Maine’s State Innovation Model (SIM) Grant

Presented to the Maine Medical Associationby Commissioner Mary C. Mayhew

July 24, 2013

Maine Medicaid

Enrollment and Expenditures

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General Fund

State Fiscal Year State* DHHS % MaineCare %

2002 $ 2,583,700,000 $ 787,900,000 30.5% $ 476,500,000 18.4%

2003 $ 2,533,200,000 $ 791,600,000 31.2% $ 496,600,000 19.6%2004 $ 2,584,200,000 $ 804,100,000 31.1% $ 514,100,000 19.9%

2005 $ 2,738,100,000 $ 892,300,000 32.6% $ 595,200,000 21.7%

2006 $ 2,824,400,000 $ 970,000,000 34.3% $ 664,500,000 23.5%2007 $ 3,024,400,000 $ 1,008,100,000 33.3% $ 629,100,000 20.8%

2008 $ 3,083,600,000 $ 987,900,000 32.0% $ 643,300,000 20.9%2009 $ 3,019,800,000 $ 935,600,000 31.0% $ 593,300,000 19.6%

2010 $ 2,866,400,000 $ 813,300,000 28.4% $ 469,900,000 16.4%2011 $ 2,859,000,000 $ 859,900,000 30.1% $ 526,300,000 18.4%

2012 $ 3,087,300,000 $ 1,105,100,000 35.8% $ 776,200,000 25.1%

What is the Purpose of

The SIM Grant?

“…to test whether new payment and service delivery models will produce superior results when implemented in the context of a state-sponsored State Health Care Innovation Plan.

These plans must improve health, improve health care, and lower costs for a state’s citizens through a sustainable model of multi-payer payment and delivery reform, and must be dedicated to delivering the right care at the right time in the right setting.”

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SIM:

A High-Level View

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This grant will ultimately position Maine to assess the full impact associated with existing healthcare delivery test reform models by moving the test models to the next level through:

•Enhanced care delivery capabilities

•Greater access to high-value care information and data

•Enhanced care delivery “actor” (provider and patient) training / support

•Introduction of targeted incentives

Aligning SIM Strategies

With the Triple Aim

Goals of the “Triple Aim”:

•Improving the individual experience

of care;

•Improving the health of populations;

•Reducing the per capita costs of care

for populations.

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Building Off

Current Initiatives

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The existing healthcare delivery test reform models include MaineCare’s:

•Patient-Centered Medical Homes

•Emergency Department initiative

•Health Homes

•Accountable Communities

High-need Individual

Maine PCMH Pilot Community Care Teams

Transportation

Workplace

Environment

Food Systems

Shopping

Income

Heat

Faith Community

Literacy

Coaching

Physical Therapy

Hospital Services

Specialists

Outpatient Services

Med Mgt

HousingCare Mgt

Behav. Health & Sub

Abuse

Family

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The Emergency

Department Initiative

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• Identifying high-cost utilizers of hospital Emergency Departments and intensifying the efforts to manage their care

• Providing services in the most appropriate, cost-effective manner

• Establishing solid relationships with primary care providers andimproving patient outcomes

• Understanding the importance of social and non-medical barriers

• Total savings of $4.15 million in SFY ‘12 and $4.2 million in SFY ’13

• 1,700 patients currently participating in the program

Maine Health Homes

A Key to Sustainability

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Stage A (ongoing):

•Health Home = Medical Home primary care practice + CCT

•Currently have 150 enrolled practices and 10 CCTs

•Payment weighted toward medical home

•Eligible Members:

• Two or more chronic conditions

• One chronic condition and at risk for another

Stage B (Fall Implementation):

•Health Homes = CCT with behavioral health expertise + primary care practice

•Payment weighted toward CCT

•Eligible Members:

• Adults with Serious Mental Illness

• Children with Serious Emotional Disturbance

Maine’s Accountable Communities:

The Basic Components

• Providers will work together and propose an alternative contract to share in any savings achieved

• The amount of shared savings will depend on achieving quality benchmarks

• Open to any willing and qualified providers statewide (through application process)

• Accountable Communities are not limited by geographical area

• Members retain choice of providers

• Alignment with aspects of other emerging ACOs is desired

• Flexible design encourages innovation

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Benefits

for Providers

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Patient Accountability

•Resources for shared decision-making

•Assistance with patient incentives, benefit design

Data Analytics

•EHR for behavioral health organizations

•Connection to Health Information Exchange

•Resources for other data analytic needs

Transformation Support

•Leadership training

•Practice transformation learning collaborative

•ACO learning collaborative

Payment Reform

•Greater consistency and alignment across payers/ initiatives

•Potential for performance-based shared savings payments

Benefits

For Patients

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Ability to Compare Based on Quality and Cost Data

Coordinated CareDoctors and medical staff coordinate with other medical providers to make sure everyone is ‘on the same page’

Chronic Care ManagementAccess to care managers to make connections to non-medical resourcesTools for better self-managementCommunity health navigators

Specialized SupportAdults and children with developmental disabilities will be linked to doctors and caregivers who have been trained to meet their needs

Physical and Mental Health Integration

The Future State

Of HealthCare Delivery

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System Change and Positive Outcomes Regardless of Payor Source

High Quality, Affordable Care Supported by:•Public Reporting•Pay for Quality•Total Cost of Care Benchmarks

Engaged Patients Supported through:•Review of Performance Measures•Shared decision-making•Access to personal health data/information

Outcome-Based Reimbursement Models•apitated populations•hared savings•lobal payments

The Future State

Of HealthCare Delivery

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Data-Informed Care•Access to ‘real time’ clinical data•Timely claims data•Public health data

Improved Population Health Management through:•Patient-Centered Medical Homes•Health Homes•Accountable Care

Keys to

Our Success

• Ability to run and provide transparent, accurate and reliable member attribution, cost and quality metrics

• Provider partnership with DHHS in initiatives

• Outreach to potential providers in most rural areas

• Community-based approaches that go beyond a medical model to encompass behavioral health and social supports

• Facilitation of provider use of Electronic Health Records, Health Information Exchange and other secure data sharing methods

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For More

Information

Mary. C. Mayhew, Commissioner

Maine Department of Health and Human Services

Mary.C.Mayhew@maine.gov

(207) 287-4223

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