Connecticut State Innovation Model

1. Connecticut State Innovation Model STATE OF CONNECTICUT Overview June 12, 2013

2. Health Care Opportunities and Challenges in Connecticut Today • Ranks high on many health indicators • Many opportunities for improvement • Potential ~$1B budget deficit in 2014 and 2015 • Inefficiencies in health care utilization • Many initiatives - no common model across payers

3. State Innovation Model Initiative • Center for Medicare and Medicaid Innovation (CMMI) funding opportunity • Connecticut one of 16 “model design grant” states • Application for $30 to $45 million over 3 - 4 years

4. CMMI Guidance for Applicants • Include 80% of state lives within 5 years • Truly multi-payer approach • Accountability for outcomes, including total cost of care • Test Innovations that can lower costs maintaining or improving quality of care • 3-5 year return on investment

5. Connecticut Points of Emphasis • Population health • Primary care and behavioral health integration • Health equity • Workforce development • Consumer engagement • Reimbursement – from FFS to Value

6. Planning Process and Structure Stakeholder input • State Healthcare Innovation Planning Committee (SHIP) • Health Care Cabinet Directionsetting • Community entities • State agencies • Advocacy organizations • Employers • Core team Project management Research and analysis Planning and writing • Providerorganizations • Payers • Care delivery model work group • Payment model work group • Health information technology work group Idea generation Technical design

7. Care Delivery WorkgroupLearning from the Health Care Journey A child with asthma • Kathy is a six year old girl whom comes into the office for asthma. The exam doesn’t consider important things about Kathy, such as her history of anxiety, violence in the home, and a parent with addiction problems. Her mother doesn’t entirely understand the care plan, which contains many unfamiliar terms, and does not explain why and how conditions in the home might affect asthma. The PCP is also unaware of a longstanding infestation of mice. Kathy has a series of visits to the ED, ultimately leading to a hospitalization. The PCP learns of this several months after her discharge.

8. Care Delivery WorkgroupLearning from the Health Care Journey A older man with a heart condition • Mr. Rodriguez is a 71 year old man who lives alone. He speaks English as a second language. He has Type 1 diabetes, high cholesterol and hypertension. He suffers a heart attack and is discharged home after a brief hospitalization. He has some difficulty hear and following conversations, and this was worse than usual on the day he left the hospital. He met with the discharge nurse, but recalls little of the details of his aftercare plan. He decides to resume all his pre-hospitalization medications and waits to hear from his cardiologist. He is readmitted to the hospital within one week.

9. Care Delivery Work Group Consumer Journey – Barriers to Care STAGES OF HEALTH • Treated for acute condition • Rehabilitated post-acute condition • No single point of provider accountability for outcomes • Lack of standardization in best clinical practices • Poor peer-to-peer provider relationships • Limited incentives for acute care provider to follow patient’s care through rehab • Well-state • Sick, pre-diagnosis • Diagnosed • Consumers are not engaged effectively in promoting health and well-being • Providers do not consider an individual’s culture and context • Limited capacity of providers leads to long wait times and deters timely diagnosis • Consumers do not know to seek care in early stages of disease when disease progression can be halted • Suboptimal or no triage process to direct consumers to right site of care • Limited PCP time to follow-up beyond diagnostic visit • Treated for chronic condition • Treated for complications of chronic condition • Consumers do not know to ask providers for care coordination • Specialists have limited vision to own sphere of influence • Consumer progression not tracked between visits • Limited communication channels/ processes among patient and other providers PROPRIETARY AND CONFIDENTIAL || PRE-DECISIONAL

10. Payment Reform Workgroup • Quality and other performance metrics • Attribution • Selection of a provider who takes accountability for managing the health of an individual over a defined period of time • Payment model • Implementation process and schedule

11. Common Options for Linking Payment to Value • Prospectivepayment • Increasing provider risk • Downside • Risk sharing • Upsidegain sharing • P4P • FFS • Some models also incorporate per-member-per-month fees or enhanced fees for care coordination and/or practice transformation. PROPRIETARY AND CONFIDENTIAL || PRE-DECISIONAL

12. Health Information Technology WorkgroupKey Enablers of Care Delivery & Payment Reforms Category Description Payer analytics • Tools for payers to analyze claims and produce payment-related analytics, quality/outcome/ performance metrics and make actual payment for episodes and population health A Provider -payer - patientconnectivity • Channels (e.g., portal) for providers and patients to access and submit information, data and analytics required to support care delivery and payment models B Provider –patient care mgmt. • Provider tools (e.g., workflow, event management) and analytics to e.g., physicians, care managers) coordinate the medical services for a patient (focus on highest risk) C Provider-provider connectivity • Integrated clinical data exchange among healthcare stakeholders, including the longitudinal patient registry that can be enabled by HIE D

13. Recognizing Different Stakeholder Perspectives Patients/consumers • How will this change my experience? • How will I really know if my care is better? Example perspectives about health transformation Clinicians • How can I manage administrative burden? • Will I be able to maintain my income level? Hospitals/facilities • How will any changes affect my revenue and cost position relative to alternatives? Community/ state agencies • How will this effort affect my clients? • How will this effort impact my agency’s goals? • How can I participate in this model? Employers • How will this affect my employees and my ability to afford health insurance for them? • How can I support employee wellness? Payers • How can we manage medical expenditures and focus more on value? • Will I want to shift to this new payment model?

14. Diverse stakeholders meaningfully engaged in design, syndication, and testing, which is a longer journey • Engagement needs to be authentic and meaningful, with an opportunity for two-way dialogue • Need to engage consumers and providers in forums that are accessible to them from a timing, location, cultural, and linguistic perspective • Must hear directly from individuals within the community as well as from organized entities (e.g., consumer advocacy groups, unions) • Stakeholder engagement is a longer journey of deepening levels of stakeholder involvement – the next 8 weeks are just the start

15. We have discussed with the Health Care Cabinet a 5-part stakeholder engagement strategy for the next 8 weeks Description Timing Core process • Continue to meet regularly with small, but diverse group of stakeholdersin work groups and the State Healthcare Innovation Planning (SHIP) steering committee • Ongoing Monday meetings • Meets next on 7/08 and 7/29 1 Synthesis of existing stake-holder insights • Examine outputs from prior stakeholder outreaches to synthesize existing consumer and provider feedback on the health care system and health care needs • Ongoing 2 Existing forums • Meet stakeholders in forums that are accessible to them by joining regularly convening groups of consumers, providers, and other stakeholders to solicit input • June/ July 3 Focus groups • Hold organized sessions with small groups of stakeholders to solicit feedback on specific components of model design • June/ July 4 E-campaign • Enable individuals to submit input outside of in-person sessions by providing email, text, and online forums for individuals to submit input • Ongoing 5

16. Innovation Timeline April - September October - early 2014 Mid-2014 to 2017 Design phase Testing grant application review and selection Testing phase April May June/ July August September Options and hypotheses Design and planning Project set-up Syndication Finalization • Understand current state • Establish vision • Identify target populations and sources of value • Develop health care delivery system hypothesis • Pressure-test health care delivery system hypothesis • Develop payment model hypothesis • Align key stakeholders • Design framework for health care delivery system and payment model • Develop implemen-tation and roll-out plan • Align on key quality metrics • Draft testing proposal • Syndicate with key stakeholders • Refine and submit testing proposal PROPRIETARY AND CONFIDENTIAL || PRE-DECISIONAL

17. We invite you to join us and to share in our vision for care delivery and payment transformation for our state Ways to become involved • Participate directly in the care delivery, payment and HIT work groups by attending as a member of the gallery (meeting times and locations posted on our website) • Share your feedback with your representatives on the Health Care Cabinet and Consumer Advisory Board, who will be meeting directly with project leaders • Share your feedback directly with the project leaders and work group chairs • Follow the project’s development online through our website, and through regular email updates sent by the Lieutenant Governor Contact information Project leaders • Victoria Veltri, JD, LLM victoria.veltri@ct.gov • Michael Michaud, michael.michaud@ct.gov • Dr. Mark Schaefer, mark.schaefer@ct.gov • Website: http://www.healthreform.ct.gov/ohri/cwp/view.asp?a=2742&q=334428