Transcript of Alternative Payment Methods & Cost Savings Analysis: Emerging Results from SBHC Innovation Study.
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- Alternative Payment Methods & Cost Savings Analysis:
Emerging Results from SBHC Innovation Study
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- 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." 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."
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- Presenter Disclosures The following personal financial
relationships with commercial interests relevant to this
presentation existed during the past 12 months: University of Miami
Miller School of Medicine No relationships to disclose
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- 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.
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- 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.
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- Our Schools
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- North Miami Beach Sr.John F Kennedy MiddleFulford Elementary
G.E. / Sabal Palm Elem.Greynolds Park Elem.Booker T. Washington Sr.
Arch Creek ElementaryNorth Miami MiddleNorth Miami Sr.
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- Staffing Primary sites: NMB Sr JFK Middle North Miami Sr. BTW
Sr. Satellite sites: Elementary schools North Miami Middle Arch
Creek ARNP / MDRN / MA/LPN MSW MA / LPNCHW --
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- 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.
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- 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
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- Service Learners Nursing Medical students Residents Psychiatry
Social work Dental
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- 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
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- Immunization status: Student Populatio n # Children out of
compliance % students in compliance NMB Sr High 2119 36 99.9 JFK
Middle13043 99.8 Fulford5313 99.5 G. E. / Sabal Palm 6930 100
Greynolds Park7950 100 N Miami Sr258512 99.6 N Miami Middle96849
99.9 Arch Creek5664 99.9 BTW Sr High94940 99.9
TOTAL1051014799.8
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- The Dr. John T. Macdonald Foundation School Health Initiative
Challenge Improve Quality Provide Better Care Lower Costs
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- 1.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. 2.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. 3.To utilize community
health workers as peer educators and coordinators of care to
improve access and adherence to care plans. 4.To work with all
partners, including two HMOs and CMS to develop new patient payment
mechanisms that reward quality, innovation, and cost-effectiveness.
The Dr. John T. Macdonald Foundation School Health Initiative
Challenge Objectives
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- Preventive Dental Services (Nova): -Telehealth Oral Exams
(pilot project) -Sealants for 2 nd and 6 th graders -Varnishes
(trainings given to medical and nursing staff for application of
varnishes) -Restorative care -Referrals (to community)
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- 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
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- Expansion of Mental Health: - Guidance, Supervision of SWs -
Guidance, Supervision of CHWs for Mental Health -Telehealth
Encounters -On-call system -Psychology Services
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- 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
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- UM Telehealth Services
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- Community Health Workers (CHWs): Peer Educators Peer
Facilitators Peer Encounters
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- Medicaid Enrollment Goals: Cumulative Percentage: Number
Students: Year One15%1650 Year Two35%3850 Year Three65%7150
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- Clinic Enrollment: Student PopulationClinic Enrollment%
Enrolled NMB Sr High 2119 JFK Middle1304 Fulford531 Sabal Palm693
Greynolds Park795 N Miami Sr2585 N Miami Middle968 Arch Creek566
BTW Sr High949 TOTAL10510
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- Medicaid Enrollment:
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- Current JTMF Medicaid Enrollment
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- HMO Partners: -Medicaid Enrollment Assistance -Achievement of
HEDIS (Healthcare Effectiveness Data & Information Set)
Parameters -Data Capture & Analysis -New Payment Methods
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- Alternative payment methods -Fee-for-service -Capitation
-Shared savings -Pay for performance
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- Pay for Performance Immunization compliance Asthma control
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- 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
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- 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
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- 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 members PCP to inform them of care provided at school Step 5:
SBHC submits encounter/billing report and receives reimbursement
from Amerigroup 8
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- Top Clinic Visit Reasons Top ICD-9 Encounters (ensuring HEDIS
measures) Well child care, annual physical examinations and sport
exams Immunizations Asthma
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- Cost Savings & Effectiveness
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- Outcomes: Holistic, team approach for care of school-age
children and their parents with SBHCs 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)
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- Data Needs: -Enrollment -Disease Management -Impact of On-site
Services -Impact of CHWs -Impact of Telehealth -Impact of Team
Approach -HEDIS -Documentation of Cost-Savings
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- CHEER CHEER (Childrens 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.
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- CHEER Encounter Screen
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- CMMS Innovations Project School Health Clinic Clients CHW
39
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- 40
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- Kathryn McCollister, Ph.D. Associate Professor and Health
Economist Department of Public Health Sciences University of Miami
Miller School of Medicine Economic Analysis of the Enhanced
School-Based Health Center
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- 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 Miamis
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
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- 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
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- 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 Miamis SBHC plus enhancements
operating in nine middle and high schools around Miami-Dade County,
Florida
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- 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)
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- 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: $376
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- Student/Patient Information Number of Students Seen During the
Year 5,572 Total Number of Visits During the Year17,223 Average
Number of Students Seen Per Week 521.4 Average Number of Indirect
Contacts Per Week 33.5 Cost Information$ Personnel including
volunteer labor701,403 Contracted Services63,363 Center for Haitian
Studies657,699 Larkin Hospital55,170 Nova (dental)92,579 Staff
travel1,254 Indirect Costs138,540 Total Annual Cost1,710,008 Annual
Cost Per Student/Patient16,398 Average Cost Per Visit400 Average
Cost Per Contact (health suite + indirect contacts) 376
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- 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
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- 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
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- Cost Savings & Effectiveness (Contd) 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
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- Cost Savings (continued) Total annual savings calculated by
valuing improvements in these outcomes For instance, the avoided
costs by diagnosing and treatment chlamydia is $329 per case The
avoided costs of tooth decay from sealants is $XXXXX The avoided
costs from Tdap (reduced incidence of pertussis) is $XXX Table 2
presents a cost-savings template that will allow us to estimate
benefits accruing across many outcomes The monetary conversion
factors describe the economic value per unit of outcome and come
from published scientific studies
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- Table 2 - Cost savings template Outcome Estimates - Incidence
During Past Year (Apr 2013 - Mar 2014) Monetary Conversion Factors
(cost per outcome in 2013 dollars) Total Savings Over the Year in
2013 dollars Sexually Transmitted Infections a Chlamydia - number
of positive screens38329$12,502 HIV2233174$466,348 Gonorrhea 169
Pregnancies 7670 Chronic Conditions Asthma - cases treated b
1755300 Asthma - uncontrolled cases66 Asthma - controlled cases106
Obesity/Overweight - cases diagnosed c 3262 Diabetes - cases
diagnosed or monitored as borderline d 7979 Mental Health Disorders
ADHD - cases diagnosed Depression diagnoses Anxiety diagnoses Other
Mental Health Substance Use Disorders - diagnoses Dental Health e
Sealants517 Varnishes316 High Caries risk (%) Plaque (%) White
spots (%) Obvious decay (%) Bleeding gums (%) Restorations - number
411443.4$178,548 Immunizations Influenza h 35 HPV 1657.8 Tdap i
512.1 Hib -- Hep B -- Varicella -- MMR -- % in compliance with
immuniz. status98.3% Health Services Emergency department visit
6240 Hospital (inpatient) day 2122 Educational Attainment
Graduation from high school Day missed from school Total Annual
Savings $ DRAFT
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- Cost savings and effectiveness preliminary results Reflecting
on past year, main areas of impact are seen in sexually transmitted
infections and pregnancies, dental health, and immunizations Also
improving management of asthma and mental health disorders results
still being evaluated over a longer timeframe Preliminary results
presented in Table 3
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- Discussion Preliminary findings show notable savings being
generated across multiple areas The most immediate impacts are
occurring in diagnosing and treating STIs, improving dental health,
and promoting immunizations Benefits also accruing to health care
system from reduced ED visits, getting families enrolled in
Medicaid and connected with health care services through the SBHCs
Even more distal outcomes such as fewer days missed from school and
higher graduation rates could be associated with SBHC
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- Discussion (continued) Limitations include limited baseline
data to analyze changes pre- and post-SBHC and no control group
Also reliance on estimates from the literature that are in some
cases outdated or generated from a different population Next steps
are to examine changes in outcomes between Year 1 and Year 2 Also
conducting multivariate analyses to estimate key predictors of
uncontrolled asthma cases and associated costs in this population
(mainly African American and Hispanics)
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- 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." 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."
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- Questions? Thank you!