Making the most of payment reform

1. WELCOME April 18,2014 This webinar will begin promptly at 1pm EDT Making the most of payment reform

2. presenters Host: Sabrina Edgington, MSSW, Program and Policy Specialist, National Health Care for the Homeless Council MelissaHansen, MPH, Program Principal, National Conference of State Legislatures DaShawn Groves, MPH, Assistant Director, State Affairs, National Association of Community Health Centers Monica Bharel, MD, Chief Medical Officer, Boston Health Care for the Homeless Program

3. Overview

4. Health centers and payment reform In expansion states, health centers are expected to absorb many newly eligible beneficiaries. Many high cost health system users with complex health needs will now have coverage.

5. Baltimore health care for the homeless program

6. Triple aim

7. Many Payment models being tested Hospital Pay-for Performance Payment Adjustment for Readmissions Payment Adjustment for Hospital-Acquired Conditions Physician Pay-for-Performance Payment for Shared Decision making Global Payment ACO Shared Savings Program Medical Home Bundled Payment Hospital-Physician Gainsharing Payment for Coordination Source: Schneider, E., Hussey, P., and Schnyer, C. (2011). Payment Reform: Analysis of Models and Performance Measurement Implications. http://www.rand.org/pubs/technical_reports/TR841.html

8. Making the Most of Payment ReformPayment Reform and State Legislatures

9. Introduction: Payment Reform & State Legislatures • History of reforms • Private market reforms • Medicare activities • State activities • Payment reform efforts have accelerated in last few years for multiple reasons

10. Medicaid Policies & Payment Reforms, State Legislatures • Improving Medicaid value is at the top of some legislative agendas (over 520 Medicaid related bills filed) • Driven by a number of factors: • Continual pressure on state budgets; • Health reform: challenges and opportunities; • Reforms aimed at better care, better outcomes, lower cost – provides potential for bipartisan efforts (payment reform)

11. Legislative Role in Payment Reform Efforts • Purchaser of health care • Medicaid, state employers, other programs • Purse strings and policymaking • Infrastructure (e.g. HIT) • Regulatory levers (state agencies) • Convening key stakeholders • Focus on Medicaid reform

12. Factors to Consider • Budgetary pressures • ACA: challenges and opportunities • Federally support for payment reform

13. Pressure on State Budgets

14. Top Fiscal Issues for 2014 Legislative Sessions 13 13 29 Medicaid/ Health Care Taxes and Revenues State Employee Salaries and Benefits 9 12 6 Education Infrastructure Corrections/ Public Safety Source: NCSL survey of state legislative fiscal offices, fall 2013.

15. Medicaid Expansion

16. State Structures for Health Insurance Marketplaces/Exchanges NCSL Data: April 1, 2014

17. The “New Coverage Gap”

18. Payment Reform: Federally Supported Opportunities • Medicaid (examples) • Health Homes for Enrollees with Chronic Conditions • State Innovation Models Initiative • Medicare (examples) • Medicare Shared Savings Program • Medicare Value-based Purchasing Program • Federal Employees Health Benefit Program (examples) • Office of Personnel Management Support for Patient-Center Medical Homes

19. Triple Aim – Better Care, Better Outcomes, Lower Cost – Medicaid Payment and Delivery System Reforms • Sources: • Kaiser Commission on Medicaid and the Uninsured, Medicaid in a Historic Time of Transformation: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2013 and 2014, October 2013, available at http://kff.org/medicaid/ • Joan Henneberry joined Health Management Associates 2013 • Risk based managed care • Non-risk care management • ACOs (CCOs, RCCOs, ACEs) • Health homes • Integrated primary care and behavioral health

20. State-Based Medical Home Initiatives NH VT WA AK ME MT ND MN OR MA NY WI ID SD RI MI WY PA CT NJ IA NE OH DE NV IL IN WV MD UT VA CO KS MO KY CA NC TN OK SC AZ AR NM GA AL MS HI LA TX FL As of August 2013 Source: NASHP Medical home activity (45 states and Washington, D.C.) Making medical home payments (29 states) Payments based on provider qualification standards (27 states)

21. State Innovation Models InitiativeTypes of Awards

22. Workforce Demands of New Payment and Delivery Models Models New or Expanded Roles for: • Nurses • Behavioral Health Specialists • Community Health Workers • Social Workers • Peer Specialists • Pharmacists • Health Coaches

23. Mandated Coverage for Telehealth Services

24. Becoming a Key Stakeholder • Track payment reform efforts in your state (or local area). • Establish and maintain a relationship with legislator(s) representing your area(s). • Get involved in collaborative efforts. • Self assessment of capacity (infrastructure, HIT, workforce). • Be clear, concise in communications.

25. Legislative Concerns With Payment Reform Activities, Some Examples Privacy issues Fraud and abuse Market concerns (anti-trust) Network adequacy and patient satisfaction Do new payment methods improve value?

26. Contact: Melissa Hansen Melissa.Hansen@ncsl.org For More Information http://www.ncsl.org/documents/health/PaymentRTK13.pdf

27. Making the Most of Payment Reform DaShawn Groves, MPH Assistant Director, State Affairs National Association of Community Health Centers

28. Overview • State Developments on Payment Reform Impacting Health Centers • Missouri (Health Homes) • Minnesota (ACOs) • Oregon (APM Development) • Successfully Engaging in Payment Reform • Considerations for PCAs • Key Capabilities for Health Centers • Key Steps • Resources

29. Missouri • First Section 2703 Health Homes for Chronically Ill State Plan Amendment (SPA) targeting safety-net providers • 18 Health Centers • Eligible chronic conditions include: • Asthma • Diabetes • Heart disease • BMI >25 • Development Disabilities • State pays $58.47 PMPM • Performance measures outlined in SPA • Developing shared savings methodology

30. Missouri: Lessons Learned • Be involved from early stages • Set clear, simple goals • View 2703 as a “safe” opportunity to leverage federal funds and take a step towards capitation

31. Minnesota (FUHN ACO) • Part of a three-year Medicaid payment reform demonstration • Ten urban health centers located in Minneapolis and St. Paul • Paid on PPS basis • Total Costs of Care targets include: • Inpatient • Outpatient • Professional • Ancillary • Some mental health and chemical health services • Savings • 1st 2% will be retained by state • 98% will be split equally between the state and FUHN

32. Minnesota (FUHN ACO) • Keys to Success • Appropriate program governance • Access to population health management technology • Inclusion of performance management coaches • Enhancing care coordination

33. Oregon • Health centers asked PCA for methodology to better align to PCMH model • Delinks payment from a face-to-face visit • Convert PPS into a capitated bundled payment • Includes: • Physical health services • Mental health services after one year • Eventually Dental services • Able to receive incentive payments • Three-year commitment from both parties

34. Oregon: Lesson Learned • Hard to keep all the balls in the air • APM implementation and refinement • Bridging towards value-based pay • Practice transformation • Data collection • Patient engagement • Population management • Access • Team-based care • Clinics face many demands

35. Successfully Engaging in Payment Reform Considerations for PCAs

36. Considerations for PCAs • Keep a Pulse on the Broader Payment Reform Environment • Build Support for Delivery System Transformation as a Primary Goal of Payment Reform • Secure Input in Payment Reform Design • Encourage Innovation among Leading Health Centers • Facilitate Development of Health Center Capacity for Participation.

37. Key Capabilities for Health Centers

38. Analytic Capabilities • Document the Value of Enabling Services • coding in billing systems • enabling services in EHR/PM templates • Assess Impact of Social Determinants • Define and capture social determinants

39. Analytic Capabilities (continued) • Use Data for Design, Monitoring, and Evaluation • Develop data partnerships/ strategies to secure data • inpatient • specialty care • long-term care • ancillary data • Use data robustly: prospectively as well as retrospectively

40. Operational Capacities • Leadership and Appetite for Innovation • Sophisticated use of Health Information Technology • Partnership Capabilities

41. Key Steps for PCAs and Health Centers

42. Key Steps • Robust understanding of payment reform efforts in the state and local environment • Ensure a clear, shared vision of organization’s role in achieving the Triple Aim. • Critically assess current operations and capabilities. • Work collaboratively with other health centers, stakeholders, and partners to accelerate transformation.

43. Resources Publications: Health Center and Payment Reform: A Primer Health center Payment Reform: State Initiatives to Meet the Triple Aim, State Policy Report #47 www.nachc.com/state-policy.cfm Contact Info: DaShawn Groves. MPH dgroves@nachc.org 202-331-4606

44. Payment Reform: Experiences from the Field Monica Bharel, MD, MPH Boston Health Care for the Homeless Program

45. A Framework for Preparing for Health Care Reform at your Program • Clearly defining the issue • Having data and knowing the facts • Using the data to be involved early in process • Understanding that change is hard • Working collaboratively • Be willing to be in it for the long run

46. A Framework for Preparing for Health Care Reform at your Program • Clearly defining the issue • Having data and knowing the facts • Using the data to be involved early in process • Understanding that change is hard • Working collaboratively • Be willing to be in it for the long run

47. Accountability for defined population Pay for value Comprehensive and transparent care Current situation Future possibility Inconsistent quality Vulnerable populations Accountable Care Fragmented delivery Fragmented payment Volume incentives

48. A Framework for Preparing for Health Care Reform at your Program • Clearly defining the issue • Having data and knowing the facts • Using the data • Understanding that change is hard • Working collaboratively • Be willing to be in it for the long run

49. U.S. Health Care Expenditures are Rising

50. Massachusetts Spends More on Health Care than Any Other State PER CAPITA PERSONAL HEALTH CARE EXPENDITURES, 2009 NATIONAL AVERAGE State NOTE:District of Columbia is not included. SOURCE:Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2011.