LEADERSHIP GROUP MEETINGAUGUST 6TH, 2013

Iowa Collaborative Safety Net Provide Network

AGENDA12:00 PM-12:10 PMWelcome and Introductions

Network Staff

12:10 PM-12:40 PMFunding Recommendations for SFY14Network Staff

 12:40 PM-12:55 PM Commonwealth Fund Project Update

Dr. Pete Damiano

12:55 PM-1:15 PM Community Care Coordination Project Update Sarah Dixon Gale

1:15 PM-1:40 PM Safety Net Care Coordination EntitySarah Dixon Gale

1:40 PM-1:45 PM Rural Health Clinic Practice Transformation Learning CollaborativeNetwork Staff

1:45 PM-1:50 PM Outreach and Enrollment StrategyNetwork Staff

1:50 PM-2:00 PM Other Items, Next Steps, and Adjourn

SFY14 BUDGET  SFY13 SFY14 Request SFY14 ActualProvider Awards      Rural Health Clinics $141,544  $142,192  $141,544 Family Planning Agencies $0  $100,000  $0 Free Clinics $273,322  $400,000  $348,322 Federally Qualified Health Centers $75,000  $75,000  $75,000 

     Pharmaceutical Initiative      Iowa Prescription Drug Corporation $318,415  $415,000  $413,415        Specialty Care Grants $308,474  $450,000  $378,474       Board of Health Medical Home Grants $77,153  $77,609  $77,153       Maternal/Child Health Medical Home Grants $95,126  $95,582  $95,126       Network Management $145,785  $146,563  $145,785       Sexual Assault Response Teams $50,000  $50,000  $50,000       TOTAL $1,484,819 $1,951,946 $1,724,819

SFY14 FUNDING RECOMMENDATIONS Rural Health Clinics Free Clinics Federally Qualified Health Centers SART Initiative Pharmacy Initiative Medical Home Specialty Care

RURAL HEALTH CLINICSAmount Available $141,54

4Recommendation:

IARHC SupportRHC Provider Awards

$ 5,176$136,368

Eligibility for RHC Provider Awards

FREE CLINICSAmount

Available$348,3

22Recommendation: FC Provider

AwardsFree Clinics of Iowa

$125,000

$223,322

Line item increase for SFY14 of $75,000 FCI allocation would be used for state-wide

support including enhancing education and access of patients from free clinics toward the Iowa Health and Wellness Plan. 

FQHCSFQHCs Amount Available $75,000Recommendations Funding be allocated

evenly to the state’s 14 FQHCs to support statewide reform initiatives

SART INITIATIVEIowa Coalition Against Sexual Assault

Amount Available

$50,000

Recommendations FundReviewer Comments •What is the retention rate of SANEs?

•Would like to see a map of SANE coverage in the state

PHARMACY INITIATIVEIowa Prescription Drug Corporation

Amount Available $413,425

Recommendations FundReviewer Comments

•This project is dependent on state funding. Suggest a sustainability plan •The work plan could have included more concrete dates•Lack of diversified funding streams•How many Pharmacists? •How will the ACA affect the demand for these services?•Would be good to explore partnerships with the Integrated Health Home•Great work

MEDICAL HOME INITIATIVELocal Boards of

HealthAmount Available

$77,153Comments/Questions

Warren County Fund : $25,717 • Lacking Oral Health•Visionary, less concrete •Feels like health promotion than medical home

Cerro Gordo County

Fund : $25,717 •No reference to oral health• How will medical home be supported?•Low number of patients served•Connect with the United Way to enhance efforts for both entities

Plymouth County Fund : $25,717• Developing a registry-population management system •Suggest they consider Mercy Health Coach training •Lacking oral health component•Intended outcomes need clarity

MEDICAL HOME INITIATIVEMaternal Child Health

Amount Available: $95,126 Questions/Comments

Webster County Fund: $31,708 •Lacking oral health component •Suggest incentive for patients in the Better Choices program •Deliverable #4 needs clarity•Progressive, innovative community•How will this spread to other counties

Clayton County Fund: $31,708 •Kids and families were not a very prominent part of the proposal•Do providers include dentist?•Strong partnerships, strong agency; •Exploring ACOs

Iowa County Fund: $31,708 •Included dental component•Great abstract•A sealant program is not a dental home •What are the gaps in the obesity issues

SPECIALTY CARE INITIATIVESpecialty Care $378,474

Applicant Amount Requeste

d

Recommendation

Questions/Comments

Blank Children’s Hospital

$3,000

Medications for free clinic patients

Fund: No •Should partner with IPDC•Didn't follow the format.•Might be able to apply to ECI to support work•Not a specialty care initiative

Crawford County Memorial Hospital

$154,828

Bilingual health coach; Hispanic patients

Fund: Yes ($49,802)

•Clinical Outcome measures are ambitious but not achievable; •Should address impact of Health Care Reform•Need to revise work plan

SPECIALTY CARE INITIATIVESpecialty Care $378,474

Applicant Amount Request

ed

Recommendation

Questions/Comments

Polk County VPN

$237,960

Continued funding and program expansion

Fund: Yes (213,748)

•Need more detail in numbers served •Budget is staff heavy; suggest focus on sustainability •More information about how referrals are tracked

SPECIALTY CARE INITIATIVESpecialty Care $378,474

Applicant Amount Requested

Recommendation

Questions/Comments

Primary Health Care

$135,660

Expansion of integrated behavioral health program to 2 additional sites

Fund: Yes ($114,924)

•Good job diversifying funding•Could be a statewide model•Very well leveraged; expanding•Ahead of the game

Linn County Project Access

$69,500

Project Access expansion

Fund: No •Abstract or narrative was missing. •Work plan dates were all past•How is data tracked?•Many of these services will be covered under the ACA

SPECIALTY CARE SUMMARYSFY13 SFY14

RequestRecommenda

tion

Blank Children’s Hospital Free Clinic

$ 0

$ 3,000

$ 0

Crawford County Memorial Hospital $ 0

$154,828

$ 49,802

Polk County Medical Society VPN $153,748

$237,960

$213,748

Linn County Project Access $ 39,802

$ 69,500

$ 0

Primary Health Care $114,924

$135,660

$114,924

Total $308,474

$600,948

$378,474

Health Benefits MarketplacePerceptions of Consumers in Iowa

Pete DamianoSuzanne Bentler

Dan Shane

Iowa Safety Net Network Leadership Group MeetingAugust 6, 2013

In this presentation• Consumer survey–Methods– Demographics– Insurance coverage and factors affecting choice– Knowledge and Attitudes toward the ACA–Marketplace preferences and assistance

Methods-Consumers• Mixed mode (On-line and written in person)• Convenience sample:

– IA Caregivers Assoc. (both)– one Iowa FQHC (written)– Iowa State Extension (written)– IA Public Health Association (online)– AARP (online)– IDPH partners and local agencies

• 85 questions maximum– 43 questions with some tables of multiple subquestions

• 498 responses so far– 367 On-line– 131 Written

Insurance Coverage Types• Employer-based (<HBMP)-80% (n=396)• Non-employer-based (>HBMP)-20% (n=102)– Uninsured now or in last 12 months (5%; n=24)– Self insured (5%; n=25) – Public (10%; n=53)

• Medicaid• IowaCare• CHAMPUS• VA• Military

*Medicare was excluded

Type of Assistance• Who helped choose coverage:–Myself-39%–Work/HR-37%– Friends/family-10%

Health Status

0%10%20%30%40%50%60%70%80%90%100%

18%8% 4% 11%

46%

43%

17%

30%

31%37%

38%

40%

5% 12%

39%

16%

Fair/PoorGoodVery GoodExcellent

Current coverage meets needs

Excellent

Very good

GoodFair/Poor

0%

5%

10%

15%

20%

25%

30%

35%

40%

31%

36%

24%

9%

15%

29%33%

22% Employer Insurance

Not Employer Insurance

Public Insurance rated higher for kids than private: IA Household Health Survey

Current cost: Delayed care

Yes0%

10%

20%

30%

40%

50%

60%

70%

80%

30%

71%

Employer Insurance

Not Employer Insurance

Out of pocket costs and worry about costs much greater for non-employer group

Importance of coverage: self/family

0%10%20%30%40%50%60%70%80%90%100%

89%

9%2% 1%

71%

18% 20%

1%

92%

5% 3% 0%

Self: Employer Insurance

Self: Not Employer Insurance

-

All Family

How much HEARD about ACA

Employer Insured Not Employer Insured0%10%20%30%40%50%60%70%80%90%100%

1% 4%15%

43%

46%

57%

38%

15%

A lotSomeNot muchNot sure

How much KNOW about ACA

Employer Insured Not Employer Insured0%10%20%30%40%50%60%70%80%90%100%

1% 6%9%

24%33%

35%

48%

27%

9% 9%

A lotSomethingHeard of butNot anythingNot sure

Support/Knowledge of ACA

Preexist

Prev Cov

Biz credits

Kids to 26

HBMPLg Biz Cover

Mcaid exp

Support HI

Ind Man

0%10%20%30%40%50%60%70%80%90%100%

91%86% 85%

80%70% 68% 64%

58%

45%

58%

43%36%

73%

41% 40% 44%

29%

52%

SupportKnow

Support=Strongly and support;    Know=strongly and know

Knowledge less, support similar, : For those most likely to use Marketplace

Knowledge• Less for all areasSupport• Age 26 coverage less  (83% vs 69%)• Marketplace credits more (65% vs 57%)

How learned about ACA• Television: 54%– Employer 58%– Non employer 46%

• Newspaper: 41%– Employer 47%– Non employer 23%

• Family/friends: 35%– Employer 36%– Non employer 30%

• Internet: 33%– Employer 36%

– Non employer 28%• Public health agencies: 29%– Employer 34%– Non employer 16%

Radio 27%; All others less than 20%: HI agents, Direct Mail, informational meetings at Hosp, Brochures at MD, Public forums, social media

Factors affecting choice of plan*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

72% 71% 70%

55%

38%

28%

17%

83%79% 77%

65%

38% 39%

22%

CurrentFuture

*Percentage Responding Very ImportantFew differences between groups

Preference for number of plans

Employer Insured Not Employer Insured0%10%20%30%40%50%60%70%80%90%100%

23%39%

57%

47%

15%13%

6% 1%

Not sure

Just a few

A moderate number

As many as possible

Choice guidance preference

Employer Insured Not Employer Insured0%10%20%30%40%50%60%70%80%90%100%

14% 17%

30% 22%

53%55%

3% 7%

Not sure

Combination

Guide to best plan

Simply show  options

Comfort w/online system choosing plan

Employer Insured Not Employer Insured0%10%20%30%40%50%60%70%80%90%100%

17% 20%

24% 19%

28% 24%

26%29%

5% 8%

Not SureNot ComfortSomewhatComfortableVery Comfort

Need for help with online system

Employer Insured Not Employer Insured0%10%20%30%40%50%60%70%80%90%100%

25%40%

52%

42%

17% 12%2% 1%4% 4%

Not SureNoneVery littleSomeA lot

Preference for how to get help: Marketplace

0%

10%

20%

30%

40%

50%

60% 57%

41%

32%26%

23% 22%

1%

47%43%

30%27%

30%

21%

3%

Employer

Not Em-ployer

How much help with plan info: Marketplace*

Out pocket

Services

Monthly$

PlanQuality

Reputation

Providers

0%

5%10%

15%

20%25%

30%35%

40%

45%50%

37%39%

30%

23%19%

22%

43%40%

35%

30%

25% 25%Employer

Not Em-ployer

*Percentage Responding A lot of help

Confidence in sources for help*

0%

10%

20%

30%

40%

50%

60%

70% 65%

56% 56% 54%48%

45% 44% 44%

33%

22%

54% 55% 56% 54%51%

39%45%

39%34%

28% Employer

Not Em-ployer

*Percentage Responding Confident or Very Confident

Plan information post-purchase help

Services

Out pocket

Monthly$

Claims pa...

Providers

Billing pro...

Adjustm...

Appeals

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

75%

65%58% 60%

44%

65%

48% 48%

77% 75%67%

55% 53% 52%

41% 40% Employer

Not Em-ployer

Trusted sources for post-purchase help with previous services

0%

10%

20%

30%

40%

50%

60% 56%53%

34%31% 29%

26%

14%

36%39%

28%

44%

29%26%

19%

Employer

Not Em-ployer

Top 5 most trustworthy sources of Marketplace information

Employer

Pub Hlth

Ins. agent

Fam/Frie

Brochures

0%

10%

20%

30%

40%

50%

60%55%

49%

28%24% 23%

40%43%

27% 29%24% Employer

Not Em-ployer

Conclusions:For those most likely to use Marketplace

• Current situation worse• Much less aware and knowledgeable about change

• Similarly supportive• Need help with choice– Not as comfortable with on-line system–Want one on one help

Conclusions: General• Cost most important for choice of marketplace plan • Most likely to learn about Marketplace from:

– Employer, TV• Trusted sources for marketplace information

– Work HR, Public Health Agencies• Trusted sources for marketplace purchase help

– Work HR, Print, Community resources• Trusted sources for post-purchase help

– Work HR, Marketplace website, Community resources, providers– Preferred Marketplace name over Exchange

COMMUNITY CARE COORDINATION

VISION To develop regional community care

coordination entities across Iowa to coordinate care for high-risk patients and to support primary care providers.

GOALS Provide assistance to local primary care

providers to meet the unique needs of their highest risk patients

Deploy care coordinators and additional support to help assist practices in providing services for their highest need patients such as targeted disease and care management interventions, addressing gaps in care, education, self-management support, transitional care, connection to community resources, pharmacy management, and behavioral health management

Improve quality, population health, and cost of care at local level

Develop regional community care coordination entities that become extension of primary care teams

GOALS, CONT. Engage practices in quality improvement initiatives Establish connections with other community

resources to link patients to support systems that address social and behavioral needs

Demonstrate value of community care coordination and linkages to community resource approaches to payors in meeting the Triple Aim goals

Foster community innovation and response by building upon local champions and early adopters

TARGET POPULATIONWHO NEEDS OUR HELP THE MOST?

Current and new Medicaid members and the uninsured population

Definition of Safety Net population Under 138% federal poverty level Individuals without a medical home Uninsured and underinsured

Examples: People showing up in the ER that do not require

admission People in need of pain management coordination

and services

IMPLEMENTATION STEPS Conduct community outreach and education

sessions in partnership with an outside technical assistance provider from a state already engaged in building this type of infrastructure. Bring together partners Identify clinician champions

Execute and monitor contracts for at least two and no more than three developmental regional community care coordination entities.

IMPLEMENTATION STEPS, CONT. Develop state-level infrastructure to

support regional community care coordination entities and local practices based on community outreach and education sessions and barriers identified through the RFA process.

Develop an evaluation plan for the regional community care coordination entities and statewide entity.

TIMELINE FOR IMPLEMENTING THIS MODEL

The Iowa Primary Care Association has a contract with the Iowa Department of Public Health to implement this model which includes the following: Planning and Model Development: July

– September 2013 Implementation of State Level

Resources: October – December 2013 Regional Implementation: December

2013 – June 2014

TIMELINE FOR IMPLEMENTING THIS MODEL, CONT.

Below are several high-level phases of implementation for the model for care coordination entities: Letter of Intent Released August 12, 2013 Letter of Intent Due September 13, 2013 Release of Request for Proposal September 23, 2013 Answers to Questions Posted As available Proposals Due by 5 pm CT October 25, 2013 Contract Award Notification November 15, 2013 Begin Work December 2, 2013 Contract End Date June 30, 2014

RFP DEVELOPMENT Timeline of Key Dates Background Eligible Applicants and

Entity Qualifications Scope of Work Data and Reporting

Requirements Alignment with key

state initiatives already in place

Plan for Partnerships

Provider Champions Anticipated Challenges

and Technical Assistance Needs

Budget and Budget Narrative

Financial Documents Plan for Sustainability Evaluation and

Selection Process Appendices

LESSONS LEARNED

Primary care is foundational Data essential (timely and patient specific) Additional community based resources to

help manage populations needed (best is located in practice)

Collaborative local networks builds local accountability and collaboration

Physician leadership essential Must be flexible (health care is local) and

incremental Make wise choices of initiatives (where you

can make a difference- success breeds success)

Denise Levis Hewson, CCNC

CARE COORDINATION ENTITY

WHAT IS A SAFETY NET CARE COORDINATION ENTITY?

The business entity that will oversee care coordination by and within Safety Net providers on behalf of Safety Net patients

… that could participate in financial arrangements that incentivized performance against Triple Aim Goals

… and provide the infrastructure to efficiently manage the clinical and payment needs that span the payers of care and the providers of care.

WHAT IS A SAFETY NET CARE COORDINATION ENTITY?

The envisioned CCE would follow similar guiding principles as a CMS ACO: A group of providers that voluntarily work

together… To coordinate care for a defined population

of patients with a goal of reducing waste and unnecessary care…

And participates in the financial rewards when costs are reduced and quality is achieved.

HOW WOULD THIS ENTITY BENEFIT THE STATE OF IOWA?

Focus on achievement of Triple Aim goals.

Coordination of programs across multiple payment sources.

Ability to serve as the vehicle to modify payment methodologies to safety net providers.

Delivers more robust technology infrastructure to better coordinate care.

WHO WOULD BE THE PARTICIPANTS? Formal participants

Iowa PCA A care coordination infrastructure partner The member organizations of the Iowa

Collaborative Safety Net Provider Network Other participants

Non-safety net hospitals Other settings of care Insurers

WHAT NEEDS TO HAPPEN? Develop payment methodology with the State:

Build on existing base-payments Determine population cost goals and shared-savings

"corridors" Establish measures of quality

Develop internal funds distribution methodologies Align each organizations compensation with the

methodology determined at the State level Set internal standards for clinical, operational, and

financial performance

WHAT NEEDS TO HAPPEN? Create payment technology infrastructure

Actuarial evaluations Risk adjustment Total medical expense measurement Performance measurement and reporting

Design and implement care coordination programs and standards, create provider technology infrastructure Identify high-priority care coordination goals Develop necessary participation agreements Assess gaps in existing infrastructure Create capacity to evaluate Total Medical Expense and

prioritize interventions

PROGRAM GOALS Reduce Medicaid and other spending

increases Improve measurable quality of care Expand medical decision making across

settings of care Real-time identification of waste in the

system and appropriate responses

REQUEST FOR INFORMATION PROCESS Need to identify a single partner or a

group of partners that is (are) qualified in the building of necessary care coordination and payment infrastructure to create a single organizational structure which coordinates care on behalf of Safety Net health beneficiaries served by safety net providers and to participate in new models of health care payment.

REQUEST FOR INFORMATION PROCESS Company Background Input on Governance Input on Service Delivery Model Input on Payment Models Input on Advocacy Options Input on Technology

SIM ALIGNMENT Desire to have both community care

coordination and care coordination entity development align with the SIM planning process recognizing the needs of safety net patients differ than commercially and Medicare-insured populations.

RHC PRACTICE TRANSFORMATION LEARNING COLLABORATIVE Background – RHCs have little capacity for practice

transformation/medical home, making it hard to participate in payment reform, other programs

Partners – Telligen, Iowa Association of Rural Health Clinics, Iowa PCA, CoOportunity Health

Overview – Learning collaborative with RHCs

Next Steps – Planning phase through September, implementation October – October 2014

OUTREACH AND ENROLLMENT STRATEGY Mark Your Calendar—October 23

What are you currently doing?

What types of resources would you like to see?