New Hampshire s DSRIP Waiver Program, Alternative Payment Models and Safety Net Providers

Transcription

1 1 New Hampshire s DSRIP Waiver Prgram, Alternative Payment Mdels and Safety Net Prviders Natinal Academy fr State Health Plicy s Value Based Payment Refrm Academy Meeting Washingtn D.C. July 25-26, 2017

2 Agenda 2 Overview Integrated Delivery Netwrks Pathways and Prjects Financing Planning fr Alternative Payment Mdels

3 Overview f New Hampshire s DSRIP Waiver Prgram: Building Capacity Fr Transfrmatin 3 The waiver represents an unprecedented pprtunity fr New Hampshire t strengthen cmmunitybased mental health services, cmbat the piate crisis, and drive delivery system refrm. Key Driver f Transfrmatin Integrated Delivery Netwrks : Transfrmatin will be driven by reginally-based netwrks f physical and behaviral health prviders as well as scial service rganizatins that can address scial determinants f health Three Pathways Imprve care transitins Prmte integratin f physical and behaviral health Build mental health and substance use disrder treatment capacity Funding Features Menu f mandatry and ptinal cmmunity-driven prjects Funding fr prject planning and capacity building Up t $150 m ver 5 years Perfrmance-based funding distributin Supprt fr transitin t alternative payment mdels

4 Integrated Delivery Netwrks (IDNs) 4 7 new, reginally-based netwrks f prviders called Integrated Delivery Netwrks ( IDNs ) will drive system transfrmatin by designing and implementing prjects in a gegraphic regin. Key Elements Participating Partners: Includes cmmunity-based scial service rganizatins, hspitals, cunty facilities, physical health prviders, and behaviral health prviders (mental health and substance use). IDN Administrative Lead Structure: Administrative lead serves as crdinating entity fr netwrk f partners in planning and implementing prjects. Respnsibilities: Design and implement prjects t build behaviral health capacity; prmte integratin; facilitate smth transitins in care; and prepare fr alternative payment mdels. Cmmunity Supprts Behaviral Health Prviders (Mental Health and SUD) Physical Health Prviders Nte: pending final apprval by CMS and subject t change

5 Prject Menu Structure 5 IDN Cre Cmpetency Prject Cmmunity- Driven Prjects Cmmunity-Driven Prjects IDNs will select 3 prjects frm a menu that reflects cmmunity pririties One must be fcused exclusively n SUD ppulatin IDN-led based n hw best t implement in their cmmunities IDN Cre Cmpetency Prject IDNs will participate in a mandatry prject fcused n integrating behaviral health and primary care IDN-led based n hw best t implement in each IDN s cmmunity State-Wide Prjects State-Wide Prjects IDNs will participate in 2 State-wide prjects: 1. Strengthen mental health and SUD wrkfrce 2. Develp health infrmatin technlgy infrastructure t supprt integratin State-facilitated with crdinatin acrss IDNs Nte: pending final apprval by CMS and subject t change

6 Cre Cmpetency Prject 6 Each IDN will implement the Cre Cmpetency Prject. Integrated Healthcare Primary care prviders, mental health and SUD prviders, and scial services rganizatins will partner t: Prevent, diagnse, treat and fllw-up n bth behaviral health and physical cnditins Refer patients t cmmunity and scial supprt services Address health behavirs and healthcare utilizatin Standards will include: Cre standardized assessments fr depressin, substance use, and medical cnditins Integrated electrnic medical recrds and patient tracking tls Health prmtin and self-management supprt Care management services NCQA accreditatin is nt required Nte: pending final apprval by CMS and subject t change

7 Cmmunity-Driven Prject Menu 7 Each IDN will implement three cmmunity-driven prjects frm a DHHS-defined menu. Care Transitins: Supprt beneficiaries with transitins frm institutinal settings t the cmmunity Care Transitin Teams Cmmunity Reentry Prgram fr Justice-Invlved Adults and Yuth with Substance Use Disrders r Significant Behaviral Healthy Issues Supprtive Husing Prjects Capacity Building: Supplement existing wrkfrce with additinal staff and training Medicatin Assisted Therapy f Substance Use Disrders Expansin f Peer Supprt Access, Capacity, and Utilizatin Expansin in intensive SUD Treatment Optins, including partial hspital and residential care Multidisciplinary Nursing Hme Behaviral Health Service Team Integratin: Prmte cllabratin between primary care and behaviral health care Wellness Prgram t address chrnic disease risk factrs fr SMI/SED ppulatin Schl-Based Screening and Interventin Substance Use Treatment and Recvery Prgram fr Adlescents and Yung Adults Integrated Treatment fr C- Occurring Disrders Enhanced Care Crdinatin fr High Need Ppulatins Bldfaced prjects exclusively fcus n children; italicized prjects have children r yuth in target ppulatin

8 Funding fr the Transfrmatin Waiver 8 Key Funding Features: The transfrmatin waiver prvides up t $150 millin ver 5 years. State must meet statewide metrics in rder t secure full funding beginning in 2018 State must keep per capita spending n Medicaid beneficiaries belw prjected levels ver the five-year curse f the waiver Up t 65% f Year 1 funding will be available fr capacity building and planning. In Years 2-5, IDNs must earn payments by meeting metrics defined by DHHS and apprved by CMS t secure full funding. Under the terms f New Hampshire s agreement with the federal gvernment, this is nt a grant prgram. A share f the $150 millin will be used fr administratin, learning cllabratives, and ther State-wide initiatives (Year 1) 2017 (Year 2) 2018 (Year 3) 2019 (Year 4) 2020 (Year 5) Ttal Funding Capacity Building (Up T 65% f Year 1 Funding) Other Funding (IDN payments, administrative expenses, etc.) $19,500,000 n/a n/a n/a n/a $19,500,000 $10,500,000 $30,000,000 $30,000,000 $30,000,000 $30,000,000 $130,500,000 Percent at Risk fr Perfrmance 0% 0% 5% 10% 15% Dllar Amunt at Risk fr Perfrmance ($0) ($0) ($1,500,000) ($3,000,000) ($4,500,000) TOTAL $150,000,000 Nte: pending final apprval by CMS and subject t change

9 State-wide and IDN-level Metrics 9 Perfrmance metrics at the state- and IDN-levels will be used t mnitr prgress tward achieving the verall waiver visin. Payments frm CMS t the state and frm the state t IDNs will be cntingent n meeting these perfrmance metrics. Accuntability shifts frm prcess metrics t perfrmance metrics ver the curse f the 5-year prgram. State-wide perfrmance metrics Prcess Metrics Steps taken by the State t establish and manage the waiver prgram Perfrmance Metrics Select quality and utilizatin indicatrs that measure statewide impact IDN-level perfrmance metrics Steps required t be taken by an IDN t rganize its netwrk and implement its prjects Quality, access, and utilizatin measures tied t ne r mre prjects Relative dependence f IDN perfrmance payments % 10% 15% State-wide funding at risk fr State-wide utcme measures Nte: pending final apprval by CMS and subject t change

10 New Hampshire s DSRIP Medicaid Waiver and the Transitin t Alternative Payment Mdels 10 Gals and Requirements: NH s APM Radmap Under DSRIP, New Hampshire s funding mdel will shift frm planning supprt t perfrmance payments t lng-term sustainability. The Special Terms and Cnditins f the waiver require that the state develp a plan, r Radmap fr: Sustaining the DSRIP investments beynd the life f the waiver, including hw it will mdify its Medicaid managed care cntracts t reflect the impact f the waiver and the state s APM gals Mving at least 50 percent f Medicaid prvider payments int alternative payment mdels APM Radmap: Imprtant Dates Develpment f Radmap Deadline fr submissin f Radmap t CMS Deadline fr CMS apprval f Radmap Develpment and submissin f annual updates t Radmap Summer 2016 Fall 2016 April 1, 2017 July 1, NH Medicaid Managed Care Prcurement Prcess Begins Deadline fr submissin f Medicaid Managed Care Cntracts and Rates t CMS Medicaid Managed Care Cntract RFP Target date

11 STC Sptlight: Radmap Requirements 11 Per the STCs, the state s Radmap must address the fllwing areas: 1. Payment Appraches: What appraches service delivery prviders will use t reimburse prviders t encurage practices cnsistent with IDN bjectives and metrics, including 2. Path t 50 percent APM Gal: Hw the state will plan and implement a gal f 50 percent f Medicaid prvider payments t prviders using Alternative Payment Methdlgies. 3. Impact n Prviders and Alignment with IDN bjectives/measures: a. Hw alternative payment systems deplyed by the state and MCO/Medicaid service delivery cntracts will reward perfrmance cnsistent with IDN bjectives and measures. b. Hw the IDN bjectives and measures will impact the administrative lad fr Medicaid prviders, particularly insfar as plans are prviding additinal technical assistance and supprt t prviders in supprt f IDN gals, r themselves carrying ut prgrams r activities t further the bjectives f the waiver. The state shuld als discuss hw these effrts, t the extent carried ut by plans, avid duplicatin with IDN funding r ther state funding; and hw they differ frm any services r administrative functins already accunted fr in capitatin rates. 4. Stakehlder Engagement: Hw the state has slicited and integrated cmmunity and MCO/Medicaid service delivery cntract prvider rganizatin input int the develpment f the plan. Cntinued n fllwing page

12 STC Sptlight: APM Radmap Requirements 12 Per the STCs, the state s APM Radmap must address the fllwing areas (cnt d): Cntinued frm prir page 5. Managed Care Rates: a. Hw managed care rates will reflect changes in case mix, utilizatin, cst f care and enrllee health made pssible by IDNs, including hw up-t-date data n these matters will be incrprated int capitatin rate develpment. b. Hw actuarially-sund rates will be develped, taking int accunt any specific expectatins r tasks assciated with IDNs that the plans will undertake. Hw plans will be measured based n utilizatin and quality in a manner cnsistent with IDN bjectives and measures, including incrprating IDN bjectives int their annual utilizatin and quality management plans submitted fr state review and apprval by January 31 f each calendar year. 6. Cntracting Apprach: a. Hw the state will use IDN measures and bjectives in their cntracting strategy apprach fr MCO/Medicaid service delivery cntract plans, including refrm. b. If and when plans currents cntracts will be amended t include the cllectin and reprting f IDN bjectives and measures.

13 Discussin Pint 1: What is the Purpse? 13 Beynd Satisfying CMS Requirements What are NH s gals? What is the state aiming fr with value-based payment? T what extent will the APM initiative address Medicaid services NOT affected by DSRIP (i.e., beynd behaviral health and integratin services)? Hw will the APM initiative intersect with ther payment initiatives? What will the APM initiative s relatinship be t Medicaid managed care prcurement and rate setting?

14 Discussin Pint 2: What Cunts As a Value-Based Payment? 14 What types f VBP will be allwed? Alternative payment mdels fr integrated care practices (NH-specific definitin) Bundles Acute Chrnic Glbal capitatin Fr an entire ppulatin (ttal csts fr ttal attributed ppulatin) Fr a special needs subppulatin What are the risk sharing arrangements assciated with each mdel? Cmbinatins (e.g., plan culd cntract with an ACO and still als prvide enhanced reimbursement fr integrated care practices)

15 Discussin Pint 2: What Cunts As a Value-Based Payment? (cnt.) New Yrk Apprach Optins Level 0 VBP Level 1 VBP Level 2 VBP Level 3 VBP Ttal Care fr General Ppulatin Integrated Primary Care Bundles Ttal Care fr Subppulatin Des nt cunt as VBP FFS with bnus and/r withhld based n quality scres FFS (plus PMPM subsidy) with bnus and/r withhld based n quality scres FFS with bnus and/r withhld based n quality scres FFS with bnus and/r withhld based n quality scres FFS with upside nly shared savings when quality scres are sufficient FFS (plus PMPM subsidy) with upside nly shared savings based n ttal cst f care (savings available when quality scres are sufficient) FFS with upside-nly shared savings based n bundle f care (savings available when quality scres are sufficient) FFS with upside-nly shared savings based n subppulatin capitatin (savings available when quality scres are sufficient) FFS with risk sharing (upside available when utcme scres are sufficient; dwnside is reduced r eliminated when quality scres are high) FFS (plus PMPM subsidy) with risk sharing based n ttal cst f care (upside available when utcme scres are sufficient; dwnside is reduced r eliminated when quality scres are high) FFS with risk sharing based n bundle f care (upside available when utcme scres are sufficient; dwnside is reduced r eliminated when quality scres are high) FFS with risk sharing based n subppulatin capitatin (upside available when utcme scres are sufficient; dwnside is reduced r eliminated when quality scres are high) Revised Radmap specifies new criteria fr Level 1 and Level 2 Arrangements: 15 Glbal capitatin (with quality-based cmpnent) PMPM capitated payment fr primary care services (with quality-based cmpnent) Prspective bundled payment (with qualitybased cmpnent) PMPM capitated payment fr Ttal Care fr Subppulatin (with quality-based cmpnent) T cunt as Level 1, MCOs must allcate at minimum 40% f ptential savings t high-scring prviders. T cunt as Level 2, MCOs must allcate at least 20% f lsses (3-5% f the target budget) t lw-scring prviders.

16 Discussin Pint 2: What Cunts As a Value-Based Payment? 16 What types f VBP will be allwed? Alternative payment mdels fr integrated care practices (NH-specific definitin) Bundles Acute Chrnic Glbal capitatin Fr an entire ppulatin (ttal csts fr ttal attributed ppulatin) Fr a special needs subppulatin What are the risk sharing arrangements assciated with each mdel? Cmbinatins (e.g., plan culd cntract with an ACO and still als prvide enhanced reimbursement fr integrated care practices)

17 What Cunts as an Alternative Payment Mdel? New Hampshire Apprach Likely Categries 3 and 4 17

18 What Cunts as an Alternative Payment Mdel? New Hampshire Select Experiences t Date 18 Six f ur 10 FQHCs have shared savings arrangements with ne f ur Medicaid Managed Care Organizatins in which the shared savings is accessible fr hitting particular quality and cst targets Ten Cmmunity Mental Health Centers had risk-sharing agreements with Managed Care Organizatins that include quality metric targets.

19 Other Key Decisins 19 Additinal threshld decisins culd include: 1. What structures will NH need t help versee implementatin? 2. Hw will the state initiatives align with Medicare and Cmmercial activities? 3. What data/tls will the state supply in supprt f value-based payment? 4. Will NH take steps t review APM cntracts? 5. Which f the IDN investments being made under DSRIP will require additinal lng-term funding t be sustainable? (e.g., Cre Cmpetencies, services addressing scial determinants f health) 6. Beynd the DSRIP waiver s behaviral health-specific gals, what are the Departments ther Medicaid delivery system refrm pririties t be supprted thrugh payment refrm? 7. Are there sme high impact services that the state may want t exclude frm value-based payments?

20 Range f APM Cntracting Mdels 20 APM appraches tend t differ based n the level f risk prviders assume and the structure f payments Level f Risk and Cmplexity* Glbal Budget/Capitatin Shared Savings/Lsses Bundled Payments fr Episdes f Care Pay fr Perfrmance (P4P) Nte: sme framewrks d nt cnsider P4P prvider risk-expsure sufficient t be classified as an APM Ptential fr Imprved Efficiency and Quality Nte: actual level f risk can vary depending n specific arrangement; e.g., a bundled payment prgram with upside and dwnside risk-sharing may have ptential fr greater lsses than a limited shared-savings prgram.

21 APM Cntracting Mdels: Capabilities Required 21 APM arrangements at higher levels f risk will require increasing prvider capabilities Less Risk Mre Risk Pay fr Perfrmance Bundled Payments Shared Savings/Lsses* Glbal Budget/Capitatin Prvider Netwrk Prvider Netwrk Prvider Netwrk Prvider Netwrk Clinical and Care Clinical and Care Clinical and Care Clinical and Care Financial Financial Financial Financial Gvernance and Crprate Structure Gvernance and Crprate Structure Gvernance and Crprate Structure Gvernance and Crprate Structure Analytics and Infrmatin Analytics and Infrmatin Analytics and Infrmatin Analytics and Infrmatin Level f risk can vary depending n arrangement Level f Capabilities Required Lw Medium High Nte: *Shared savings arrangements with lwer levels f risk may require fewer capabilities.