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TRANSCRIPT
7/19/2013
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ALIGNING PAYMENT WITH PATIENT-CENTERED CARE AND VALUE-BASED PAY
Craig HostetlerMPCA Annual Conference
August 5th, 2013
Why Are We Doing This?
Why Take the Risk?
Our stakeholders wanted something better
Patients
Payers
Providers & support staff
Recruitment getting harder
Increased pressure
Transparency and accountability increasing
Payment moving from volume to value
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Policy Environment
Policy Environment in Oregon
Legacy of innovation Oregon Health Plan
Legislature has worked well together
Oregon Health Authority
Created in 2009 Led by nine-member board Consolidates most state health
care programs: Public Health, Oregon Health Plan,
Healthy Kids, employee benefits, public-private partnerships
Purchasing power to affect cost, quality, access
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Coordinated Care Organizations
Oregon’s version of ACOs for Medicaid Key elements: PCMH – Needs to address access and quality Local control CoordinationHealth equityMetrics/performance measuresGlobal budgets (pmpm) & shared savings
Value-based pay the burning platform
Pressure from State
State knows our clinics well Questions our value for
enhanced rate Pressure to align more with
value-based payment reform Become part of local solution:
Include enhanced rates in CCO global budget
Pressure from CMS
FQHC wrap not part of CCO global budget
CMS wants wrap growth < 3.4% New patients counted against
growth limit Exceptions:NAP Federally initiated service expansions Change in Scope
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National Pressure
Medicaid Directors questioning value of enhanced reimbursement
CMS is asking same question of BPHC CMS and Medicaid Directors want:
Alignment with value-based pay, and/or Movement away from FFS
Pressure way up in the last 12 months
Partnering with Medicaid
Pressure on the Current Payment System
Health care cost increases not sustainable
State budget deficit in Oregon
Reformed health system needs as its foundation: Primary care Prevention Wellness
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Starting the Conversation with Medicaid
Our missions are aligned Payment reform should make
primary care more effective Value-based pay makes sense Must account for behavioral
and socio-economic barriers Let’s work together on a
bridge to value-based pay
Adjusting/Stratifyingfor Patient Complexity
Not adjusting could increase disparities Hong et. al., “Relationships Between Patient Panel Characteristics
and Primary Care Physician Clinical Performance Rankings,” Journal of the American Medical Association, 9/8/10.
Chien et.al., “Do Physician Organizations Located in Lower Socioeconomic Status Areas Score Lower on P4P Measures?,” Journal of General Internal Medicine, 12/13/11
Paying for health homes in the safety net Long A., Phillips K., Hoyer D., ”Payment Models to Support Patient-
Centered Medical Home Transformation: Addressing Social, Behavioral, and Environmental Factors,” Qualis Health, 8/11.
Not adjusting could penalize safety net Tyo et. al., “Methodological Challenges for Measuring Primary Care
Delivery to Pediatric Medicaid Beneficiaries Who Use CHCs,” American Journal Of Public Health, 2/13.
APM Model
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Alternative Payment Methodology
States have Alternative Payment Methodology (APM) option
APM must pay at least as much as PPS
FQHCs/RHCs can keep PPS or transition to APM
Goal and Intent
2010: PCMH clinics asked OPCA for methodology to better align with model Current reimbursement is a barrier to medical
home transformation Provider team retention issue
Goal of APM: De-link payment from the traditional, face-to-face, patient-provider encounter
Building the Will to Transform
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Removing the Biggest Barrier
Provider satisfaction and patient outcomes started improving, BUT Providers were becoming
dissatisfied
Providers still have F2F visit targets Additional PCMH responsibilities
lengthening their day
Basic APM Construct
Convert PPS into a bundled, pmpm rate CCO will pay a pmpm rate comparable to any
primary care provider State will pay a pmpm wraparound based on
prior year’s wraparound payments PCPCH payments, Pay for Performance or other
bonus payments are separate
Oregon’s APM Process
Fall 2010 Initial meetings between CHCs, OPCA and state
November 2010 Board and full membership engaged
Spring 2011 MCO engaged
Spring 2011 – June 2012 Model developed – Laura Sisulak, Curt
Degenfelder, Don Ross, CHCs
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Oregon’s APM Process, cont’d
June 2012 SPA submitted to CMS
September 2012 SPA approved
March 1, 2013 “Go Live”
APM
Budget-neutral Includes:
Physical health services Mental health services after one year Dental services
Will be more difficult, but intended to be carved in
Inpatient care/prenatal/deliveries carved out All sites, all patients (managed care and open card) Three-year commitment from both parties Change in Scope process - similar to PPS
Oregon PPS Change in Scope
Pretty Robust “PCMH Implementation” EMR ongoing costs Change in patient mix Provider mix fluctuation Services mix fluctuation, including enabling
services that don’t require a F2F visit Addition of services out of scope
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APM , cont’d
Clinics to provide: Process and outcome data to the state “Touches” with the patient
Demographic data will be collected OCHIN has been an outstanding partner State/CCO to provide total patient cost info Aligning with other state reform efforts (e.g.,
PCMH, CCO) CHCs join based on readiness MOU with the state is key
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APM, cont’d
Attribution To be developed and paid on current users for
Day 1 18 month look back Add patients through F2F visit with
licensed professional Thorough intake:
Medical history Problem Rx list
At minimum
Next Steps with APM
March 1, 2013 was our “go live” Submit/analyze quarterly data Track financial impact Add clinics to pilot Add mental health (and
eventually dental)
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Non-Visit Based Care
We’re re-imagining how the medical home would be structured if we eliminated the incentive to “crank” visits
What Have We Learned?
Lessons Learned
Framing conversation with Medicaid critical
APM took longer than we expected
Attribution issue
Competing priorities for state
We need to get a lot better with data: Tracking
Reporting
Using
A good offense can be more effective than a good defense, but you need both
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Elements of Risk We Shouldn’t Underestimate
CHC work for each patient may increase while payment remains the same
Transparency in data (cost, quality and access) shortens bridge to value-based pay
Little time remains to adjust for behavioral and socio-economic barriers
Elements of Risk We Shouldn’t Underestimate, cont’d
Oregon’s focus on short-term cost-cutting It’s alarming Everything else appears
secondary Our data needs to be
cleaner yesterday Must focus on showing
CHC value in a managed care and ACO/CCO environment
Social Determinants
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Game, Set and Match
Bridging to value-based pay must take psychological and socio-economic complexities into account
Focusing Adjustmentson What Matters
Social circumstances
15%
Environmental exposure
5%
Health care10%
Behavioral patterns40%
Genetic predisposition
30%
Source: McGinnis J.M., Williams-Russo P., Knickman J.R. “The Case for More Active Attention to Health Promotion,” Health Affairs 2002;21(2):78-93.
Reasons: Many safety-net
providers not penalized Denver Health
Need to hold all hospitals accountable for the same outcomes
Medicare gave grants to these hospitals
No adjustment for social determinants
Medicare Readmission Penalties
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Does This Sound Familiar?
“We all should target the same outcomes, period.”
“Providers need to be held accountable, not given excuses.”
“Psycho-social characteristics show up in medical complexity, so it would be double counting.”
“If clinic X can meet the health outcome benchmarks without adjustments, why can’t they all?”
Addressing Naysayers
Target the same outcome…and: Safety net clinics need more time & resources
Clinic choices without psycho-social adjustments: Improve/add services Limit seeing complex patients
To hold providers accountable: Stratify patients Hold providers accountable for patients with
similar barriers
Addressing Naysayers, cont’d
Stratified patients Same high blood pressure or
glucose readings Different psycho-social barriers
Producing outcomes through fundraising
“Deal with the Devil” BUT, we need to get our
house in order
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What Can We Do?
Taking Charge
Value perceptions of CHCs Cost, quality and ACCESS (CHC focus on quality vs. access) Complete/share complexity research and link to cost studies
Research issue nationally Determine three-five SDOH to standardize and collect
Most impact on PCMH work and health outcomes Standardize and collect data on enabling services Develop ROI nationally
Payment reform Develop payment strategy for state Advocate for risk adjustments beyond medical Determine payment methodologies to support continuation of
enabling services in CHCs
Current Research
Cost comparisons: CHC vs. non-CHC (All Payers) In process
Complexity comparisons: CHC vs. non-CHC 500 charts reviewed
Looking for chart notes that would indicate: Social and environmental circumstances Enabling services delivered
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Preliminary Results
CHC patients have more extreme barriers Higher SPMI Homelessness Unstable social situations
CHC patients have higher rates of chronic conditions CHCs invest more in supporting social issues
Housing, access to food, linking to other benefits (food stamps, alcohol & drug services)
CHC patients have less of a social support network CHCs invest less in wellness
Nutrition takes a back seat when patients are homeless
Coordinated Care Organizations
Designing incentive programs No ability to risk adjust for
social determinants of health Community Advisory Councils
Will they have teeth? Short-term cost reduction vs.
system transformation
Provisions of SB 1522
CCOs to account for psychological & social barriers Quality measures Payment
All providers to meet same outcomes For providers treating complex patients:
Measurement/payment stratified for extra time & resources required
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Get Our House in Order
Bring up low
performers
Get clean data
Work With Your PCA
Data to promote and improve CHC value
Research Payment reform PCMH has to be about
transformation
Questions
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Thank You
Craig HostetlerOregon Primary Care Association
503-228-8852 x [email protected]