Slide 1

Gulf Region Health Outreach Program Regional Care Collaborative

National Models & Success Factors for Accountable Care

Readiness

October 23, 2015

Slide 2

Housekeeping

Please type in any questions that you may have in the ‘Question’ section of the webinar dashboard (right side of screen).

The presentation and session recording will be available on the wiki: http://pccpcliniccommunication.lphi.wikispaces.net/Past+Events

Slide 3

Introductions

• Julie Peskoe, Director of Health Care Capacity Building, PCDC

• Daniel Lowenstein, Senior Director of Public Affairs, PCDC

• Elena Thomas Faulkner, Senior Consultant, John Snow Inc.

Slide 4

Learning Objectives for this Webinar

• Update on Payment Reform: Where we’re headed• Payment Reform in the Gulf States• VBP arrangements for Primary Care providers• Competencies Health Centers need for VBP• Explain the origin and purpose of the NACHC Payment Reform

Readiness Assessment Tool• Review the structure of the tool

Slide 5

Value-Based Payment: Where We’re Heading• Introduction of Value-Based Payments

– Medicare • 85% of FFS linked to quality/value by 2016, 90% by 2018• 30% of in alternative payment models (i.e. ACOs) by 2016, 50% by 2018.• MACRA – financial rewards an penalties/APMs

– Medicaid• Many states adopting quality/value or aligning with Medicare• Medicaid Managed care reform

– Commercial (2014)• 40% of in-network payments value-oriented• 24% of in-network primary care payments

Slide 6

Medicare P4P goals

Slide 7

Medicare Pay for Performance

Slide 8

Preparing Providers for VBP• CMS testing numerous innovation models to achieve better care for

patients, better health for our communities, and lower costs through improvement for health care system

• HRSA incentivizing value in FQHCs• Focus on building primary care capacity and readiness for value-

based payment

Slide 9

FQHC Advanced Primary Care Demonstration

• 434 participating sites• Goals: Achieve NCQA PCMH Level 3, coordinate care and manage chronic conditions• Monthly care Medicare management fee

Slide 10

FQHC APCD – Gulf Region sites

Slide 11

Comprehensive Primary Care Initiative

• Collaboration between CMS, commercial and State health insurance plans (multi-payer)• Population management fees and shared savings to participating practices for Risk-

Stratified Care-Management; Access and Continuity; Care Planning; Patient/Caregiver Engagement; Care Coordination

Slide 12

Advance Payment ACO

• For physician–based and rural providers • Receive advance on shared savings they are expected to earn

Slide 13

Pioneer ACO

• For healthcare organizations and providers experienced in coordinating care across care settings

• Goal: move rapidly from shared savings to population-based payment model

Slide 14

State Innovation Models

• Financial and technical support to states testing state-led, multi-payer healthcare payment and delivery models for all residents

• States develop State Health Innovation Plans with strategy to use all of levers available to transform healthcare delivery system through multi-payer payment reform and other state-led initiatives.

Slide 15

Transforming Clinical Practice Initiative

• Peer-based learning networks designed to coach, mentor and assist clinicians in developing core competencies specific to practice transformation

• Supports 140,000+ clinician practices in sharing, adapting and further developing comprehensive quality improvement strategies

Slide 16

Impact of VBP on Health Centers

• Historic underinvestment in primary care (~5% of HC spending) • Challenges to the Prospective Payment System

– Alternative payment methodologies (not FFS)– Payment tied to quality– Population-based and capitation payments

• Competition for patients– Opportunities in treating complex patient needs effectively

• Need for innovation partnerships/collaborations– Payers and other providers– Coordinating care, sharing data

Slide 17

Why Health Centers Are Valuable to VBP

• Meeting increased demand for quality primary care (Medicaid/private insurance expansion)

• Safety net providers• 69% are Patient Centered Medical Homes• 92% use Electronic Health Records • Clinical and cost data reported publicly (UDS)• Potential to reduce total cost of care/improve outcomes

Slide 18

HRSA Gulf State FQHC Quality Measures

EHR PCMH National Quality Leader

Health Center Quality Leader

Louisiana 100% 71% 6.7% 20%

Alabama 86% 86% 0% 7.1%

Mississippi 95% 71% 0% 33%

Florida 95% 65% 2.1% 41.7%

National 92% 69% 4.8% 30.4%

National Quality Leader: Health center exceeded national clinical benchmarks for chronic disease management, preventive care, and/or perinatal/prenatal care.Health Center Quality Leader: Health center among the top 30 percent of all health centers that achieved the best overall clinical outcomes.

Source: HRSA Health Center Quality Improvement Awards FY 2015

Slide 19

Recent Evidence of Health Center Value1

• UC Irvine– 10%-30% lower Medicare costs than physician offices and outpatient clinics1

• Chicago Center for Diabetes Translation Research– 24% Lower Medicaid costs than non-health center settings: 23% lower

Primary Care, 14% lower Rx, 11% lower ER, 27% lower Inpatient

• JSI Medi-Cal (California Medicaid) study. Non-FQHC patients– Twice as likely as FQHC patients to have an inpatient stay– 2.62 times as likely of 30-day readmissions– 1.27 times as likely to have an ED visit

• Idaho commercial payer study– FQHCs 21% more cost effective compared to peers

1 “Are Health Centers Cost Effective?” A Review of Recent Research on Health Center Cost of Care HRSA/BPHC Webinar Thursday, July 23, 2015

Slide 20

Payment Reform for Health Centers

Getting Ready

Slide 21

Value Based Payment (VBP) Continuum of methodologies transitioning from FFS to full

capitation. • Payments for specific activities, services, or procedures that are

not traditionally reimbursable, such as care coordination or PCMH

• Pay-for-performance programs • Shared savings but with no risk when savings are not realized• Partial risk - upside and limited downside• Partial capitation – limited categories of service included in

capitation• Full Capitation – for a specified population over a specific time

period

Slide 22

Slide 23

Primary Care Provider Capabilities Required for VBP

• Understand your data and costs• Have the ability to exchange and use data• Truly patient centered medical homes• Coordinate care and managing costs across the continuum• Quality Improvement• Engage patients• Risk Stratification of patients• Comfort with transparency

Slide 24

RCC Survey Results

Slide 25

To What extent has your health center begun to prepare for Value-Based Payment (VBP)?

• Not started• Not sure where to start• In process• Have a plan to address VBP readiness• Have begun to assess readiness• Other

Slide 26

What are the most challenging aspects of payment reform readiness for your health center?

• Quality Assurance 40%• HIT 20%• Payer Contracting 20%• Finance 60%• Clinical Services 20%• Staff Training 50%• Relationships with hospitals and other providers 20%• Leadership 20%

Slide 27

NACHC Payment Reform Readiness Assessment Tool

Elena Thomas Faulkner, Senior Consultant, JSI ethomas@jsi.com (303)262-4320

Slide 28

This Part of the Call Will:

Explain the origin and purpose of the NACHC Payment Reform Readiness Assessment Tool

Review the structure of the tool

Slide 29

NACHC Payment Reform Primer

Help health centers understand the role of payment reform in achieving the Triple Aim

Identify core capacities health centers need to participate successfully in payment reform

http://www.nachc.com/Medicaid-Prospective-Payment-System.cfm

Slide 30

Readiness Assessment Tool Objectives

Involve key staff in assessing payment reform readiness

Identify four areas of competency required for successful participation in payment reform

Differentiate between three levels of readiness for payment reform

•The NACHC Payment Reform Readiness Assessment Tool was supported by Grant/Cooperative Agreement Number U30CS16089 from the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA/BPHC.

Slide 31

Competency Areas: four domains key to payment reform readiness

Assessment Elements: 8 -11 readiness elements for each competency area with descriptive statements to assist health

centers identify their level of readiness.

Rating Elements:

Tool Structure

Slide 32

Four Competency Areas

Slide 33

Organizational Leadership and Partnership Development

1. The BOD is knowledgeable about payment reform efforts and their implications for the health center’s mission and services.

2. The health center’s governance requirements and structure facilitate governance role in payment reform initiatives.

3. Administrative and clinical leadership have a shared organizational vision for and commitment to involvement in payment reform.

4. Administration and clinical leadership demonstrate commitment to payment reform model being pursued

5. The health center examines implications of specific payment reform opportunities in relationship to existing mission, service area, and scope of services.

6. The health center has experience developing partnerships to address service area needs and take advantage of opportunities in the local health care marketplace.

7. The health center partners with local hospitals and specialists to meet the goals of the payment reform models.

8. The health center has established relationships with social services and/or other organizations in the community needed to support the payment reform model.

Slide 34

Change Management and Service Delivery Transformation

9. The health center has experience with and knowledge of change management practices.

10. Clinical and administrative leaders support change processes in a systematic fashion.

11. The health center has experience managing care for groups of patients and/or populations with chronic conditions.

12. The health center has experience managing high-utilizer/high cost patients.

13. The health center provides robust care coordination.

14. The health center is a Patient Centered Medical Home (PCMH)/Patient Centered Health Home (PCHH).

15. The health center provides patient-centered care.

16. Behavioral health services are integrated with primary care services.

17. The health center provides enhanced access to meet the needs of the target population.

18. The health center has linguistic and cultural competence to meet the target population’s needs.

19. The health center engages in population health assessment and initiatives.

Slide 35

20. The health center regularly uses data to understand the socio-economic characteristics of population in service area

21. The health center regularly uses data to understand the specific health needs of population in its service area.

22. The health center uses data to understand its role within the broader health care marketplace, and its market share.

23. The health center has assessed the capacity of its current providers and facilities, and the need for additional staffing or space to support the services to be provided under a specific payment reform model.

24. The health center’s health information technology (HIT) systems allow for tracking of client and service information needed to inform payment/service delivery models.

25. The health center’s electronic health record (EHR) supports clinical practice and care management of client populations.

26. The health center has robust Health Information Exchange (HIE) with providers/partners of proposed payment reform effort.

Robust Use of Data and Information

Slide 36

Financial and Operational Analysis, Management and Strategy

27. The health center has identified the up-front costs of participation in the proposed payment model.

28. The health center is able to track system-level utilization and cost data for its patients.

29. The health center has analyzed how payment timing and methodology for a proposed payment reform model relates to health center revenue cycle management needs.

30. The health center has experience and capacity to manage performance-based contracts.

31. The health center has secured appropriate legal and compliance expertise for payment reform activities.

32. The health center has developed a business case for linking reimbursement to utilization and social complexity of health center patients and health center cost structure.

33. The health center has analyzed its ability to engage in risk-based contracts.

34. The health center has an established strategy for coordination of performance-based incentives and payment reform strategies across payer types.

35. The health center has analyzed the relationship between payment reform models and health center PPS or alternate payment methodology (APM) payment for Medicaid.

36. The health center has developed internal payment incentives based on quality and patient outcomes rather than volume.

37. The health center is leveraging all the available state and local assistance and funding to support payment reform and service delivery transformation efforts.

Slide 37

Lets look at an example from the first domain

Slide 38

Organizational Leadership and Partnership Development 1. The BOD is knowledgeable about payment reform efforts and their implications for the health center’s mission and services.

2. The health center’s governance requirements and structure facilitate governance role in payment reform initiatives.

3. Administrative and clinical leadership have a shared organizational vision for and commitment to involvement in payment reform.

4. Administration and clinical leadership demonstrate commitment to payment reform model being pursued

5. The health center examines implications of specific payment reform opportunities in relationship to existing mission, service area, and scope of services.

6. The health center has experience developing partnerships to address service area needs and take advantage of opportunities in the local health care marketplace.

7. The health center partners with local hospitals and specialists to meet the goals of the payment reform models.

8. The health center has established relationships with social services and/or other organizations in the community needed to support the payment reform model.

Slide 39

Slide 40

Slide 41

Note: There is no “right answer” or expected readiness level.

Answering openly and frankly will allow your health center to identify useful next steps or questions.

Slide 42

Find a PDF copy at:http://tinyurl.com/k8bvctb

NACHC is developing an on-line tool for release toward end of year

Slide 43

Questions?

Slide 44

PCDC Contact information

Dan Lowenstein,Senior Director of Public AffairsPCDC - Primary Care Development Corporation45 Broadway, 5th Floor

New York, NY 10006T: (212) 437-3942dlowenstein@pcdc.orgwww.pcdc.org