APPENDIX 3: STATE HEALTH CARE INNOVATION PLAN

1. Provide a Vision Statement for health system transformation.

Washington State aims to achieve better health, better care, at a lower cost with an integrated health system that provides coordinated services across a continuum of care settings. Internal and external stakeholders will work together in a unified effort to transform the current system with strong leadership, shared compromise, and vision for a better future.

Five key reform transformations will accelerate Washington’s movement from: volume-based to value-based purchasing; fragmented to coordinated care; purchasing costly, ineffective treatments to procuring evidence-based and cost-effective options; and management of disease to prevention. These reforms encourage managing costs, improving patient safety and quality of care, and increasing access to care that is coordinated to meet the needs of individuals and communities.

Value Based Benefit and Payment Reform. Value-based payment is designed to give healthcare providers adequate resources to deliver efficient, quality care and to remove the disincentives that exist today for improving quality and efficiency. Payment systems should be tailored to promote efficient, high-quality care. Episode-of-care payments are most appropriate for conditions where there is not a problem with overuse of treatment (e.g., hip fractures and labor and delivery) but where there are opportunities to reduce the cost and complications of the treatment. Comprehensive care payments are suitable for

D. Hanig May 21, y

Public /private payers and providers test, confirm, and adopt new, common business models that sustain a strong primary care base and promote the delivery of value-based, patient-centered care.

Value-Based Benefit and

Payment Reforms

Integrated system where providers respond to routine reporting that highlights efficient and inefficient practices, and where consumers, providers, and payers make informed decisions for more effective and efficient use of health care resources resulting in better health outcomes.

Delivery Systems Reforms

Informed consumers that take greater responsibility for managing their own health.

Consumer Engagement

Prevention-focused health care and community efforts aimed at maintaining good health rather than treating illnesses.

Prevention and Wellness

Reduction in administrative costs for public and private entities through timely and efficient processing of business transactions between providers, payers, and government.

Administrative Simplification

1

conditions such as chronic diseases where there is concern about unnecessarily high rates of hospitalizations and specialty care. This payment reform is also considered for conditions contributing to overuse of certain types of procedures (e.g., heart surgery vs. medical management of heart disease). Areas of underutilization, such as the delivery of prevention services with long-term impacts, may be best addressed through fee-for-service payment.

Washington is keenly aware that setting the right payment amount (i.e., the price) is as important as using the right payment method. If the amount is too low, providers will be unable to deliver quality care, and if it is too high, there is no incentive to seek out efficiencies. Differential price-setting approaches need to be responsive in different regions and for different providers and services depending on the local market structure.

Delivery Systems Reforms. The ideal health care delivery system is driven by high performance. This requires a system where a patient’s clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems. Patient care should be coordinated among multiple providers, and transitions across care settings actively managed. Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other’s work, and collaborate to reliably deliver high-quality, high-value care. Moreover, patients have easy access to appropriate care and information, including after hours; there are multiple points of entry to the system; and providers are culturally competent and responsive to patients’ needs. There is clear accountability for the total care of patients. The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery. Leadership is a critical factor in the success of delivery system reform.

Consumer Engagement. Consumers who are actively engaged in their care make choices that have a significant impact on both costs and outcomes of care. At the individual level, patient or consumer engagement means involvement in one’s own health and health care and decisions about one’s treatment. At the community level, consumer engagement involves participation in decisions about the design, delivery and evaluation of health services. Engaged consumers can be powerful partners in their own health and health care and advocates for higher-value health care and a more efficient and effective health care system.

The current system presents multiple barriers preventing consumers from acting as full partners in their own care and in playing a meaningful role in improving the quality of local health care systems. These include difficulty in wading through complicated choices of services and treatments, getting enough time with harried providers, perceived lack of consumer expertise, logistical and financial barriers and low levels of organizational commitment. These barriers are even more acute for consumers of specific racial, ethnic and socio-economic backgrounds.

Consumer engagement holds great potential to spur health quality improvements; but, it is not a silver bullet, since consumers have neither the power nor the skills to transform

D. Hanig May 21, y2

health care systems on their own. Change will require a joint effort on the part of many stakeholders: consumers, providers, employers, payers, insurers, public health, and policy-makers.

Prevention and Wellness To maintain global economic competitiveness, reduce burgeoning health care costs, and ensure that our children have healthy futures, disease prevention and health promotion must become core objectives for state government. Although personal responsibility is one factor in attaining wellness, Washington can play an essential role in reorienting states’ actions toward prevention of poor health outcomes through three primary avenues: communities, worksites, and schools creating culture of wellness. State programs and policies should be consistent with wellness goals and public health messages delivered throughout the state. This includes educating the public about existing community resources; partnering with community organizations to communicate information and encouraging healthy lifestyles; promoting civic and personal responsibility for health; improving access to healthy options in disadvantaged communities; and publicly sharing their efforts to get healthy.

Creating successful statewide health improvement programs requires three key elements; 1) coordination of activities across multiple state agencies to make everyone’s efforts more efficient; 2) fully engaging communities how services are delivered locally; and 3) drawing upon the expertise of public health policy and research experts.

Administrative Simplification Physicians spend a reported 43 minutes per day on average – the equivalent of 3 hours per week and nearly 3 weeks per year – on administrative interactions with health plans and not on patient care. Efforts to streamline and harmonize payment and reporting requirements as basic, straightforward, and practical prerequisites to eliminating substantial systemic administrative costs are vital to lowering costs. Reform should encourage the spread of administrative simplification through the full healthcare delivery “supply chain,” from employer or plan sponsor, to health plan or plan administrator, to EMR (electronic medical record) or practice management systems vendor, to medical practice. In addition, policies promoting such spread should encourage fidelity of adoption in order to maximize harmonization across payers and care providers.

To drive reform, a decision-making and implementation framework is needed, an organized infrastructure to promote collaboration and well-informed discussions and decisions. Together, stakeholders will bring about broad adoption of the common standards and processes necessary for administrative simplification and cost reduction. By formalizing a public/private approach between all affected entities, including clearly defining roles, administrative simplification is more likely to occur with greater acceleration then if attempted on an ad hoc basis.

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2. Describe population demographic including Medicaid and CHIP populations.The following tables provide key demographic information, starting with Medicaid and CHIP populations:

Table 1. Medical Assistance Eligible Persons Report - April, 2012Adults Children Total

FFS Managed Care

Total Eligible

FFS Managed Care

Total Eligible

FFS Managed Care

Total Eligible

Medicaid CN Family Medical 19,539 93,840 113,379 17,835 166,699 184,534 37,374 260,539 297,913AHK - Medicaid CN Mandatory Children

187 969 1156 39,835 244,374 284,209 40,022 245,343 285,365

AHK - Medicaid CN Optional Children 88 446 534 35,556 143,539 179,095 35,644 143,985 179,629AHK - Medicaid CN Foster Care and Adoption Support Children

927 0 927 21,448 30 21,478 22,375 30 22,405

AHK - Children's Health Insurance Program (CHIP)

13 58 71 4,442 19,483 23,925 4,455 19,541 23,996

AHK - Non-Citizen Children 121 0 121 20,554 0 20,554 20,675 0 20,675Medicaid CN Pregnant Women 7,950 14,401 22,351 307 345 652 8,257 14,746 23,003Title XXI Non-Citizen Pregnant Women 5,932 0 5,932 95 0 95 6,027 0 6,027Medicaid CN Family Planning - Post Partum

25,950 6 25,956 17 0 17 25,967 6 25,973

Medicaid Family Planning - 31,576 0 31,576 4,387 0 4,387 35,963 0 35,963Medicaid CN Elderly 62,858 945 63,803 2 0 2 62,860 945 63,805

Dual Eligible 61,068 877 61,945 0 0 0 61,068 877 61,945Non Dual Eligible 1,790 68 1,858 2 0 2 1,792 68 1,860

Medicaid MN Elderly 4,117 0 4,117 1 0 1 4,118 0 4,118Dual Eligible 3,904 0 3,904 0 0 0 3,904 0 3,904Non Dual Eligible 213 0 213 1 0 1 214 0 214

Medicaid CN Blind/Disabled (SSI Related)

133,220 4,725 137,945 19,296 17 19,313 152,516 4,742 157,258

Dual Eligible 44,744 460 45,204 20 0 20 44,764 460 45,224Non dual Eligible 88,476 4,265 92,741 19,276 17 19,293 107,752 4,282 112,034

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Adults Children TotalFFS Managed

CareTotal

EligibleFFS Managed

CareTotal

EligibleFFS Managed

CareTotal

EligibleMedicaid MN Blind/Disabled (SSI Related)

7,653 1 7,654 6 0 6 7,659 1 7,660

Dual Eligible 4,401 0 4,401 0 0 0 4,401 0 4,401Non dual Eligible 3,252 1 3,253 6 0 6 3,258 1 3,259

Medicaid CN Health Care for Workers with Disabilities

1,528 0 1,528 0 0 0 1,528 0 1,528

Dual Eligible 1,065 0 1,065 0 0 0 1,065 0 1,065Non dual Eligible 463 0 463 0 0 0 463 0 463

Medicaid CN Women with Breast and Cervical Cancer

1,035 0 1,035 0 0 0 1,035 0 1,035

Medicaid MN Others (Pregnant Women and Children)

49 0 49 147 2 149 196 2 198

Medicaid Alien Emergency Medical 431 0 431 0 0 0 431 0 431Medicaid Refugee Assistance 662 2 664 87 1 88 749 3 752Medicaid/Medicare Cost Sharing (Partial Duals)

44,808 0 44,808 5 0 5 44,813 0 44,813

Medical Care Services  - Disability Lifeline

4,117 6,905 11,022 0 0 0 4,117 6,905 11,022

Medical Care Services - ADATSA 4,452 0 4,452 4 0 4 4,456 0 4,456Detoxification Services Only 12 0 12 0 0 0 12 0 12Involuntary Psychiatric Treatment 267 0 267 16 0 16 283 0 283Voluntary Treatment - Psychiatric 62 0 62 0 0 0 62 0 62Total MAA 357,554 122,298 479,852 164,040 574,490 738,530 521,594 696,788 1,218,382Total MMA less Family Planning 300,028 122,292 422,320 159,636 574,490 734,126 459,664 696,782 1,156,446Apple Health (including adults on children's only programs)

1,336 1,473 2,809 121,835 407,426 529,261 123,171 408,899 532,070

Notes: Adults are persons age 19 and older; children are persons under age 19.Managed Care persons enrolled in health plans that are paid a monthly capitation rate to service enrolled clients. (Excludes PCCM and Care Management Enrollments). Total Eligible = sum of Fee For Service and Managed Care Enrolled.

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Table 2. Demographic Characteristics of Nonelderly Adults by Baseline Coverage TypeInsurance Type

Uninsured Medicaid PrivateN % N % N %

Total Nonelderly Adults 729,504 100.0 359,644 100.0 2,990,493 100.0

Health StatusExcellent 139,566 19.1 38,885 10.8 938,405 31.4Very Good 152,535 20.9 48,127 13.4 953,633 31.9Good 281,366 38.6 129,784 36.1 853,490 28.5Fair 115,272 15.8 79,723 22.2 196,176 6.6Poor 40,764 5.6 63,126 17.6 48,788 1.6

Modified Adjusted Gross Income (MAGI)

Under 138% FPL 336,565 46.1 250,676 69.7 203,609 6.8138% - 200% FPL 104,775 14.4 41,358 11.5 177,432 5.9200% - 300% FPL 128,858 17.7 37,836 10.5 382,294 12.8300% - 400% FPL 77,502 10.6 14,655 4.1 426,313 14.3400%+ FPL 81,804 11.2 15,119 4.2 1,800,845 60.2

Age19 - 24 years 166,041 22.8 60,199 16.7 327,290 10.925 - 44 years 360,940 49.5 173,108 48.1 1,272,476 42.645 - 64 years 202,523 27.8 126,337 35.1 1,390,727 46.5

Race/EthnicityWhite, Non-Hispanic 485,473 66.5 225,880 62.8 2,399,999 80.3Black, Non-Hispanic 25,383 3.5 19,177 5.3 94,195 3.1Hispanic 144,243 19.8 62,664 17.4 147,914 4.9Other1 74,405 10.2 51,923 14.4 348,385 11.6

Coverage CategoryEligible for Medicaid 72,578 9.9 359,644 100.0 110,214 3.7Undocumented Immigrant2 62,603 8.6 0 0.0 67,502 2.3Other 594,323 81.5 0 0.0 2,812,777 94.1

HIU Type3

Single, No Dependents 395,261 54.2 155,051 43.1 746,613 25.0Single, With Dependents 71,547 9.8 69,149 19.2 135,852 4.5Married, No Dependents 89,837 12.3 32,234 9.0 950,003 31.8Married, With Dependents 172,858 23.7 103,210 28.7 1,158,025 38.7Kid Only 0 0.0 0 0.0 0 0.0

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Insurance TypeUninsured Medicaid PrivateN % N % N %

Employment StatusUnemployed 350,966 48.1 236,977 65.9 690,764 23.1Employed - Unidentifiable Firm Size

143,251 19.6 54,019 15.0 845,583 28.3

Small Firm (< 50) Employees)

139,696 19.1 39,071 10.9 464,333 15.5

Medium Firm (50 - 500 Employees)

37,358 5.1 15,860 4.4 429,505 14.4

Large Firm (500+ Employees)

58,233 8.0 13,717 3.8 560,308 18.7

Tobacco UseYes 182,978 25.1 106,652 29.7 615,704 20.6No 546,525 74.9 252,992 70.3 2,374,789 79.4

Chronic Condition Prevalences4

Angina 7,396 1.0 8,121 2.3 44,501 1.5Arthritis 81,621 11.2 75,374 21.0 449,712 15.0Asthma 69,000 9.5 56,267 15.6 239,186 8.0Coronary Heart Disease 10,831 1.5 12,352 3.4 63,998 2.1Diabetes 30,615 4.2 38,698 10.8 177,540 5.9Emphysema 6,276 0.9 6,191 1.7 21,978 0.7Heart Attack 14,693 2.0 9,203 2.6 55,630 1.9High Blood Pressure 109,075 15.0 85,671 23.8 664,601 22.2Other Heart Disease 42,586 5.8 34,158 9.5 170,467 5.7Stroke 7,806 1.1 10,937 3.0 34,006 1.1

Source: Urban Institute (UI) Analysis of Augmented Washington State Database1) Other includes, among the non-Hispanic population, American Indian/Alaskan Native,

Native Hawaiian/ Other Pacific Islander, and Multiracial2) Excludes those undocumented immigrants who are eligible for Medicaid through

special programs3) "Married" includes health insurance units with a married individual even if the spouse

is not within the unit4) Except for asthma, all prevalences reflect any diagnosis of the disease in question,

regardless how long ago the diagnosis occurred. The asthma prevalence reflects a current asthma diagnosis.

D. Hanig May 21, y7

Table 3. Demographic Characteristics of Washington Children by Baseline Coverage

CharacteristicInsurance Type

Uninsured Medicaid PrivateN % N % N %

Total Children 56,900 100.0 735,611 100.0 925,276 100.0

Health StatusExcellent 22,060 38.8 232,504 31.6 535,891 57.9Very Good 9,766 17.2 144,777 19.7 239,962 25.9Good 20,060 35.3 297,309 40.4 138,577 15.0Fair 5,014 8.8 53,066 7.2 9,642 1.0Poor 0 0.0 7,955 1.1 1,204 0.1

MAGI

Under 138 FPL 16,698 29.3 457,590 62.2 48,120 5.2

138 - 200 FPL 12,595 22.1 120,801 16.4 47,098 5.1200 - 300 FPL 11,944 21.0 89,666 12.2 146,855 15.9300 - 400 FPL 9,068 15.9 37,533 5.1 183,576 19.8400%+ FPL 6,594 11.6 30,020 4.1 499,625 54.0

Race /EthnicityWhite, Non-Hispanic 38,496 67.7 368,962 50.2 693,208 74.9Black, Non-Hispanic 2,430 4.3 38,800 5.3 33,616 3.6Hispanic 9,260 16.3 223,408 30.4 69,654 7.5

Other1 6,715 11.8 104,442 14.2 128,798 13.9

Coverage Category

Eligible for Medicaid 35,930 63.1 735,611 100.0 318,460 34.4

Undocumented

Immigrant2 2,291 4.0 0 0.0 4,755 0.5

Other 18,679 32.8 0 0.0 602,061 65.1

HIU Type3

One Parent 15,051 26.5 332,021 45.1 135,854 14.7

Two Parents 35,720 62.8 360,698 49.0 774,412 83.7Kid Only 6,129 10.8 42,892 5.8 15,010 1.6

Source: Urban Institute Analysis of Augmented Washington State Database

D. Hanig May 21, y8

1. Other includes, among the non-Hispanic population, American Indian/Alaskan Native, Native Hawaiian/ Other Pacific Islander, and Multiracial

2. Excludes those undocumented immigrants who are eligible for Medicaid through special programs

3. "Married" includes health insurance units with a married individual even if the spouse is not within the unit

4. Except for asthma, all prevalences reflect any diagnosis of the disease in question, regardless how long ago the diagnosis occurred. The asthma prevalence reflects a current asthma diagnosis.

3. Describe population health status and issues or barriers that need to be addressed.

GENERAL HEALTH STATUS TRENDSWashington differs in a few areas from national statistics. Demographically, the state has fewer minorities than the national average. Longevity is slightly higher and teen birth rates are substantially (28%) lower in WA – in part due to robust family planning and sexual education in the state.Table 4. Kaiser Family Foundation – State Health Facts

WA US Notes# % # %

Birth Rate 13.4 - 13.5 -Teen Birth Rate per 1,000 Females 26.7 - 34.3 - ages 15-19White 4.3 - 5.7 -Black 7.8 - 13.4 -Hispanic 4.5 - 5.5 -Total 4.9 - 6.8 -Life Expectancy at Birth 79.7 - 78.6 - Years

Overweight/Obese Children - 29.5 -31.

6 % childrenChildren (19-35 mo.) Immunized - 74 - 75Child Mortality Rate per 100,000 Children 16 - 18 - ages 1-14

Overweight/Obesity Adults - 61.8 -63.

8

Cancer Incidence Rate per 100,000472.

2 - 462.1 -Asthma among Adults - 9.6 - 8.6Adults who Visited the Dentist/Clinic - 72.1 -

69.7

Violent Crime Rate per 100,000313.

8 - 403.6 -

D. Hanig May 21, y9

Figure 2. Dual Medicare-Medicaid Enrollees by Age Group and Gender: WA, 2007

18%

27%

19%

14%

<45 45-64 65-74 85+

All Dual Dual Age 65+ Dual Age 18-640

102030405060708090

100

39% 31%49%

61% 69%51%

Male Female

Figure 3. Racial Distribution by Enrollment Group: Washington, 2007

Dual Dual Age 65+ Dual Age 18-64 Medicare Only0

10

20

30

40

50

60

70

80

90

100

77% 72%83%

93%

3%4%

3%<1%

6%6%

8%2%11% 18%

3% 2%3% 3% 2% 3%

OtherAsianBlackHispanicWhite

Washington is ranked one of the healthier states in the nation. The United Health Foundation placed Washington 15th in overall health in 2012 and the state took 10th in the Commonwealth Fund’s 2011 Child Health Score Card.

D. Hanig May 21, y10

Figure 4. Better than the Nation on Critical Health and Population Measures

0

5

10

15

20

25

30

20

27

20

17

10

6.8

15

21

18

13

64.9

USWA

Washingtonians may be healthier in some areas; they are on par with national trends in others. Approximately 21% of adults in the 11 counties are living at 200% of the Federal Poverty Level (FPL) or below. Large imbalances in the distribution of health risk by income persist in these counties. According to self-report data from the Washington State Behavioral Risk Factor Surveillance System (BRFSS), low-income adults in priority counties are at significantly higher risk, with the largest imbalances by income for obesity, tobacco use, diabetes, and lack of screening for cholesterol, breast cancer, and colon cancer.

D. Hanig May 21, y11

Figure 5. Federally Designated Health Professional Shortage Areas for Primary Care

Washington State struggles to maintain the number of health care providers needed to serve rural communities and underserved populations. This not only affects access to routine care, but it also impacts the health of many in our state.

D. Hanig May 21, y12

CHRONIC DISEASE In Washington, nearly two out of three deaths annually are from smoking and obesity-related diseases, including heart disease, stroke, cancer, diabetes, and chronic lower respiratory disease (2009 death data, Washington State DOH Vital Statistics System). It is not just older people dying from these diseases; almost one-fourth of these deaths are among people younger than 65. The causes of many of these deaths are related to tobacco use, poor diet, insufficient physical activity, and alcohol consumption, and they unevenly impact communities of color, individuals with lower socioeconomic status, and other underserved sectors of the population. For example, while obesity, diabetes, and hypertension have increased for all income groups in Washington since 1993, they have increased more rapidly among people with lower incomes. Smoking rates have decreased for all income groups in the state since 2000, but these decreases are happening more slowly in low-income populations.The state’s Department of Health1 has found that the prevalence of diabetes and the incidence of melanoma are on the rise, while rates of mortality or incidence of many other diseases are declining. Death rates for stroke, breast cancer, and lung cancer in Washington are similar to those seen nationally, while rates of coronary heart disease mortality, diabetes prevalence, and incidence of invasive cervical and colorectal cancers are lower for Washington than the nation. Rates of asthma prevalence and melanoma incidence have consistently exceeded national levels since the 1990s. The following table from the Agency for Healthcare Research and Quality (AHRQ) shows the prevalence of certain chronic conditions in Washington State, along with goals for improvement.2

Table 5. Chronic Disease in WA by Health People 2020 (HP2020 Targets)

Measure HP 2020Target

Most Recent Baseline DefinitionState Rate

Data Year

State Rate

Data Year

CancerAll cancer deaths 160.6 178.0 2007 196.0 2000 per 100,000 population

Lung cancer deaths 45.5 49.5 2007 57.6 2000 per 100,000 population

Colorectal cancer deaths per year

14.5 14.9 2007 18.3 2000 Per 100,000 population

Prostate cancer deaths

21.2 24.4 2007 27.5 2000 per 100,000 male population

HIV deaths 3.3 1.6 2007 2.1 2000 per 100,000 population

Immunization and Infectious DiseasesFlu vaccine - age 65 and over

90.0 70.3 2009 72.9 2001 Adults age 65 and over who received an influenza vaccination in the last 12 months

Pneumonia vaccine 90.0 71.3 2009 66.9 2001 Adults age 65 and over who

1 http://www.doh.wa.gov/Portals/1/Documents/5500/CD2007.pdf 2 Washington

D. Hanig May 21, y13

Measure HP 2020Target

Most Recent Baseline DefinitionState Rate

Data Year

State Rate

Data Year

ever - age 65 plus ever received pneumococcal vaccination

Flu vaccine for high-risk persons

80.0 39.7 2009 32.2 2003 Percent of high-risk persons ages 18-64 who received an influenza vaccination in the past 12 months

Pneumonia vaccine ever - high-risk, age 18 to 64

60.0 30.5 2009 22.0 2003 High-risk people ages 18-64 who ever received a pneumococcal vaccination

Mental Health and Mental IllnessSuicide deaths 10.2 13.0 2007 12.3 2000 Suicide deaths per 100,000

population

Duals have greater prevalence of chronic disease compared to Medicare-only beneficiaries. And both duals and non-duals served in the state’s Medicaid program show a high incidence of chronic conditions as depicted in Figures 6 and 7 below:Figure 6. Number of Chronic Conditions by Enrollment Group: Washington 2007

None 1 to 2 3 to 4 5+05

101520253035404550

Dual

Medicare-Only

D. Hanig May 21, y14

Figure 7. Prevalence of Select Chronic Conditions by Enrollment Group: WA 2007

Alzheimers/Dementia

Arthritis

Cancer

Chronic Kidney Disease

COPD

Congestive Heart Failure

Depression

Diabetes

Heart Disease

Osteoporosis

Stroke

No Chronic Condition

0 5 10 15 20 25 30 35 40 45 50

Medicare-onlyDual

These profiles highlight the significance of behavioral health, long term care and physical ‐health needs among both elders and working age duals, and point to the importance of ‐efforts to better coordinate health services for this vulnerable population. In just Medicare, over 50% of beneficiaries have 1 or more chronic conditions. Characteristics of Medicaid single and dual eligibles show considerable need for improved coordination of care. For example, one quarter of Medicaid Disabled clients are considered “high risk”. Of these, nearly 90% receive services from two or more programs, including Long-Term Care (LTC), Severe Mental Illness (SMI), Alcohol or Drug Abuse (AOD) and Developmental Disabilities (DD). The state’s predictive modeling database (PRISM) generated the following Venn diagram showing the overlap of risk factors among high-risk single-eligible Medicaid disabled clients:

D. Hanig May 21, y15

Figure 8. Venn diagram: Overlap of risk factors among high-risk single-eligible Medicaid disabled clients

MOTHERS AND BABIES3

Background: Washington State has seen a downward trend in births in recent years. In 2011, there were 85,494 birth, 86,480 in 2010, and 90,270 in 2008. Medicaid funded over half (50.4%) of all deliveries, up from 48.5% in 2009. Birth rates and pregnancy rates decreased in 2010, especially among women 15-24.The singleton low birth weight rate for African Americans has significantly decreased since 1990.After increasing from the early 1990s through 2006, the preterm birth rate appears to be declining. SIDS rates decreased from 1990-2005, and remain low. In 2010, 80.2% of Washington women received prenatal care in the first trimester. First trimester prenatal care has increased each of the last three years. Smoking just before and after pregnancy decreased from 1996 through 2008. In 2010, 20% of women reported smoking in the

3 Paragraph cites material from the 2007 DOH Maternal & Child Health Plan. Cathy.wasserman@doh.wa.gov, polly.taylor@doh.wa.gov.

D. Hanig May 21, y

Shaded Area BetweenDotted Outline and Circles = 7,052

29%

TOTAL LTC= 6,068

25%

TOTAL DD = 2,941

12%

TOTAL SMI= 8,867

37%

TOTAL AOD = 7,281

30%

DD ONLY = 1,9888%

LTC ONLY = 2,73311%

SMI ONLY = 2,54211%

AOD ONLY = 2,51610%

GRAND TOTAL

ALL HIGH/MED RISK (Dotted Outline) = 24,006

DD + SMI + LTC = 24<1%

SMI + LTC = 47<1%

SMI+DD 7893%

AOD + SMI+ LTC = 941

4%

SMI + LTC= 1,550

6%

AOD + LTC= 7693%

AOD + SMI = 2,96212%

16

three months before pregnancy, using a slightly different definition of smoking. Approximately 95% of new mothers reported ever breastfeeding in 2010. Both initiation of breastfeeding and breastfeeding at two months postpartum are increasing.

Areas of concern:Almost 43% of women were either overweight or obese prior to pregnancy in 2010; over 46% of all women gained more than recommended amounts. The singleton low birth weight rate overall, and among all race and ethnic groups except African Americans, has increased since 1990. Though not yet statistically significant, rates may be stabilizing.The Native American infant mortality rate remained high and exceeds the infant mortality rates of other race and ethnic groups.Women receiving Medicaid continued to have lower first trimester prenatal care rates and higher rates of late/no prenatal care than women who did not receive Medicaid. Smoking rates during pregnancy continued to be significantly higher for women receiving Medicaid than for women who did not receive Medicaid.The unintended pregnancy rate remained high, but in 2010 dropped below 50% for the first time since we began measuring it in 1996.Around half of women report not taking a multivitamin at all in the month prior to pregnancy.C-Sections. The overall C-section rate in Washington State increased 73%, from 1996 to 2009, one of the biggest increases in the nation. In Washington State C-section rates vary greatly by hospital and region, from 10 to 39%. The following graph shows the growth in total C-section rates in Washington State.

Figure 9. Total C-Section Rates: Medicaid and Non-Medicaid Births 1989-2009

19891991

19931995

19971999

20012003

20052007

20090.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Medicaid Non-Medicaid

Of great concern is the correlation between early term C-sections and NICU admissions. The evidence indicates that early deliveries lead to poorer neonatal outcomes, leading to our focus on decreasing such deliveries when not medically necessary:

D. Hanig May 21, y17

Table 6. C-Sections and NICU Admissions

For C-Sections Conducted at: The Risk of NICU Admission is:

37 weeks 20.8%

38 weeks 16.5%

39-41 weeks 7.8%

There is considerable regional variation in low risk C-sections unrelated to risk factors, ranging from 15% - 30% in facilities across the state.Inductions. The percentage of induction of labor among Washington State hospitals varied from 3% to 48%, in 2011 (includes both elective and non-elective inductions). Reasons for the wide variation are the same as for elective deliveries before the 39th week: 1) the mother requests the procedure; 2) provider decisions (indications for whether and when to perform inductions of labor and elective inductions of labor are gray areas); 3) scheduling for convenience reasons. Like inductions, no national labor and delivery management standards or guidelines exist for whether and when to perform a C-section once labor has started. Washington State and the Bree have suggested standards that are now being applied across all hospital and payers. The CMMI/SIM offer a means to more rapidly apply, train and feedback reports for rapid cycle improvements.

4. Describe health system models “current as is” and “future to be” states, including the level of integration of behavioral health, substance abuse, developmental disabilities, elder care, community health, and home and community-based support services.

CURRENT SYSTEMWashington State’s current system mirrors the strengths and weaknesses of the U.S. health care system:1. Administrative inefficiency. Multiple payers covering different services have distinct requirements and payment methods, resulting in high administrative costs for providers. A study4 conducted by the Washington Office of the Insurance Commissioner found that upward of 40% of health care costs are spent in administrative activities and each primary care provider must hire more than 4 FTEs to accommodate the administrative burden of differing payers’ requirements for formularies, prior authorizations and payment methods.

2. Siloed services. Most services, and especially publicly funded services such as Medicaid, usually operate in a siloed fashion, with many clients receiving services from different state agencies without any coordination of care. The division of state and federal responsibilities for dual eligible Medicare and Medicaid clients compounds this fragmentation further. Currently, the following programs largely operate through separate delivery and payment systems:

4 http://oic.wa.gov/legislative/reports/SimplificationRpt.pdf

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1. Primary, specialty, rehabilitative and acute care2. Long-term services and supports3. Mental health and recovery services4. Substance abuse prevention and treatment services5. Diverse range of supports for people with developmental disabilities

Each system has unique performance outcomes and goals that make sense within each sphere but typically do not hold providers accountable for influencing overall health outcomes or expenditures. That creates significant barriers in the face of mounting evidence that the greatest public expenditures and most preventable health outcomes are associated with individuals who have complex needs that cut across the disciplines represented by each of the current delivery silos.Payment is tied to the provision of distinct services, treatments or interventions and therefore is not oriented to prevention or performance based outcomes. Money saved in one silo or funding stream due to the intervention by another cannot easily be moved to incentivize the outcomes desired. As such, there are few incentives for the system to work together to comprehensively meet complex needs. The result is often uncoordinated service delivery, where beneficiaries express frustration in accessing necessary services and navigating across systems of care.Without a comprehensive, patient-centered orientation to care , it is difficult to identify whether patients are: 1) getting the care they need; 2) experiencing avoidable emergency room visits, hospitalizations and institutional stays; 3) knowledgeable about opportunities to improve health outcomes; 4) accessing preventative care and routine labs; or 5) experiencing gaps in care or service transitions. Getting this full view is complicated by separate Medicare and Medicaid funding streams where data systems are not aligned and cost shifting between fund sources is common.

3. Fee-for-service (FFS). Another key feature is the reliance on fee-for-service (FFS) payment (described in detail under Question 6 below).

Approximately 1.2 million individuals enrolled in Medicaid receive primary care, other physical health and limited mental health services purchased by the Health Care Authority (HCA) through managed care and fee-for-service financing arrangements. Those services cost the state and federal government approximately $10 billion each biennium. Since July 1, 2012, about 70 percent of all Medicaid enrollees are covered by one of five managed care plans.

RECENT PROGRESSWashington State has made promising progress in the integration of allied services, such as behavioral health, substance abuse, developmental disabilities, elder care, community health, and home and community-based support services. The state recently submitted its Pathways to Health : Medicare and Medicaid Integration in Washington State proposal to CMS to accelerate integration of these services under §2703 of the Affordable Care Act,

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including improved care for dual eligibles. This proposal requires providers serving high-risk populations to identify a lead caregiver and coordinate the care provided.The state can also point to several successful initiatives to integrate care across systems, including:1. Disability Lifeline Program (DL) 5: For over two decades, Washington has provided cash

and medical benefits for disabled adults who had not (yet) qualified for SSI or SSDI disability benefits. In 2010, the Legislature modified the program to transition clients to a managed care plan – Community Health Plan of Washington – whose network is largely comprised of FQHCs and RHCs. The new program added onsite behavioral health coverage or active coordinate to link to behavioral health. Subsequent evaluation found that the target population, which was at high risk for substance and mental health problems, showed improvements in behavioral health status as well as reductions in inpatient days.

2. HB 1738 : The Legislature demonstrated its commitment to integrating care across systems when, in 2011, it passed HB 1738, requiring the Health Care Authority and Department of Social and Health Services to conduct a community-based process to more effectively coordinating “. . . the purchase and delivery of care, including the integration of long-term care and behavioral health services.” The agencies’ report included concrete steps to purchase health care through MCOs that “. . . compete based on service, access, quality and price and . . . [through] robust health home functions . . ..”

3. Chronic Care Management (CCM) : program provides high-risk clients with enhanced nurse care management services in five pilot sites across Washington State. Early results showed reduced inpatient and ER utilization, resulting in net savings of $27 PMPM, as well as longer lifespans and less care in institutional settings.

4. Washington Screening, Brief Intervention, and Referral to Treatment (WASBIRT): evidence-based public health practice training providers, including primary care, to conduct routine alcohol and drug screening. Results show more rapid access to treatment leading to better health outcomes.

Multipayer Medical Home Project : There are a growing number of efforts in Washington focused on how to measure and pay for better outcomes.  Currently nine clinics across the state are engaged in medical home projects.  Participating providers receive a PMPM ($2.50) to cover care coordination, expand access to after hours, disease registries and team management.

See Appendix A for a more complete list of current Washington State health care system delivery initiatives.

FUTURE HEALTH SYSTEMOnce implemented, the future health system will have the following characteristics: 1) evidence based practices, 2) effective management of chronic conditions, and 3) value based accountable care.

5 Unützer, J, et al. Quality Improvement With Pay-for-Performance Incentives in Integrated Behavioral Health Care, in American Journal of Public Health, April 19, 2012.

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1. Evidence-based Practices: As described in this plan, Washington State has been in the forefront of states emphasizing rigorous reviews of services and products to assure that they are safe and effective, including the Bree, the Generics First program and the Health Technology Assessment Program (HTAP). The project will extend these efforts through the Bree Collaborative, i.e., developing best practice recommendations; providing training via the DOH Collaborative Learning program, and modifying payment strategies to support best practices. The state will also explore changes to help providers and payers lower their risk of liability exposure by following approved evidence-based guidelines. Using these approaches, we intend to transform the practice culture in Washington State to provide care that is supported by research and found to be safe and effective.2. Effective Management of Chronic Conditions: The Model’s efforts will complement those of the §2703 Health Home and Dual Eligibles projects. There will be greater emphasis on primary care, especially medical homes serving people with chronic conditions. Strengthening primary care, through training, modified reimbursement and contractual performance metrics, will be critical to achieving the Triple Aim. A key element of enhanced primary care will be the inclusion of behavioral health services. For example, building on earlier projects cited above, and consistent with the Pathways to Health proposal, there will be an expectation for medical services delivery integrated or closely linked with behavioral health services. Training provided under DOH collaboratives will include behavioral health screening and intervention and, since the project affects both private and public payers, training regarding long-term care will focus on screening, referral and coordination. Primary care practices need not be experts in long-term care services, but training will develop capacity to screen for unmet needs and refer to appropriate resources. For clients receiving LTC services, the focus will be on shared treatment planning and regular communication.3. Value Based Accountable Care. Typically, ACO’s use primary care as central tools; however the most successful programs have integrated specialty and hospital care - where expenditures are highest. Nationally models like the PROMETHEUS, ProvenCare (Geisinger), Group Health Cooperative (GHC) and Inter-Mountain Care are called out in the literature along with a promising model in Blue Cross Blue Shield of Massachusetts where the health care system’s in which financial and clinical goals are aligned. However, these systems are already highly integrated (and have developed over many years cultures that support higher-value, lower-cost care) and do not fit situations where PCP and specialist practices operate independently of facilities. The grant will offer a testing ground where larger systems do not exist or are not integrated across professional and facility care. The Model will adapt elements of the Massachusetts BC/BS Alternative Quality Contracts (AQC) payment model. The AQC can help construct “virtual” ACOs by aligning incentives:

1. Gain sharing to stabilize spends and trends;2. Feedback reports to reduce variation3. Functional integration of systems (e.g., PCP, facility and medications)4. Incentive payments f for providers achieving quality metrics

This approach has particular resonance for communities that are developing Regional Health Improvement Collaboratives. Communities, like Whatcom (Bellingham), Yakima, Thurston, Spokane and Clark (Vancouver) counties are moving to link and coordinate a

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wide range of services at the local level where services are delivered. The AQC model provides a natural vehicle to accelerate these efforts.As a first step, Washington proposes to adapt the AQC model to pay for integrated services for births starting with a global budget negotiated with a set of professionals and their associated hospital(s). Professionals and hospitals that achieve a lower target cost will receive a portion of the savings.Providers can receive additional payments upon achieving quality outcomes, such as very low 37-39 week elective non-medically necessary delivery rates. In 2011-12, Washington used a similar model (the hospital quality assessment) to pay an incentive based on five quality targets with four gates. The program demonstrated a significant change in all quality measures, including a 65% reduction in 37-39 week elective deliveries6.Payers will agree to a core standard set of quality and utilization measures for the infant and maternal project and the chronic care medical home as a requirement for participating in the CMMI project.The Legislative health care committee chairs have expressed willingness to support legislative changes, where recommended, to further incentivize providers and facilities to coordinate efforts.  The chairs are currently conducting meetings with stakeholder groups on this topic.

5. Report on opportunities for or challenges to adoption of Health Information Exchanges (HIE) and meaningful use of electronic health record technologies by various provider categories, and potential strategies and approaches to improve use and deployment of HIT.

Washington State the advantage of being an early adopter of electronic health records and a health information exchange. In a prescient move, 2009 Legislature passed SB 5501, establishing a lead agency and process to build a health information exchange. Shortly after passage, the state received ARRA funding enabling it to proceed quickly in constructing the Exchange. The HIE provides centralized shared services, including: Hub for secure exchange of HL7 and X12 transactions; Master Person Index (MPI) to match patient identities; and Provider Directory. Patient information will be accessed in a secure fashion from decentralized sites. Over time, the HIE will benefit this project in two ways: 1) assist in the aggregation of patient data to generate timely reports so providers can better coordinate care; and 2) permit providers to directly query patient data, such as lab results and medications prescribed by other practitioners, to improve day-to-day care.Washington has a variety of Health Information Technology (HIT) and Health Information Exchange (HIE) initiatives in communities and organizations across the state. Electronic Health Record (EHR) adoption appears to be above average compared to the nation as a whole, and there is an active interest in Personal Heath Records (PHR). While no community or organization has met all its HIE needs, there is a significant electronic health information infrastructure that serves as a foundation for statewide HIE including

6 http://www.wsha.org/0382.cfm

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Medicaid, Public Health, other state agencies, the Regional Extension Center, the Beacon Community grantee, the Community College Consortia, and various Federal organizations.

HIE Organization for Washington, OneHealthPort. HCA designated OneHealthPort, a private sector health information technology management organization, to serve as the lead HIE organization for Washington. In this role, OneHealthPort is responsible for:

1. Leading initial development of HIE in a manner that will comply with the new State law (SB 5501 is now part of the Revised Code of Washington, Chapter 41.05);

2. Satisfying the grant objectives of the Federal Health HITECH Act; and 3. Attracting private and public sector stakeholders to invest and participate in HIE.

OneHealthPort is governed by the Foundation for Health Care Quality, a community not-for-profit organization that also plays a key role supporting the efforts of the Bree Collaborative. The HCA coordinates the work of the public sector and other American Recovery and Reinvestment Act (ARRA) programs while providing any additional oversight needed by the Foundation and OneHealthPort.

The architecture is a “thin-layer” model built to harness and leverage the existing HIT/HIE capabilities in the state. The modest scope of the HIE also enhances sustainability of the HIE and reduces privacy and security barriers to information exchange. The shared services to be centralized in the HIE include:

1. Hub for secure exchange of HL7 and X12 transactions 2. Master Person Index (MPI) to match patient identities 3. Record Locator Service (RLS) to find where patient data resides 4. Provider Directory to identify and locate trading partners 5. Standards and conventions to support trusted and efficient exchange 6. Management organization to operate the HIE

The services to be decentralized and offered in the marketplace by other parties include: 1. Data repository for storing patient information 2. Data transformation to edit and translate information 3. Applications for viewing, storing and using information

Figure 10. HIE Organization for Washington, OneHealthPort

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Current State and Gap Analysis of EHR Adoption and Meaningful Use Washington State has higher adoption rate of EHRs than many other markets (75% of office-based practices in Washington vs. 57% nationally). Since launching in June 2011, the EHR Incentive Program has received more than 2,700 Washington registrants. As of June 25, 2012, more than 2,140 professionals and hospitals have been approved as eligible for more than $104 million in federal incentive payments.

Although EHR adoption rate is relatively high, considerable gaps remain related to the emerging definitions of meaningful use. The biggest gap in the current structure is the inability to exchange all required CCD information between these hospitals and the care provider at the transition of care. 27 of the 50 hospitals within this region are currently connected and can exchange information, and all physicians have the ability to electronically receive information from those hospitals as well as reference laboratories and imaging centers. However, there needs to be a more robust exchange available to connect those not currently sharing information. Beyond HIE, providers in the region need help to make better use of their existing EHRs for chronic disease management and quality measure reporting. Organizations in this region have significantly promoted chronic disease management, most notably the Washington State Diabetes Collaborative. This initiative of the WA DOH provided physicians with tools and guidance to implement best practices regarding patients with diabetes. The Collaborative has been very successful and has served as a model for the rest of the country. However, small physician practices

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generally have not adopted tools to support disease management or utilized existing capability in their EHRs. Providers also need to be able to generate and submit reports to quality monitoring organizations and provide patients with electronic access to their health information.

6. Describe delivery system payment methods both “current as is” and “future to be” payment methods.

CURRENT SYSTEMAs noted under Question 4, in Washington State fee-for-service is the predominant payment method – one that tends to incent volume of care with even when it may not be necessary. Like all other regions, Washington sees considerable service variation, as documented by the Dartmouth Atlas and similar studies. The state does have a noteworthy fully integrated HMO in Group Health Cooperative, which has been able to document gains in quality and efficiency. However, it is worth noting that even in a system like Group Health, where incentives are well-aligned, recent research7 indicates that actual physician practices can reflect community standards – even if those standards lack an evidence basis.

FUTURE SYSTEMFour years into implementation, we will see wider adoption of non–FFS payment methods that are tailored to address the particular conditions or patient needs and providing greater flexibility than the current system. Examples include:1. Bundled rates for specific conditions or episodes of care . These will all share an

emphasis on combining payment for all stages of treatment (including facility and outpatient) to strengthen coordinated care and follow-up. All Washington payers (FFS and managed care) currently pay professionals and hospitals using CPT and DRG coding, and have some experience paying a global professional fee for prenatal, delivery of any type and post-natal care.  More recently, Washington Medicaid changed the DRG weights, paying low risk C-sections high risk vaginal rates (effectively lowering the average payment by nearly $1000 per low risk C-section).

2. Gain- Sharing. In the future, certain episodes of care, such maternity and delivery, will benefit from gain-sharing. Professionals meeting a defined goal would be given an enhanced rate for the following year.  Professional and hospitals not integrating care would not gain share.  Adapting existing FFS payment systems for this purpose will achieve our goals while minimizing administrative overhead and changes to existing contracts.

3. Upfront payments for certain services, such as primary care, to build an infrastructure capable of employing best practices.

4. Continued use of FFS and capitated payments for certain episodes of care.

The payment changes will occur under the rubric of contracts modeled after the AQC contract, as described under Question 4 in this document.

7 http://jama.jamanetwork.com/article.aspx?articleid=1182858

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In sum, we expect greater diversity of payment approaches in the future. However, at the same time, we expect less diversity among payers’ administrative practices. To assure providers will participate in reformed systems, we expect participating payers to agree to use the core standard set of quality and utilization measures for the obstetrics project and managing chronic conditions.

7. Describe health care delivery system performance “current as is” and “future to be” performance measures.

One of the key features of this proposal is its emphasis on systemic change across many payers. This distinguishes it from other concurrent initiatives such as §2703 funding for Health Homes and the Dual Eligibles project – both of which are limited to the Medicaid and Medicare populations. While these are critical efforts, we recognize it is difficult for providers to modify their practices for certain payers and not for others. This proposal addresses that issue by engaging providers and large payers to promote practice transformation – changes that will also enhance the Health Homes and Dual Eligibles projects.

CURRENT SYSTEMEfforts to measure performance in the current system can be described as fragmented, at best. As is the case nationally, most providers are paid based on the volume of services delivered rather than on quality or value. Across the system, there are some broader yardsticks, such as accreditation entities (e.g., JCAHO); but accreditation often reflects adherence to process requirements, instead of health outcomes. There are some entities – such as Group Health Cooperative, the Everett Clinic and the Virginia Mason Medical Center, among others, who have moved beyond the status quo by implementing evidence-based practices, conducting their own research, and using LEAN methods to promote continuous quality improvement. In addition, there is growing reliance by purchasers on performance measures as exemplified by the Puget Sound Health Alliance and the Health Technology Assessment Program (HTAP), but their direct linkage to payment levels is limited. For example the HTAP has successfully reduced reliance on unproven or non-beneficial interventions; but its findings have been applied primarily by state health purchasing agencies and not widely in the private sector. The Puget Sound Health Alliance has successfully aggregated claims data to generate provider quality reports; but, until recently, these were limited to five counties in the metropolitan Seattle area (King, Kitsap, Pierce, Snohomish and Thurston counties). Beginning in 2013, the Alliance will report statewide, with quality metrics by county.In addition, the physician driven, clinically derived quality measurement programs of the Foundation for Health Care Quality are nationally unique and have been successful for years in providing measured, benchmarked feedback to physicians and hospitals statewide. Many improvements have been, and continue to be documented in the fields of interventional cardiology, general and pediatric surgery, vascular surgery, spine care and surgery, and obstetric care. This important work will continue and it will be available to form the necessary clinical basis of any quality/cost analyses.

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FUTURE SYSTEM: The CMMI grant will have an enormous impact on the use of evidence-, performance-based measures. The Bree Collaborative and the Puget Sound Health Alliance will be the grant implementation venues. The Bree currently evaluates the research and selects up to three episodes of care that are high-cost but low value and then develops recommended evidence-based best practices. Under the grant, the Bree Collaborative’s role will be expanded to include payment reforms, such as bundled payments for obstetrics care. The Collaborative will apply this improvement cycle to other episodes of care, such as appropriate management of low back pain, potentially avoidable readmissions and interventional cardiology services. The grant will convene payers, purchasers and providers followed by rapid, broad adoption through the DOH collaborative learning programs and payment modifications. These steps will lead to broad adoption of agreed-upon performance measures across payers and providers in the state by the end of the grant period.

The Alliance has extensive experience in aggregating claims data to generate reports (community checkups) depicting performance of provider organizations. This role will continue on a broader basis in the future with the Alliance accepting claims data from payers statewide. The aggregated data will support the development of performance metrics and related reports.

The following table provides examples of performance measures, a subset of which the project will employ during the life of the grant. These will be refined during the first six months of the grant period and are expected to continue in use after the grant expires.

Table 7. Performance Measure Inventory Is this complete?# Measure Existing Quality Effort Inventory1 Flu Shots2 BMI Assessment DOH used CDC funding through Healthy Communities program to provide

outreach to providers to raise awareness of the Medicare obesity screening benefit. DOH will integrate improvement strategies into provider training through collaboratives, other initiatives

3 Breast Cancer Screening

CHC funds a cancer screening coach through DOH to provide education to clinics on breast cancer guidelines. Will incorporate into collaborative learning where there is clinic-level interest.

4 Cervical Cancer Screening

CHC funds a cancer screening coach through DOH to provide education to clinics on cervical cancer guidelines. Will incorporate into collaborative learning where there is clinic-level interest.

5 Smoking Cessation

One of the Million Hearts Campaign core aims. DOH contracts to provide training and outreach to providers in the screening and treatment of tobacco users, including modification of their clinical systems.

6 Depression Screening & Follow-up

DOH will be incorporating PHQ-9 and other mental health screening tools into collaborative learning activities.

7 Readmissions There are many statewide initiatives including those involving DOH, QUALIS, WSHA, WSMA, and the Alliance under contract to HCA to improve the safety

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# Measure Existing Quality Effort Inventoryand efficacy of transitions across health care settings and reduce admits.

8 Diabetes Admissions

9 COPD Admissions10 CHF Admissions11 Adult Asthma

AdmissionsDOH currently provides technical assistance and training to safety net providers and tribal clinics on asthma upon request and supports several pilot home visiting programs.

12 Chlamydia Screening

DOH does not currently have a targeted improvement effort underway beyond on-going consultation and assistance to Take Charge providers and in support of adolescent health services.

13 MH Hospital Follow-up

14 Elective Delivery Extensive statewide QI project just concluding. The Governor’s Bree Collaborative published their final obstetrics care report and recommendations in August 2012. Since 2009 DOH has sponsored and staffs the quality work plan of the Perinatal Advisory Collaborative with support from HCA and in collaboration with WSHA.

15 Antenatal Steroids16 Annual HIV/AIDS

visit17 High Blood

PressureReflects one of the Million Hearts Campaign core aims. DOH provides support to clinics through collaborative learning to improve measurement and management of blood pressure, including medication and lifestyle management.

18 LDL-C screening Reflects one of the Million Hearts Campaign core aims - for all patients (not just those with diabetes).

19 A1c Testing DOH will be integrating strategies for A1C improvement through collaboratives and other initiatives.

20 Antidepressant Med Mgmt.

The Alliance asks providers to track and use the PHQ9 reporting tool to assess mood.

21 Antipsychotic Adherence

The HCA uses a statewide set of reports on Red Flags (dose, poly-pharmacy and adherence) to all CMHCs in WA.

22 Persistent Med Mgmt.

DOH and training partners (WSHA, Qualis, WSMA, the Alliance) are developing strategies to support more frequent medication reconciliation and monitoring, particularly in transitions between healthcare settings.

23 CAHPS Survey DOH is looking at aligning CG-CAHPS survey strategies with those used by the Puget Sound Health Alliance to provide clinics with feedback on patient experience in their practices.

24 Care Transition Record

DOH is working with Qualis, WSHA, WSMA, and managed care organizations under contract to HCA to improve the safety and efficacy of transitions across health care settings and reduce readmits.

25 AOD Initiation & Engagement

26 Postpartum Care Rate

DOH is not currently providing on-going training on prenatal and postpartum care, but does monitor rates and is very concerned about access issues due to primary care shortages. DOH sponsors and staffs the Perinatal Collaborative with support from HCA.

27 NICU Data All but two level 3 NICUs (UW and Fort Lewis) report to the VON data set. Ten Level 1-2 NICU report to the FHCQ/OB-COAP

28 ED Utilization HCA tracks total ED use, low acuity, PRC/Lock-in and narcotic utilization using the NY University list of non-emergent conditions. The Alliance tracks non-emergent ED utilization with the CA list of non-emergent conditions. The “ER is for Emergencies” campaign of WSHA, WSMA, and WA-ACEP is implementing seven target strategies to reduce unnecessary use of the ER.

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# Measure Existing Quality Effort Inventory26 Brand Generic

UseHCA tracks brand generic use in six drug classes targeting high brand use providers. The Alliance targets drug four classes publically reporting rates by clinic.

8. Describe the current health care cost performance trends and factors affecting cost trends (including commercial insurance premiums, Medicaid and CHIP information, Medicare information, etc.). Section to be completed by fiscal staff based on assumptions used in financial modeling

9. Describe the current quality performance by key indicators (for each payer type) and factors affecting quality performance.

CURRENT QUALITY PERFORMANCE MEASURESWashington State agencies maintain numerous health care databases for their own programs, but strong interagency relations allow departments to share and link data effectively, including:

• Vital statistics records (birth and death certificates);• Medicaid claims data;• Washington State employee claims data;• Claims and chart reviews mirroring the NQF;• CMS children and adult quality measures.

Washington State currently uses vital records data to monitor statewide all 37-39 week preterm outcomes through the quality assessment project8, supplemented by individual hospital data from the Washington State Hospital Association.. Two other JCAHO metrics (i.e., NTSV C-sections, and Vaginal Births after C-section) are publicly reported by hospital with peer-to-peer comparisons and statewide goals. By the fourth quarter of 2012, provider specific peer-to-peer comparisons reporting on OB outcomes will be available for individual providers on a secured website. These efforts are augmented by the Puget Sound Health Alliance (the Alliance) with public reporting of clinic variation and will soon be reporting prescriber data with generic and brand use rates. This grant will allow us to progress to the next phase of linking professional and facilities outcomes.The HCA and the Alliance use claims data across public and private programs to produce predictive modeling and feedback reports to providers. The DSHS PRISM program allows a provider to view historical claims data (prescription history, hospital and ED use) as well as a prediction score that categories a client’s risk level. PRISM is a tool to assist providers

8 http://www.wsha.org/wshaNews.cfm?EID=2012-05-09%2000%3A00%3A00%2E0

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and case managers in targeting and prioritizing interventions in medical homes and mental health clinics.Claims histories are also used in feedback reports to providers to reduce inappropriate variation. The power of this approach is demonstrated by the Generics First initiative that targeted 800 high users of brand name medications. By feeding back prescription utilization data, generic fill rates rose from 68% to 85% in the Medicaid program. This was accomplished by targeting only the highest variation providers. At this time only four prescribers remain statistically variant from their peers. Other feedback reporting includes ED utilization (over use, low acuity use and narcotic prescriptions), statewide mental health prescribing history (too much, too many, too young and medication adherence) in conjunction with the PRISM data.Many of our payers have similar risk adjustment programs (AP-DRG, DXCG, ETG groupers), which can mirror the DSHS PRISM predictive modeling. Washington State has found that providers and case managers are very interested in this data to supplement care decisions. This grant will allow learnings to be shared across these multiple payers and assist us with standardizing reporting and integrating these models into the HIT solutions.Factors affecting quality performance. As discussed above, Washington has been on the cutting edge for adopting quality performance measures; nevertheless, major barriers remain. Key factors include:1. Fragmentation resulting from multiple payers . Providers answer to many payers, many

of which have few or no quality performance metrics. Others employ such metrics but what is measured and how it is measured can vary among payers.

2. Lack of agreement on what is important to measure . Historically, credentialing organizations tended to emphasize process measures as proxies for measuring quality. In recent years, as evidence-based research has expanded, there has been increased effort to construct measures reflecting that research; however, we are still at an early stage of developing such measures.

FUTURE QUALITY MEASURES: Quality Improvement in Episodes of CareMoving from low value/high costs to high/value low cost paymentsObstetrics: There is growing national consensus on what constitutes quality OB outcomes, spurred by good evidence that elective delivery of pre-term infants can lead to morbidity, mortality, and higher costs (NICU admissions, infection, re-hospitalization and long term poor academic performance)9.Washington’s recent quality assessment saw a 65% reduction in elective 37-39 week deliveries across all hospital, achieved due to the efforts of the statewide perinatal collaborative with the support of the WSHA and other professional associations. Meeting our statewide goal of less than 5% elective preterm delivers will likely be realized.In addition, there is now agreement through the Bree and statewide Perinatal Advisory Committee and by OB COAP members that reductions in elective deliveries including inductions and primary C-sections can have a positive effect on quality, reduce costs and

9 Hoffmire CA, et al. “Elective delivery before 39 weeks: the risk of infant admission to the neonatal intensive care unit”, in Maternal Child Health J. 2012 Jul;16(5):1053-62.

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improve access to needed services. Washington State has seen a 75% increase in the use of C-sections over the past decade and a drop in access to VBAC services (from 40% to 15%). By linking professional and facility care payments we hope to reduce trends in primary C-sections by replacing them with higher value lower cost vaginal deliveries. By targeting prematurity we hope to increase statewide average gestational age thus reducing NICU admissions and other downstream costs. The central theme is to use evidence-based best practices based on accurate clinical data -+measurements, quality metrics and payment reform as an incentive to improve infant and maternal outcomes. This approach to changing practices is at the heart of our efforts under this grant.

Performance Measures in Managing Chronic Conditions: The medical home offers better access to primary care, prevention efforts and integrated case management. Reducing hospitalizations, re-hospitalizations and ED use are all good indicators of the cost of care reductions, yet may not be indicators of better care. These measures have already been employed in various pilot projects, such as the Boeing IOCP, and the Multi-Payer Health Home project. The CMS adult measures offer more process-oriented metrics to track the health of clients and reduce inappropriate variations in care. In addition, we note the important link between chronic diseases, mental illness and or substance abuse. At present, integrated solutions are few and far between. By linking professional and facility payments we hope to improve effective care transitions for those clients that represent the 5% of the population who spend 50% of the dollars. For this reason Washington intends to look at new metrics (i.e. episodes of care outcomes) to design, educate and measure the effectiveness of a medical home. Measures for managing chronic conditions are described in detail under Question 12 below.

10. Describe population health status measures, social/economic determinants impacting health status, high-risk communities, and current health status outcomes and the other factors impacting population health.

The Washington Legislature’s passage of Substitute Senate Bill 6197 in 2006 is an example of our state’s effort to reduce health disparities. This legislation created a governor’s interagency council on health disparities, charged with conducting health impact reviews to determine the extent to which proposed legislative or budgetary actions improve or exacerbate disparities in health. The interagency council is also required to develop an action plan to develop policies and strategies that address social factors driving health disparities. Developing a better understanding of the social and economic determinants of health is essential to reduce health disparities among Washington State residents. Public health professionals are partnering with communities and with local and state agencies to implement policies and programs designed to address social and economic factors associated with poor health outcomes.In 2007, Washington State Department of Health addressed the impact of social determinates in their statewide assessment of health status, health risks, and health care services The Health of Washington State.Factors related to lifestyle. Several important behavioral risk factors for poor health are more common among people in lower socioeconomic position (SEP) groups. Washington

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adults with lower incomes or less education are more likely to smoke, be obese, or eat fewer fruits and vegetables than adults with higher incomes and more education. Lack of money and conditions associated with poor neighborhoods can make healthy lifestyles or ways of living difficult to achieve for people in lower SEP groups. The broader culture also influences ways of living so that an individual’s risk of illness mirrors that of the population group to which he or she belongs. For example, in cultures where smoking is culturally unacceptable for women, women die less often from smoking-related diseases than women in groups where smoking is socially accepted. Factors related to medical care. Lack of access to or inadequate use of medical services, especially preventive services, contributes to relatively poorer health among people in lower SEP groups. Some research suggests this occurs because health care received by the poor is inferior in quality or because other factors, such as cultural differences, remain as barriers to access. People might also need social resources, such as knowledge, wealth, prestige, and social connections to take advantage of new health-enhancing technologies. International comparisons suggest that higher medical expenditures do not necessarily result in better community measures of health, such as life expectancy. This research suggests that broader social and economic conditions that lead to poor health are more important for the health of the population as a whole than medical care once a person has become sick.21 Support for this perspective comes from the 2006 World Health Report, which shows that the United States ranks first among all 192 member nations in per capita health care expenditures ($5,711 per person per year in 2003 U.S. dollars) but ranks 24th in life expectancy.Income inequality. The distribution of wealth in a society often plays a role in health disparities. Income distribution is often studied in terms of quintiles or fifths. If income were evenly distributed across all households in an area, a fifth of all households would receive a fifth of the total income. In 2000, the wealthiest 20% of Washington households received almost 50% of the income, while the poorest 20% received less than 5%. A widening gap between rich and poor might adversely affect the health of all members of society. This has been demonstrated in the United States. Greater inequality in income distribution has been linked to WA’s disparities in infant mortality, teen birth rates, as well as violence and all-cause mortality.Factors related to the physical environment. Low socioeconomic neighborhoods often do not have safe parks and trails that provide opportunities for physical activity. They can also lack access to affordable, healthy foods. In addition, tobacco products and alcohol are marketed more aggressively in low-income communities. People with lower incomes often live or work in environments where they are exposed to harmful chemicals and other toxins. For example, children who live in older or dilapidated housing can be exposed to indoor allergens and irritants that provoke asthma and increase its severity. Members of lower socioeconomic groups are also more likely to work as manual laborers. These jobs are associated with increased risk of occupational injury or death and exposure to toxic substances. Low socioeconomic neighborhoods are frequently located near toxic waste sites and other potential environmental hazards.

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11. Describe specific special needs populations (for each payer type) and factors impacting care, health, and cost.

The Department of Social and Health Services (DSHS) provides $7 billion in services each biennium to people with needs related to physical, cognitive, or developmental disabilities, and for people facing challenges related to mental health or chemical dependency. Those services reach approximately one in five of the people enrolled in Medicaid. DSHS spends its funds on four main types of activities: 1) community-based services; 2) institutional services; 3) eligibility, case management and quality assurance; 4) program support/administration.

DSHS community-based and institutional spending on the populations that are the focus of this report is organized in four main ways (all numbers are for the 2011-13 Biennium, are rounded and approximate):

1. Long-term services and supports for people with physical and/or cognitive disabilities.

$3 billion is appropriated and distributed to providers on a fee-for-service basis for the following major services:

a. $1 billion for nursing home care for approximately 11,000 people each month. b. $2 billion to purchase assistance with activities of daily living, such as bathing,

dressing, personal hygiene, and help with mobility, for 44,000 people each month. $1.4 billion of that provides help in the client’s own home, with the balance provided in adult family homes or boarding homes.

Figure 11. Community Based and Institutional Spending: DSHS/ADSA Expenditures, All Fund Sources 2011-2013 Biennium

Community-Based Services67%$4.9 Billion

Institutions26%

$1.9 Billion

Eligibility, Case Management, Quality Assurance$383 Million

5%

Program Support$109 Million

1.5%

SOURCE: Aging and Disability Services Administration, March 2012

2. Long-term services and supports for people with developmental disabilities.

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$2 billion is appropriated and distributed to providers on a fee-for-service basis for the following major services:

a. $350 million for state-operated Residential Habilitation Centers, which care for 800 people.

b. $577 million for instruction and support to persons who live in their own homes in the community.

c. $527 million for activities of daily living assistance similar to what is described above for long-term care.

d. $330 million in supports that help people live in the community, including employment, family support and programs to preserve public safety.

3. Supports for people with serious mental health diagnoses.

$1.6 billion is appropriated for the following services:

a. $445 million for state-operated mental health hospitals that serve 2,400 people in a year.

b. $1.1 billion for community mental health services, purchased through 13 Regional Support Networks operating as Prepaid Inpatient Health Plans. Community mental health services reach 129,000 people each year and include outpatient and residential treatment, crisis and commitment services, crisis stabilization, family treatment, medication management, peer supports and employment and housing supports.

4. Supports for people with chemical dependency challenges.

Approximately $345 million is appropriated for services that reach approximately 40,000 people each year, primarily purchased through DSHS-administered contracts with counties. The services include: assessment, crisis management, acute and subacute detoxification, outpatient and residential treatment and criminal justice programs.

The conditions and support needs that are the subject of this report—disabilities, mental illness, and substance abuse—frequently co-occur. For people who are high medical risk and not dually eligible for Medicare, almost two thirds have at least one of those additional risk factors and 28 percent have more than one additional risk. For those who are high risk and dually eligible for Medicare and Medicaid, 91 percent have at least one additional risk factor and 31 percent have more than one additional risk.

The current medical system and the systems of support managed by DSHS are not designed to address that level of complexity. Service planning does not create coordinated responses to address co-occurring needs. Financing is not aligned to support comprehensive responses. The current administrative structures have not been charged with the responsibility or given the authority to be held accountable for addressing such complexity. More than any other factor, correction of those shortfalls is the driving force behind the recommendations in this report.Washington State has made promising progress in the integration of allied services, such as behavioral health, substance abuse, developmental disabilities, elder care, community health, and home and community-based support services. The state recently submitted its

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Pathways to Health : Medicare and Medicaid Integration in Washington State proposal to CMS to accelerate integration of these services under §2703 of the Affordable Care Act, including improved care for dual eligibles. This proposal requires providers serving high-risk populations to identify a lead caregiver and coordinate the care provided.The state can also point to several successful initiatives to integrate care across systems, including:1. Disability Lifeline Program (DL) 10: For over two decades, Washington has provided

cash and medical benefits for disabled adults who had not qualified for SSI or SSDI disability benefits. In 2010, the Legislature modified the program to transition clients to a managed care plan – Community Health Plan of Washington – whose network is largely comprised of FQHCs and RHCs. The new program added in situ behavioral health coverage or active coordinate to link to behavioral health. Subsequent evaluation found that the target population, which was at high risk for substance and mental health problems, showed improvements in behavioral health status as well as reductions in inpatient days.

2. HB 1738 : The Legislature demonstrated its commitment to integrating care across systems when, in 2011, it passed HB 1738, requiring the Health Care Authority and Department of Social and Health Services to conduct a community-based process to more effectively coordinate “ . . . the purchase and delivery of care, including the integration of long-term care and behavioral health services.” The agencies’ report included concrete steps to purchase health care through MCOs that “ . . . compete based on service, access, quality and price and . . . [through] robust health home functions . . ..”

3. Chronic Care Management (CCM) : program provides high-risk clients with enhanced nurse care management services in five pilot sites across Washington State. Early results showed reduced inpatient and ER utilization, resulting in net savings of $27 PMPM, as well as longer lifespans and less care in institutional settings.

4. Washington Screening, Brief Intervention, and Referral to Treatment (WASBIRT): evidence-based public health practice training providers, including primary care, to conduct routine alcohol and drug screening. Results show more rapid access to treatment leading to better health outcomes.

Multipayer Medical Home Project : There are a growing number of efforts in Washington focused on how to measure and pay for better outcomes.  Currently some nine clinics across the state are engaged in medical home projects.  Participating providers receive a PMPM ($2.50) to cover care coordination, expand access to after hours, disease registries and team management.

12. Describe delivery system cost quality and population health performance targets that will be the focus of delivery system transformation. Note: cost and population health targets are being developed as assumptions under the financial modeling. Once drafted, those will need to be referenced here.

10 Unützer, J, et al. Quality Improvement With Pay-for-Performance Incentives in Integrated Behavioral Health Care, in American Journal of Public Health, April 19, 2012.

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Selection of delivery system cost quality and population health performance targetsReview of metrics relating to deliveries and medical homes finds both national and consensus definitions from which to build a quality incentive program. Beginning with the 26 core adult measures, several relate to deliveries and all relate to the Medical Home. Many of these measures currently exist in statewide reports based on vital records (all births). Other measures are being acquired across hospital systems (e.g. level 3 NICU supply outcomes data to the Vermont Oxford Network) and several hospitals participate with the FHQC OB-COAP efforts. Many of the measures are in keeping with Healthy People 2020, National Quality Forum, and the Joint Commission.Washington will use its reporting to include a disparities analysis to detect those with greater needs and warp programs around these needs.

Managing Chronic Conditions Performance Targets: will use a subset of the same quality measures tracked in the Community Checkup reports of the Puget Sound Health Alliance (drawn from HEDIS indicators). These quality indicators are defined in Table X as follows:

Table 8. Chronic Care Medical Homes Quality Measures

# Quality Measure Definition

1 Diabetes - HbA1c testing Percentage of people with diabetes 18 -75 years old that had a hemoglobin A1c test in the last year.

2 Diabetes - Cholesterol testing Percentage of people with diabetes 18-75 years old that had a LDL cholesterol test in the last year.

3 Diabetes - Nephropathy screening

Percentage of people with diabetes 18-75 years old that had a kidney-screening test in the last year.

4 Heart Disease - cholesterol testing

Percentage of people with cardiovascular disease 18-75 years old that had LDL-C screening in the last year.

5 Heart Disease - cholesterol lowering medication

Percentage of people with cardiovascular disease 18-75 years old who are prescribed a lipid lowering therapy in the last year.

6 Depression medication adherence at 12 weeks

The percentage of people 18 -75 years old of the measurement year who were diagnosed with a new episode of major depression, were treated with antidepressant medication and remained on an antidepressant drug during the entire 84-day (12-week) Acute Treatment Phase.

7 Depression medication adherence at 6 months

The percentage of people 18 -75 years old of the measurement year who were diagnosed with a new episode of major depression, were treated with antidepressant medication and remained on an

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# Quality Measure Definition

antidepressant drug during the entire 180-day (6 months) Continuation phase.

The Alliance will convene a work group for quality measure assessment and achieve agreement on a set of measures, including those above and others, particularly targets already set by the Department of Health, Department of Labor & Industries COHE program, Medicare STAR ratings, which, for example, Regence has already incorporated. The Alliance will report these measures in a timely fashion, and the data set for these metrics will accompany the separate data files constructed for the project evaluation under a data use agreement similar to those utilized in prior projects. The quality measures will be aggregated to the practice and facility level and scored as a practice-level composite reflecting the seven individual metrics. An actuarial firm will perform this calculation on data submitted to it from health plans and calculate the margin of error using practice data from the baseline time period. The practice will receive payment if the quality score in each observation period is within the margin of error at or above the baseline quality score.

OB and Delivery Performance Targets:OB and Delivery targets will reflect measures described above, i.e., reducing morbidity, mortality, unsupported variation in care and costs by reducing elective pre-term deliveries including inductions and primary C-Sections, and increasing the rate of VBACs. By targeting prematurity we hope to increase statewide average gestational age, thus reducing NICU admissions and other downstream costs. The central theme is to use clinically based evidence, quality metrics and payment reform as an incentive to improve infant and maternal outcomes. Measures: The following table depicts a range of metrics for quality and health

performance for OB and delivery. A subset of these plus other measures will be used in the project:

Table 9. OB & Delivery Quality Performance Measures # Measure Existing Quality Effort Inventory1 Elective Delivery The current Washington Medicaid Quality Assessment

Program uses The Joint Commission elective delivery measure, which is supported by the National Quality Forum (NQF) and the Hospital Corporation of America,. The measure is “patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed.”

2 Postpartum Care Rate

DOH is not currently providing on-going training on prenatal and postpartum care, but does monitor rates and is very concerned about access issues due to primary care shortages. DOH sponsors and staffs the Perinatal Collaborative with support from HCA.

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# Measure Existing Quality Effort Inventory3 NICU Data All but two level 3 NICUs (UW and Fort Lewis) report

to the VON data set. Ten Level 1-2 NICU report to the FHCQ/OB-COAP

13. State goals for improving care, population health and reducing health care cost. Principle Goal: The project’s principle goal is to shift the health delivery system from reliance on non-empirical standards of care to evidence-based best practices, thereby improving quality and containing costs.Change Process: Our goal is attainable through the grant’s change process:

1. Via the Collaborative, sequentially identify episodes of care that are high-volume and low-value;

2. Develop recommendations for evidence-based best practices;3. Engage professional organizations and their members through collaborative

learning to broadly adopt recommended practices; and4. Selectively reform payment methods to support those practices.

Approach: The model will involve multiple payers including Medicaid (fee for service and managed care), Medicare (including dual eligibles), private payers (including Premera, Regence and GHC), and large employers (such as Boeing, Costco, the state and King County). It will build on our state’s existing collaboratives, the Bree and the Alliance, to engage other stakeholders, including the state and legislature.The state has already completed significant work related to specific component areas: (1) chronic care medical homes (CCMH); and (2) infant and maternal care. The Alliance will be the lead organization for chronic care medical homes, while the Bree will coordinate implementation for evidence-based best practices – initially for infant and maternal care and later, other episodes of care, such as spine surgery and care, hospital readmissions, and interventional cardiac care. Each organization’s roles and responsibilities are described in Table 10 below. Participation by payers and providers will be optional; but incentives will encourage broad participation.

Managing chronic conditions. The Alliance will be responsible for facilitating implementation of the CCMH across multiple payers. The goal is to focus attention on those patients with chronic conditions requiring costly care in the public and commercial coverage in Washington State. In the public programs, this population is described as the 5% of patients who account for 50% of health spending. This initiative will build on past efforts, such as the Boeing Intensive Outpatient Care Program (IOCP), the Patient Centered Medical Home Multi-payer Reimbursement project and SB 5394 – Primary Care Health Homes and Chronic Care Management.

Key elements:

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1. Private and public predictive modeling tools to identify patients with chronic conditions11 and then provide information to help providers manage and coordinate their patients’ care;

2. Enhanced payment or incentive for CCMH services to fund coordination of care and data-driven interventions;

3. Integrated behavioral health services;4. Incentives such as gain-sharing or shared savings;5. The Alliance will convene the multiple parties to ensure statewide coordination and

stakeholdering towards the use of consistent quality indicators among models, while ensuring business flexibility for payers; and

6. The plans will agree to secure data reporting for academic evaluation and research through the Foundation for Health Care Quality (FHCQ) and University of Washington (UW).

Payment Reform. Professional and facility services will be integrated using a core set of statewide quality and utilization measures designed to address the Triple Aim. The state will accomplish this by adapting an approach like the BCBS of Massachusetts “Alternative Quality Contracting” (AQC) model which creates an accountable delivery system but does not require providers and facilities to be part of a single organization. Professionals and facilities that achieve savings and improve quality will be eligible for gain sharing. An advantage of this approach is that it integrates better with local initiatives, such as Regional Health Improvement Collaboratives, that are building community-based approaches to improving the health of local residents. The project will establish goals enabling providers who meet additional quality metrics to receive higher payment. This produces a win-win value proposition where payers have predictable expenditures and providers retain predictable revenues. In light of our experience, we believe this approach will 1) enable distinct provider groups to operate in an accountable payment environment and 2) maximize provider and payer participation in the project. This approach has been described as a virtual Accountable Care Organization (ACO), without the corporate structure, for those who are familiar with that model. It is important to note that how payers reimburse providers may differ and some providers may choose to not participate. All participating payers will agree to provide core standard claims data in a timely manner. Core data elements include quality and utilization measures for the infant and maternal project and chronic care medical home.

Feedback Reports. To strengthen adoption of evidence based best practices, we will share performance data, and provide secure peer-to-peer feedback reports to providers and aggregated data to communities. Purchasers, including Medicaid and Boeing, have experience using such reports. Feedback reports will provide information on infant and maternal outcomes, as well as prevention and chronic care in medical homes, and will provide communities with a comprehensive picture of their local health care system.

11 Per the ACA and SB 5394: a mental health condition; substance use disorder; asthma; diabetes; heart disease; and being overweight, as evidenced by a body mass index over twenty-five.

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Feedback reports serve one other purpose: they can be used to identify outliers for outreach and education.

Obstetrics & Deliveries: As mentioned previously the Bree Collaborative recently completed its report on obstetrics care12 which recommends developing a new bundled payment to promote labor and delivery best practices and to eliminate elective deliveries and reduce elective inductions including primary C-sections.13 The Bree Collaborative will work on establishing a bundled payment that combines doctor and facility fees and incentivizes providers and hospitals to provide the most appropriate care to mother and baby. Since Washington has few integrated systems of care, the project will work with hospitals and providers to facilitate the establishment of operating agreements enabling practices to maintain their independence while operating in a more integrated fashion.

14. Describe delivery system models and approaches including how public healthcare entities, such as publicly-supported university hospitals and facultypractices will transition to value-based business and clinical models

The Model involves all WA health care providers, including those who practice at public health care entities, such as publicly-supported university hospitals, critical access hospitals, rural health clinics, federally qualified health centers, community health centers and faculty practices, to value based care models. Simply put, public health entities are full participants in all aspects of the project. The Model will leverage the collaboratives as vehicles to align payment reform with our policies, quality initiatives, and evidence based medicine to transform the structure for service delivery across the state. The modified payment approaches will include 1) bundled rates for specific conditions or episodes of care; and 2) upfront payments for certain services to support an infrastructure capable of employing best practices. Bundled payments will combine payment for all stages of treatment (including facility and outpatient) to strengthen coordinated care and follow-up. This approach to transforming payment will work well as all WA payers (FFS and managed care) have experience paying a global professional fee for prenatal, delivery of any type and post-natal care. The Model includes gain-sharing for meeting quality measures in episodes of care.Specific institutions – the University of Washington and the Oregon Health Sciences University – are actively involved in the Bree Collaborative and similar initiatives and will have an expanded role in developing evidence-based practices, and in conducting evaluative research of the Model.The Model will weave evidence based quality assessment and adoption into the fabric of our delivery system. Advancing knowledge in areas that need it the most, specifically those practice patterns that have high rates of variation or high use of services that do not result in improved outcomes. Further, HCA will work with the Health Care Personnel Shortage Task Force and WA’s medical schools to integrate the Model’s evidence based best practices and develop continuing medical education sessions to promote adoption. Since

12 See http://www.hta.hca.wa.gov/documents/bree_ob_report_final_080212.pdf 13 See Massachusetts Blue Cross Blue Shield Alternative Quality Contract and Transitioning to Accountable Care by Harold Miller of the Center for Healthcare Quality and Payment Reform.

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1999, the DOH has offered Learning Collaboratives for health care providers. These include in-person training, webinars, and other e-Tools, primary care practice coaching, community asset mapping and other technical assistance all of which are supported with pooled funds from federal grants and support from Medicaid health plans. Today, the DOH partners with Qualis Health and the University of WA Advancing Integrated Mental Health Solutions (AIMS) Center to support statewide initiatives such as WA Community Transformation Grant, Beacon Grant, WA State Perinatal Collaborative, and Emergency Cardiac and Stroke System. DOH can identify how to streamline CQI activities, expand existing programs and mitigate overlapping initiatives, as well as, facilitate and mobilize community partners- community health improvement efforts.The Model prepares the provider for the accountable care future by collecting, aggregating and providing feedback in performance measures to improve care and lower costs. The core quality and utilization metrics will be streamlined and aligned with CMS' Physician Quality Reporting System (PQRS) and Meaningful Use incentive programs to avoid duplicative processes.

15. Describe proposed payment and service delivery models.WA will implement both quality and payment reforms over the life of the project. The principles of the Model include:

1. Accountability: There is increasing agreement on the need for accountability for quality and cost across the continuum of care. The consistent provision of high-quality care, particularly for chronic conditions, will require coordination and engagement of multiple health care professionals across different institutional settings and specialties including: medical, behavioral, developmental disability, substance abuse, safety net providers, Area Agencies on Aging and long term services and support providers.

2. Flexibility: The reform must be viable across the diverse practice types and organizational settings that characterize the WA health care system and be sufficiently flexible to allow for variation in the strategies that local health systems use to improve care. One size does not fit all.

3. Aligned Incentives: The reform requires a shift in a payment system that rewards volume and intensity to one that promotes value (higher value at lower cost), encourages collaboration and shared responsibility among providers, and ensures that payers, both public and private, offer a consistent set of incentives to providers.

4. Transparency: With increased providers’ accountability, the reform will present greater transparency for consumers and community stakeholders. Measures of overall quality, cost, and other aspects of performance will support the provider’s clinical decision making and increase consumers’ confidence in the care they are receiving in their local community.

Features of the Model

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1. Align and Incent Performance Metric Across Payers: The Collaboratives will engage facilities and professionals to link provider payment to an agreed-upon common core set of quality and utilization metrics that will define global budget targets. Initially, they will focus on the areas of obstetrics and managing chronic disease, aiming to increase use of evidence-based care and reduce overuse of low-value, high cost services at the professional and facility levels. Payers’ commitment to the Model is predicated on the flexibility to use their own contracting and payment mechanisms to incentivize common core quality outcomes and utilization targets. All payers have agreed to adopt a core set of performance measures and are willing to link those measures to opportunities for differential gain sharing (based on performance) and increase our current peer-to-peer comparisons to support improvement. The core quality and utilization metrics will be streamlined and aligned with CMS' Physician Quality Reporting System (PQRS), National Quality Forum , Joint Commission and Meaningful Use and other nationally recognized incentive programs to avoid duplicative processes and improve administrative efficiencies. To that end, the Model has received full support from the three key agencies in the state: 1) Qualis Health, which serves as the state’s Quality Improvement Organization (QIO) and operates the Regional Health Extension Center; 2) the State’s Health Information Exchange, OneHealthPort; and 3) the federal Beacon Grant in eastern WA.

2. Conduct Statewide Data Aggregation and Performance Metrics Reporting: The Collaboratives will engage health care provider organizations, health insurers and self-funded purchasers to adopt consistent processes for data collection, monitoring cycles, and use of a core set of quality and utilization metrics to support statewide Provider Feedback Reports in the areas of obstetrics and managing chronic disease. Successful examples of such activities are currently active in WA, and address clinical conditions in obstetrics cardiology, general surgery, vascular surgery, spine surgery and obstetrics. As expansion of data volume grows, Collaboratives will identify and work local with outlier practices/processes and support access to local rapid cycle improvement processes. Hands-on coaching and peer learning opportunities will be provided by the WA Department of Health (DOH) in coordination with the WA State Medical Association, the WA State Hospital Association and FHCQ. Publicly reported at the medical group or facility level, the feedback provides communities with a comprehensive picture of their local health care system. Publically reported outcomes currently exist and will be enhanced with this grant.

3. Build Workforce Capacity to Promote Adoption of Evidence Based Practice and Performance Metrics: Resources will be allocated to increase internal workforce capability to adopt evidence based best practice in the areas of obstetrics and managing chronic disease. Financial grants will be directed to key professional organizations to champion initiatives among their membership. The Model will fund an expansion of the WA DOH’s Collaborative Learning Model to bring training to areas typically not seen as viable ACO venues. DOH’s existing hands-on learning sessions complement toolkits, “how-to” guides, checklists, and patient decision aids will be used to support evidence based recommendations. Structured stakeholder education, including conference calls, webinars, and listservs will provide practical insight to adapt recommendation to various settings.

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Recommendations will be incorporated into accredited continuing medical education programs and medical training programs with support of DOH.

4. Explore Policy Levers to Secure Adoption of Evidence Based Care: The Legislature and Governor have voiced the desire to see systemic reform instead of piecemeal initiatives. “No more pilots” is a refrain that is increasingly heard in WA and nationally. To this end, the chairs of the Senate and House health care committees support this grant and are willing to introduce legislation as needed to help the effort succeed. Using policy levers to support reforms has precedence; in 2007, the Legislature passed SB 5930, linking patient decision aids to liability reform. This first-in-nation program was designed to lower provider liability risks by better informing patients. Examples of potential legislation include: setting minimum standards for uniform payer submission of claims data (encounter/utilization and payment) to a data aggregator; broadening the statutory role of the Collaboratives; and reducing provider and payer liability to the extent they employ evidence based practices. Similarly, the Model may explore the State’s authority to certify integrated care systems, such as ACOs, virtual ACOs, and RHICs to support professional and facility integration.

5. Increase Coordination Among WA Quality Collaboratives. The Model will strengthen the infrastructure among WA’s federal and state QI grant programs and initiatives to raise awareness of program activities, share lessons learned, collaborate around similar goals and promote best use of limited resources. The Model will convene biannual events targeting state, regional and local quality initiatives. Their purpose is to identify overlapping efforts and duplication to promote collaboration, share best practices, advocate for federal and state policy reform, and overall make better use of existing, limited resources. The Model is committed to principles that align WA’s strong regional quality collaboratives such as the Alliance. The Model leverages the success of public/private partnership such as those pioneered by providers-Group Health Cooperative, Virginia Mason Medical Center, and by payers – Boeing and Regence’s, Intensive Outpatient Care Program, Premera’s Global Outcomes Contracts or homegrown initiatives such as Whatcom Alliance for Healthcare Access, CHOICE, or Central and Eastern Regional Health Improvement Collaboratives. Networked together, they create a strong infrastructure incorporating employers, consumers, local health agencies, tribal governments, educational systems, community service and support organizations, and faith-based organizations.

16. Provide a timeline for transformation.Timeline for implementation: In the following table, we assume the contract effective date starts January 1, 2013. The actual start date, however, will be the effective date of the executed agreement between the State of Washington and CMMI:Table 10. Implementation Timeline

Timeframe Actions

1/13 – 3/13 HCA hires project staff, organizes internal functions, develops allocations

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Timeframe Actions

3/13 HCA establishes oversight advisory committee for grant project.

2/13 – 4/13 HCA negotiates contractual terms with Alliance and Collaborative. Contract executed by 6/30/2013

2/13 – 5/13 Informatics tools developed, tested

3/13 – 6/13 Recruitment of collaborative clinics and hospitals

3/13 – 6/13 Bree and Alliance each develop internal work groups and expand their roles and responsibilities

1/13 – 4/13 Each collaborative devises scope, details of collaborative intervention

6/13 Bree finalizes proposal for modified payment system for obstetrics and deliveries. Alliance finalizes proposal for broad adoption of chronic care medical homes (CCMH).

6/13 – 9/13 Bree provides instruction on the modified payment systems. Alliance starts rollout of CCMH model.

7/13 – 6/16 DOH led training, in conjunction with provider groups, is initiated and continues through grant period

10/13 Modified payment systems go into effect

10/13 – 6/16 Reformed obstetrics and deliveries payment methodology is broadly adopted, tracking of implementation and reporting on attainment of performance measures.

1/14 – 6/16 Conduct rapid cycle improvement programs and outcome evaluation. Bree expands efforts to additional episodes of care, including hospital readmissions and spine surgery.

1/2013 – 3/2013

Analyze baseline data; discuss grant-funded opportunity with key stakeholders (providers/provider groups, client advocacy groups, state agencies, managed care entities, hospitals/hospital associations) for input, coordination with existing efforts

7/13 - 6/15 Run 36 month collaborative training on quality improvement and cost efficiencies

2/14 – 6/15 Produce, disseminate evaluation/progress reports

9/14 – 6/15 Conduct program evaluation and disseminate findings/ recommendations

Gross measures of progress:o Number of episodes of care for which the Collaborative develops

recommended best practices;

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o Number of hospitals and medical groups, and other types of providers, that agree to implement each set of recommendations. Independent review to verify provider implementation.

o Number of payers that promote adoption through their contracts by citing recommendations and by employing reformed payment methods. Number of covered lives affected by those contracts. Independent review to verify contractual changes

o Attainment of quality measures and patient satisfaction discussed elsewhere in this document.

17. Review milestones and opportunities. Timeframes start with the date the effective date of an agreement subsequent to the awarding of the grant.

Table 11. Milestones and OpportunitiesObjective Grant Activities Milestones

Grant administrative structure.

a. Agreement between state and CMMI

o HCA and Governor’s Office negotiate contract/ agreement with CMMI for deliverables

Finalized contract

b. Staff o HCA hires staff required for implementation – project manager, contracts manager, data staff, etc. Sets in place contractual requirements and reporting expectations.

Hiring completed

c. Contracts o HCA contracts with the Collaborative and the Alliance to convene work groups, establish metrics, oversee implementation, etc.

Contracts executed.

Bree Collaborative

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Objective Grant Activities Milestones

d. Implement evidence-based interventions, including obstetrics and deliveries

Collaborative members modify scope of Bree duties

HCA and FHCQ negotiate contract to implement grant-requirements.

Collaborative determines whether any statutory changes are needed. If so, submit recommended changes to HC chairs for 2012 Legislative session

Collaborative puts in place any additional work groups needed to effect implementation

Bree Collaborative internal roles defined

Contract finalized. Legislative proposals submitted to

chairs

e. Complete bundled payment design for obstetrics and deliveries

Standards established.

f. Promote implementation in collaboration with DOH and professional organizations and payers

Training and dissemination activities initiated

g. Implement payment modifications Multi-payer contracts with obstetric and delivery providers and facilities put in place (due 6 months after grant start)

h. Implement reforms for other identified episodes of care (including hospital readmissions and spine surgery)

Repeat process employed with obstetrics and deliveries – i.e., rigorous review of evidence, develop recommended best practices, develop payment modifications as needed, and facilitate dissemination and adoption.

Puget Sound Health Alliance

i. Refine role Board members modify scope of Alliance’s duties

Alliance and HCA negotiate contract Collaborative determines whether any

statutory changes are needed. If so, submit recommended changes to HC chairs for 2012 Legislative session

Collaborative puts in place any additional work groups needed to effect implementation

Bree Collaborative internal roles defined

Contract finalized and put in place. Legislative proposals submitted to

chairs

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Objective Grant Activities Milestones

j. Data aggregation and reports

Determine data elements for collection Seek and reach agreement on data elements Negotiate contracts with payer and

purchasers to submit approved data elements.

Collect data on regular schedule Aggregate reported data Issue feedback reports on regular basis

Feedback reports finalized and deployed

k. Chronic care medical homes

Convene work groups of payers, purchasers, providers and stakeholders

Define core performance measures Defined data elements required to

implement core measures Finalize agreement with providers and

payers on core elements, frequency of reporting, etc.

Begin data collection and monitoring of chronic care medical homes

Core performance measures defined Agreements to report on measures

finalized. Data collected and reports issued.

Data

l. Improve managed care encounter data completeness and accuracy

a. Review/modify encounter data specsb. Audit existing submissions; develop correction plansc. Check progress; modify as needed

a. Specs update completeb. Correction plans completec. Re-check complete

m. Develop method for care transition collection consistent with HIE

1. Assess methods used in other states; emerging methodology2. Test if possible3. Create written recommendations; vet with stakeholders

1. State of the art assessment complete2. Test complete3. Written recommendations complete

n. Develop customer survey and focus group processes

1. Assess methods used in other states; emerging methodology (CHAPS and focus group questions)2. Test if possible3. Create written recommendations; vet with stakeholders

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Objective Grant Activities Milestones

o. Promote all payer standard setting for HIE

1. For process measures requiring chart-based extracting, work with Multipayer groups to standardize collection; incorporate into meaningful use.2. Develop methods for standardized data collection for measures that lend themselves to EMR data mining, e.g., lab data or medical record content.

1. Standardized collection recommendations complete2. Standardized collection recommendations complete

p. Create new and combined feedback reports, clinical support tools

1. Develop feedback reports, clinical support tools for QI projects2. Test3. Put in production

1. Tool design complete2. Testing complete3. Production complete

q. Produce and use disparities analyses

1. Teams identified; analysis templates determined2. Administrative baselines produced3. Baseline analyses completed; opportunities identified4. Incorporate race/ethnicity considerations into all quality projects, including those selected for this grant.5. Targeted QI interventions are designed to impact at least one under-served population

1. Teams identified; templates complete2. Administrative baselines produced3. Baseline analyses completed; opportunities identified4. Disparity reports in production5. Incorporation complete

r. Report clusters of measures to relevant clinical, stakeholder groups

1. Develop review summaries for measures grouped arounda. Health homesb. Behavioral healthc. Diabetesd. OB/Maternal

1. Reporting to relevant review groups:a. HeathPath Washington Advisory Boardb. TBDc. Diabetes Collaboratived. Perinatal Collaborative

s. Review predictive modeling and risk adjustor

1. Develop review of multi-payer risk adjustor fora. Health homesb. Behavioral healthc. Diabetesd. OB/Maternal

1. Baseline analysis complete2. Literature review complete3. Detailed intervention design complete4. Intervention deployed5. Re-measurement complete

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Objective Grant Activities Milestones

t. Review health services utilization reports for disparities

1. Conduct detailed baseline analysis including disparities2. Conduct literature review to identify best practices and disparities3.  Define intervention(s)4.  Deploy and monitor interventions5.  Conduct re-measurement

1. Baseline analysis complete2. Literature review complete3. Detailed intervention design complete4. Intervention deployed5. Re-measurement complete

PLACEHOLDER

a.

b.

18. Describe policy, regulatory and/or legislative changes necessary to achieve the State’s vision for a transformed health care delivery system. States are encouraged to describe their approach to using the broad array of policy levers available to create a statewide policy context that supports and drives delivery system transformation. This should also document how proposed multi-payer supported service delivery and/or payment models fit into this context and how data and evidence will be collected and used to support the state goals and strategies.Washington State benefits from having legislative and regulatory authority already in place that will serve as a firm foundation for implementation of the project. Specifically:

SB 5930 (2007): Implemented recommendations of the Blue Ribbon Commission on Health Care Reform which included several initiatives including patient decision aids for preference sensitive treatments;

HB 2956 (2010): Established hospital quality incentives that were used, among other things, to incent the reduction of early inductions.

SB 5934 (2011): Established statewide standards for chronic care management, health homes, multidisciplinary health care teams, and primary care. Law required state programs to modify managed care contracts to enhance payment for chronic care medical homes in exchange for meeting performance measures such as reducing inpatient and emergency department use. Last, the bill linked chronic care medical homes to the Department of Health’s Collaborative Learnings for training in best practices.

HB 1311 (2011): Established the Bree Collaborative to identify highly utilized medical procedures and promote the use of evidence based best practices to improve health care outcomes and reduce costs.

Puget Sound Health Alliance : the Alliance was not established under statute (it’s an independent not-for-profit); but is included in annual agency appropriations for submitting claims data and supporting the Alliance’s operations.

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Both the Executive and Legislative branch leadership are fully committed to supporting the implementation of the grant.14 The grant is sponsored by the Governor’s Office. As noted above, the chairs of the legislative health care committees have offered to bring forward legislation in support of the grant, such as:

Modifications, if needed, to the statute establishing the Bree Collaborative to accommodate any changes in their scope of authority;

Consideration of changes to liability statute to provide limited protections to providers and payers following recommended, evidence-based guidelines; and

Enhancement of claims reporting and data aggregation efforts under the Puget Sound Health Alliance. The chairs recognize the possible need for legislation to enforce timely reporting of claims data for the purposes of this project. Their past support for systemic reform is reflected in recent legislation they sponsored and passed, including SB 5934 (chronic care medical homes) and HB 1311 (Bree Collaborative).

19. Describe any waiver or State plan amendment requirements and their timing to enable key strategies for transformation, including changes or additions required to position the Medicaid and CHIP programs to take advantage of broad health care delivery system transformation.Implementation of this grant does not rely on approval of a SPA or waiver. However, in July 2012, the state submitted an 1115 waiver request to modify the payment methodology for FQHCs and RHCs. Approval of this waiver request would better align FQHC payment methods with those proposed under this grant application. Currently, FQHCs are reimbursed using an encounter-based reconciliation process. Implementing the proposed waiver would allow the state to apply a reimbursement methodology that would better support the flexibility required for effective chronic care medical homes. While approval of the waiver request would enhance implementation of this grant, the absence of waiver approval would not jeopardize implementation of the CMMI grant.

14 There are two candidates running for Governor this November. Members of their staff have been briefed on this project and seem generally supportive.

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Appendix A: List of Washington State System Reform Initiatives

Following is a list of key initiatives in Washington focused on achieving the “Triple Aim”.

1) Legislative initiatives and state-payer initiatives: following is a list of innovative initiatives that were supported through legislation.a) Health Technology Assessment Program (HTAP) b) Public-private partnership on best practices for reducing non-emergent care in

the ERc) Prescription drug and therapeutics program d) Generics First with prescription feedback e) Advanced Imaging Management (AIM) f) Administrative simplification g) Multi-payer Medical Home Project h) Primary care health homes and chronic care management legislation i) DOH Primary Care Collaboratives j) Perinatal Collaborative k) Hospital Quality Assessment l) Dr. Robert Bree Collaborative (Bree Collaborative) m) Workers’ compensation Centers for Occupational Health and Education ( COHE s)

2) Community-based initiatives: Washington State has seen dozens of community-based initiatives to improve quality of care and bend the curve. Some notable examples include:a) Foundation for Health Care Quality (FQHC) : since 1998, the foundation has led

dozens of evaluations ranging from use of comparison quality standards by consumers to supporting public health agencies in the surveillance of sudden health risks, including:i) Clinical Outcomes Assessment Program (COAP):ii) Surgical Care and Outcomes Assessment Program (SCOAP):iii) Obstetrics Clinical Outcomes Assessment Program (OBCOAP):

b) Puget Sound Health Alliance ( Alliance ) : Created by a coalition of businesses, providers, payers and state agencies, the Alliance focuses on four interconnected areas to drive change:i) Performance Measurement and Public Reporting ii) Performance Improvement iii) Consumer Engagement iv) Payment Reform

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c) King County Health Reform Planning Team has staged a platform for stakeholder engagement in state-led activities such as HealthPath Washington and the Medicaid Health Homes Network.

3) Provider-based Initiatives: Washington has benefitted from the efforts of providers who have pioneered high-value health care:a) Virginia Mason Medical Center : has developed a rich set of initiatives, including

its Marketplace Collaboratives that address the most costly medical conditions for purchasers.

b) Group Health Cooperative : Based on a cooperative model of delivering health care, Group Health has 65 years experience fostering innovations, including advanced medical homes, shared decision-making and comparative effectiveness research conducted at its research institute.

c) Everett Clinic : The Everett Clinic has pioneered the provision of coordinated and integrated care in Washington State, including coordinated care for Medicare beneficiaries.

4) Health Plan Initiatives: Washington health plans have pioneered a variety of payment innovations that reward providers for quality, affordable health care.a) Premera Blue Cross has implemented a statewide medical home program with

Providence Health & Services, as well as Global Outcomes Contracts with 12 medical groups and an IPA, covering nearly 100,000 attributed members.

b) Regence has worked with the Governor and the Boeing Company to implement the Intensive Outpatient Care Program (IOCP), a successful chronic care model for high-needs patients that uses clinic-based nurses and a redesigned payment system to share in savings to provide higher quality care, save time and money. This is a good example of a successful multi-purchaser campaign to change health care.

5) Regional Health Improvement Collaboratives: Several communities in Washington State have initiated efforts to strengthen regional integration of services to improve health quality and outcomes, including:a) Central Washington Regional Health Improvement Collaborative : Provides a

formal venue to organize planning and action, determine regional priorities, and guide implementation of interventions and initiatives among collaborating public and private interests within a specific regional health care market.

b) CHOICE : Located in the South Puget Sound Region, CHOICE is a non-profit coalition of rural and urban hospitals, practitioners, public health, clinics, community health centers, behavioral health providers and other partners dedicated to improving the health of their region.

c) Eastern Washington Regional Health Improvement Collaborative : This collaborative provides a formal venue to organize planning and action, determine regional priorities, and guide implementation of interventions and initiatives among collaborating public and private interests within a specific regional health care market.

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d) Southwest Washington Regional Health Alliance : The Alliance seeks to achieve better health for the population, better care for individuals and reduced costs. The goal is to manage resources efficiently and effectively, in collaboration with local governments (tribal and county), state government, health plans serving at-risk, vulnerable populations, hospitals, local providers, other insurers, and, most importantly, the people served.

e) Whatcom Alliance for Healthcare Access : Located in Bellingham in Whatcom County, the Alliance connects community members to health care services; promote system improvements and foster public engagement to develop sound health care policies.

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Appendix B: PRISM: The Predictive Risk Intelligence System

With support from the Health Care Authority and DSHS Aging and Disabilities Services Administration, the DSHS Research and Data Analysis Division has developed a web-based clinical decision support application, called PRISM, which features state-of-the-art predictive modeling tools and data integration to support care management for high-risk Medicaid clients. Listed below are some of the key features of the PRISM application.

1. PRISM is an electronic health record for Medicaid enrollees. PRISM contains comprehensive longitudinal health information supporting care management for high-risk Medicaid clients.

2. PRISM integrates medical, behavioral health, social service and health assessment data to provide a comprehensive view of patient risk factors, service utilization and health outcomes.

3. PRISM uses state-of-the-art predictive modeling to identify patients at greatest risk of high future medical costs. PRISM also predicts each patient’s likely primary care provider, and assesses the extent to which emergency department visits are potentially avoidable. The risk scoring algorithms are based in part on open source software maintained at UC San Diego and calibrated to Washington State’s Medicaid client populations by the PRISM team.

4. PRISM is refreshed weekly. Predictive modeling scores for the entire Medicaid population are recalculated on a weekly basis to reflect changes in patient service events and patient risk factors.

5. PRISM currently supports more than 600 authorized users. The current primary user groups include:

a. Medicaid health plans;

b. Regional Support Networks;

c. Area Agencies on Aging providing care management for high-risk patients;

d. HCA and DSHS staff performing care management or program management functions.

6. PRISM uses robust security measures to protect patient data security and privacy. PRISM is fully compliant with HIPAA and other state and federal confidentiality requirements.

7. The PRISM team provides ongoing training and technical support for PRISM users.

For more information, please contact David Mancuso, or mail to prism.admin@dshs.wa.gov.

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