1

Accountable Care: A New Era of Health Care in Ohio

Patrick Beatty, JDAssistant Deputy Director

Ohio Office of Health Plans

Kinsey JolliffPolicy Development

Ohio Office of Health Plans

DRAFT

WARNING! This is NOT your father’s

Oldsmobile!!

2

Quote of the Day “There was an important job to be done

and Everybody was sure that Somebody would do it.  Anybody could have done it, but Nobody did it…Everybody blamed Somebody…when Nobody did what Anybody could have done.”

(American Medical Directors Association, 2010)

DRAFT

3

Statewide Statistics - WHY “Medicaid…covered 38% of Ohio children, including nearly

38,000 children with disabilities in 2010” (Health Policy Institute of Ohio, May 2011)

Ohio ranked 14th worst on Child Health Scorecard for potential to lead healthy lives (Commonwealth Fund, 2011)

90% of the most costly 5% within Medicaid’s child population have manageable conditions such as behavioral health, asthma, minor infections, or prematurity (OHP, Medicaid Quality Strategy Presentation, 2011)

High Prevalence of Children Receiving Primarily Hospital-Based Care in the Costliest Five Percent of Medicaid Children: 40% in ABD and 50% in CFC (OHP, Medicaid Quality Strategy Presentation, 2011)

DRAFT

4

The Bottom Line - WHY

We have to get BETTER in order for Ohio to have the

HEALTHIEST KIDS in the nation!

DRAFT

5

Better Care = Better ResultsBreakdown BarriersEncourage InnovationTeamworkTrack impacts, not numbersEngage familiesReverse the trends

DRAFT

6

WHAT - is a Pediatric ACO?Providers who work together,

alongside families, to provide and coordinate services for individuals under 21 years of age; and collectively take accountability for improving the lives of these children.

DRAFT

7

WHAT - a Pediatric ACO is NOT?

• Answer: Managed Care. BUT… an MCO can establish an entity that seeks recognition as an ACO.

DRAFT

8

Ohio’s Situation - HOW This is not paint by numbers. There is NO guidance from CMS. We have a blank canvas and you get

to help paint.

DRAFT

9

Authority for Ohio’s Pediatric ACO Program – more HOWPPACA Sec. 2706: Pediatric

Accountable Care Organization Demonstration Project

O.R.C. 5111.161: Recognition of Pediatric Accountable Care Organizations

DRAFT

10

WHEN• The process for applying for recognition as a

Medicaid pediatric ACO will be in place in July 2012.

DRAFT

11

SOUP TO NUTS• OBJECTIVES• RECOGNITION PROCESS• GOVERNANCE STRUCTURE• FLEXIBILITY IN GOVERNANCE STRUCTURE• ENROLLEE AND FAMILY RIGHTS• THREE ACO MODELS• PERFORMANCE MEASURES

DRAFT

12

Pediatric ACO Objectives Improve health outcomes Incentivize more appropriate care Assign high risk families and children a primary

support team that will coordinate services across traditional boundaries

Smoother transitions Create a single care plan for high risk families

and children Track performance measures Share data across providers and public agencies

DRAFT

13

The Recognition Process The law calls for a process to recognize Pediatric ACOs and new

approaches to coordinating care. Those seeking to be recognized in Ohio as Pediatric ACOs will have to

explain how they will be accountable for care; how they will share data, and how they will collaborate with MCPs and community based organizations such as schools and social services.

They will also be required to have collaborative agreements with agreements with Primary Care Medical Homes, Pediatric Specialists, Community Pharmacies, Dentists, and CBHCs.

They must explain what region of the State they will be covering. Finally, they must demonstrate they have performance measures in place,

and that they are tracking those measures; certain types of pediatric ACOs will be required to agree to the State’s performance measures.

DRAFT

14

Governance of Pediatric ACOs All Pediatric ACOs in Ohio will be not-for-profit If the Pediatric ACO is made up of independent entities,

then they will have a 9 member governing team that will include majority physicians

The governing team will also include an Advanced Practice Nurse, a Child Consumer Advocate, and a Parent Advocate

Executive will be chosen by the governing team and medical director will be chosen by the Executive

The Governing team will be responsible for partnering with community stakeholders such as schools, children services agencies, businesses, and other payers such as insurance companies and hospitals

DRAFT

15

Flexibility in Governance If the governing team can not meet certain

requirements, the Pediatric ACO must communicate to the State why it seeks to differ from these requirements, and how it will involve Pediatric ACO families and community stakeholders in Pediatric ACO governance.

If the Pediatric ACO is an existing organization, then the governing body can be the same as it is currently, as long as the governing team can explain how it will involve Pediatric ACO families and community stakeholders in Pediatric ACO governance.

DRAFT

16

Enrollee and Family RightsNo consumer or family will be required to

receive services from a Pediatric ACO. Educational materials (created by the Pediatric ACO) will be

given to Medicaid recipients and their family/legal guardians, and will be available online.

Educational materials will include participating providers and their contact information, pediatric specialty locations, Website information and amount, duration, scope and type of services offered by the Pediatric ACOs.

Ombudsmen programs and internal dispute resolution will be responsibilities of Pediatric ACOs.

Pediatric ACOs will be required to have a staff member manage Healthchek services ensuring that federal EPSDT laws are being met.

DRAFT

17

Pediatric ACO Models Type 1 Model: Includes a demonstrated shared savings model and

performance measures within a contractual arrangement between a Medicaid managed care plan and a Pediatric ACO who has been recognized by the State of Ohio. The practitioners involved with a Pediatric ACO under this type must acknowledge in

writing that they are accountable for the care they provide. Type 2 Model: Includes requirements of Type 1. The State will now set and

track the performance measures. The care coordination and case management requirements will be delegated to the Pediatric ACO. Other administrative functions will remain with the managed care plan. Encounter data will be required. The payment methodology must include shared savings and shared risk with the

Medicaid program. Type 3 Model: A qualified Medicaid provider with direct payer-provider

relationship with the State Medicaid agency. The full responsibility for care will be assigned to the Pediatric ACO for a specific region for those not in Medicaid managed care. The payment methodology must include shared savings and shared risk with the

Medicaid program.

DRAFT

18

Pediatric ACO focus• Moderate and high risk

DRAFT

19

Create and support the foundation for

HEALTH

Education

Behavioral Health

Physical Health

Social Environment

DRAFT

20

Even with good foundations, there are still those at risk, and others experiencing poor health

These groups needMore than routine preventive care

TransparencyLeadership

Support them with a FrameworkOf trustTransparencyAnd Leadership

DRAFT

21

Uncomplicated cases:

Wellness care

Moderate risk:

Case management

Highest Risk:

Hub model

Education

Behavioral Health

Physical Health

Social Environment

Trust

TransparencyLeadership

DRAFT

22

Pediatric ACO Mandatory Elements for performance

• Education• Social• Mental Health• Physical Health• Transparency• Community Leadership• Consumer Trust

DRAFT

23

Pediatric ACO Performance Measures

• Type I Model: Performance measures and benchmarks set by applicant, must be commensurate with child measures set for Medicaid MCO’s.

• Type II Model: Performance measures must include 1 measure from each CHIPRA initial core set measures, and one additional measure. MCO measure can fulfill function. Measures will be set in negotiation with the state.

• Type III Model: Performance measures must include 1 measure from each CHIPRA initial core set measures, and two additional measures. Measures will be set in negotiation with the state.

DRAFT

24

Medicaid Quality Strategy

• Clinical Focus Areas for Children:– High Risk Pregnancy/Premature Births– Behavioral Health – Asthma– Upper Respiratory Infections

• Priority Areas:– Promote Best Prevention & Treatment Practices– Improve Care Coordination– Support Person & Family Centered Care

DRAFT

25

CHIPRA Initial Core Set Measures areas

• Prevention and health Promotion.• Availability.• Management of Acute Conditions.• Management of Chronic Conditions.• Family Experiences of Care.

DRAFT

26

Homework assignmentRecommendations for Benchmarks

on each performance measure.Recommendations for additions to

Soup or Nuts.Other recommendations for

alterations to proposed structure or process.

DRAFT

27

Next StepsMore meetings with stakeholdersConsumer/family forumsLegislature involvementPhysician champions involvementFormal rule process

DRAFT

28

Questions?

DRAFT