state innovations in value -based care: acos and beyond...medicaid acos are just one of many types...
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Advancing innovations in health care delivery for low-income Americans
www.chcs.org | @CHCShealth
State Innovations in Value-Based Care: ACOs and Beyond
Rachael Matulis, Senior Program OfficerNational Academy of Medicine Value Incentives & Systems Innovation CollaborativeMay 18, 2017
© 2017 Center for Health Care Strategies
About the Center for Health Care Strategies
Non-profit policy center dedicated to improving the health of low-income Americans
CHCS Projects Focused on Advancing Delivery System and Payment Reforms
• Medicaid Accountable Care Organization (ACO) Learning Collaborative
• State Innovation Model• Innovation Accelerator
Program (IAP) for Value-Based Payment (VBP)
• Delivery System Reform Incentive Payment (DSRIP) VBP Roadmaps
Alternative Payment Model (APM) Framework
Leve
l of f
inan
cial r
isk
Degree of care, provider integration, and accountability
Category 1:
Category 2:
Category 3:
Category 4: Goal is to shift U.S. health care system toward payment models in Categories 3 and 4. In 2016, ≈18% of Medicaid payments fell in these categories.
Fee-for-service payments not link to quality/value
(e.g., traditional FFS, DRGs)
Alternative payment models built on fee-for-service payment
(e.g., shared savings/risk)
Fee-for-service payments linked to quality/value
(e.g., pay-for-performance)
Population-based payment
(e.g. global payments)
4Source: Health Care Payment Learning & Action Network (LAN) APM Framework, available at: https://hcp-lan.org/workproducts/apm-whitepaper.pdf
What is the Current ACO Market?
Rapid expansion across payers
Over 25 million covered lives
Widespread penetration
Over 800 ACOs in the United States
Commercial: 17.2 million Medicare: 8.3 million Medicaid: 2.9 million
ACO service areas in all 50 states and the District of Columbia
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Source: Health Affairs: Accountable Care Organizations in 2016: Private And Public-Sector Growth And Dispersion. http://healthaffairs.org/blog/2016/04/21/accountable-care-organizations-in-2016-private-and-public-sector-growth-and-dispersion/ .
Medicaid ACO models vary greatly, but we generally see three models:
What Does an ACO Look Like in Medicaid?
Regional/Community Partnership-driven
Regional/community organizations form care teams with providers and receive payments
MCO-driven
MCOs retain financial risk but implement new payment model and partnerships with providers
Provider-driven
Provider establishes collaborative networks and assumes accountability for cost of care
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Current Medicaid ACO Landscape
WY
WI
WV
WA
VA
VT
UT
TX
TN
SD
SC
RIPA
OR
OK
OH
ND
NC
NY
NM
NJ
NH
NVNE
MT
MO
MS
MNMI MA
MD
ME
LA
KYKS
IAINIL
ID
GA
FL
DC
DE
CT
COCA
ARAZAL
States pursuing Medicaid ACO programs
States with active Medicaid ACO programs
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In 2013, MN launched its Medicaid ACO program, Integrated Health Partnerships (IHPs)
Key IHP program features include: » Provider-led with two tracks: (1) larger systems providing inpatient and
outpatient care; and (2) smaller systems not integrated with a hospital
» Shared savings payment arrangement, with upside/downside risk for larger systems and upside only for smaller systems
» 21 IHPs oversee care for 465,000 enrollees, approximately 45% of MN Medicaid population
Accomplishments:» Estimated savings of $156 million compared to trended targets, over
first three years; IHPs received 85%+ of dollars at risk for quality
State Example: Minnesota
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In 2012, OR launched Coordinated Care Organizations (CCOs), a type of Medicaid ACO
Key CCO program features include: » Payer-led organizations with governing boards that include Medicaid
members, providers, and local government
» Global budgets with a fixed rate of growth to cover physical, oral, behavioral health; flexibility to spend funds on “health-related” services
» 16 CCOs provide care for nearly 1 million enrollees, approximately 90% of OR’s Medicaid population
Accomplishments:» Estimated 23% decrease in emergency department visits; cost growth
below national average; 15 of 16 CCOs earned 100% of quality bonuses
State Example: Oregon
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Future of Medicaid ACOs
Version 2.0Version 1.0Fee-for-service payment models (shared savings or P4P) Capitated or global payments
Physical health only Behavioral health, LTSS, dental, pharmacy, social services
Medicaid only Multi-payer
Many quality measures Fewer, more aligned quality measures
Payment tied to quality reporting / performance on process measures
Payment tied to quality outcomes and care coordination metrics
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Other Innovative State Approaches to Advance VBP
Medicaid ACOs are just one of many types of delivery system and payment reforms being implemented or planned by states
State Example: Tennessee’s Health Care Innovation Initiative
Primary Care Transformation
Episodes of Care
Long-Term Services and Supports
Patient Centered Medical Homes
Tennessee Health Link for Individuals with Serious Mental Illness
20 retrospective episodes of care in place
75 episodes of care designed by 2020
Quality and value-adjusted payments for nursing facilities and home and community-based services
12 Source: Adapted from https://tn.gov/assets/entities/hcfa/attachments/IntroductionEpisodes.pdf
In general, lack of evidence on payment reform initiatives in Medicaid » Only 17 of 355 payment reform evaluations identified through Duke’s
“Payment Reform Evidence Hub” focused on Medicaid
However, early evidence indicates that a variety of state VBP initiatives have been successful» Reported improvements in quality and cost performance in both
Colorado and Oregon’s Medicaid ACO models (McConnell et al, JAMA Internal Medicine, 2017)
» 7 percent relative reduction in Oregon’s CCO expenditures compared to Washington state, primarily attributable to reductions in inpatient use (McConnell et al, Health Affairs, 2017)
» Tennessee reported aggregate savings of $6.2 million in 2015 for three episodes of care (perinatal, acute asthma exacerbation, and total joint replacement)
What Does the Evidence Tell Us?
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State interest in VBP continues to grow, with focus on…
• Implementation of VBP through managed care contracting
• Integrating long-term services and supports, behavioral health, and social determinants into VBP
• Alignment with MACRA
Visit CHCS.org to…
Download practical resources to improve the quality and cost-effectiveness of Medicaid services
Learn about cutting-edge efforts to improve care for Medicaid’s highest-need, highest-cost beneficiaries
Subscribe to CHCS e-mail, blog and social media updates to learn about new programs and resources
Follow us on Twitter @CHCShealth
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McConnell, K. John, Stephanie Renfro, Benjamin KS Chan, Thomas HA Meath, Aaron Mendelson, Deborah Cohen, Jeanette Waxmonsky, Dennis McCarty, Neal Wallace, and Richard C. Lindrooth. "Early Performance in Medicaid Accountable Care Organizations: A Comparison of Oregon and Colorado." JAMA Internal Medicine 177, no. 4 (2017): 538-545.
McConnell, K. John, Stephanie Renfro, Richard C. Lindrooth, Deborah J. Cohen, Oregon's Medicaid Reform And Transition To Global Budgets Were Associated With Reductions In Expenditures Health Affairs 36, no.3 (2017):451-459. doi: 10.1377/hlthaff.2016.1298.
M. McClellan, R. Richards, and Mark Japinga. “Evidence on Payment Reform: Where Are The Gaps?” Health Affairs Blog (April 25, 2017). Available at: http://healthaffairs.org/blog/2017/04/25/evidence-on-payment-reform-where-are-the-gaps/
Oregon Health Authority. Oregon’s Health System Transformation: 2015 Mid-Year Report. January 20, 2016. Available at: https://www.oregon.gov/oha/Metrics/Documents/2015%20Mid-Year%20Report%20-%20Jan%202016.pdf
Resources
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