SustiNet Board of DirectorsSeptember 22, 2010Anya Rader WallackKatharine LondonLinda GreenStan Dorn

Recap of September 8 meeting

• Discussion of SustiNet covered services• Discussion of the need for broader public health

investments• Review of SustiNet law, federal law, original policy

proposal and committee and task force reports on same

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Preliminary conclusions regarding covered services• Comprehensive benefits, consistent with “mainstream” of commercial

marketplace• Emphasis on prevention• Integrated medical-behavioral health• Flexibility to change over time• Supportive of Patient-Centered Medical Home Model, with emphasis

on prevention, care coordination and chronic care management• Encourage personal responsibility for controllable health risks• Design benefits to make SustiNet an attractive option in the

marketplace• Benefit design should contribute to reductions in disparities

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Preliminary conclusions regarding public health investments• State needs to invest in:

• Broad obesity prevention efforts• Reducing disparities in access to resources,

improvements in infrastructure that support healthy lifestyles

• Better training the health care workforce to support individuals and families from multiple cultures in healthy living

• SustiNet should invest in interventions for individual patients, the state should invest in interventions that affect broader populations

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Topic for today• Delivery system reform (and, by implication, payment

reform) through SustiNet

• What changes in health care service delivery and care management should be included in the SustiNet design to achieve two goals:

1) Maximize the health of the covered population

2) Minimize cost

• Can SustiNet control costs by giving providers flexibility and holding them accountable for outcomes?

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Part I

Background:SustiNet lawFederal law

Advisory committee and task force recommendations

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Three core components:

1) Patient-centered medical homes serve SustiNet members

2) Health Information Technology supports practice transformation

3) Incentives provided for evidence-based medicine

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SustiNet law: Delivery System

SustiNet law: Patient-centered medical home

• PCMH functions: patient education, care coordination, 24/7 availability

• Reimburse PCMH functions

• Community-based resources to help small practices

• A “menu” of functions from which offices can choose

• Model can be modified by Board

• Enrollment in PCMH could be prioritized based on potential cost savings

• Advisory committee to make more detailed recommendations on functions, standards and payments

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SustiNet law: Health information technology

• Implementation of interoperable electronic heath records (EHRs)

• Must allow for specific functionalities (e.g., auto reminders to patients, decision support to providers)

• Advisory committee should recommend software, vendors, etc.

• By date certain, require providers in SustiNet to have HIT

• Lower implementation cost to providers without tapping into General Fund dollars, using CHEFA’s bonding authority and negotiating leverage on behalf of all providers

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SustiNet law: Evidence-based medicine• Clinical care guidelines for particular conditions

• Use of nationally and internationally promulgated guidelines

• Flexible practice guidelines

• Confidential comparison of practice patterns

• Hospital safety standards

• Certification of high quality providers for specific conditions, based on standards developed by peers

• Policies and procedures to encourage evidence-based medicine (e.g., EHRs embed prompts identifying and recording departures from guidelines)

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Federal health reform: Delivery and payment system changes

• Increased Medicaid and Medicare payments for primary care MDs

• Better coordination of policy re: dually-eligible population

• New quality measures

• Health homes for chronically ill

• Demonstration of global payments and bundled payments

• Value-based purchasing for Medicare

• Reduced payments for hospital-acquired conditions and preventable readmissions

• Incentives for prevention in Medicaid

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Guidance from the provider and quality advisory committee• Use evidence-based standards of care• Use recognized quality metrics for quality measurement and

provider feedback• Implement effective cost control through a combination of

payment design and delivery system redesign that promote provider accountability for costs and reduce unnecessary care

• Institute ongoing oversight of and advisement on quality, safety and payment by standing committees

• Support providers through health information technology, implementation of the medical home model and payment for better, more efficient care management

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Guidance from task forces and advisory committees: Patient Centered Medical Home (PCMH) Model

• Provide access to PCMH for every CT resident (not just SustiNet)

• A PCMH will:• Coordinate care• Develop an individual care plan with each patient• Provide care in culturally competent environment• Offer same day appointments & after hours care• Offer patients self-management supports• May include alternative care providers, where appropriate• Meet NCQA certification standards (1 of 3 levels)• Provide core PCMH functions internally; may contract to

provide some functions

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Guidance from task forces and advisory committees:

Patient Centered Medical Home Implementation

• Pilot PCMH first with practices that are most enthusiastic; build on early successes to roll out to additional practices

• Establish an independent guiding council or organization to coordinate PCMH activities, with membership representing critical stakeholder groups

• Develop a CT PCMH Learning Collaborative to provide ongoing training for PCMH providers and staff and to share best practices

• CT should join other New England states in developing a Medicare waiver for a multi-payer pilot, in sharing resources and best practices, and developing uniform performance and data standards.

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Guidance from task forces and advisory committees:

Payment system• Provide incentives for primary care practices to become a PCMH,

but do not penalize practices that do not adopt the PCMH model• Develop a new payment model, which may be a blend of global

payments, episode-based payments, performance-based payments, and limited fee for service (FFS) payments

• Pay for Performance (P4P) should reward providers for improvement as well as for meeting benchmarks

• P4P should specifically reward providers for caring for patients with the most complex and least well-controlled conditions

• P4P should reward providers for reducing racial and ethnic disparities

• Positive financial incentives should be targeted to the delivery and receipt of especially cost-effective and under-delivered clinical preventive services

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• The environment has changed• Since SustiNet enactment in 2009, HIT activity in several

areas includes:• Development of a statewide health information technology

plan• Designation of the statewide Regional Health Information

Organization (DPH now; HITECT, as of January 1, 2011)• Federal grant for the Regional Extension Center (e-Health

CT) to provide support and training to providers• Federal Office of the National Coordinator activity around

standardization and rule making

Guidance from task forces and advisory committees:

Health Information Technology

• Align SustiNet with other state and national efforts• Formal Sustinet representation on the HITECT Board of Directors

• Leverage grants and ongoing collaborations to promote EHR adoption• Develop a long term HIT/HIE funding stream• Prioritize CHC requests for EHR funding• Fund transition to EHR for qualifying providers• Provide EHR assistance to non-physician medical providers

• Set uniform minimum standards for EHR/HIT capacities• Require certification, not a particular vendor• Ensure seamless integration with existing EHR users• Add race and ethnicity data• Create links among registries and EHRS• Promote research applications of EHRs/HIE• Develop a robust administrative IT and analytic capacity for innovative payment

methods; enrollment and eligibility operations and information exchanges with providers

Guidance from task forces and advisory committees:

Health Information Technology

So where does this leave us?

• PCMH and HIT require up-front investments• They also could produce savings through

care coordination, efficiency and avoided use of more expensive care

• Investment and savings do not occur at the same time, so it is important to link the two through payment reforms

• What models are available?

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Part II

Major models of delivery system and payment reform

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The old model

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Care coordination primarily through payer efforts

The new model

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PCMH and P4P are the first steps in a continuum

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Performance-based contracting and pay-for-performance (P4P)

• Upfront negotiations about defining baseline and measuring achievement

• Accurate data sources and analytic capacity• Incorporate each year’s achievements into

subsequent year’s minimum standards• Strong contract oversight capability to objectively

assess progress

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Global Payment/Accountable Care Organizations

• Provider group or network accepts shared or full financial risk for care of covered persons.

• Provider receives fixed dollar payments per month for each person.

• Payments should be risk-adjusted.

• Addresses volume incentive, but creates a concern re: undertreatment

Some believe this can be addressed through linking financial gains to access and quality metrics

Source: Massachusetts Special Commission on Healthcare Payment Reform

Part III

Medicaid and State Employees Plan

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Examples of Value Based Purchasing and Benefit Design in CT

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State Employee Health Plan

Medicaid HuskyCommercial

Insurers: Small Businesses

Performance Incentives

Percentage of ASO fee

Yes Limited use

Preventive care low/no co-pay

Yes No co-pay Yes

Waived co-pay for chronic care

Diabetic supplies Limited use

Restricted or tiered networks

No Restricted Evolving

Gym discounts Yes NA Some

Medicaid HUSKY Primary Care Case Management (PCCM)

• Pilot program beginning February 2009• Initially offered to HUSKY families in Waterbury &

Willimantic areas, then expanded to New Haven & Hartford areas

• Providers receive $7.50 per member per month for care coordination and other PCMH functions, in addition to regular FFS rates for medical services

• 403 members as of June 1, 2010

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State employee PCMH pilot

• Pilot program established in Office of the State Comptroller’s December 2009 re-procurement of the state employee health plan

• Pilot site is ProHealth, a large primary care group practice with 75 sites in Hartford, New Haven, Middlesex, Tolland and Litchfield counties. ProHealth serves 350,000 patients including 35,000 state employees.

• ProHealth’s goal is to achieve NCQA PCMH Level II or III certification at all sites by early 2011

• Anthem, United Healthcare and other payers providing financial support in various ways: enhanced FFS rates, PMPM fees, performance-based incentives and/or upfront investments

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Care delivery requirements for Medicaid Managed Care Organizations (MCOs)

• Coordination and Continuation of Care: General requirement that MCOs provide “management and integration of health care through a PCP, gatekeeper or other means” and coordination of EPSDT/well-child screening services. No detailed requirements.

• Case Management: MCOs must provide case management (including assessment and referrals) for individuals under 21 requiring coordination of medical, social, and educational requirements.

• Quality Assurance: MCOs must develop and implement a quality assessment and performance improvement program including 2 projects required by DSS and 2 projects chosen by the MCO

• Pay for Performance: MCOs must use 1% of the capitation payments they receive for provider incentive payments

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Behavioral Health Partnership care coordination

• Intensive Care Management activated when an individual experiences barriers to recovery, has multiple ED admissions

• Coordination of Physical and Behavioral Health Care to promote communication between behavioral health and primary care providers. Contractor also supports management of psychiatric medications.

• Quality Management Project Plan developed annually

• Satisfaction Surveys conducted with members and providers

• Clinical Issue Studies to develop recommendations for intervention

• Quality Improvement Initiatives established based on data from CT or other states

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Part IV

Decision points and potential recommendations

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Decision points

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• What elements of delivery system reform should be included in the Board’s recommendations to the General Assembly?

• What additional reforms should be recommended?• How prescriptive should the board and legislature be

about delivery system reforms? To what extent should they allow flexibility?

• What broader (statewide) reforms or infrastructure development should be recommended to support and encourage delivery system change?

Potential recommendations: PCMH

• The PCMH model should be made available to all of (or, as a matter of staging, some of?) the SustiNet population and should include all (or some?) primary care providers

• Practices should receive financial and other support from SustiNet to become a PCMH

• SustiNet should pay for PCMH functions• Practices should meet (or show progress toward) national standards to

receive enhanced payments• SustiNet should establish a Learning Collaborative and community health

teams to provide ongoing training and support for PCMH providers and staff

• CT should join other New England states in developing a Medicare waiver for a multi-payer pilot

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Potential recommendations: HIT• Ensure that Sustinet is represented on the HITECT Board

• In conjunction with HITECT, comprehensively review EHR adoption in CT provider practices that serve Medicaid and SEHP members        

• Convene a standards group across Medicaid, SEHP and Sustinet initiatives to develop minimum, consistent PCMH EHR capacity        

• Require adoption of provider agreement and contract language describing baseline capacity for PCMHs       

• Within HITECT, create a timeline for EHR adoption for all CT providers; prioritize funding allocations to  practices that serve Sustinet, Medicaid and SEHP members

• Within HITECT, develop approaches to assess quality and outcomes, including how race and ethnicity data will be obtained and linked

• Within SustiNet, use EHRs to track the accomplishment of specific and measurable objectives involving racial and ethnic disparities, chronic care costs, and other priority areas.

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Potential recommendations: evidence-based medicine and quality oversight

• Clinical care guidelines for particular conditions, chosen from among nationally and internationally promulgated guidelines

• Flexible practice guidelines, not cookbook medicine • Confidential comparison of practice patterns• Hospital safety standards• Certification of high quality providers for specific conditions,

based on standards developed by peers • Policies and procedures to encourage evidence-based

medicine (e.g., EHRs embed prompts identifying and recording departures from guidelines)

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Potential recommendations: payment reform• The SustiNet governing body should pilot payment models that go

beyond the PCMH and P4P, which may include a blend of global payments, episode-based payments, performance-based payments, and limited fee for service (FFS) payments

• Pay for Performance (P4P) should reward providers for improvement as well as for meeting benchmarks

• P4P should specifically reward providers for caring for patients with the most complex and least well-controlled conditions

• P4P should reward providers for reducing racial and ethnic disparities• Positive financial incentives should be targeted to the delivery and

receipt of especially cost-effective and under-delivered clinical preventive services

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Potential recommendations: ongoing advice and oversight• SustiNet should establish an independent guiding council or

organization to coordinate PCMH activities, with membership representing critical stakeholder groups

• SustiNet should establish standing committees on quality, safety, and HIT that include broad provider and other stakeholder input

• The legislation should give the SustiNet governing entity broad authority to revise health care delivery and reimbursement methods, responding to emerging evidence

• The Board’s final report should include both legislative proposals and additional information and recommendations that are addressed to the future SustiNet plan, rather than the CGA

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Work plan for the next three months

• October: administration and governance (includes presentation on implications of offering SustiNet as an option in the exchange)

• November: costs and financing (includes implications of pursuing the federal Basic Health Program option)

• December: draft report

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Appendix: PPACA Grants, Pilots & Demos related to delivery system reform• Planning Grants to Provide Health Homes for Chronically Ill Patients

(Sec. 2703)

• Establish Community Health Teams to Support Patient-Centered Medical Homes (Sec. 3502)

• Pediatric ACO Demonstration (Sec. 2706)

• Medicare Shared Savings Program, ACOs (Sec. 3022)

• Co-locating primary and specialty care in community‐based mental health settings (sec. 5604)

• Community-based Care Transitions Program (sec. 3026)

• Extension of Rural Community Hospital Demonstration (Sec. 3123)

• Medicare Hospice Concurrent Care Demonstration Project (Sec. 3140)

• Grants or contracts to implement medication management services in treatment of chronic diseases (Sec. 3503)

Appendix continued: PPACA Grants, Pilots & Demos related to payment reform• Demonstration project to evaluate integrated care around a

hospitalization, bundled payments (sec. 2704)

• Medicaid Global Payment Demonstration (Sec. 2705)

• Value-based purchasing demonstration programs (Sec. 3001)

• National Pilot Program on Medicare Payment Bundling (Sec. 3023)

• Medicare demonstration based on the study of home health agencies (Sec. 10315)