Public Sector Healthcare Service Delivery and Purchasing Reform

1. Public Sector Healthcare Service Delivery and Purchasing Reform Presentation for Health Care Cabinet Delivery System WorkgroupDecember 5, 2011 Mark Schaefer Director, Medical Care Administration

2. Health Purchasing Challenges

3. Health Purchasing Challenges • Loss of confidence in managed care • Poor encounter data • Uncertain cost-effectiveness • Modest measured performance • Limited partnership with providers • Inequity • 50% of Medicare vs. sizable MCO profits

4. Health Purchasing Challenges • Recognition that service delivery problems (inefficiencies, duplications, gaps) are local and variable • Structural reforms must provide local accountability for value • Defining, measuring, and rewarding value must be coordinated across payers

5. Health Purchasing Challenges • Multi-payer coordination is a challenge • Cannot do anything about the multitude of commercial payers • But we can simplify the strategy of the state’s large public payer

6. Focus on Value Multiple MCOs

7. Focus on Value Single Statewide ASO Make Value Transparent

8. Health Purchasing Model

9. Medical Administrative Services Organization

10. Medical ASO: Program Goal • Near term • Improve access, quality, health outcomes • Better manage high risk/high cost individuals • Reduce unnecessary and inappropriate service use • Long term • Administrative support for service delivery and purchasing reforms • Support migration of resources and accountability to local providers and systems

11. Medical ASOFunctions • Call center services (i.e., referral assistance, appointment scheduling, benefit information), • Attribution or assignment to a usual source of care (PCP or Person Centered Medical Home)

12. Medical ASOFunctions • Utilization management • Routine Care Coordination for all members • Intensive Care Management services for those with complex needs

13. Medical ASO Functions • Coordination with dental, behavioral health, pharmacy, transportation, and waiver programs • Health informatics such as health risk stratification and predictive modeling to support population health management and disease management • Cost and quality data aggregation and analysis to support profiling of state, providers and local systems • PCMH practice support • Not responsible for provider network (contracting, credentialing or claims)

14. Promoting Change in Service Delivery and Organization • ASO provides uniform structure for reporting, customer service, and care management • Changes in the delivery and organization of services at the local level are of equal or greater importance. • New model moves beyond simple PCP assignment to promote the emergence of medical homes and health homes

15. Migration of Intensive Care Management BHP ASO Medical ASO Intensive Care Management Intensive Care Management Assigned PCP Medical Home CT Medical Assistance Program (CMAP) Provider Network

16. Migration of Intensive Care Management BHP ASO Medical ASO Intensive Care Management Intensive Care Management Assigned PCP Medical Home CT Medical Assistance Program (CMAP) Provider Network

17. Migration of Intensive Care Management BHP ASO Medical ASO Intensive Care Management Intensive Care Management Assigned PCP Health Home Medical Home CT Medical Assistance Program (CMAP) Provider Network

18. Migration of Intensive Care Management BHP ASO Medical ASO Intensive Care Management Intensive Care Management Assigned PCP ICO/Health Home Medical Home CT Medical Assistance Program (CMAP) Provider Network

19. Service Delivery and Organization Summary • ASO positioned to support clients and improve care for all individuals • Gradual emergence of medical homes with ability to facilitate referrals, help individuals navigate the system, and coordinate care • More advanced medical homes will be qualified to serve as health homes for individuals with chronic illnesses • ASO resources can be reduced as providers are better able to provide services and supports • ASO resources will likely remain for selected functions and to address gaps in the system • ASO can continue to provide care coordination and intensive care management for individuals without a medical or health home

20. Person Centered Medical Homes: Improving Value in Health Care Delivery

21. PCMH: Program Rationale • “Triple-Aim”: • Enhance the care experience of individuals, • Enhance the health outcomes of individuals and populations, and • Control the cost of care • Measure and reward performance across a range of domains for both: • Meeting targets, and • Ongoing improvement

24. PCMH Standards for Participation • National Committee for Quality Assurance (NCQA) Recognition required: • Level 2 or 3 • 2008 or 2011 (with 2011 going forward) • Additional DSS PCMH participation requirements (in process): • Federal EPSDT requirements • Smoking cessation incentive program (iQUIT) • Efforts to decrease racial and ethnic disparities among consumers • Consumer protections (PCMH and ASO)

25. PCMH Glide Path • Support less well resourced practices or those who are just beginning the PCMH transformation process • Support over time • Support actual PCMH development processes • Medical ASO support for: • DSS Glide Path requirements • NCQA application process and related requirements • And data analysis/quality on an ongoing basis

26. PCMH Glide Path • All Glide Path practice sites must: • Submit a gap analysis to achieve PCMH recognition • Develop a detailed work plan based on gap analysis • Comply with requirements (consistent with Meaningful Use and NCQA process) to meet timeframes: • PCMH Phase 1 Glide Path – no more than 6 mos. • PCMH Phase 2 Glide Path – no more than 6 mos. • PCMH Phase 3 Glide Path – no more than 6 mos. • Opportunity for 6 month extension total • Total Glide Path timeframe not to exceed 24 months

27. Glide Path Financial Support • Glide Path practices will receive: • Portion of fee differential paid to fully qualified PCMH practices or clinics • Increment will cease if a practice fails to advance to the next phase • Supplemental start-up payments • For 5 FTE equivalents or fewer • $13-$25K over Glide Path Phases w/in first 12 months of participation based on practice size • Funding must be returned if a practice doesn’t ultimately qualify within 24 months of starting • Support from the medical ASO and UCONN BMI

28. Performance Measurement • Proposed criteria for the selection of measures: • Relevance to consumers, improved experience and improved health • Relevance to PCMH and improved quality • Basis in evidence • Minimize or manage the burden on providers and the State to collect data • Actionable for improvement

29. Performance Measurement • Year 1 to start: • Claims-based measures • EHR Documentation to demonstrate phone/e-mail, care coordination, disease education • PCMH CAHPS to look at consumer experience • Year 2: Performance payments based on both claims-based and EHR measures and outcomes (plus consumer experience)

30. Performance Measurement • Year 3: Review all measures with gradual movement toward increased EHR submission • Outcome/EHR measures will be established going forward based on: • Data to inform priorities • Experience of PCMH practices who have actual EHR experience • Consumer, provider and advocate input

31. Hybrid Reimbursement Components * Available only to independent practices with 5 FTE equivalents or less

32. Incentive Payments • Incentive payments will be paid for each measure based on performance relative to other participants • 25th – 50th percentile => 25% of possible incentive • 50th – 75th percentile => 50% of possible incentive • 75th – 90th percentile => 75% of possible incentive • 90th – 100th percentile => 100% of possible incentive PCMH Model Summary November 4, 2011

33. Improvement Payment • Improvement payments will be paid for each measure based on meeting improvement targets • 5% improvement over prior year results => 50% of possible improvement incentive payment • 10% improvement over prior year results => 75% of possible improvement incentive payment • 90th – 100th percentile => 100% of possible improvement incentive payment PCMH Model Summary November 4, 2011

34. Integrated Care Organizations: Improving Care for Connecticut’s Dual Eligibles

35. Facts about Dual Eligibles • In 2007, dual eligible individuals represented 19% of Connecticut’s Medicaid beneficiaries and 19% of its Medicare population • However, they accounted for 58% of Connecticut’s Medicaid expenditures, fully 50% higher than the national rate of 39% in the US and about 25% of Medicare’s expenditures.

36. Facts about Dual Eligibles • Medicaid spending per dual eligible in Connecticut is nearly twice the national average • $27,619 compared to $15,900 nationally, • Connecticut has approximately 75,000 dual eligible individuals with full Medicaid coverage and about 50,000 dual eligible individuals with partial Medicaid coverage • 60% of the full coverage duals are over 65 • 40% are disabled or chronically ill.

37. Dual Eligibles Core Challenges • Services are highly fragmented, duplicative or unnecessary, and often delivered in inappropriate settings • Coordination of medical care, behavioral health care, long-term care and social supports is critical and lacking • Providers do not have complete information on an individual, leading to service gaps and duplication in treatments

38. Dual Eligibles Core Challenges • Lack of access to physician specialists • Financial and performance incentives are not aligned among providers and with the best interests of the beneficiary in mind • Results in unnecessary and avoidable… • emergency department visits • hospital admissions • diagnostic and treatment services • nursing home placements • Results in poor quality of life

39. Dual EligiblesCurrent Initiatives • State unit on aging initiatives for chronic care • Eric Coleman model of transitional coordination • Stamford Chronic Disease Self-Management Program • Behavioral Health Partnership (CT BHP) expansion to include ABD and dual eligibles • UCONN medication management and dementia care initiatives • Centers of care focused on geriatrics

40. Dual EligiblesCurrent Initiatives • BH/primary care integration with several Local Mental Health Authority led initiatives • Primary Care Case Management program (PCCM) • Primary Care Medical Home accreditation • Multi-payer Advanced Primary Care Demonstration (MAPCP)

41. Dual Eligible Demonstration Core Problem • Isolated initiatives cannot overcome the fragmentation inherent in the way that services are organized and delivered • No system of providers in any part of the state can measure the value they provide to dual eligible beneficiaries • No system of providers can tell you whether they are providing better overall value over time

42. Integrated Care Organizations: Program Goal Create dynamic, innovative local systems of care and support that are rewarded for providing better value over time State of the State on PCMH

43. Integrated Care Organization Program Model • Establish local Integrated Care Organizations • A consortium of provider partners contracted with DSS • Broadly accountable for: • Primary, specialty and hospital care and other healthcare services • Long term care services and supports • Includes person centered medical homes and health home(s)

44. ICO/ACO/Health Home Expanding PCMH to the Medical Neighborhood

45. Program Features Population, Freedom of Choice • Stage 1 focus on dual eligibles over 65, in communities and institutions • Stage 2 focus on expansion to under 65 with disabilities • Freedom to change PCPs and/or ICOs • Freedom to go to any other Medicare or Medicaid provider • Preserves existing Medicare and Medicaid fee for service systems

46. Person Centered Health Home Core Team • Primary Care Providers (PCPs) • APRNs for ongoing support during and between regular visits, as well as in hospital or rehab facilities to facilitate communication and discharge planning • Care coordinators (w/ appropriate specialization) • Access Agency Case Managers (or other waiver case manager in out years) • Pharmacist to provide consultation for persons with multiple chronic medications, and • Behavioral health practitioners

47. Person Centered Health Home Enhanced Services and Supports • Comprehensive initial and annual assessments of medical, behavioral, social, transportation, medical equipment, and support needs • Home visit upon enrollment and at subsequent annual comprehensive assessments • Specialty care clinics including at least two specialties that meet the needs of the elderly population

48. Person Centered Health Home Enhanced Services and Supports (cont) • Assistance with linking to services such as transportation, specialty medical services, and needed social services and supports, • Person-centered care plans developed with and by dual eligibles and family caregivers that provide for the maximum amount of self-direction desired, • Medication management services through an on-site consultation with the PCP and pharmacist, • Hospital, rehab and nursing home transition coordination including medication reconciliation by the pharmacist

49. Person Centered Health Home Enhanced Services and Supports (cont) • Dementia assessment with family education and support curriculum, • On-site assessments of activities of daily living and level of care, • Enhanced communication through use of electronic health records and an electronic person-centered care plan, • Warm line access to a nurse practitioner, care coordinator, case manager, or other team member as a way to ask questions about health, treatment, housing, family, transportation, safety, or other issues

50. State and CMSMedicare Program • Medicare currently pays and would continue to pay for physician, hospital, lab, home health, medial equipment and supplies and other services • Under demonstration, state would measure Medicare savings (if any) for the demonstration population • Medicare and state would share Medicare savings net of administrative costs • Sharing of savings contingent on achieving statewide quality and outcome targets