Colorado’s State Innovation Model A Vision of Integration, Implications for Primary Care, Intersection with CPC

1. Colorado’s State Innovation ModelA Vision of Integration, Implications forPrimary Care, Intersection with CPC Working Together to Transform Health Care Colorado Health Care Innovation Plan Kick-Off May 29, 2013 CPC Payers June 11, 2014

2. Today’s Discussion • SIM background, overview of current opportunity • VatsalaPathy, SIM Project Director • Kate Kiefert, State HIT Coordinator-Office of Gov. John Hickenlooper/SIM Management Team • Integrated Care – rationale, framework for SIM • Ben Miller, SIM Management Team • SIM ask of payers and expectations of practices • Edie Sonn, SIM Management Team

3. CO SIM Background, Current Opportunity VatsalaPathy, SIM Project Director Kate Kiefert, State HIT Coordinator-Office of Gov. John Hickenlooper SIM Management Team

4. Members of Core Management Team • Vatsala Pathy, Project Director with key staff from: • Governor’s Office • Colorado Department of Health Care Policy and Financing • Colorado Department of Human Services • Colorado Department of Public Health and Environment • Center for Improving Value in Health Care • Colorado Health Institute • University of Colorado School of Medicine

5. Our Vision & Goals • To create a coordinated, accountable system of care that gives Coloradans access to integrated primary care and behavioral health in whichever setting counts as the patient's medical home. • To leverage the power of our public health system to achieve broader population health goals and support delivery of care. • To use outcomes-based payments to enable transformation. • To engage individuals in their care.

6. How We Got Here • Original funding opportunity from CMMI late summer 2012 • 6-week timeframe to develop multi-stakeholder Innovation Plan • Spring 2013 “pre-testing” award to CO to flesh out plan • December 2013 – submitted revised State Health Innovation Plan to CMMI • May 2014 – Round 2 SIM funding opportunity announced

7. CMMI Requirements • Movement away from FFS • Multi-payer participation • Explicit commitments from payers and providers • HIT component • Population health plan • Quality measure alignment • Alignment with other state and federal investments and innovations • Plan for sustaining after SIM funds expire

8. Project Update • Next steps • Respond to the Funding Opportunity Announcement (FOA) for Round 2 Test Awards (Available at http://innovation.cms.gov/Files/x/StateInnovationRdTwoFOA.pdf ) • LOI due 6/6/14 • Submission due 7/21/14 • Award notification 10/31/14 • Grant period: 1/1/15-12/31/18 with a one year ramp-up

9. Our Ask of You • Letters of Commitment no later than 7/7/14 that reflect: • Non-FFS payment model consistent with what you’re already doing • Note: SIM dollars will supplement your current investments • Core set of quality measures (CPC measures plus 3) • Data aggregation • We’ll provide a template this week

10. Integrated Care:Rationale, Approach Ben Miller, Psy.D SIM Management Team

11. Definition of Integration (Peek, 2013) • The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. • This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization.

12. Why It Matters

13. Fit with CPC? • Builds on CPC investments in practice transformation • Supports practices that have chosen “behavioral health integration” for CPC Milestone 2 • Next evolution of high-performing primary care

14. Overview – SIM Path Toward Integration

15. Phase 1: Coordination How it Might Look for a Practice • PCP develops coordination compacts, HIE agreements with behavioral health providers addressing referral expectations, record-sharing, case conferences, etc. • Partners may be remote and accessed through telehealth. • Care coordinator provides behavioral coaching as necessary (NOTE: NOT MENTAL HEALTH OR SUBSTANCE USE COUNSELING) and referrals to community partners. • Practice uses EHR, registry and claims data to track agreed-upon measures. • Practice meets certain minimal thresholds for treating patients with comorbid behavioral health conditions. • SIM dollars support these care coordination services.

16. Phase 1: CoordinationPayer Support • Demonstrate that you are already providing a care coordination payment at a level appropriate to the risk profile of the patient population. • Not asking you to increase your current CPC PMPM – SIM dollars would support the additional services/ infrastructure necessary. • Create shared savings opportunity as appropriate. • Use core set of quality measures (CPC measures plus 3) to assess contracted practices’ performance. • CPC + 3 behavioral health measures. • Provide regular quality and cost reports, aggregated with those from other payers, to practices.

17. Phase 2: Co-LocationHow it Might Look for a Practice • Contract with BHP/agency to deliver services on site for minimal number of hours (TBD) per week. • May be separate from the primary care team, and may solely rely on referrals from primary care. • Primary care providers identify patients who are in need of some type of behavioral health intervention. • Patients referred to the onsite BHP for them to see whenever the BHP’s schedule allows. • Since the BHP and PCP are likely keeping separate notes, a data use agreement/sharing arrangement must be in place to assure communication. • Use EHR, registry and claims data to track agreed-upon measures. • Meet thresholds for treating patients with comorbid behavioral health conditions.

18. Phase 2: Co-LocationPayer Support • Same as Phase 1 • Demonstrate your existing PMPM is sufficient for the practice’s patient population. • Create shared savings opportunity as appropriate. • Use core set of quality measures (CPC measures plus three) to assess contracted practices’ performance. • Provide regular quality and cost reports, aggregated with those from other payers, to practices. • Not asking you to increase your investment

19. Phase 3 (The Goal!): IntegrationHow it Might Look for a Practice • Incorporate full-time BHP as part of primary care team (e.g., 1 BHP:2500 patients). • Include in morning huddles, conduct warm hand-offs, etc. • Have shared care plan and EHR. • Seamless interventions, collection of data, and sharing of patient data. • Use EHR, registry and claims data to track agreed-upon measures. • Meet minimal thresholds for treating patients with comorbid behavioral health conditions.

20. Phase 3 (The Goal!): IntegrationPayer Support • As appropriate for practices that are capable of assuming risk: • Annual prospective payment including downside risk. • For practices that aren’t ready for annual prospective payment: • PMPM plus shared savings opportunity. • Use core set of quality measures (CPC measures plus 3) to assess contracted practices’ performance. • Provide regular quality and cost reports, aggregated with those from other payers, to practices.

21. Expectations for Providers Edie Sonn SIM Management Team

22. Potential Practice Selection Criteria • Meet minimum MU designation (align with CPC) • Already providing team-based care • Basic measurement competencies • Willingness to develop population health focus • Nice to have but not essential: • Already partnering with behavioral health

23. Practice Recruitment Approach • Year 1 (summer 2015) – early adopters, e.g.: • CPC practices that selected behavioral health for milestone 2 • Practices participating in ACT and SHAPE pilots • Large primary care groups (e.g., New West, PHP, CSHP, iPN) • Hospital-owned primary care practices • FQHCs and CMHCs with existing partnerships • Practices identified by participating payers that demonstrate characteristics of high-performing primary care • Include urban and rural practices • Target: 80-100 practices • Years 2-3: Add practices (target number TBD) • Year 4: TBD

24. SIM Request of You Edie Sonn SIM Management Team

25. Important Context • Not asking you to join another pilot • Rather, build upon what you’re already doing • SIM team knows – and appreciates – how much you’re investing in primary care transformation already – through CPC, your proprietary PCMH and ACO models, HIT support, etc. • Thank you for that! • Not asking you to invest more at this time • SIM dollars will supplement your existing care coordination payments to support movement toward integrated care

26. Requested Payer Commitments – by 7/7/14 • Demonstrate that you are providing a PMPM care coordination payment at a level sufficient to support appropriate BHP services given the practice’s position along the integration continuum, size of the practice and the risk profile of the patient population. • Commit to move to shared savings opportunities within 2-3 years for appropriate practices (sooner for practices that are already capable). • Commit to move to prospective payments in 5 years for appropriate practices (sooner for practices that are already capable). • Commit to using core set of quality mesaures(CPC measures plus 3). • Can add others of your own. • Aggregate data and share with practices. • Can leverage CPC investments in HIT, HIE and data aggregation.

27. Advantages to Payers • Leverages your existing investments: • Practice transformation • Technology • Data • Supports your own transition to non-FFS payments by helping practices get there too

28. Summing Up • SIM team will provide template commitment letter this week • July 7 deadline for sending letter of commitment to the State – • Sooner is better!

29. Questions? ColoradoSIM.org sim_grant@state.co.us