Health Plan and Provider Collaboration Really?

Transcription

1 Health Plan and Provider Collaboration Really? Ken Janda President and CEO Community Health Choice, Inc. February 26,

2 About Community Community Health Choice, Inc. (Community) is a Texas nonprofit corporation (IRC 501(c)4), organized for the promotion of social welfare and community benefit Licensed and regulated by the Texas Department of Insurance as a Health Maintenance Organization (HMO) and Third Party Administrator (TPA) A Safety Net Health Plan as defined by the Affordable Care Act, focused on serving low-income populations Affiliate of the Harris County Hospital District (Harris Health System); created by Harris Health in

3 Our Programs Community serves over 425,000 Members in the following programs: Medicaid STAR Program for low-income children and pregnant women (1997) Children s Health Insurance Program (CHIP) for the children of lowincome parents, including CHIP Perinatal benefits for unborn children (2006) Health Insurance Marketplace Plans offered to individuals under the ACA, primarily with subsidized premiums for lower income families (2014) Regional HMO coverage for State of Texas employees (ERS) (2015) Administrator for Marketplace plans offered by Sendero Health Plans in Austin (2017) Administrator for collaborative safety net projects including TexHealth 3-Share insurance subsidies (2008), DSRIP (2013), and NAIP (2015) 3

4 Service Area Map 4

5 Health Care Triple Aim 5

6 What Are Our Goals? A Health Policy Home Run Third Base: Simplify funding and administration of programs Second Base: Coverage for everyone Home Plate: Slow healthcare cost increases through provider payment reform First Base: Personal accountability for health and financing 6

7 A Health Policy Home Run: Principles for Health Care Reform 1B: Personal accountability for health Encourage healthy behaviors and consumerism Everyone pays something: cost-sharing based on income Choices of plans and benefits, with transparency of costs 2B: Coverage for everyone A basic benefit plan for all based on age, disability, family need Ability to buy up for additional services Individual mandate or auto-enrollment, with subsidies based on age and income 3B: Simplify funding and administration of programs Reduce administrative burden on providers and consumers through consistent program administration across Medicare, Medicaid, and private plans Eliminate complex supplemental provider funding in government programs Require multi-year rate guarantees from insurers HP: Slow healthcare cost increases through provider payment reform Encourage coordinated, less fragmented care (medical homes, ACOs, etc.) Restructure provider payments to reward efficiency and quality (value-based payments) Assure fair payment rates across programs, including safety net providers 7

8 Health Care System Still in Need of Reform In the past, we operated in a system that emphasized volume where providers treated patients and payers reimbursed providers for the cost of treatment - fee-for-service. 8

9 Shift in our Health Care System Recognizing the need for payment reform that improves the performance and sustainability of the U.S. health care system, a new strategy began developing across the country - value-based care. ACOs in ACA, MACRA, DSRIP projects in Medicaid and other governmental drivers, quickly followed by commercial carriers. Even with recent CMS backtracking, value-based contracting is the future Value-Based Care Quality of Care Cost Effectiveness Population Health Mgmt. 9

10 Shift in our Health Care System LAN Alternative Payment Model Framework Source: DSRI_APM_Refresh_2017_05_23&utm_medium= &utm_term=0_1b87e2051f-8b39f5033d

11 Shift in our Health Care System Payment Reform Goals Source: DSRI_APM_Refresh_2017_05_23&utm_medium= &utm_term=0_1b87e2051f-8b39f5033d

12 Measuring Outcomes/Quality Healthcare Effectiveness Data and Information Set (HEDIS): o Standardized measures, some outcomes, but many process measures: Potentially Preventable Events (PPEs): o Admissions (PPAs) o Readmissions (PPRs) o Emergency room visits (PPVs) Cost effectiveness measured by Quality Adjusted Life Years (QALY): o Living longer is the best method to measure outcomes o Being able to walk, talk, see, hear is better than not (quality of life) o Being able to work and getting back to work faster is important to employers/government entities that pay most of the cost o Pain, suffering or financial burden of treatment should be worth the gain o All things being equal, lower cost/less service with same outcome is a positive outcome 12

13 Healthcare Effectiveness Data and Information Set (HEDIS) Sponsored by National Committee for Quality Assurance (NCQA) Tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service Consists of 81 measures across 5 domains of care o Effectiveness of Care o Access/Availability of Care o Experience of Care (Patient Satisfaction) o Utilization and Relative Resource Use o Health Plan descriptive Information HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis 13

14 Texas Medicaid and the Pay for Quality Program (P4Q) New program will kick-off CY 2018 putting 3% of MCO capitation at risk Designed to focus on prevention, chronic disease management and maternal and infant health Goal simple and easy to understand, reward high performance and improvement and promote transformation and innovation Types of at-risk measures: o HEDIS o Potentially Preventable Events (PPEs) Performance on each measure is evaluated against: o Performance against benchmarks (national HEDIS percentiles, actual to expected ratio) o Performance against self (previous year s performance) New Bonus Pool measures; not at risk measures 14

15 At-Risk Measures Measure STAR CHIP STAR+PLUS Adolescent Well Care Well Child Visits in the First 15 Months of Life Prenatal Care Postpartum Care Weight Assessment and Counseling for Nutrition Weight Assessment and Counseling for Physical Activity Upper Respiratory Infections Potentially Preventable Emergency Visits Controlled Hemoglobin A1C Diabetes Screening Antipsychotics Cervical Cancer Screening Controlling High Blood Pressure 15

16 Bonus Measures (Revenue Not at Risk) Measure STAR CHIP STAR+PLUS Potentially Preventable Admissions Potentially Preventable Readmissions Potentially Preventable Complications Childhood Immunization Status (Combo 10) Low Birth Weight Prevention Quality Indicator (PQI) Composite CAHPS Children/Adults Good access to urgent care (C) (C) (A) CAHPS Adults Rating their health plan a 9 or 10 CAHPS Caregivers Rating their child s health plan a 9 or 10 16

17 HEDIS How are we Doing? Measure (CY 2015) Community s Results NCQA 90 th Percentile Adolescent well-care 85.38% 83.75% Prenatal care (STAR) 89.66% 91.73% Postpartum care (STAR) 63.22% 72.43% Childhood immunizations 70.85% 78.06% Well child check-up in the first 15 months of life 59.62% 73.88% 17

18 Consumer Assessment of Healthcare Providers and Systems (CAHPS) CAHPS Surveys are a set of tools that assess patient satisfaction with the experience of care and service. Developed and maintained by the National Committee for Quality Assurance (NCQA) and the Agency for Health Research and Quality (AHRQ). Increasingly important for providers and health plans Community Rating above the 2015 NCQA 95 th percentile. 18

19 Why Focus on Cost Control? More services do not necessarily improve outcomes More costly technologies do not necessarily produce better outcomes Patients have limited ability to compare outcomes to cost (i.e., value). Lack of transparency of provider pricing is a big problem. Chandra, Amitabh, Anupam B. Jena, and Jonathan S. Skinner "The Pragmatist's Guide to Comparative Effectiveness Research." Journal of Economic Perspectives, 25(2):

20 Payer/Provider Relationship Moving Forward: Paradigm Shift Integrated delivery systems o Improved ability to coordinate care o New payment mechanisms (bundled payments, gain sharing, and capitation) o Understanding insurance risk (prevalence) vs. management risk (resource utilization) Impact of data o Sharing of EHR data o Thinking populations, not just patients o Building trust between providers and insurers o Consumerism requires more cost transparency 20

21 Community is Helping Providers Transition Category 2: Provider Incentive Program (PIP) for primary care and Ob-Gyns (Fee-for-Service with incentives) o Foundational incentives including electronic medical records o Incentives for PPVs o HEDIS incentives Category 3: Bundled payment pilot for maternity o Mom and baby o Includes prenatal and post-partum care plus nursery/nicu Category 4: Full-risk capitation with experienced integrated systems like Kelsey Seybold 21

22 Health Care Moving Forward No matter what happens in DC, it s time for payers AND providers to learn to trust each other and work collaboratively to navigate the transformation of our health care delivery system. Health Plan and Provider Collaboration.Really! 22

23 Questions & Discussion Contact Information: Ken Janda (713)