Presented by John Snow, Inc. October 23, 2014 OREGON SCHOOL-BASED HEALTH CENTERS PAYMENT REFORM.

Presented by John Snow, Inc.October 23, 2014

OREGON SCHOOL-BASED HEALTH CENTERS

PAYMENT REFORM

INTRODUCTIONS

John Snow, Inc. (JSI)

JSI is a health care consulting and research organization dedicated to improving the health of individuals and communities, in particular underserved and vulnerable populations.

www.jsi.com

JSI RECENT PROJECTS

• RWJF – Safety-net ACOs• BSCF – Whole-person-centered care• California Primary Care Assoc/California

Association of Public Hospitals and Health Systems – FQHC payment reform

• AHRQ Medicaid Readmissions• California Association of School-based Health

Centers• Colorado Health Care, Policy and Financing• NACHC Payment Reform

OBJECTIVES

• Provide national context on payment reform• Reflect on: How should SBHCs be paid?• Provide overview of reform models

• FFS • Capitation• Supplemental PCHH• Performance-based

• Posit additional strategies for SBHCs to consider:• Braiding• Layering

• Discuss opportunities and challenges for SBHCs

Oregon is a national leader with its 1115 Waiver and CCO activityCollaboration in community needs assessments are in the vanguard nationally

WHY PAYMENT REFORM?

• Goal: Delivery system transformation to meet Triple Aim and Reduce Disparities

Better Healt

h

Improved Cost

per Capita

Reduced Health

Disparities

Better Care

Payment Reform

Delivery System

Transformation

Triple Aim

Better Health

Improved Cost per

Capita

Reduced

Health Disparities

Better Care

PAYMENT REFORM IS PROMOTING COLLABORATION

Patient-Centered Health Home

Patient-Centered Medical Home

Accountable Care Organization

Accountable Care Community

PAYMENT REFORM IS PROMOTING COLLABORATION

• But reform is not that neat….• Delivery system and payment reform are

mutually reinforcing PCHH

PCMH

ACO

ACC

Managed Care

2 KEY QUESTIONS TO ASK

1)How is a provider paid?2)How is a larger system paid?

Payment Strategies

Support More Robust Primary Care

Support Integration/Coordination across Settings

Moving toward Accountable Care

Grants • PCMH transformation grants

• Meaningful Use • Community Transformation Grants

Fee-for-service strategies • pay for traditionally

unfunded services • non-payment for

services• limit payment for

services

• New Medicare Transitional Care Management Codes

• Medicare Payment rates for PC Medicaid

• Non-payment for Medicare readmissions

• Reference Pricing

Episode-based payments

Hospital episode-based payments

Partial capitation (PMPM)

•PC Capitation•PCMH

•PCHH (care mgt and care coordination)

•Professional services capitation

Performance payments (withholds, P4P and shared savings)

•P4P based on quality •Value-based pay-for-performance

•Shared Savings in MSSP and various ACOs •Global Budgets

Global Capitation • Managed Care? • ACOs• Integrated

Delivery Systems

Blended funding streams

Duals demonstrations Accountable Care Communities

Foundation for change Increasing Coordination Transforming Care

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PAYMENT REFORM IN ONE PAGE

2 KEY QUESTIONS TO ASK

1)How is a school-based health provider paid?

2)How is a larger system paid?

A couple of Delivery System Transformations

to keep in mind

ACCOUNTABLE CARE ORGANIZATIONS

• Organizations that assume accountability for a defined patient population across a continuum of care with payment tied to quality and cost outcomes

• Shared savings designed as strategy to encourage cost saving and quality outcomes under global budget or global capitation

• A wide variety of entities are emerging as ACOs – Oregon’s CCOs

ACCOUNTABLE CARE COMMUNITIES

• ACOs may not be enough• Need to be better connected to the community• Need to connect to public health and prevention

• Collaboration across sectors to address social determinants

• Building on top of or incorporating ACOs, PCMH, Community Health Teams

• Political lever to engage whole community• Leadership coming from States, foundations and local

community

How should a school-based health

provider be paid?

KEY PAYMENT REFORMS

Key Payment strategies:1. FFS for traditionally non-funded services2. Capitation

• Primary Care (a provider)• Global capitation (a system)

3. PCMH and PCHH supplemental payment4. Value-based pay-for-performance (P4P)5. Braiding6. Innovative grant funding under ACA

#1: FFS STRATEGIES

• Execute contractual agreements for specific preventive services to be paid for traditionally unfunded services

• As risk-bearing entities assume responsibility for global costs of a population, SBHCs could propose being paid for: • asthma prevention/treatment• teen pregnancy prevention• diabetes prevention• behavioral health • oral health• access to care for high-risk populations

• Explore Opportunities to Expand FQHC Scope of Service to include SBHC services

#1: FFS STRATEGIES

Considerations:• Contracting FFS for previously unfunded services

requires a compelling return on investment case• Particularly relevant for non-assigned patients

(that a payer holds financial accountability for)• For Medicaid, could require policy change

(Medicaid funding for preventive services rendered by non-licensed providers)

• FQHC scope only relevant for Medicaid patients at FQHC SBHCs

#2: PRIMARY CARE CAPITATION

Financial Objective of PC Capitation in FQHC

Delivery System Transformation Objective

• Maintain comprehensive primary care in transition to new system

• Monthly payment per member

• Flexibility to deliver care in more cost-effective and patient-centered ways

• Some visits converted to new modes of care; use of care teams

#2: PRIMARY CARE CAPITATION

Considerations• Requires being PCP for assigned patient

population• Can be negotiated with multiple payers• Increasingly comes with accountability

#3: SUPPLEMENTAL PCMH/PCHH

• 29 Medicaid programs are making PCMH payments

• Based on services and/or recognition

• Payments tend to be relatively small ($2-10PMPM)

Map Source: NASHP

#3: SECTION 2703 - PCHH

• ACA Section 2703:• 90/10 Federal Match for 8

quarters• Medicaid and Dual eligibles

with chronic conditions and SMI

• PCHH services: • Comprehensive Care

Management• Care coordination and

health promotion• Comprehensive transitional

care • Individual and family

support• Referral to community and

social support services,• Use of HIT to link services

• Payments significant (avg. $50PMPM) Map Source: NASHP

#3: SUPPLEMENTAL PCHH

Considerations: • Often requires being PCP for assigned patient

population• Can be based on provider capabilities/recognition• Can be negotiated with multiple payers• Comes with accountability

#4: PAY FOR PERFORMANCE INCENTIVES

Community Outcome (reduced obesity

prevalence)

Systems- Wide

Outcome (inpatient days)

Primary Care Outcome

(reduced BMI)

Primary Care Process

(BMI assessment & plan)

• P4P is increasingly moving to Triple Aim P4P and shared savings

#4: PAY FOR PERFORMANCE INCENTIVES

Considerations: • Often requires being PCP for assigned patient

population• Can be associated with being part of an ACO• Can be negotiated with multiple payers• Requires accountability for processes and

outcomes • What could SBHCs help an ACO or RBE to

achieve? • HEDIS• Access• Avoidable admissions

#5: BRAIDING FUNDING

• Braiding funding• Use of multiple sources of funding while maintaining

individual funding stream obligations and reporting requirements

Relevant Examples:1. Braid education and health $

• Ex. Michigan used K-12 funds appropriated for SBHCs to leverage federal Medicaid matching funds to support SBHC outreach and education services

2. Braid hospital community benefit $ and health $3. Braid BH, Dental, health - CCOs

#6: GRANT FUNDING

• Hospital Community Benefit• Non-profit hospitals must invest a certain percentage of their

revenue in the community• Non-profit hospitals must conduct a community health needs

assessment and develop an implementation strategy every three years

• Accountable Communities for Health

• Considerations:• Could SBHCs collect data for needs assessements• Could SBHCs position themselves to be regular recipients of

Wellness Trust $ or CB $

NO SINGLE PAYMENT REFORM “SOLUTION”

• There is no one way• Depends on payers, state regulations, other transformations

LAYERING PAYMENT REFORMS STRATEGY

• Payment/Delivery System Models can be layered and phased as part of a Comprehensive Multi-Layer Strategy

CPCA COMPREHENSIVE PAYMENT REFORM STRATEGY

Payment Reform

OPPORTUNITIES

• SBHCs may be only access point for some patient populations (and families)

• Movement toward increased accountability of broader health system – what are leverage points?

• Regional CCOs with accountability for all Medicaid may be more interested in population health investment (teen pregnancy prevention)

• Addressing social determinants of health increasingly being recognized as part of the solution

• ACCs/grants – investment in kids is a political advantage• State Innovation Model?

KEY CHALLENGES

• SBHCs are a diverse group• Health systems are moving toward assigned

patient populations – are SBHCs the assigned PCP?

• Need access to total health system data and sophisticated analytics to make ROI case

• FQHC is an opportunity; becoming an FQHC is complex

• Policy change required for funding some preventive services

• Negotiating contracts with MCOs/RBEs may be a new skill

THINGS TO WATCH

Reimburse non-provider preventive services in Medicaid:• Medicaid agencies allowed to reimburse for preventive services

provided by professionals that may fall outside of a state's clinical licensure system

Primary Care Extension Program (authorized but not funded)• Focus on “preventive medicine, health promotion, chronic disease

management, mental and behavioral health services…in order to enable providers to incorporate such matters into their practice and to improve community health by working with community-based health connectors

Community Health Teams (authorized but not funded)• Program to establish health teams to “collaborate with local primary care

providers and existing State and community based resources”• Some states have implemented with other funds: VT, ME, MD

QUESTIONS

CONTACT

Rachel TobeyJohn Snow, Inc. (JSI)116 New Montgomery St. Suite 605San Francisco, CA [email protected]