What’s Next for Maryland Hospitals HFMA Maryland Chapter

1. What’s Next for Maryland HospitalsHFMA Maryland Chapter Michael Robbins Senior Vice President Maryland Hospital Association January 27, 2017

2. All-Payer Model (Waiver) • All-payer system • All pay same price for same service at same hospital • Rate setting system • State commission sets hospital rates • Federal Medicare payment rules had to be “waived” • Brings over $2 billion per year to Maryland • Entered into new demonstration with CMS in 2014; We are in year four of the five-year agreement

3. Maryland Waiver Requirements • Three financial metrics: • Annual hospital spending cap – 3.58 percent per capita • Medicare savings target - $330 million over five years • Growth in Maryland spending (hospital and non-hospital spending) cannot exceed the nation • Two quality metrics: • Reduce 30-day readmissions to national average • Reduce complications by 30 percent in five years • Tells us what to do; not how to do it • Maryland decision: hospital global budgets

4. Maryland Waiver Performance DashboardCumulative Performance – Jan 2014 to Most Recent Data Available

5. Medicare All Provider SpendingGrowth Per Beneficiary Trends (Total Cost of Care) Annual Medicare All-Provider Spending Growth per Beneficiary Trend Spending Growth per Beneficiary Source: CMS data, see disclaimer

6. Triple Aim

7. New Incentives Changes how hospitals are paid to reward the right things • Success under the new rules requires • cost reduction • care for patients in the community • care in lower cost setting • reduce unnecessary care • The key: population health management

8. Population Health Management “Managing the health outcomes of a group of individuals” • Central role of primary care • Patient activation, involvement and responsibility • Care coordination through wellness, disease and chronic care management 8

9. Population Health Management Changes how hospitals think • Do more to earn more  Rewards for efficiency and quality • Care for an individual patient  Care for an entire population • Acute care  Ambulatory care  Community care • Competition  Collaboration • Hospital care  Health care

10. Health is About More Than Clinical Care Health is driven by multiple factors that are intricately linked – of which medical care is one component. Personal Behaviors 40% Family History and Genetics 30% Environmental and Social Factors 20% 10% Medical Care Source: Determinants of Health and Their Contribution to Premature Death, JAMA

11. Maryland’s Transformational Change • Maryland at leading edge of innovation • Demo still in its infancy; performance very positive to date • Dramatic and difficult transformation • Transformation underway but not complete • Where from here? Provider alignment • We need: • Partnership and collaboration • Laser-like focus • Flexibility to focus on outcomes • Time to prove success and sustainability • Can’t jeopardize core hospital model

12. Expectations Chasm • Insert Dashboard Here

13. Maryland Demonstration Next Steps • “Care Redesign” amendment to current Maryland All-Payer Model • Hospital Care Improvement Program • Complex and Chronic Care Improvement Program • Primary care model • Primary Care Homes with patient-designated providers (primary care physicians and specialists) • Regional care management entities (ACOs, local care improvement coalitions, regional partnerships, others) • New Medicare Part B funding for care management fees, MACRA bonuses • Dual eligible model • Model progression plan

14. Care Redesign Amendment • HSCRC proposed amendment to the All-Payer Model • Provides access to new tools: • Detailed, patient-identifiable Medicare data • Fraud and abuse waivers under two initial programs: • State can modify programs without CMMI approval • Details to watch for: • “Voluntary” program • Hospital-specific total cost of care guardrail • State oversight functions

15. Primary Care Model • Led by Dr. Howard Haft, Deputy Secretary DHMH • Structure: • Standardized, common performance metrics • Details to watch for: • Impact on total cost of care guardrail • Funding source(s) • Interaction with existing care management models • Role of commercial payers

16. How Does Transformation Feel?

17. New Developments • The Affordable Care Act – Repeal and Replace

18. ACA – Repeal and Replace • What we know: lack of clarity • Our message: coverage is paramount • Continue our focus on value: extend our demonstration

19. The Road Ahead

20. What’s Next for Maryland HospitalsHFMA Maryland Chapter Michael Robbins Senior Vice President Maryland Hospital Association January 27, 2017