This activity is made possible by grant number U30CS09746 from the Health Resources and Services Administration, Bureau of Primary Health Care. Its contents are solely the responsibility of the presenters and do not necessarily represent the official views of HRSA. MAKING THE MOST OF PAYMENT REFORM WELCOME April 18,2014 This webinar will begin promptly at 1pm EDT
WELCOME April 18,2014 This webinar will begin promptly at 1pm EDT. Making the most of payment reform. presenters. Host: Sabrina Edgington , MSSW, Program and Policy Specialist, National Health Care for the Homeless Council - PowerPoint PPT Presentation
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This activity is made possible by grant number U30CS09746 from the Health Resources and Services Administration, Bureau of Primary Health
Care. Its contents are solely the responsibility of the presenters and do not necessarily represent the official views of HRSA.
MAKING THE MOST OF PAYMENT REFORM
WELCOMEApril 18,2014
This webinar will begin promptly at 1pm EDT
PRESENTERS
• Host: Sabrina Edgington, MSSW, Program and Policy Specialist, National Health Care for the Homeless Council
• Melissa Hansen, MPH, Program Principal, National Conference of State Legislatures
• DaShawn Groves, MPH, Assistant Director, State Affairs, National Association of Community Health Centers
• Monica Bharel, MD, Chief Medical Officer, Boston Health Care for the Homeless Program
OVERVIEW
The role of the state in payment reform
State efforts and health center engagement
The Boston HCH Program experience
HEALTH CENTERS AND PAYMENT REFORM
• In expansion states, health centers are expected to absorb many newly eligible beneficiaries.
• Many high cost health system users with complex health needs will now have coverage.
BALTIMORE HEALTH CARE FOR THE HOMELESS PROGRAM
TRIPLE AIM
Improved health (outcomes)
Improved quality (patient satisfaction)
Reduced cost
MANY PAYMENT MODELS BEING TESTED
• Global Payment• ACO Shared Savings
Program• Medical Home• Bundled Payment• Hospital-Physician
Gainsharing• Payment for Coordination
• Hospital Pay-for Performance
• Payment Adjustment for Readmissions
• Payment Adjustment for Hospital-Acquired Conditions
• Physician Pay-for-Performance
• Payment for Shared Decision making
Source: Schneider, E., Hussey, P., and Schnyer, C. (2011). Payment Reform: Analysis of Models and Performance Measurement Implications. http://www.rand.org/pubs/technical_reports/TR841.html
Workforce Demands of New Payment and Delivery Models Models
New or Expanded Roles for:– Nurses– Behavioral Health Specialists– Community Health Workers– Social Workers– Peer Specialists– Pharmacists– Health Coaches
Mandated Coverage for Telehealth Services
Becoming a Key Stakeholder• Track payment reform efforts in your state (or local area).• Establish and maintain a relationship with legislator(s)
representing your area(s).• Get involved in collaborative efforts.• Self assessment of capacity (infrastructure, HIT,
workforce).• Be clear, concise in communications.
• Privacy issues• Fraud and abuse• Market concerns (anti-trust)• Network adequacy and patient satisfaction • Do new payment methods improve value?
Legislative Concerns With Payment Reform Activities, Some Examples
A Framework for Preparing for Health Care Reform at your Program
Clearly defining the issueHaving data and knowing the factsUsing the data to be involved early in processUnderstanding that change is hardWorking collaborativelyBe willing to be in it for the long run
A Framework for Preparing for Health Care Reform at your Program
Clearly defining the issueHaving data and knowing the factsUsing the data to be involved early in processUnderstanding that change is hardWorking collaborativelyBe willing to be in it for the long run
Current situation Future possibility
Volume incentives
Fragmented payment
Accountable Care
Vuln
erab
le
popu
lation
s
Accountability for defined population
Pay for value
Comprehensive and transparent care
Fragmented delivery
Inconsistent quality
A Framework for Preparing for Health Care Reform at your Program
Clearly defining the issueHaving data and knowing the factsUsing the dataUnderstanding that change is hardWorking collaborativelyBe willing to be in it for the long run
U.S. Health Care Expenditures are Rising
Massachusetts Spends More on Health Care than Any Other State
50
PER CAPITA PERSONAL HEALTH CARE EXPENDITURES, 2009
NOTE: District of Columbia is not included.SOURCE: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2011.
How does this compare to homeless individuals in Massachusetts?
Lack of data tracking homeless individuals Starting point becomes obtaining data
Boston Homeless Cohort:Mental Health and Substance Use AJPH 2013
All (N=6,494)
Mental Illness 4,384 (68%)
Schizophrenia 1264 (19%)
Bipolar Disorders 1889 (30%)
Depression 3068 (47%)
Anxiety 2627 (40%)
Substance use disorders 3890 (60%)
Alcohol use disorder 2628 (40%)
Drug use disorder 3118 (48%)
Co-occurring mental illness and substance use
3135(48%)
Boston Homeless Cohort:Selected Chronic Physical Conditions AJPH 2013
18
10
37
26
4
6
23
0 10 20 30 40Diabetes
Ischemic HD
HTNAsthma/COPD
Cirrhosis
HIV
Hep C
Ch
ron
ic C
on
dit
ion
Percentage
BHCHP PCC Patients versus members of the PCC Plan
Bharel et al, AJPH 2013
Diagnostic and Other Characteristics StatewideBHCHP
Patients*Number 426,768 3,998DxCG Score 1.5 3.4Both Mental Health & Substance Use 10% 51%Asthma or COPD 6% 24%Diabetes 6% 15%Hospital Discharges Per 1,000 129 859ED Visits Per Person 1.1 4.2Average Annual Cost $6,679 $20,925
*Medicaid-only BHCHP patients enrolled in the PCC plan.
Total Annual Expenditures by Expenditure Group for BHCHP Users with Medicaid in 2010
Users (N=6,493) Expenditures ($149 million)0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
25.0%
1.4%
25.0%
6.5%
25.0%
18.6%
15.0%
25.5%
10.0%
48.0%
Total Annual Expenditures by Expenditure Group for BHCHP Users with Medicaid, CY 2010
90 – 100% (650 users)
75 – 90% (974 users)
50 – 75% (1,623 users)
25 – 50% (1,623 users)
Lowest 25% (1,623 users)
Health Care Utilization and Housing
Studies in New York, Seattle and Chicago have found that housing homeless individuals can decrease use of services including: Emergency department Hospital inpatient Detoxification services
Am J Public Health. Apr 2004, JAMA. Apr 1 2009, JAMA. May 6 2009.
A Framework for Preparing for Health Care Reform at your Program
Clearly defining the issueHaving data and knowing the factsUsing the data to be involved early in
processUnderstanding that change is hardWorking collaborativelyBe willing to be in it for the long run
Long History of Reform in Massachusetts
1997
• Medicaid 1115 waiver to expand Medicaid, including MCO development
2006
• Comprehensive Health Reform: shared individual and state government, responsibility for access
2007
• Despite a recession, Massachusetts succeeds at having the lowest rate of uninsured in the nation
2012
• Chapter 221 passed with focus now on cost containment while providing high quality care
2013
• One Care Program begins to coordinate care for dual eligible patients (both Medicaid and Medicare)
2014
• Primary Care Payment Reform beings to coordinate behavioral health and primary care services in a global payment to primary care practices
One Care: Medicaid Plus Medicare
• October 2013• MA launched program to integrate care and align
financing for dual eligible patients• Interdisciplinary Care Teams develop patient care
plans and covered services include primary care, BH, specialty care, dental, vision ,medications and long term care.
• March 2014• 9,722 members have enrolled• Payments remain fee-for-service with a supplemental
payment for care coordination and management
Primary Care Payment Reform Initiative (PCPRI)
• Chapter 221 requires transition of Medicaid patients from fee-for-service to alternate payment methods with 80% transformation by July 2015
• PCPR is an alternative payment program where primary care providers are held accountable for cost and quality of care using a BH integration model and patient centered medical home.
• Payments are risk adjusted per member per month global payments
• Goal of delivery system to increase care coordination and care management, improve access to primary care, integrate BH and practice population management
Collaborator Issue
Local community organizations
Academic medical centers
MedicaidExecutive Office of
Health and Human Services
Elected Officials
Special populationAttribution of care
issueMedical respite
needsBH integration
needs
Using the data to advocate
A Framework for Preparing for Health Care Reform at your Program
Clearly defining the issueHaving data and knowing the factsUsing the data to be involved early in processUnderstanding that change is hardWorking collaborativelyBe willing to be in it for the long run
Opportunities Flexibility in clinical
design Flexibility in outreach
model Behavioral health and
primary care integration
Coordination across the health care system
Challenges Change is hard Uncharted territory Attribution of patients Risk adjustment is not
adequate Taking on risk at
provider level Want clinical staff to
remain blind to insurance type
Payment Reform and Health Care for Homeless Individuals
A Framework for Preparing for Health Care Reform at your Program
Clearly defining the issueHaving data and knowing the factsUsing the data to be involved early in processUnderstanding that change is hardWorking collaborativelyBe willing to be in it for the long run
Collaborations: who else is a stakeholder?
Neighborhood hospitals and academic medical centers
State MedicaidState Legislators/local politicians Consumer advocacy groupsOther organizations caring for special
A Framework for Preparing for Health Care Reform at your Program
Clearly defining the issueHaving data and knowing the factsUsing the data to be involved early in processUnderstanding that change is hardWorking collaborativelyBe willing to be in it for the long run
Mission Statement:
Photos courtesy of J O’Connell
Provide and assure access to quality health care for all homeless individuals and families in the greater Boston area.
QUESTIONS AND ANSWERS
For more informationwww.nhchc.orgwww.nachc.orgwww.ncsl.org