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America’s Physician Groups (APG)&

Inland Empire Health Plan (IEHP)Meeting - Tuesday, March 25, 2019

Agenda

• IEHP Overview

• IEHP Strategy Map

• IEHP Strategies to Improve Access

• IEHP Pop Health Strategy and Programs

• IEHP Value Based Care Strategies

• Opportunities for Partnership 2

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IEHP Overview

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Who We Are:Our Structure and Governing Board

Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California.

• Region’s first Medi-Cal managed care plan.

• Knox-Keene licensed plan and organized as a Joint Powers Agency.

• NCQA accredited.

• An annual revenue of approximately $4.5B.

Governing Board

2 Elected San Bernardino

County Supervisors

2 Elected Riverside County Supervisors

3 Appointed Public Members

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Medi-Cal Managed Care Model in the IE

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Medi-Cal Beneficiaries inSan Bernardino and Riverside Counties

1.2M Members 153,000 Members

89%Market Share

11%Market Share

*Data as of September 4, 2018 5

Dual Eligible Managed Care Model in the IE

Dual Eligible inSan Bernardino and Riverside Counties

Cal MediConnect Plans:DSNP Plans:• Blue Cross• Scan• Molina• Kaiser• Others

FFS27,000 Members 4,000 Members

*Data as of September 4, 2018 6

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IEHP Membership by Region

Region Medi-Cal CMC

High Desert 11% 13%

San Bernardino Proper 24% 29%

Low Desert 11% 14%

Temecula/Corona/Hemet 15% 18%

Riverside Proper 27% 16%

West San Bernardino 12% 10%

Medi-Cal, 1,213,122

Cal MediConnect(CMC), 27,000

*Data as of September 4, 2018

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IEHP Member Profile

Gender Age

*Data as of March 20188

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IEHP Member Profile Continued

Ethnicity Language

*Data as of March 20189

Who We Are:Managed Care Model

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IEHP Direct IPAs

Mixed Model HMO16

IPAs

42%of total

Membership

58%of total

Membership

*Data as of September 3, 2018. IEHP Direct includes Medi-Medis.

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IEHP Contracted Providers

PCP 1,288

Mid Levels 855

Specialists 2282

Behavioral Health 1,164

Vision 290

Hospitals 38

SNF’s 91

Mission:To organize and improve the delivery of quality, accessible, and wellness

based healthcare services for our community

Core Values:Health and Quality Before Costs – Think and Work LEAN – Team Culture – Foster Innovation

Partner With Members, Providers, and the Community – Stewardship of Public Funds

Provide a network

that delivers

high quality and timely care

MemberExperience Network

Optimize core

processes to deliver

compliant, high quality and efficient

services

Operational Excellence

Deliver innovative & valuable technology solutions

Technology

Ensure financial

stability of IEHP in

support of enterprise

goals

Financial Stewardship

Go

als

Vis

ion

Ensure members

receive the high quality

care and services

they need

IEHP Strategy Map

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Make a Difference Improve Lives

Members - Providers - Team Members - Community

Make IEHP a great place to

work, learn, and

grow

Team Member

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Strategies to Improve Access

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California Healthcare Foundation Access Reports

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Prop 56 Reimbursement

CPT Code Description Medi-Cal Rate Supplemental PaymentMedi-Cal Rate + Supplemental

Medicare RateDollar

DifferencePercent

Difference

99201Office/Outpatient Visit New I $ 11.41 $ 18.00 $ 29.41 $ 47.09 ($17.68) 62%

99202Office/Outpatient Visit New II $ 34.30 $ 35.00 $ 69.30 $ 79.05 ($9.75) 88%

99203Office/Outpatient Visit New III $ 57.20 $ 43.00 $ 100.20 $ 113.08 ($12.88) 89%

99204Office/Outpatient Visit New IV $ 68.90 $ 83.00 $ 151.90 $ 172.01 ($20.11) 88%

99205Office/Outpatient Visit New V $ 82.70 $ 107.00 $ 189.70 $ 216.00 ($26.30) 88%

99211Office/Outpatient Visit EST I $ 12.00 $ 10.00 $ 22.00 $ 23.10 ($1.10) 95%

99212Office/Outpatient Visit EST II $ 18.10 $ 23.00 $ 41.10 $ 46.46 ($5.36) 88%

99213Office/Outpatient Visit EST III $ 24.00 $ 44.00 $ 68.00 $ 76.79 ($8.79) 89%

99214Office/Outpatient Visit EST IV $ 37.50 $ 62.00 $ 99.50 $ 113.24 ($13.74) 88%

99215Office/Outpatient Visit EST V $ 57.20 $ 76.00 $ 133.20 $ 152.34 ($19.14) 87%

Prop 56 Reimbursement

GAME CHANGER!!

IEHP Network Expansion Fund (NEF)

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NEF was launched September 2014. Since inception we have spent $33M. This has translated to the hiring of 287 new Providers in the Inland Empire:*

*Data as of November 2018

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Virtual Care (Telehealth) Strategy

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mHealth

Virtual VisitVideo visits between Provider & Patient

eVisitOnline exchange between Provider & Patient

Virtual ConsultVideo consult: Provider to Patient’s Provider

eConsultOnline consult: Provider to Patient’s Provider

Mobile Health (mHealth)

IEHP Population Health Strategies and Programs

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What Is Population Health & IEHP’s Vision

• Population Health Management Definition: population health management refers to strategically managing the engagement, treatment, and clinical outcomes of selected populations

• IEHP’s Population Health Vision: IEHP commits to assure a Culture of Health and Equity,internally and along with our members, providers, and partners, where everyone in the Inland Empire has the opportunity to live their healthiest and most joyful life.

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Health of the Inland Empire Community

Population Health Management-IEHP Members

Dr. David Kindig, American Journal of Public Health 2003

The Critical Role of Risk Stratification

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HIGH RISK

RISING RISK

LOW RISK-STAYING HEALTHY

What is Risk Stratification:• A process of separating members into

populations based on their risk• IEHP stratifies members according to

physical, behavioral and social factors

Why is it Risk Stratification Critical:• Allows IEHP to tailor interventions and

resources based on population needs• “Right Care, Right Member, Right Time”• Helps us to avert further rising and high

risk

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Charter

Pain COE

IEHP CCM

Housing

My Path – Palliative Care

Gender Health Program

Integrated Remote Care Team

MAT / BHI

PCP Depression Screening Campaign

Clinical Pharmacy Programs

Diabetes Prevention Program (DPP)

Wildflower Prenatal App

CHW – non clinical

Co-located Social Services & CRCs

Immunizations Campaign

Adolescent Sexual Health Programs

Early Childhood Development Screening

Virtual Care Strategies

Practice Transformation Strategies (Model Practice, Shared Savings/Risk, etc.)

HIGH RISK

RISING RISK

LOW RISK –STAYING HEALTHY

KeyBHICCI = Behavioral Health Integration and Complex Care InitiativeCOE = Center of Excellence CCM = Complex Care ManagementMAT = Medication Assisted TreatmentBHI = Behavioral Health IntegrationPCP = Primary Care PhysicianCHW = Community Health WorkerCRC = Community Resource CenterHHP = Health Home Program

Health Homes Program

IEHP Programs by RiskLandmark

BHICCI

Social Determinants of Health (SDOH)

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IEHP invests in interventions to address both clinical conditions and social determinants:

• Housing Program• Community Resource Centers• Behavioral Health Integration and Complex

Care Initiative• Health Homes Program

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Evidence for PSH* – Medical Cost Reduction

$15,999

$7,294

$5,639 $5,130 $4,740

$2,503

$0

$5,000

$10,000

$15,000

$20,000

LTC Residents SNF Diversions Community Diversions

Total PMPM Cost by Population (6 Months Pre- and Post-Transition)

Pre

Post

LA County Department of Health Services Health Plan of San Mateo

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Improvements in objective and self-reported measures of health and quality of life

*PSH = Permanent Supportive Housing

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Housing Program

Permanent Supportive Housing (PSH) Program:

• IEHP investing $10 million annually towards PSH for IEHP Members in Riverside and San Bernardino Counties

• Goal: PSH for 350 Members by end of 2019

o 150 Long Term Care IEHP Members – transition those without skilled need into community with supports

o 200 3H IEHP Members – 3H Identified as Homeless-High-utilizer of health services-High-cost

• Tracking cost savings and improved health outcomes for housed members / RAND evaluation

• As of March 2019 – housed 86 Members

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Overview

• The Health Home Program (HHP) is a new DHCS required, Medi-Cal benefit providing comprehensive care management and whole person care to eligible patients with chronic conditions and a certain level of acuity.

Start Date

• January 1, 2019 for Members with qualifying physical conditions and substance use disorders (SUD), and July 1, 2019 for Members with severe mental illness (SMI)

Membership

• Estimating roughly 50,000 eligible HHP Members

BHICCI & HHP

• The Behavioral Health Integration and Complex Care Initiative (BHICCI) is the IEHP footprint for HHP

What is the Health Homes Program (HHP)

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HHP Core Services and Care Teams

HHP Core Services:

• Comprehensive care management

• Care coordination

• Health promotion

• Comprehensive transitional care

• Individual and family support

• Referral to community and social support services

Each CB-CME (Community Based Care Manage Entity – Care Team):

• Nurse Care Manager

• Behavioral Health (BH) Clinician

• Care Coordinator

• Community Health Worker (CHW)

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Two Models of CB-CMEs

Model 1 Provider-based teams embedded onsite at

practices

Model 2

Plan-based regional teams serving patients in low volume

practices & high volume regions

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My Path Palliative Care Program

SB 1004 – Mandated that Medi-Cal managed care plans (MCPs) provide palliative care to beneficiaries starting January 1, 2018.

IEHP’s response – My Path:• Home/Community-based with 24/7 access for Members• Expanded General criteria to prognosis 2 years or less, non-compliance issues• Expanded disease criteria to include neurodegenerative, dementia, ESRD, AIDS,

etc.

Goals of My Path include:• Improve quality of life• Goal setting by multi-disciplinary team that is Member and caregiver focused• Decrease unwanted or futile medical interventions

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My Path Program is home based

My Path Services include: • 24/7 Telephonic palliative

care support • Advanced care planning• Pain and symptom

management• Mental health and social

services• Care coordination with

regular PCP communication

My PathTeam composed of:• Physician• Nurse• Social worker• Spiritual counselor

IEHP Value Based Care Strategies

Quality / Cost = Value

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Medi-Cal Spending Trends are Unsustainable

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California State Budget

Medi-Cal$82,000,000 per year

Source: Medicaid and CHIP Payment and Access CommissionSource: CA Legislative Analyst’s Office 2018-2019 Medi-Cal Fiscal Outlook

Projected Annual Growth in CA Medicaid Spending (General Fund)

FY 2017-2022

9%Medicaid spending growth in California is unsustainable relative to tax revenues and the growth of the economy.

If plans and providers can’t control costs, patients may face reduced access as pressure will increase to cut benefits or eligibility.

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IEHP Costs Calendar Year (CY) 2018

Value-Based Care is Necessary to Protect PatientsBy committing to a value-based approach to care, we can reduce cost increases while improving quality and protecting patients.

Value-based care is based on two broad ideas:

• Aligning incentives between providers and payers so that providers are rewarded for improving quality while controlling costs.

• Aligning the interests of patients and providers by increasing provider accountability for the full spectrum of care across office visits, hospital stays, and pharmacy use.

These ideas hold the promise of improving care while ensuring that our health care dollars are spent wisely to most benefit patients.

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IEHP Value-Driven Care Strategies

IEHP’s strategic priorities and initiatives support investments in value-driven care to improve member experience and foster a high-performing provider network.

Value-based PaymentDelivery System

Supports for Population Health Management

Enhanced Data and Analytics

Value-Driven Care

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Manifest MedexHIE

32 IE Hospitals

• Admissions• Discharges• Transfers• ER• Labs/Rad

Physicians

• Visits• Lab• Diagnosis

Plan

• Claims• RX• Lab Results• Ancillaries

DB - Motion

Data Integration

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Global Quality Pay for Performance (P4P)

• GQ P4P Provides financial rewards to IPAs and PCPs that provide high quality care to Members, and provides an opportunity to receive performance based revenue above capitation

• PCP Global Quality P4P: $67 million budgeted for 2019 performance period

• IPA Global Quality P4P: $20 million budgeted for 2019 performance period

▪ New Per Member Per Month (PMPM) quality payment started in 2019

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2018 Global Quality P4P Measures Categories # of Measures

Clinical Quality 16

Behavioral Health Integration 2

Patient Experience 4

Encounter Data 2

Total 24

Questions

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2018 Global Quality PCP P4P Sample Report

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2018 Global Quality IPA P4P Sample Report

Hospital Pay for Performance (P4P)

• New program introduced January 2018 for all Contracted Medi-Cal Hospitals in San Bernardino and Riverside Counties

• To qualify, hospital must participate in data sharing with California Maternal Quality Care Collaborative (CMQCC)

• 30 Hospitals eligible for 2019 Program

• $31 million budget for 2019 performance year, quarterly payments

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2018 Hospital P4P Measures Categories

All Cause Readmissions (SPD and Non-SPD)

Post Discharge Follow Up within 7 Days

NTSV Cesarean Delivery Rate*

Manifest MedEx Active Participation

POLST** Registry Utilization*NTSV: Nulliparous Term Singleton Vertex **POLST: Physician Order for Life Sustaining Treatment

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Redacted

Shared Savings Program

Goal: Modernize the shared savings arrangement to create accountability for cost and quality of services beyond primary care and create a new financial opportunity for medical groups.

HOSPITAL

Traditional Capitation: Primary Care

Shared Savings Program: Hospital, pharmacy, professional &…

+

Included Services

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Shared Savings Framework

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Budget Target•Annual, PMPM-based•Set prospectively•Based on 12 months of historical claims for included services•No provider responsibility for the top 1% outliers

Actual Performance•Measured retrospectively for included services•Risk-adjusted to account for any changes in patient panel composition

Shared Savings(actual < target)•Up to 60% of savings credited before potential quality adjustment •Cap on potential gains at $4.50•1% “Minimum Savings” threshold

Quality Measures•All Cause Readmissions•Controlling High Blood Pressure•NTSV C-Section Birth•Exclusive Breast Feeding Intent•Post Discharge Visit within 7 Days of Discharge

IEHP Commitment With Shared Savings Partners

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IEHP will make the following investments:

Support plan infrastructure

Reporting specific to organizations

Data/analytics and progress in value based care and systems

Expectations from healthcare organizations:

• Significant commitment of time and energy

• Participation of clinical and administrative leadership

• IT systems development

• Coordination with IEHP

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Political/Financial Landscape

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California

• Funding levels for Medi-Cal – always in play depending on the economy

• Single payer/universal coverage discussions with new administration

• Hospital Quality Assurance Fee (QAF) changes – private hospital directed payment program

• Undocumented Medi-Cal coverage to age 26

• New Governor emphasis on pediatric preventive measures. Health plan sanctions

National

• Repeal/reform of ACA versus Executive/Regulatory actions

• Medicaid reforms/funding

• Waivers

Questions

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Questions

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