IowaHealth+ Update April 2019
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IowaHealth+ UpdateApril 2019
Who We Serve (2018 numbers)
779,547PATIENT VISITS
216,738TOTAL PATIENTS
3,618VETERANS SERVED
10,013HOMELESS PATIENTS
Iowa Policy Environment• Generally a moderate state politically but prone to big swings in political control• Marginal extra state support for safety net providers but relatively generous
programs and favorable policies• After big political battle, expanded Medicaid in 2014• State had started moving toward value-based pay in Medicaid in early 2010s,
including PCMH push, health homes, ACO authorization• Successfully lobbied to have FQHC-led ACO for expansion program pre-managed care
• State moved to managed care in 2016• Rollout was too quick, all populations in on day one, underfunded capitation payments• Four plans initially selected
• One was forced out, two have now failed, and a fifth is now entering the market July 1• Iowa PCA serves as liaison between MCOs, State, and CHCs
• Provider agreement contract review• Revenue cycle management• Communication locus• Value-based purchasing (IowaHealth+)
Future State We’re Preparing For
Value Based Care & Payment
Uncertain federal funding
Payor agnostic patient care
Increasingly competitive
healthcare sector
There’s opportunityhere if we’re ready
IowaHealth+ is a voluntary business venture owned and managed by 11 Iowa health centers and the Iowa PCA.
IowaHealth+ = Integrated Primary Care Network
Patients served in 2018
170,000+ Attributed Medicaid
lives in 2018
58,000+
• Initially created in 2011 to apply for a Medicare ACO opportunity in partnership with the AllianceChicago
• Repurposed for Medicaid Expansion MCO in 2014; hired Optum to manage
• Passed UHC integration test in 2015 to begin serving as Medicaid MCO in 2016 under managed care; hired in-house expertise
The Value of IowaHealth+Within the context of an ever-changing healthcare environment and accelerating pressure to move to value-based care/payment, IH+ facilitates:
• Safeguarding our mission• Ensuring we are not subsumed by larger systems, relieving pressure to
align with one system over another, safeguarding ability to partner with other providers
• Building and better leveraging capacity and economies of scale, sharing investment and risk, (i.e. analytics, performance improvement, etc.)
• Proactively defining our path forward and holding each other accountable to shared standards
• Developing statewide primary care-focused system of care that more fully leverages our integrated model & reinvests in it
• Ensuring vulnerable patients’ access to care within a larger system and grow market share
• Providing one-stop shop for patients/payors/partners (negotiating power, influence, administrative ease)
• Empowering practice transformation and value-based payment reform
IowaHealth+ Governance Structure
IowaHealth+ is a limited liability corporation fully owned by 11 Iowa health centers and the Iowa PCA. Operations are supported through a
management agreement with the Iowa PCA.
All Members• Full ownership of IH+, has authority to
accept new members/owners, remove a member/owner, request a capital contribution from members/owners, and authorize financial distributions to member/owners
• Typically meets bi-monthly
Board of Managers• Consists of four health center CEOs selected
by All Members and the Iowa PCA CEO, functions similar to an Executive Committee
• Meets monthly to advise and direct operations
IowaHealth+ CommitteesIowaHealth+ has three working committees composed entirely of health center representatives. Participation in the committees is an IH+ participation standard.
Consumer AdvisoryProvides advice to the Board on policies and programs including:• related to cultural competency• outreach plans• beneficiary educational materials, prevention
programs, and satisfaction surveys
Clinical Quality CommitteeProvides advice to the Board on clinical and quality matters, including: • quality improvement programs• recommended clinical pathways and protocols• participant quality incentive targets and
satisfaction thereof
FinanceProvides advice to the Board on financial matters, including:• developing capital and operating budgets• financial forecasting• reviewing financial statements• engaging auditors to the extent deemed necessary by the Board
IowaHealth+ Participation Standards
Clinical Standards Clinical Quality
Consumer Advisory Finance All Member
Hypertension Lead Support Informed Ratify
Colorectal Cancer Screening Lead Support Informed Ratify
Financial StandardsInitial Capital Contribution Informed Informed Lead Ratify
Capacity Planning Model Informed Informed Lead Ratify
Operational StandardsTeach-back Support Lead Informed Ratify
Outreach & Enrollment Support Lead Informed Ratify
Committee Participation Support Support Support Lead, Ratify
Use of Data (VIS) Support Support Support Lead, Ratify
PCMH Certification Support Support Support Lead, Ratify
Transformation Collaborative Participation Support Support Support Lead, Ratify
Brand Integration Support Support Support Lead, Ratify
Lead
This committee has the first opportunity to develop a proposal, whether to edit or delete a current standard or to create a new standard. This committee is expected to give due consideration to feedback and recommendations made by the Supporting committee, but has authority to submit a final recommendation to the Ratifying committee.
SupportThis committee offers feedback and recommendations based on the initial proposal developed by the "Lead" committee.
InformedThis committee is kept informed of any changes to the participation standards, but doesn't have a role in developing recommendations.
Ratify This group has the authority to approve and codify changes to the participation standards.
IowaHealth+ participation standards are established by IowaHealth+ member/owner centers in order to pursue continuous improvement and hold each other accountable to shared goals.
History of Innovation & Partnership: Medicaid Prior to Managed Care
Iowa Medicaid Healthy Behaviors
In 2015, IowaHealth+ was the highest performing ACO in Iowa for the wellness exam (68%) and the second highest performance ACO for the HRA (34%).
IowaHealth+ tied with UIHA as the top-performing ACO for patients completing at least one activity and second highest for patients completing both activities.
History of Innovation & Partnership
IowaHealth+ has partnered with DHS before and after managed care.
Project ECHO for BH integration, MAT, and HEP C – more to come
IowaHealth+ partners with IDPH to address HTN, CRCS, ER utilization, etc.
IowaHealth+ participated in the 2016-17 SNAC learning & action collaborative.
IowaHealth+ centers have participated in the NACHC Value Transformation and Elevate.
IowaHealth+ participates in the 2018-19 behavioral health integration collaborative.
History of Innovation & Partnership
SIM dollars support rollout of PRAPARE tool across all IowaHealth+ centers; Iowa PCA primary consultant to providers and communities on SDOH.
Two-year partnership increased rates of same-day access, ER and IP follow-up, and PCP visits for high risk patients.
Multiple partnerships since managed care rollout, focused on data sharing and quality measures.
Clinical Integration
Quality & Transformation• Implementation arm for the three companies• Interdisciplinary team to support health centers
• Clinical informaticist• Nurse• Behavioral health specialist• Oral health specialist• Data analyst
• Share best practices, network, and share decision-making through:• Clinical Quality Committee, Consumer Advisory Committee, Finance Committee &
Care Coordination Workgroup• Regular in-person learning collaborative• Health center on-site assessment and support for collective and local clinical quality
and performance improvement priorities (quality, cost, patient experience, staff fulfillment)
• Provide leadership and support for data analysis and reporting, business and population health strategy to improve outcomes and lower costs
IowaHealth+ Model of Care
Integration of Care Ensure Patients’ Timely Access to Care
Manage Patient Care Transitions
Improve High Risk Care Coordination
Provide High Quality Care
Social Determinants of Health
Supported by Health Information Data and Analytics• VBC Analytics & Enli implementation
Supported by Patient Engagement Strategies• Motivational Interviewing & Teach-Back
Quality & Transformation: IH+ Model of Care
Quality & Transformation: IH+ Model of Care
Integration of Care Ensure Patients’ Timely Access to Care
Manage Patient Care Transitions
• Behavioral Health Integration Strategy
• Oral Health Integration Pilots
• PCMH Recognition • Transitions of Care Minimum Set of Services
• ER Utilization Reduction • Admits, Discharges, Transfer (ADT)
alerts
Quality & Transformation: IH+ Model of Care
Improve High Risk Care Coordination
Provide High Quality Care
Social Determinants of Health
• UHC Actionable Patient Program• Care Coordination Workgroup,
including focus on risk stratification and care team design
• Colorectal Cancer Screening• Diabetes Control• Hypertension• Antidepressant Med Mgmt• Adolescent Well-Care• Childhood Immunizations• Breast & Cervical Cancer
Screening
• PRAPARE / Tableau• Exploring Referral Tools
• Clinical and other care team members, meet weekly• Focus on payor partnership metrics
• High risk care coordination• HEDIS Quality Measures
• Diabetes Testing• Adolescent Well-Care• Childhood Immunizations Status (CIS)• Antidepressant Medication Management (AMM)
• Risk stratification and care team design• Minimum services definitions – transitions of care, ER utilization,
diabetes care, adolescent well-care• Risk stratification and care team design• Make recommendations to Clinical Quality and Consumer Advisory
Committees
Care Coordination Work Group
Financial Integration
Financial Integration• Capital contribution required• First demonstration – financial clawback provision and incentive pay
in Expansion ACO contract• Revenue Cycle Management benchmarking and support• Shared savings contracts in Medicaid• Business intelligence analytics (building capacity now)• Alternative Payment Methodology development• Note: constant tension between resourcing network operations while
simultaneously rewarding health center outcomes
Alternative Payment MethodologiesGoal: Better align quality outcomes and cost containment expectations with right revenue stream/incentives; move toward risk based contracting.
Proposal: Prepare and implement primary care subcapitationmodels as a path to higher-risk/higher-reward models.
Health Plan 2018 2019 2020 2021
MCOs Care Coordination / Shared Savings
Care Coordination / Shared Savings
Primary Care Capitation
Primary Care Capitation
Benefits of this proposal:• Budget predictability for payer & provider• Greater flexibility to manage patients as needed (e.g. supporting innovative services)• Removes disincentives inherent in fee-for-service system (e.g. maximizing PCP utilization)• Greater accountability and incentive for provider performance
Network Analytics SolutionIowaHealth+ recognizes that data is destiny.
IowaHealth+ and member health centers are mutually investing in a shared data analytics platform that will• Empower timely, data-driven, patient-centered care at the health center level• Facilitate efficient data reporting and effective resource deployment at the network level• Set centers and the network up for success in risk-based contracting arrangements in the future
We need analytics capabilities that support care management and decision-making systems that are EHR vendor agnostic and allow us to provide cost effective, high quality care regardless of the patients’ payor (or lack of one).
We need to collaborate with our payor partners to access claims and other information to realize the potential of the analytics system.
We chose the Arcadia (business intelligence) and enli (population health management) products, which integrate with the Centricity EMR while also connecting to three other EMR products currently used in Iowa.
Key Payor Partnership Parameters• Clinical and performance improvement prioritization – look across our three company and
partner priorities (HRSA, UDS, HEDIS, Dept of Public Health, utilization, etc.) and push for alignment
• Example: we are currently measured on these four HEDIS measures in each of our Medicaid contracts, plus emergency room utilization rates
• Childhood immunization status combination 10• Adolescent well-care visits• Antidepressant medication management - acute• Comprehensive diabetes care: HbA1c testing
• Build system-level infrastructure – data analytics and reporting, care coordination capacity, quality and performance improvement support
• Demonstrate how these systems can perform to meet contract expectations & how partnership resources are invested to improve these
• Use these tools to have a more level playing field during negotiations• Example: data analytics platform
Key Partnership Parameters (continued)
• Relationship/system building – how do we proactively partner to streamline communication, leverage resources, reduce duplication
• Example: high risk care coordination micro incentive program• Sufficient financial support – change requires investment
• Need to be sufficient to support real change (empower adaptive not technical changes), metrics must be stretchy yet achievable, and payment timeframes must not be too distant
• Example: PMPM vs. shared savings reliance (bridge to future payment reform)• Layering incentive programs – reduce duplication and move toward value-based programs
while ensuring adequate financial support• Example: health home programs
Approach to Contracting• Build relationships – like nearly all things in life, success is often determined by the
strength of relationships• Know your value – and be able to demonstrate it (data is destiny)• Scale is important – move toward being big enough to impact statistics but small enough
to be nimble (health centers and statewide CHC networks are often in this sweet spot)• Have a plan – move from reacting to proactively defining mutually beneficial partnerships• Don’t be afraid to walk from a bad deal – you likely have more power than you realize• Know your state’s context – align with state incentives when possible and understand the
underlying financials of your Medicaid program• Hire a lawyer – duh; don’t forget about fair out-clauses, clear payment methodologies,
TCOC calculations, catastrophic loss levels, regression to the mean, etc.
What’s Next?• Optimize data systems to empower population health and contracting
• Analytics infrastructure operationalized over the next year• PRAPARE (social determinants of health) survey deployment over the next year• Medicaid claims connection
• Secure partnerships to financially support payor agnostic, primary care-centric care system
• Work with Medicaid and Managed Care Organizations to establish a new value-based alternative payment methodology to empower care team redesign
• Closeout UnitedHealthcare partnership, build on Amerigroup partnership, and establish Iowa Total Care partnership
• Create and deploy multi-payer partnership strategy (Medicare, Medicare Advantage, Veterans Administration, commercial insurance)
• Continue progress on quality and performance improvement• Enhance brand awareness• Support leadership development and enhance change
management capacity
Key Takeaways
• Recognize and know your value – you deploy the model that works• We’re stronger together and we need each other• Managed care is a new world – take the time to learn the motivations and
measurement (HEDIS) and clearly articulate your value proposition/business case within it
• Build centralized systems and resources that can be brought to scale (data infrastructure, staff expertise, etc.)
• Be proactive and planful • Don’t forget about leadership development and change management
(change is hard and scary!)• Relationships matter, always
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