D. (Harvard School of Public Health. Conducting Oregon specific analyses on: Medical Panels Joint and several liability options Caps on damages Extension of Tort Claims Act to Medicaid Administrative compensation systems Bill Wright, Ph.D. (Providence Center for Outcomes Research) and Kate Baicker, Ph.D. (Harvard School of Public Health) are conducting Oregon surveys on defensive medicine and over-utilization DOJ looking at constitutional limitations of the reform options and Stark laws 39 Report presented on January 11 to OHPB
Questions? bryan@theoma.org courtni@theoma.org 41