Alternative Payment Methods & Cost Savings Analysis: Emerging Results from SBHC Innovation Study

1. Alternative Payment Methods & Cost Savings Analysis: Emerging Results from SBHC Innovation Study

2. The project described is supported by Grant Number 1C1CMS331028 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. • "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies."

3. Presenter Disclosures University of Miami Miller School of Medicine “No relationships to disclose” The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

4. Our Vision • The Dr. John T. Macdonald Foundation School Health Initiative, founded in July 2000, shares in the vision of serving school-aged children and their families while striving to become a center of excellence for school health care.

5. Our Mission Deliver high quality medical, dental, social and mental health services to children and adolescents in their schools; Participate as a community partner to ensure that the health care needs of youth and their families are met; Serve as a national and local advocate for school health and; Educate and train our health professions students through service-learning to ensure the future of health care delivery for our youth; Increase school performance of the students in the target schools by improving their health status, attendance, and ability to focus on academics.

6. Our Schools

9. Staffing

10. Indicators of poor health status: • HPSA • Minority status • 85% of students on free school lunch program. • Federal poverty level • 20% of families in NMB • 24% North Miami • 30% Overtown • A high prevalence of obesity or overweight (32%) exists among students in these areas • Of 638 second grade students seen for sealant placement, 225 (35%) had existing caries. • 33% of parents with children enrolled within the SBHCs report having Medicaid. 4% reported having private insurance. The remainder reported being uninsured. • Asthma surveillance conducted by the DOH revealed that our schools are in zip code areas ranked 3rd highest for child ER visits due to asthma. • Estimated 25% have serious mental health issues.

11. Current Services: • Physical examinations • Telehealth specialty consultations • Immunizations • Mental health services (social workers) • Dental sealant and varnish program • Chronic disease management • Acute care • Episodic care • Laboratory services • Pulmonary function testing • EKG testing

12. Service Learners • Nursing • Medical students • Residents • Psychiatry • Social work • Dental

13. Outcomes and Individual Success Stories • Reduction in 911 calls • Improved absenteeism rates • 87% return to class rates • High detection and treatment of STDs • Tracking • The case of eczema herpeticum • Chest pain in a teen • Homeless teen

14. Immunization status:

15. The Dr. John T. Macdonald Foundation School Health Initiative Challenge • Improve Quality • Provide Better Care • Lower Costs

16. The Dr. John T. Macdonald Foundation School Health Initiative Challenge Objectives • Build upon our current school-based health center network for 12,000 school-aged children for primary care, nursing and social work services to include preventive dental and mental health services. • To address the health needs of the parents of these children and through a partnership with a grassroots primary care clinic at the Center for Haitian Studies. • To utilize community health workers as peer educators and coordinators of care to improve access and adherence to care plans. • To work with all partners, including two HMOs and CMS to develop new patient payment mechanisms that reward quality, innovation, and cost-effectiveness.

17. Preventive Dental Services (Nova): • Telehealth Oral Exams (pilot project) • Sealants for 2nd and 6th graders • Varnishes (trainings given to medical and nursing staff for application of varnishes) • Restorative care • Referrals (to community)

18. Off 555 students seen for services, 35.2% had dental caries in permanent teeth. 6.1% had existing caries in primary teeth. 19.7% of students had fillings of permanent teeth. 3.4% had fillings of primary teeth. Oral Health - NSU

19. Expansion of Mental Health: - Guidance, Supervision of SW’s - Guidance, Supervision of CHW’s for Mental Health • Telehealth Encounters • On-call system • Psychology Services

20. Telehealth: • School-to-school consultations • Dermatology, nutrition, psychiatry • Reimbursement? HB 499 2013 F L O R I D A H O U S E O F R E P R E S E N T A T I V E S A bill to be entitled An act relating to health care coverage; requiring health insurers, corporations, and health maintenance organizations issuing certain health policies to provide coverage for telemedicine services; providing definitions; prohibiting the exclusion of telemedicine cost coverage solely because the services were not provided face to face; specifying conditions under which an insurer, corporation, or health maintenance organization must reimburse a telemedicine provider for certain fees and costs; authorizing provisions requiring a deductible, copayment, or coinsurance requirement for telemedicine services under certain circumstances

21. UM Telehealth Services

22. Community Health Workers (CHW’s): • Peer Educators • Peer Facilitators • Peer Encounters

23. Medicaid Enrollment Goals:

24. Clinic Enrollment:

25. Medicaid Enrollment:

26. Current JTMF Medicaid Enrollment

27. HMO Partners: • Medicaid Enrollment Assistance • Achievement of HEDIS (Healthcare Effectiveness Data & Information Set) Parameters • Data Capture & Analysis • New Payment Methods

28. Alternative payment methods • Fee-for-service • Capitation • Shared savings • Pay for performance

29. Pay for Performance • Immunization compliance • Asthma control

30. Medical home incentives • Value based incentives related to improved care coordination and case management • Practices with PCMH recognition most likely to be offered • Incentives may include funding to hire care coordinator, per month stipend for care coordination activities, shared savings from decrease ER utilization

31. Initiative Overview Amerigroup has embarked on an initiative to ensure that all members with access to school based health centers could easily obtain quality healthcare services at these locations by contracted providers (MDs, PAs or ARNPs. As part of this initiative, Amerigroup is working closely with SBHCs to identify and engage non-compliant members in need off required care (e.g. Annual Well Child Visit) who attend these schools. 2

32. How Amerigroup Works with SBHCs to Provide Care to Non-Compliant Members Step 1: Amerigroup conducts location-analysis identifying non-compliant school-aged members Step 2: Amerigroup securely transfers non-compliant member file to SBHC-Provider - for matching with school or health center database Step 3: SBHC-Provider engages families of ‘matched’ members and schedules an appt at school health center Step 4: SBHC-Provider communications with member’s PCP to inform them of care provided at school Step 5: SBHC submits encounter/billing report and receives reimbursement from Amerigroup 8

33. Top Clinic Visit Reasons • Top ICD-9 Encounters (ensuring HEDIS measures) • Well child care, annual physical examinations and sport exams • Immunizations • Asthma

34. Cost Savings & Effectiveness

35. Outcomes: • Holistic, team approach for care of school-age children and their parents with SBHC’s serving as medical, dental and mental health homes. • New payment methods that save Medicaid money while rewarding cost-effectiveness, quality and innovation. • Return on investment – direct costs (healthcare: ER visits, ambulance transport, diagnostic tests, nonhealthcare: transportation to clinic), indirect costs (time lost from school)

36. Data Needs: • Enrollment • Disease Management • Impact of On-site Services • Impact of CHW’s • Impact of Telehealth • Impact of Team Approach • HEDIS • Documentation of Cost-Savings

37. CHEER • CHEER® (Children’s Health, Education and Economic Resource) is a web based student encounter record used by health care professionals in schools • Instantaneously access data at point of service • View of the child across systems of care • Updated with school district data every night, enabling accurate registration, look-up of encounter history, and data capture.

38. CHEER Encounter Screen

41. Economic Analysis of the Enhanced School-Based Health Center Kathryn McCollister, Ph.D.Associate Professor and Health Economist Department of Public Health SciencesUniversity of Miami Miller School of Medicine

42. Overview of Presentation • Importance of examining financial impact and economic viability of school-based health centers • Present results of the cost analysis of University of Miami’s school-based health centers with enhancements through CMS Health Care Innovation Challenge Award • Describe range of outcome domains and specific measures that will factor into benefit-cost analyses • Present preliminary results of cost-savings during first year of CMS HCIA project

43. Introduction • School-based health centers effectively reduce barriers to accessing primary health care services and promote better management of chronic conditions among school-age children • Have important role in reducing health disparities among minority and low-SES groups • Reduce unnecessary and costly health services utilization such as emergency department visits • Provide potential important indirect benefits to families of children attending schools with a SBHC

44. Introduction (continued) • In addition to evaluating effectiveness of SBHCs, sustainability of these programs depends on showing that they are cost-saving • Need to critically evaluate both costs of operating SBHC and outcomes to demonstrate that the benefits of these programs outweigh the costs (i.e., generate a positive return-on-investment) • This presentation describes results of an economic evaluation of Miami’s SBHC plus enhancements operating in nine middle and high schools around Miami-Dade County, Florida

45. Cost Analysis • Cost data were collected for the academic year August 20, 2012 – June 6, 2014 • Data come from detailed staffing records and financial reports provided by UMMSM Department of Family Medicine • Implementation costs including enhancements provided by the HCIA were comprised of: • Personnel costs including volunteer labor • Contracted services (dental, mental health) • Telemedicine services • Staff travel • Indirect costs (administrative overhead)

46. Cost Analysis (continued) • Results presented in Table 1 • Total annual cost: $1.7 million • Opportunity cost of volunteer labor amounted to $409,712 • Average cost per student visit: $400 • Average cost per contact including family visits: $376

47. Table 1: Cost Analysis of HCIA Enhancements to School-Based Health Centers

48. Cost Savings • Several outcomes of interest to examine cost-savings of the SBHCs • Some more directly related to presence of SBHC, others indirectly related • Sexually transmitted infections and pregnancies • Chlamydia • HIV • Chronic conditions • Asthma (controlled/uncontrolled cases, total cases treated) • Obesity/overweight • Diabetes

49. Cost Saviongs • Mental Health Disorders • ADHD • Depression • Anxiety • Substance use disorders • Dental Health • Sealants (total cases treated) • Varnishes (total cases treated) • High risk for caries • Plaque • White spots • Obvious decay • Bleeding gums • Restorations

50. Cost Savings & Effectiveness (Cont’d) • Immunizations • Influenza • Tdap • Hib • Varicella • MMR • HPV • Hep B • Health Care Services • Emergency department visit • Hospital inpatient day • Educational Attainment • Graduation from high school • Day missed from school