MA Primary Care Payment Reform: Progress Report on a Transformation

Alexander Blount, EdDDirector, Center for Integrated Primary Care

Judith Steinberg, MD MPHDeputy Chief Medical Officer, Commonwealth Medicine

University of Massachusetts Medical SchoolCollaborative Family Healthcare Association 16th Annual Conference

October 16-18, 2014 Washington, DC U.S.A.

Session F4aSaturday, October 18, 2014 – 10:30 AM

Faculty Disclosure

• I/We have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Describe the way that the Massachusetts Primary Care Payment Reform fits into the national movement toward behavioral health integration as part of the Patient Centered Medical Home.

• List the three tiers of behavioral health integration that are designated in the PCPR clinical model.

• Discuss the advantages and challenges inherent in statewide Medicaid payment reform.

Bibliography / Reference

Steinberg J.  Implementing integrated care in the Patient-Centered Medical Home: The MA experience. Part of SAMHSA-HRSA Center for Integrated Health Solutions Webinar: Integrated care within the Patient Centered Medical Home: The Health Center perspective, http://www.integration.samhsa.gov/about-us/webinars, November, 2012.Steinberg, J, Blount A. Health Care Reform and Behavioral Integration. Oral Presentation – MA Health Policy Commission, Joint Committee Meeting. Boston, MA. April 2014.Blount, A, Steinberg, J.  From Integration to the Patient Centered Home.  Oral Presentation – National Council for Behavioral Health Annual Conference, Washington, DC, May, 2014. Blount, A. (2012). Form(s) in the patient centered medical home. Families, Systems, & Health: 30, 189.Blount, A. (2010). A special issue on the Patient Centered Medical Home, Families, Systems, & Health: 28, 197.Blount, A., Schoenbaum, M., Kathol, R., Rollman, B., Thomas, M. O’Donohue, W., & Peek, C.J. (2007). The economics of behavioral health services in medical settings: A summary of the evidence. Professional Psychology: Research and Practice, 38, 290-297.Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems & Health: 21, 121-134.

Learning Assessment

• A question and answer period will be conducted at the end of this presentation.

Agenda Background Primary Care Payment Reform

• Payment Model • Key Clinical Components• The Quality Strategy • Contract Milestones

Progress to Date

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Original Joint Principles of the Patient-Centered Medical Home

Personal physician Physician directed medical practice Whole person orientation Care is coordinated and integrated Quality and safety are hallmarks Enhanced access Payment recognizes added value of patient-centered

medical home

Integrating Behavioral Health into the PCMH Joint Principles

Personal PCPWhole person orientationCare coordinatedQuality and safetyEnhanced accessAppropriate payment

Home of the teamRequires BH service as part of careShared problem & med listsRequires BH on teamIncludes BH for patient, fam & providerFunding pooled & flexible

Ann Fam Med 2014; 183-185; Joint Principles from AAFP, ABFM, STFM

Accountable Care Organizations

Provider-led organizations with a strong base of primary care that are collectively accountable for quality and total per capita costs across the full continuum of care for a population of patients.

Payments linked to quality improvements that also reduce overall costs.

Reliable and progressively more sophisticated performance measurement

McClellan M, McKethan AN, Lewis JL, et al. A national strategy to put accountable care into practice. Health Aff.2010;29(5):982–90.

PCMHs are the Foundation of ACOs

Miller, HD. How to Create Accountable Care Organizations. Center for Healthcare Quality and Payment Reform, September 2009. Available at http://www.chqpr.org/downloads/HowtoCreateAccountableCareOrganizations.pdf .

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Affordable Care Act

MA Health Care Reform Legislation

Health Homes

MA Statewide Healthcare Reform Initiatives

Primary Care

Payment Reform

Safety Net Medical Home

Initiative

CHIPRA Medical Home

Massachusetts Patient-Centered Medical Home Initiative

Multi-payer, statewide initiative Sponsored by MA Health & Human Services,

legislatively mandated 44 participating practices 3-year demonstration; Start: March 29, 2011 Includes payment reform Vision: All MA primary care practices will be PCMHs

by 2015

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Primary Care Payment Reform

• MassHealth’s flagship alternative payment program that will enable MassHealth to move from fee-for-service reimbursement towards alternative payment models.

Goals: • To improve access, patient experience, quality, and

efficiency through care management and coordination and integration of behavioral health

• Increase accountability for the total cost of care

28 participating practice organizations, 47 sites

THE PAYMENT MODEL

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Comprehensive Primary Care Payment (CPCP)

• Risk-adjusted capitated payment for primary care services

• Options for including outpatient behavioral health services

Quality Improvement Payment

• Annual incentive for quality performance, based on primary care performance

Payment Structure

Shared savings payment

• Primary care providers share in savings on non primary care spend, including hospital and specialist services

A

B

C

Building 3 Behavioral Health Tiers into the Comprehensive Primary Care Payment

Tier 1• Integrated care management• No fee-for-service behavioral

health billable services

Tier 2 • BH services by Master’s or

Doctoral level professional• Fee-for-service billable

outpatient

Tier 3 • Fee-for-service billable

outpatient BH services provided by prescribing clinicians and psychotherapists

• Medication management• Psychiatric assessments• Psychotherapy

Cost of outpatient billable Services

Medical Home Load

Reimbursement to cover medical expenses

Additional funding for implementation of care coordination, clinical care management, behavioral health integration and practice/clinic management

Determination of Comprehensive Primary Care PaymentA

B

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Adjusted for panel complexity and estimation of utilization outside of PCC group

PCPR KEY CLINICAL COMPONENTS

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PCPR aims to help practices transform to provide high quality care efficiently

Patient-Centeredness

Multidisciplinary Care Team-based

Approach

Population-based Tracking and

Analysis

Care CoordinationClinical Care Management

Services

Patient Centered Medical Home with

Integrated Behavioral Health

Planned Visits and Follow-up Care

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Enhanced Access to Services

Integration of Quality

Improvement Strategies and

Techniques

Self-management Support

Clinic System Integration

Behavioral Health Integration Tier 2

Maintain a master’s or doctoral level Behavioral Health Provider who is co-located at each Participating Practice Site, for no less than 40 hours per week

Possess the ability to schedule “first available” Behavioral

Health Services appointments with a master’s or doctoral level Behavioral Health Provider at each Participating Practice Site within 14 days from time of request

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Behavioral Health Integration Tier 3

• Psychiatrist, is co-located with Practice, as part of the Multidisciplinary Care Team, for at least 8 hours a week

• Practice provides 24 hour / 7 day per week coverage for Panel Enrollees to a Behavioral Health Provider

• Practice has 24 hour / 7 day per week access to the following components of the Behavioral Health record, for each Panel Enrollee:– Diagnoses – Medications– Acute safety issues

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THE QUALITY STRATEGY

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Goals of the Strategy

Measurement to support both quality improvement and payment reform• QI: regular feedback to practices of measure results support

transformation efforts• Pay 4 Reporting: two-year ramp-up provides time to build capacity

and competency at the PCC and practice site level in the timely, complete and accurate collection of data

• Pay 4 Quality: phased implementation beginning in Year 2 with incentives tied to five well-established measures

• Shared Savings: deliberate approach to implementation focused on gaining experience with practice-level measurement

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SUPPORT FOR TRANSFORMATION

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Learning collaborative Data reports

Technical assistance

Stakeholder meetings

• Targeted technical assistance for qualified participants

• Member roster list • ED utilization• High risk members• Raw claims feed

Primary Care Payment Reform Transformation Plan• Curriculum based on

participant readiness review• Focus on BH integration

• Participant feedback on program implementation

• Quality reporting assistance

Approach to Learning Collaborative

General principle: • Integrating Behavioral Health in Primary Care

means integrating behavioral health in each component of the Patient-Centered Medical Home

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Sequence of Training: Build the home from the foundation up

Leadership Engagement

Data-Driven Quality Improvement

Patient Involvement in Transformation

Multidisciplinary Care Team

Evidenced-based, Pro-active care delivery

Patient-centeredness

Care Coordination

Clinic System Integration

Clinical Care Management

PCPR Progress to Date

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Survey Tools• Transformation Assessment

– Assesses level of “medical homeness” – Helps identify opportunities for improvement– 8 aspects of transformation

• Behavioral Health Integration Assessment – Assesses:

• level of behavioral health integration services,• patient & family centeredness • practice organization for bhi

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Transformation Survey Results

0

1

2

3

4

5

6

7

8

9Overall and domain scores by mean and standard deviation

(N=43)

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Transformation Survey Results: By Practice Type

Overal

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QI S

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Empan

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Cont & Te

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Org Ev

idence-Base

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terac

tions

Enhan

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ss

Care Coord

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00 Overall and domain scores by practice type

Pediatric Only (N=7) Adult only (N=4) Family Practice (N=32)

PCPR Support Activities and Timeline

• Practices respond to RFA and are chosen- 2013• Official Launch and start of payments – March, 2014• Governance structure• Quality Reporting – P4R• Learning Collaborative:

– Leadership conference – Jan 2014– Practice Learning conference – Sept 2014– Monthly webinars – starting April 2014 – Baseline Transformation and Behavioral Health integration practice

assessments– Collaboration with University of Colorado

• Technical assistance – preferred vendor list32

Some of the many challenges…

• IT and data systems• Additional grant program introduced to try to rectify infrastructure issues.

• The tradition of using data to correct and improve care is new to many practices.

• The trust that underlies many professionals’ willingness to change is hard to build without extensive face to face contact.

• The staff “politics” of each practice is an unknown but possibly powerful factor.

• The mental health/medical care mind set that we were all trained in is very durable because it underlies so much of how we think and perceive.

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Summary PCPR is akin to a Level 1 ACO model PCPR includes a robust payment reform model that

incentivizes development of PCMHs with behavioral health integration, quality care and accountability

The transformation approach requires integration of behavioral health in each component of the PCMH

There are many challenges. It takes a lot to time and steering to turn a big ship around.

Integrated care management, supported by the provision and use of payer data, is a central component of PCPR 34

Acknowledgments

• Jean Carlevale Co-Project Director, PCPR• Dr. Ann Lawthers, Director Quality Center, MassHealth

Contact:judith.steinberg@umassmed.edualexander.blount@umassmemorial.org

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