Rumana rubBani Meredith Ferraro. MS

1. Achieving the Triple Aim and Health Equity through Community Health Workers: Payment Models that align with the Affordable Care Act and SIM-CT RumanarubBaniMeredith Ferraro. MS CPHA October 23, 2015

2. Background • Southwestern Area Health Education Center (SW AHEC) is 1 of 4 regional centers in the CT AHEC Program. • The agency is an emerging leader in developing future health professionals and in improving community health. • Mission is “Opening doors to better health in underserved communities through education, outreach, and careers.1” We do this by “Connecting students to careers, professionals to communities and communities to better health. • Community Health Workers are the newly recognized frontline public health workers in Connecticut who work to accomplish this mission Southwestern Area Health Education Center (SW AHEC)

3. Background A frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivered. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.2 Community Health Worker (CHW)

4. Examples of COST Savings BY chwiNTERVENTIONSSource: http://cepac.icer-review.org/wp-content/uploads/2011/04/CHW-Draft-Report-05-24-13-MASTER1.pdf

5. Introduction • Role of CHWs: valuable supplement to the healthcare system by helping to achieve goals of PPACA and SIM-CT through the Triple Aim: access to healthcare, improving healthcare quality and experience, and cost-containment in healthcare • Challenge: issues of legitimacy, centralization, sustainability • CT: lack of sustainable payment methods • CT CHWs mostly operate under grants or short-term funding

6. introduction • Patient Protection Affordable Care Act (PPACA) • Goals: Access to affordable health insurance, which reduces health disparities especially for vulnerable populations, increases public health preparedness, expands the healthcare workforce, improves the quality of healthcare delivery, and lowers healthcare expenditures3 • PPACA recognizes and encourages the profession of CHWs: Section 5101 of the PPACA includes CHWs in the definition for “primary care professionals”; funding through Section 5313“Grants to Promote the Community Health Workforce” of the Public Health Service Act.3 • Healthcare reform programs and payment models: Accountable Care Organization (ACO), Patient Care Medical Homes (PCMH), Pay for Performance (P4P), Value Based, Value Based Insurance Design (VBID), and Public Health Cost Savings3

7. BACKGROUND Triple Aim: Better health while eliminating health disparities, improved healthcare quality and experience, and cost-containment in healthcare

8. PPACA and Recognition of CHWs • ACA recognizes CHWs: Section 5101 defines them as “primary care professionals”; Section 5313 has “Grants to Promote the Community Health Workforce” of the Public Health Service Act • CHW work results in overall : 1. Patientsreceive greater accessibility and quality of healthcare 2. Payers and providers receive greater share of savings through: • Improved patient care and reduced healthcare costs • Higherprobability of better outcome measurements 3. Overall savings are achieved for the healthcare system

9. CHW Roles Aligned with Healthcare Reform • ACA recognizes CHWs: Section 5101 defines them as “primary care professionals”; Section 5313 has “Grants to Promote the Community Health Workforce” of the Public Health Service Act • Positive Outcomes of CHW Roles • Patients: greater accessibility to heath care system, improved patient care, reduced healthcare costs • Payers/Providers: greater share of savings, higher probability of better outcome measurements, • Overall savings to the healthcare system and attainment of the Triple Aim

10. CHWs roles Aligned with Payment & Delivery Reform Program Models • Accountable Care Organizations – (ACOs) • executes better health care models that result in greater coordination-of-care and health system cost savings. Program receives a goal for cost savings, and then after it is achieved, providers receive funds from Medicare or other Insurors that are shared with the payer • Advanced Medical Homes (AMH/PCMH) • coordination-of-care occurs across a team of medical practitioners with the intent of providing more comprehensive medical approach; in CT will be done through Medicaid and Advanced Networks

11. CHWs roles Aligned with Payment & Delivery Reform Program Models • CHW roles in healthcare reform and payment programs • Coordination-of-care • drug compliance • patient navigation • dispersing educational health information • help coordinate and facilitate healthcare information throughout a patient’s care. • Activities result in: overall improved patient care and reduced healthcare costs • Payers and providers receive greater share of savings, higher probability of better outcome measurements • Patients receive greater accessibility to heath care system, and • Overall savings for the healthcare system.

12. CHWs roles Aligned with Payment & Delivery Reform Program Models *Payment models listed below are given through advanced payment to providers) n order to provide incentivized cost-containment and higher quality of care • Enhanced fee-for-advice • provider organization is given set amount of money each month known as per-member-per-month (PMPM) payment; provide an agreed upon range of services for the patients for the coverage period • Value-based Payment • (management fee, shared savings) • provides information on Medicare's (and other insurers) plans to confidentially and publicly report physicians' cost and quality of care and to implement a physician pay-for-performance (P4P)

13. CHWs roles Aligned with Payment & Delivery Reform Program Models • Shared Savings Plan (SSP) • per-person spending target is set by Medicare. If a provider can reduce aggregate reimbursements below a specified target, then they share in the Medicare savings • Bundled payment (episode of care: disease category) • single payment to a provider, or a group of providers, for multiple healthcare services associated with a defined episode-of-care • Global Payment • (total care, capitation payment: general payment) • fixed payment to providers for all or most of the care that patients may require over a contract period, such as a month or a year, which is adjusted for illness severity.

14. Introduction • Connecticut State Innovation Model (SIM-CT)4 • $2.8 million planning grant Center for Medicare and Medicaid Innovation (CMMI) in 2013 • $45 million testing grant Center for Medicare and Medicaid Innovation (CMMI) awarded and began in February 2015 • Strives to deliver the totality of care to at least 80 percent of the population within five years and to promote the Triple Aim • CHWs’ capacity to address the pervasive, persistent, and expensive problem of health disparities has been recognized by the SIM-CT

15. SIM-CT VISION • Establish a whole-person-centered healthcare system that: • improves population health; • eliminates health inequities; • ensures superior access, quality, and care experience; • empowers individuals to actively participate in their healthcare; and • improves affordability by reducing healthcare costs

16. SIM Initiatives

17. Model Test Hypothesis for SIM Targeted Initiatives High percentage of patients in value-based payment arrangements + Resources to develop advanced primary care and organization-wide capabilities = Accelerate improvement on population health goals of better quality and affordability MQISSP Medicare SSP Commercial SSP + • Advanced Medical Home Program • & • Community & Clinical Integration Program (CCIP) MQISSP is the Medicaid Quality Improvement and Shared Savings Program

18. Primary care partnerships for accountability Primary care practice Advanced Network Advanced Network = independent practice associations, large medical groups, clinically integrated networks, and integrated delivery system organizations that have entered into shared savings plan (SSP) arrangements with at least one payer

19. Resources aligned to support transformation Community & Clinical Integration Program (CCIP) Awards & technical assistance to support Advanced Networks in enhancing their capabilities across the network Advanced Network Advanced Network Advanced Medical Home (AMH) Program Support for individual primary care practices to achieve Patient Centered Medical Home NCQA 2014 recognition and additional requirements Improving care for all populations Using population health strategies

20. Improving capabilities of Advanced Networks Community & Clinical Integration Program Awards & technical assistance to support Advanced Networks in enhancing their capabilities in the following areas: Supporting Individuals with Complex Needs Comprehensive care team, Community Health Worker , Community linkages Analyze gaps & implement custom intervention CHW & culturally tuned materials Reducing Health Equity Gaps Community Health Collaboratives Advanced Network Integrating Behavioral Health Network wide screening, assessment, treatment/referral, coordination, & follow-up Comprehensive Medication Management E-Consults Oral health

21. Improving capabilities of practices in Advanced Networks Advanced Medical Home Program Webinars, peer learning & on-site support for individual primary care practices to achieve Patient Centered Medical Home NCQA 2014 and more Patient Centered Access Performance Measurement Team Based Care Quality Improvement Population Health Management Advanced Network Care Coordination/ Transitions Whole-Person Centered

22. Objective • Gain insight into payment systems that exist in Connecticut • Receive feedback from payers regarding the incorporation of CHW roles in healthcare reform models • Gain insight of outcome measurements that payers would consider for CHW payment. • Assess payer perception of feasibility of providing payment for CHWs

23. Methods • Literature review • CHW payment methods in other states • CHW roles in alignment with PPACA and SIM • Sustainable payment methods recommended through PPACA/SIM • Interests and guidance from SWAHEC and advisors • Collaboration on project mission • Conferences/CHW meeting to gain insight • Key informant contacts • Interviews with: • 1 National private payer • 1 State private payer (multi-company representative) • 3 Medicaid representatives • 1 State representative official

24. METHODS • Transcribed and coded responses • Coding themes: • Payment Methods (e.g. value-based payment, bundled payment, grants) • Reform Program Models (e.g. P4P, Medical Homes, ACOs) • Funding Source (Medicare, Medicaid, Commercial Payers) • Roles of CHWs (e.g. Care Management and Care Coordination) • Health Reform (ACA, SIM) • Performance Measurements • Other State Models • Quotes

25. RESULTS Current Payment Methods for CHWs • Short-term grants and funding are the current sources of compensation in Connecticut • States including New York, Arizona, Tennessee, and Washington pay CHWs through management fees in Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs) within Federally Qualified Health Centers (FQHCs) • New Jersey CHWs operate within FQHCs through practices known as CAMcare and Camden Coalition • Texas, Arkansas, Oregon and Minnesota have Medicaid programs that provide CHWs with sustainable funding

26. RESULTS • PPACA and SIM-CT encourage the role of CHWs in PCMHs and ACOs • CHWs play the roles of health coaches, health literacy advocates, and care coordinators in ACOs of several states • CT Medicaid is in process of implementing CHW roles within Advanced Medical Homes • Highest level of interest was shown for  P4P, PCMHs/AMHs, and ACOs • Public and national private payers agree that CHWs are important for cost containment Roles of CHWs in Delivery System and Payment Reforms

27. results • Five out of six key informants showed interest in value-based payment and agreed that CHWs should not be reimbursed through fee-for-service • State private payers did not see an issue with fee-for-service being a problem for sustainability of CHWs nor in the healthcare system Sustainable Payment Methods Preferred by Payers • “Get away from fee-for-service.”- Medicaid Representative • “The state will pay for a package of services and the provider has the option to include community health workers in the provision of those services, but it's not a direct payment [...] specifically for CHW services.” -- Medicaid Representative

28. results • Half of the sample expressed that global payment is the optimal sustainable method Sustainable Payment Methods Preferred by Payers • “The strategy to adopt is to say payers are already advancing money that enables practices to expand their team to include care coordinators.” - State Representative Official • “There’re a lot of different variations on how [CHWs] are paid [...].It’s usually some kind of a bundle payment either for an episode or sort of global payment for all the health needs of the covered population.” - Medicaid Representative

29. results • CT Medicaid is in nascent stages of implementing enhanced-fee-for service and performance payments for CHWs employed in Advanced Medical Homes (AMHs) Sustainable Payment Methods Preferred by Payers • “Medical Homes is a building block for ACOs. It’s certain that the proliferation of Medical Homes is conducive to the deployment of CHWs.” - State Official Representative • State private payers showed no interest or were non-responsive to recommend sustainable payment methods for CHWs • All payers agreed CHWs should receive sustainable funding but do not foresee implementation in the near-future

30. results Sustainable Payment Methods Recommended by Key Informants

31. CHART from CODING

32. results • Medicare and Medicaid measure care experience to evaluate CHW impact in CT healthcare programs • Payers recommended using health outcomes, such as quality of life, chronic illness management, appropriate utilization of services, hospital readmission rates, return on investment, and health literacy as measurements • Key informants expressed concern that P4P may not be an accurate measure of CHW value and efficacy of performance. Measurement Outcomes used to evaluate CHW services

33. recommendations • CHWs should be employed in health reform programs to realize the goals of the Triple Aim • Connecticut should refer to Oregon as a reference for payment models since it has a similar healthcare system • CT should consider global payment or value-based payment for sustainable funding of CHWs Recommendations for Connecticut’s CHW Initiative

34. recommendation • Providers should be interviewed regarding their perception of sustainable payment approaches for CHWs since they directly work with and employ CHWs • Likert Scale in future studies should be used  to allow for interest level of interviewees to be more clearly determined • List of existing payment methods recommended through PPACA and SIM-CT and case examples of cost-saving CHW interventions should be provided to interviewees, especially state private payers Recommendations for future studies

35. conclusion • Our study revealed that the goals of SIM-CT align with PPACA and encourage the roles of CHWs in health reform programs, as they embody the goals of the Triple Aim. • On a national level, Medicare is using and encouraging the use of CHWs in many ACO pilots. • In Connecticut, Medicaid and SIM are in the process of implementing CHWs through a value-based payment in the AMH model.

36. Volume to Value Based Payment

37. conclusion • Our study showed that various states, especially SIM states, are encouraging or have already implemented, CHW sustainable payment programs or are using a Medicaid funds. • Connecticut should consider the design of successful programs in other states in the development of its CHW workforce. Oregon was noted as a valuable reference for Connecticut’s future payment models, as the two states share similar healthcare systems. • Seemingly the most preferred way to incorporate CHWs into healthcare delivery is through the use of global or value-based payment methods.

38. Health-in-all Policies • Health-in-all policies is defined as collaborative approach to improving the health of all people with participation from multiple sectors, including payers. • CHWs are an integral sector to help accomplish social determinants of health which is now known as health-in-all policies. • The Trust for America’s Health estimates that $10 per person per year for prevention of chronic illness in proven community-based programs could save our country more than $16 billion annually in five years – a return of $5.60 for every dollar spent. • Within these programs, CHWs often address a patient’s basic needs such as promoting economic stability, transportation access, environmental, and educational attainment. • Work of CHWs could also result in a decrease of chronic illness and unnecessary ER visits. CHWs are, therefore, a necessary work force for the health in all policies framework.

39. CASe study:Health in all policies - RI • In June 2011, law RIGL 23-64.1 directed the establishment of a Commission of Heath Advocacy and Equity. • Requires a cross-section of state agency and community members to focus on the social determinants of health, and prepare biennial reports with public participation. • The law will serve to remind the government and the public that objectives for the well-being of the population are best achieved when all sectors include health as a key component of policy development.

40. conclusion • Overall, most public and national private payers support the idea of providing funds for CHW services but it will not be in the short-term that sustainable payment methods can be realized.

41. acknowledgement • Special thanks to our preceptor, Meredith Ferraro of SW AHEC, and to Elaine O’Keefe and Mary Ann Booss of the Office of Public Health Practice at Yale University for providing contacts, information about CHW conferences, and their passionate devotion to our project. • We also thank our instructor, Dr. Debbie Humphries, for her endless support and guidance, as well as our TA, Benjamin Clopper, for his assistance and collaboration on this project. • We are also grateful for the time and contribution of our key informants.

42. Concluding remarks Questions?

43. reference 1. http://www.swctahec.org/ 2. Association Public Health America. (2014). Community Health Workers. 2014, from http://www.apha.org/membergroups/sections/aphasections/chw/ 3. .National Peer Support Collaborative Learning Network. (2013). Opportunities for Peer Support in the Affordable Care Act (pp. 16). Leawood,KS: Peers for Progress. 4.State of Connecticut. (2013). Connecticut Healthcare Innovation Plan (Vol. 225). Connecticut: State of Connecticut.