Presentation by Kevin Stone Senior Consultant and Principal Helms & Company Concord NH

Transcription

1 Presentation by Kevin Stone Senior Consultant and Principal Helms & Company Concord NH

2 Medicaid is Largest Payer- covers 1/3 of entire population Vt. funded Medicaid Expansion program pre- ACA (VHAP; Catamount) Highly Regulated Health Care Extremely Strict CON Laws Green Mountain Care Board Approves Hospital Budgets & Payor Premiums Minimal Provider Competition Essentially no Imaging or Surgery Centers Very Few Urgent Care Centers Most Hospitals are Critical Access (8/14) Only 2 small group insurers- VTBCBS; MVP 2

3 3 ACOs Originally- Shared Savings Program Model Initially -HealthFirst- Private MDs- largely in greater Burlington -Community Health Accountable Care (CHAC)- FQHCs -One Care Vermont (OCV)- All 14 Hospitals; Some private MDs State & Federal All Payer Model program Common Risk Model for Medicare; Medicaid; Exchange - Modified Medicare Next Generation Model Platform -Providers Asked to Create Single ACO - Vermont Care Org Medicaid Pilot in 4 Counties 3

4 Reduce Overall Cost Trend lock-in 3.5% (vs. 5.5% estimated) Reduce Cost Shift to Employers Improve Overall Population Health-Statewide Health Outcomes: -Substance Abuse -Suicide Prevention -Chronic Disease- COPD/Asthma; HBP; Diabetes; Tobacco Use -Access-PCP; Timely Info -ACO Quality Measures Method- Common Risk Model for Providers in Single ACO 4

5 Much variation across community network Measure OCV Range ER visits per 1,000 beneficiaries day all cause readmission rates 10% 15% Spend per SNF/swing encounters/month $658 $1,929 Spend per home health admits/month $239 $350 ISSUE - How Treat Various ACO Members with Different Performance? 5

6 Medicare Cost and Quality 2013 Upper Left = High Quality/Low Cost (High Value) High Value Quadrant 6 6

7 Medicare Cost and Quality 2014 Upper Left = High Quality/Low Cost (High Value) High Value Quadrant 7

8 Medicare Cost and Quality 2015 Upper Left = High Quality/Low Cost (High Value) High Value Quadrant 8 8

9 MSSP ACO Cost vs. Quality 2014 Results (Quality Score Fully Calculated 1 ) Average = 76.2% uality Score Average = $10,202 Cost per Beneficiary per Year 134 ACOs were above OCV s cost per beneficiary and beat their targets or generated Shared Savings 1 This figure is calculated internally as if all measures were performance scored rather than any pay-for-reporting; this calculation will more closely match the CMS- Calculated figure over time as CMS decreases the pay-for-reporting component

10 MSSP ACO Cost vs. Quality 2015 Results (Quality Score Fully Calculated 1 ) Average = 87% Quality Score Average = $10, ACOs were above OCV s cost per beneficiary yet beat their cost targets/ generated Shared Savings Cost per Beneficiary per Year 1 This figure is calculated internally as if all measures were performance scored rather than any pay-for-reporting; this calculation will more closely match the CMS- Calculated figure over time as CMS decreases the pay-for-reporting component (score does not include quality improvement points). ACOs Receiving Shared Savings Distribution 119 ACOS Beat Target but did not Earn Shared Savings 84 ACOs that did not Beat Target 189 Total 392

11 Item OCV All SSP Average CT Tests / 1, MRI Scans / 1, Hospital Discharges / 1, Day Re-Admits / 1, Hospice Expenditures / 1,000 $131 $227 ER Visits / 1, ER Visits Leading to Admin / 1, But economic gain is judged against trend; not against relative performance-achievement vs. attainment **NO Shared Savings** 11

12 Vermont Medicaid Next Generation (VMNG) Program Overview Risk-based Collaborative Program between DVHA and OCV Year 1 Pilot-4 participating at risk hospitals (CVMC, NMC, Porter, UVMMC) Migrates to state-wide Year 2 and beyond No financial risk for physician practices, FQHC s, support agencies in the network Additional $3.25 PMPM to providers with attribution for panel management; & Additional $2.50 PMPM for Care Management Attribution is prospectively assigned based on Prior Year data Benefits continue to be set by DVHA for all Medicaid beneficiaries including those in VMNG Prior Authorization waiver- ** Critical for Provider Acceptance** OneCareVT.org 12

13 Risk Corridor and Sharing Percentage- Final Target Expenditures Over/Under Target (symmetrical two-sided risk) Target to +5% OCV Risk Share 100% ($4.47M) +5 to +15% 30% ($2.68M) Total Risk $7.15M For Illustration Purposes Only 100% OCV Risk 30% OCV Risk 30% OCV Risk -15% -5% Target 5% 15% OneCareVT.org 13

14 VMNG Financial Flow Population Total Cost of Care for 29,103 Beneficiaries DVHA Pays OCV Monthly for: - Primary Care Case Management ($2.50 PMPM) - Program Administration ($3.25 PMPM) - OCV Administration ($3.25 PMPM) - Hospital Fixed Payments Pays FFS Claims all Providers other than Participating Hospitals OCV Pays Monthly Participating Hospitals Fixed Prospective Payments* PCPs: - Primary Care Case Management Payment ($2.50 PMPM) - Program Administration Payment ($3.25 PMPM) *0.5% of total cost of care is withheld from hospital fixed payments (VBIF funding) *Hospital fixed payments are net of prefunded savings (0.2% of total cost of care) OneCareVT.org 14

15 Value-Based Incentive Fund Distribution Method Approach: Initial Familiarize network with new measures: on-ramp for new practices in early years Recognize the entire network in the transition to a value-based care delivery model Approach: Later Move towards variable incentives that are aligned with measures DISTRIBUTION OF FUNDS: Measurement Strategy Year All Other Network, 30% 2017/ % to primary care based on attributed population 30% to rest of network based on % of total Medicaid spend in calendar year Primary Care, 70% % variable to primary care based on practice-level performance on a standard measure set 30% variable to entire network based on HSA-level performance on a standard set of measures OneCareVT.org CONFIDENTIAL NOT FOR DISTRIBUTION 15

16 Quality Measure Cross Walk Measure 2017 Use Data Source Measure Alignment 30 Day Follow-Up after Discharge from the ED for Alcohol and Other Drug Dependence 30 Day Follow-Up after Discharge from the ED for Mental Health Adolescent Well Care Visits All Cause Unplanned Admissions for Patients with Multiple Chronic Conditions Developmental Screening in the First 3 Years of Life Diabetes Mellitus: Hemoglobin A1c Poor Control (>9%) Hypertension: Controlling High Blood Pressure Initiation of Alcohol and Other Drug Dependence Treatment Engagement of Alcohol and Other Drug Dependence Treatment Screening for Clinical Depression and Follow-Up Plan Follow-Up after Hospitalization for Mental Illness (7 Day Rate) Timeliness of Prenatal Care Payment* Payment* Payment Payment* Payment Payment Payment Payment Payment Payment* Reporting Reporting Claims Claims Claims Claims Claims OR Clinical Clinical Clinical Claims Claims Claims + Clinical Claims Claims APM APM SSP APM SSP APM (SSP was composite measure) SSP SSP; APM SSP; APM SSP; APM SSP DVHA MCO *Use as payment measure if appropriate benchmarks can be identified for 2017 contract year, otherwise award full points in Nat l Benchmark No No Yes No No Yes Yes Yes Yes No Yes Yes OneCareVT.org CONFIDENTIAL NOT FOR DISTRIBUTION 16

17 Risk Stratification for Case Management Targeted for Care Mgmt OneCareVT.org CONFIDENTIAL NOT FOR DISTRIBUTION 17

18 The NH PROBLEM: Disparity in Medicaid Payment 60% Payments as a % of Gross Revenue 50% 40% 30% Break-even is 38% of GPSR 20% 10% 0% Average Commercial Payor Medicare NH Medicaid There is great disparity in the level of payments providers receive from payors (a 75% delta between highest and lowest payors)

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20 Performance Tracking Report Example: Medicaid November 2016 Data 6/1/2015 5/31/2016 with run out through 8/31/2016 Medicaid Benchmark 2015 = $ Benchmark Not Yet Available PMPM 12 Month Comparison % In Network to to Trend Inpatient 85.77% $38.40 $ % Inpatient Admissions (PKPY) % 30-Day Readmissions Rate 7.0% 6.9% 2.13% Outpatient 96.08% $59.68 $ % ER Visits (PKPY) % Professional Specialist 56.89% $33.37 $ % Professional PCP 94.16% $20.95 $ % Advanced Practice Provider 24.79% $7.42 $ % Office Visits (PKPY) 3,176 3, % Home Health 85.49% $0.64 $ % SNF 0.00% $0.08 $ DME 0.09% $4.49 $ % Ambulance 0.00% $1.11 $ % Other Services by State Agencies 0.00% $0.36 $ % Total 78.90% $ $ % OneCareVT.org 20