CHCS Center for Health Care Strategies, Inc. Center for Health Care Strategies, Inc. Bending the Trend Through Improved Quality of Care State Coverage.

CHCSCHCSCenter forHealth Care Strategies, Inc.Center forHealth Care Strategies, Inc.

Bending the Trend Through Improved Quality of CareBending the Trend Through Improved Quality of Care

State Coverage Initiatives WorkshopAllison HamblinAugust 2, 2007

To improve the quality and value of

health care services for people with

chronic health needs, the elderly, and

racially and ethnically diverse

populations.

MISSION

Quality as a Cost-Containment StrategyQuality as a Cost-Containment Strategy

Step 4 $$-Driven Desperate Measures

•TBD as states are figuring out that just cutting is not slowing the rate of growth

Step 3 Eligibility •Capping enrollment / eliminating optional groups

Step 2 Services •Eliminating optional services

Step 1 Reimbursement •Across the board provider rate cuts

Lev

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LOW

HIGHFocus Examples

Step 5 Quality •Care management for people with co-morbidities/high-risk conditions

•Provider-level pay for performance

Medicaid – A Land of Opportunity Medicaid – A Land of Opportunity

•High prevalence of chronic illness

•Existing systems for managing care

•Aligned financial incentives

•Growing evidence base for what works

•Imminent need to “bend the trend” to support coverage expansions

Focus on ValueFocus on Value

•Shift the focus from spending to investing

•Allocate resources to get the best value for every dollar spent in terms of improved outcomes and ROI

•Develop a “balanced portfolio” for short-term and longer-term returns

– Not everything worth doing has cost-savings potential in the short-run

– Use what does to finance what doesn’t

Tota

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osts

Percent of Medicaid PopulationSource: Sommers A. and Cohen M. Medicaid’s High Cost Enrollees: How Much Do They Drive Program Spending? Kaiser Commission on Medicaid and the Uninsured, March 2006.

Step 1: Identify the WhoStep 1: Identify the Who

•Medicaid “Best Buys”1.Care management for high-risk pregnancy

2.Care management for high-risk asthma

3.Managed care for aged, blind and disabled beneficiaries

4.Managed care for long-term care supports and services

5.Care management for high-risk, high-cost members with multiple chronic conditions

•Rethinking Care Program• Focus on high-need, high-cost populations

Step 1: Identify the WhoStep 1: Identify the Who

Step 2: Identify the What Step 2: Identify the What

•Business Case for Quality– Building the case in Medicaid managed care– 10 demonstrations looked at asthma, diabetes,

substance abuse, prenatal care, pressure ulcers

•Key findings indicate strongest ROI potential for:– Stratified target populations– Conditions responsible for large portion of

inpatient/ER utilization among target population– Childhood asthma, high-risk pregnancy

•Next steps– Strengthen the evidence– Broaden the stakeholders

Step 2: Identify the WhatStep 2: Identify the What

•The Evidence Base– Systematic review of the published literature to

identify interventions with both quality improvement and cost-savings potential

– Developed in partnership with Mathematica Policy Research

– Initial focus on asthma, CHF, depression, diabetes, high-risk pregnancy

– Inclusion criteria: study quality, generalizability to Medicaid, breadth of intervention strategies

Step 3: Identify the Where and HowStep 3: Identify the Where and How

•ROI Purchasing Institute– 12 month initiative supported by CMWF and RWJF– 8 states, including AZ, CO, CT, ID, LA, OK, PA, WA

•Project Goals:– Build state capacity to include ROI forecasting into

planning of quality initiatives

– Provide tools to facilitate analysis of and dialogue around investments in quality

– Build realistic expectations for savings and for the magnitude of change needed to achieve such savings

Step 3: Identify the Where and HowStep 3: Identify the Where and How

•ROI Forecasting Calculator– High-level planning and discussion tool for use by

states and health plans

• Determine how to target resources most effectively

• Make a financial case for obtaining resources for quality investments

• Analyze trade-offs associated with resource allocation alternatives

– Source of assumptions whose breadth, depth and overall validity will grow with use (Evidence Base)

– Complement to other planning processes and considerations

ROI Forecasting CalculatorROI Forecasting Calculator

www.chcsroi.org

Visit www.chcs.org to: Visit www.chcs.org to:

• Learn about cutting-edge state/health plan efforts to improve care for Medicaid’s highest-risk, highest-cost members.

• Download practical resources to help improve the quality and efficiency of Medicaid services.

• Subscribe to CHCS e-Alerts for regular updates on new CHCS programs and resources.

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