Accountable Care Communities:

Integrating Medical and Social Services

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HOUSEKEEPING

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• There will be several opportunities for questions please submit them using the chat feature of the GoToMeeting window

AGENDA

• Update on recent MSSP Benchmarking Methodology, & CMS-AHIP Collaborative for Multi-Payer Quality Measures

• Presentation on Accountable Health Communities by Dr. Stephen Shortell

• Shared provider insights from Julie Bluhm of Hennepin Health

• Introduction to CMS’ Accountable Health Communities (AHC) model

• Opportunity for Q&A – Members can submit questions ahead of time by emailing

members@accountablecarelc.org

MSSP Benchmarking Methodology

CMS RELEASES A PROPOSED RULE DETAILING CHANGES TO THE MSSP BENCHMARKING METHODOLOGY

• Describes improvements of methodology used for establishing a benchmark to measure an ACO’s financial performance in the MSSP program

• CMS suggests changes to shift to regional benchmark for ACOs

o Can continue in the program past their first 3-year performance period

o Benchmark rebasing methodology would apply to ACOs renewing for subsequent agreement periods beginning on or after January 1, 2017

• CMS announces a new option for ACOs in Track 1

o For those willing to move to a two-sided model (Tracks 2 or 3) for their second agreement period, but elect to defer for one additional year under Track 1.

o This will allow ACOs some time to prepare for risk without having to renew for another 3-year agreement under Track 1.

MSSP Benchmarking Methodology

CMS RELEASES A PROPOSED RULE DETAILING CHANGES TO THE MSSP BENCHMARKING METHODOLOGY

• Proposed modifications to the rebasing methodology include:

o Removing the adjustment to explicitly account for savings generated under the ACO’s prior agreement period.

o Using a regional spending growth trend, rather than the national spending growth trend,

when establishing and updating a rebased benchmark.

o Adjusting the rebased benchmark by a percentage of the difference between an ACO’s historical spending and the spending in the ACO’s regional service area.

o Updating the rebased benchmark on an annual basis to account for regional FFS spending rather than national FFS projected spending.

• Additional proposals include:

o Adding a new option to encourage ACOs to shift to “downside risk” earlier in their participation. Would allow Track 1 ACOs transitioning to Tracks 2 or 3 to extend their first performance period for an

additional year before beginning to bear risk.

o Streamlining the methodology used to adjust an ACO’s historical benchmark

o Establishing policies for making corrections to financial calculations of shared savings or shared losses

o Providing publicly available data of county-level FFS spending and risk scores to support modeling and analysis of proposed changes.

MSSP Benchmarking Methodology

CMS & AHIP Collaborative

Multi-Payer Quality Measures

CMS & AHIP RELEASE COLLABORATIVE LIST OF QUALITY MEASURES

• Measures were developed over the past 18 months o Created by a multi-stakeholder group led by AHIP, CMS and the National Quality Forum (NQF) called the

Core Quality Measures Collaborative

• The group worked with payers, providers, employers, consumers, and patient groups to identify core sets of quality measures o Attempted to discover quality measures that payers are committed to using, meaningful to patients and

physicians, and reduce variability in measure selection, administrative burden, and cost.

• The work will inform CMS’ implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) measures, o Aims to establish widely agreed upon core measure sets that could be aligned across government and

commercial payers.

• The core measure sets include: o ACOs, PCMHs, Primary Care, Cardiology, Gastroenterology, HIV and Hepatitis C, Medical Oncology,

Obstetrics, Gynecology, and Orthopedics

Collaborative Quality Measures

Introduction to

Accountable Health Communities

INTRODUCTION

DR. STEPHEN SHORTELL PhD, MPH, MBA

Blue Cross of California Distinguished Professor of Health Policy and Management and Director, Center for Healthcare Organizational and Innovation Research (CHOIR), School of Public Health, UC-Berkeley.

WHAT ARE ACCOUNTABLE HEALTH COMMUNITIES?

An Accountable Community for Health (ACH) is a multi-payer, multi-sector alliance of the major health care systems, providers, and health plans, along with public health, key community and social services organizations, schools, and other partners serving a particular geographic area. An ACH is responsible for improving the health of the entire community, with particular attention to achieving greater health equity among its residents.

Accountable Community for Health

Source: CHHS and CDPH, 2014

SOME ESSENTIAL FUNCTIONS Accountable Community for Health

• Convene a broad set of key stakeholders across sectors that influence

health – housing, transportation, education, public health, etc.

• Develop a shared vision and goals

• Conduct community health needs assessments

• Assess community assets

• Develop a “backbone” integrator organization to manage a population health

budget and allocate resources

• Create information systems for performance measurement, management,

continuous improvement and accountability

SOME APPROACHES TO FINANCING ACHS

Accountable Community for Health

• Community Benefit Funds

• Regional Global Payment

• ACO Shared Savings

• Health and Wellness Trusts

• Social Investing (e.g., Fresno Asthma Project)

Adapted from E.S. Fisher and J. Corrigan, “Accountable Health Communities: Getting There from Here,” JAMA, Nov. 26, 2014,

312(20): 2093-94.

ACHS MUST SELECT HEALTH IMPROVEMENT INTERVENTIONS

Accountable Community for Health

Five levels:

• Clinical

• Community

• Clinical-community linkages

• Systems – policy

• Environmental

INTERVENTIONS CATEGORIES SUMMARY TABLE

Clinical Interventions Community Interventions

Clinical Community Linkages

System-Policy/ Environment

SINGLE (One intervention and/or targeting one condition)

PORTFOLIO

(Addresses multiple conditions and/or uses multiple approaches, e.g., structural, process, cultural, technology, etc.)

Primary Care QI (7) Provider training (4) Shared decision making & motivational interview (2)

Medical home, chronic care model (4) Disease Management (1)

Lifestyle/behavioral Intervention (29) Exercise (10) Nutrition (3) Web-based/Internet (3) Social Network (2)

Pharmacist on the care team (20) Nurse care manager (6) Telephone-based support (3) Community health worker (CHW), lay health worker (25) Education Intervention (for patients & caregivers) (23) Health screenings (1) School-based (5)

Community collaborative (11) Built environment (4) Government policies (1)

Increasing in complexity

Incr

eas

ing

in c

om

ple

xity

PROMISING CONDITION SPECIFIC INTERVENTIONS – ASTHMA (CONT’D)

Intervention Description Time frame

Health Outcomes

ROI Ease of Implementation

Indicators of success

Data needs

Community

4. Boston Children’s Community Asthma Initiative

Proactive community based asthma services, multi-disciplinary, coordinated disease management programs to prevent costly complications and hospitalizations

1-3 years

Reduced ED visits, improved quality of life

Significant Intermediate Reduced cost, improved quality of life

Not Reported

Citation: U. Bhaumik, K. Norris, G. Charron, S. P. Walker, S. J. Sommer, E. Chan, D. U. Dickerson, S. Nethersole and E. R. Woods. “A cost analysis for a community-based case management intervention program for pediatric asthma.” J Asthma 50.3 (2013): 310-317.

PROMISING CONDITION SPECIFIC INTERVENTIONS – CARDIOVASCULAR DISEASE (CONT’D)

Intervention Description Time frame

Health Outcomes

ROI Ease of Implementation

Indicators of success

Data needs

Community

2. Physical activity and weight loss

Translating weight loss and physical activity programs into the community to preserve mobility in older, obese adults in poor cardiovascular health

1-3 years Mobility, weight loss

Not reported

Easy Improved mobility as measured by time needed to complete a 400m walk

Observational

Citation: Rejeski, W. Jack, et al. "Translating weight loss and physical activity programs into the community to preserve mobility in older, obese adults in poor cardiovascular health." Archives of internal medicine 171.10 (2011): 880-886

SUMMARY Accountable Community for Health

• Studies with the strongest evidence base were primarily single focus/easier to implement, short term (1 to 3 years) and targeted the clinical or clinical-community linkages

• Strong strength of evidence was reported for diabetes interventions (4/5) and least frequent among asthma interventions (about half)

• Most common interventions were lifestyle/behavioral/ pharmacist on the care team, those involving community health workers, and patient/caregiver education

• Multi-component strategies included primary care QI efforts, exercise, community collaboratives, nurse care managers and school-based initiatives

An Accountable Care Community:

Hennepin Health

INTRODUCTION

JULIE BLUHM Clinical Operations Manager Hennepin Health

WHAT IS HENNEPIN HEALTH?

$

• Defined Provider Network, Shared Electronic Health Record

• Risk-Sharing Funding Model, Alignment of Finances

• Integration of Medical and Social Services to Address Social Determinants

• Consensus-Based Governance Model

Prospective

enrollment

via managed

care choice

or default

Capitated Reimbursement

from State Medicaid Agency

Hennepin County

Hennepin County

INNOVATION HIGHLIGHT: HOUSING NAVIGATION

• Dedicated staff work to place medically complex Hennepin Health members in supportive housing available to them

• Resulted in considerable reductions in ED (-36%) and hospital (-16%) use post-housing

Hennepin County

CHALLENGES

• Collaborative initiatives are always hard. – Leadership buy-in is essential.

– Clear roles and expectations.

– Operational authority where possible.

• Safety net culture = uncomfortable serving some and not all.

• Target social interventions for maximum health effect given limited resources...we can't realistically solve all social issues with just health care resources.

• Difficult to determine the specific effect of each piece of the care model (e.g. Did the housing unit or the care coordinator keep the patient out of the hospital?)

• Many of these kinds of investments take many years or decades to see a return, this is a mismatch with the short term savings incentives in health care

THANK YOU!

Videos, newsletter, and more information: hennepinhealth.org

Hennepin County

The CMS Model:

Accountable Health Communities (AHC)

WHY IS THE CMS AHC ANNOUNCEMENT SO TRANSCENDENT?

• First time testing social needs nationally as part of the delivery system

• First time testing unmet social needs within a payment model nationally

• First time to address what constitutes as health care by a major U.S. payer for health care services

CMS Will Test Accountable Health Communities

CMS PLANS TO TEST ACCOUNTABLE HEALTH COMMUNITIES (AHC) MODEL

• Makes available $157 million in funding for a five-year model

• Aims to identify and address beneficiaries’ health-related social needs in the following core areas:

o Housing instability and quality,

o Food insecurity,

o Utility needs,

o Interpersonal violence, and

o Transportation needs beyond medical transportation

• Examines whether systematically identifying and addressing health-related social needs of beneficiaries through referral and community navigation services can impact:

o Health care costs

o Reduce inpatient and outpatient health care utilization

o Improve health care quality and delivery

• Becomes first program to test ways to address the health-related social needs for Medicare and Medicaid beneficiaries

Overview of Accountable Health Communities (AHC) Model

EACH TRACK REQUIRES THE AWARD RECIPIENT TO SERVE AS A HUB RESPONSIBLE FOR COORDINATING EFFORTS How AHC Actually Works for Award Recipients

• Identifies and partners with Clinical Delivery Sites (CDS) (e.g., clinics, hospitals)

• Conducts systematic health-related social needs screenings, and making referrals

• Coordinates and connects community-dwelling beneficiaries

o Those who screen positive for certain unmet health-related social needs and are randomized to the intervention group to community service providers

• Aligns model partners to optimize community capacity

• Becomes the “Bridge Organization” and is expected to partner with:

o At least one state Medicaid agency

o Clinical Delivery Sites including at least one of the following types:

Hospital

Provider or practice that furnishes primary care services

Provider of behavioral health services

o Community service providers capable of addressing core or supplemental health-related social needs identified through the screening tool

AHC WILL CONSIST OF THREE-TRACK MODELS BASED ON PROMISING SERVICE DELIVERY APPROACHES

Accountable Health Communities (AHC) Model

Track Type Number of Organizations

Funding Description

Track 1

Awareness

12

$1M per Awardee

Increase beneficiary awareness of available community services through information dissemination and referral

Track 2

Assistance

12

$2.57 per Awardee

Provide community service navigation services to assist high-risk beneficiaries with accessing services

Track 3

Alignment

20

$4.51 per Awardee

Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries

Q & A

Q & A

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Questions About the ACLC? If you have questions about the ACLC please email

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