CPHA October 23, 2015

RUMANA RUBBANI MEREDITH FERRARO. MS

Achieving the Triple Aim and Health Equity through Community Health

Workers: Payment Models that align with the

Affordable Care Act and SIM-CT

Southwestern Area Health Education Center (SW AHEC) is 1 of 4 regional centers in the CT AHEC Program.

The agency is an emerging leader in developing future health professionals and in improving community health.

Mission is “Opening doors to better health in underserved communities through education, outreach, and careers .1 ” We do this by “Connecting students to careers, professionals to communities and communities to better health.

Community Health Workers are the newly recognized frontl ine public health workers in Connecticut who work to accomplish this mission

BACKGROUND

Southwestern Area Health Education Center (SW AHEC)

A frontl ine public health worker who is a trusted member of and/or has an unusually close understanding of the community served . This trusting relationship enables the CHW to serve as a l iaison/l ink/intermediary between health/social services and the community to faci l itate access to services and improve the quality and cultural competence of service delivered. A CHW also builds individual and community capacity by increasing health knowledge and self-suffi ciency through a range of activit ies such as outreach, community education, informal counseling, social support and advocacy. 2

BACKGROUND

Community Health Worker (CHW)

EXAMPLES OF COST SAVINGS BY CHW INTERVENTIONS

S O U R C E : H T T P : / / C E PA C . I C E R - R E V I E W. O R G / W P - C O N T E N T / U P L O A D S / 2 0 1 1 / 0 4 / C H W - D R A F T-R E P O R T- 0 5 - 2 4 - 1 3 - M A S T E R 1 . P D F

Role of CHWs : valuable supplement to the healthcare system by helping to achieve goals of PPACA and SIM-CT through the Triple Aim: access to healthcare, improving healthcare quality and experience, and cost-containment in healthcare

Challenge : issues of legitimacy, centralization, sustainability

CT: lack of sustainable payment methods CT CHWs mostly operate under grants or short-term funding

INTRODUCTION

Pati ent Protecti on Aff ordable Care Act (PPACA) Goals: Access to affordable health insurance, which reduces

health disparities especially for vulnerable populations, increases public health preparedness, expands the healthcare workforce, improves the quality of healthcare delivery, and lowers healthcare expenditures3

PPACA recognizes and encourages the profession of CHWs: Section 5101 of the PPACA includes CHWs in the definition for “primary care professionals”; funding through Section 5313 “Grants to Promote the Community Health Workforce” of the Public Health Service Act.3

Healthcare reform programs and payment models: Accountable Care Organization (ACO), Patient Care Medical Homes (PCMH), Pay for Performance (P4P), Value Based, Value Based Insurance Design (VBID), and Public Health Cost Savings 3

INTRODUCTION

Triple Aim:

Bett er health while eliminati ng health

dispariti es, improved healthcare quality and experience, and cost-

containment in healthcare

BACKGROUND

ACA recognizes CHWs: Secti on 5101 defi nes them as “primary care professionals”; Secti on 5313 has “Grants to Promote the Community Health Workforce” of the Public Health Service Act

CHW work results in overall : 1. Pati ents receive greater accessibility and quality of

healthcare 2. Payers and providers receive greater share of savings

through:• Improved patient care and reduced healthcare costs

• Higher probability of better outcome measurements 3. Overall savings are achieved for the healthcare system

PPACA AND RECOGNITION OF CHWS

ACA recognizes CHWs: Section 5101 defines them as “primary care professionals”; Section 5313 has “Grants to Promote the Community Health Workforce” of the Public Health Service Act

Positive Outcomes of CHW Roles Patients: greater accessibility to heath care system, improved

patient care, reduced healthcare costs Payers/Providers: greater share of savings, higher probability of

better outcome measurements, Overall savings to the healthcare system and attainment of the

Triple Aim

CHW ROLES ALIGNED WITH HEALTHCARE REFORM

CHWS ROLES ALIGNED WITH PAYMENT & DELIVERY REFORM PROGRAM MODELS

Accountable Care Organizations – (ACOs) executes better health care models that result in greater coordination-of-care and health system cost savings. Program receives a goal for cost savings, and then after it is achieved, providers receive funds from Medicare or other Insurors that are shared with the payer

Advanced Medical Homes (AMH/PCMH) coordination-of-care occurs across a team of medical practitioners with the intent of providing more comprehensive medical approach; in CT will be done through Medicaid and Advanced Networks

CHW roles in healthcare reform and payment programs Coordination-of-care drug compliance patient navigation dispersing educational health information help coordinate and facilitate healthcare information

throughout a patient’s care. Activities result in: overall improved patient care

and reduced healthcare costs Payers and providers receive greater share of

savings, higher probability of better outcome measurements

Patients receive greater accessibility to heath care system, and

Overall savings for the healthcare system.

CHWS ROLES ALIGNED WITH PAYMENT & DELIVERY REFORM PROGRAM MODELS

CHWS ROLES ALIGNED WITH PAYMENT & DELIVERY REFORM PROGRAM MODELS

Enhanced fee-for-adviceprovider organization is given set amount of money each month known as per-member-per-month (PMPM) payment; provide an agreed upon range of services for the patients for the coverage period

Value-based Payment (management fee, shared savings)provides information on Medicare's (and other insurers) plans to confi dentially and publicly report physicians' cost and quality of care and to implement a physician pay-for-performance (P4P)

*Payment models listed below are given through advanced payment to providers) n order to provide incentivized cost-

containment and higher quality of care

CHWS ROLES ALIGNED WITH PAYMENT & DELIVERY REFORM PROGRAM MODELS

Bundled payment (episode of care: disease category)single payment to a provider, or a group of providers, for multiple healthcare services associated with a defi ned episode-of-care Global Payment (total care, capitati on payment: general payment)fi xed payment to providers for all or most of the care that patients may require over a contract period, such as a month or a year, which is adjusted for illness severity.

Shared Savings Plan (SSP) per-person spending target is set by Medicare. If a provider can reduce aggregate reimbursements below a specifi ed target, then they share in the Medicare savings

Connecti cut State Innovati on Model (SIM-CT) 4

$2.8 million planning grant Center for Medicare and Medicaid Innovation (CMMI) in 2013

$45 million testing grant Center for Medicare and Medicaid Innovation (CMMI) awarded and began in February 2015

Strives to deliver the totality of care to at least 80 percent of the population within five years and to promote the Triple Aim

CHWs’ capacity to address the pervasive, persistent, and expensive problem of health disparities has been recognized by the SIM-CT

INTRODUCTION

Establish a whole-person-centered healthcare system that:

• improves population health; • eliminates health inequities; • ensures superior access, quality, and care

experience; • empowers individuals to actively participate

in their healthcare; and • improves affordability by reducing

healthcare costs

SIM-CT VISION

SIM INITIATIVES

Statewide Interventions Targeted Interventions

Plan for Improving Population Health Medicaid QISSP

Quality Measure Alignment Advanced Medical Home Program

HIT/Analytics/Performance

Transparency

Community & Clinical Integration

Program

Value Based Insurance Design

Community Health Workers

HIT / Analytics / Performance

Transparency

17

MODEL TEST HYPOTHESIS FOR SIM TARGETED INITIATIVES

High percentage of patients in value-based payment arrangements

+Resources to develop advanced primary care and organization-wide capabilities

=Accelerate improvement on population health goals of better quality and affordability

MQISSPMedicare SSP

Commercial SSP

• Advanced Medical Home Program

&• Community & Clinical Integration

Program (CCIP)

+

MQISSP is the Medicaid Quality Improvement and Shared Savings Program

PRIMARY CARE PARTNERSHIPS FOR ACCOUNTABILITY

18

Advanced Network

Primary care practice

Advanced Network = independent practice associations, large medical groups, clinically integrated networks, and integrated delivery system organizations that have entered into shared savings plan (SSP) arrangements with at least one payer

RESOURCES ALIGNED TO SUPPORT

TRANSFORMATION

Advanced Network

Community & Clinical Integration Program (CCIP)

Awards & technical assistance to support Advanced Networks in enhancing their capabilities across the network

Advanced Medical Home (AMH) Program

Support for individual primary care practices to achieve Patient Centered Medical Home NCQA 2014 recognition and additional requirements

Advanced Network

Improving care for all populationsUsing population health strategies

19

20

IMPROVING CAPABILITIES OF ADVANCED NETWORKS

Comprehensive Medication Management

E-Consults

Oral health

Integrating Behavioral HealthNetwork wide screening, assessment,

treatment/referral, coordination, & follow-up

Supporting Individuals with Complex Needs

Comprehensive care team, Community Health Worker , Community linkages

Reducing Health Equity GapsCHW & culturally tuned materials

Analyze gaps & implement custom intervention

Comm

unity Health Collaboratives

Community & Clinical Integration Program Awards & technical assistance to support Advanced Networks in enhancing their capabilities in the following areas:

21Whole-Person Centered

Patient Centered Access

Team Based Care

Population Health

Management

Care Coordination/

Transitions

Performance Measurement

Quality Improvement

Advanced Medical Home Program Webinars, peer learning & on-site support for individual primary care practices to achieve Patient Centered Medical Home NCQA 2014 and more

IMPROVING CAPABILITIES OF PRACTICES IN ADVANCED NETWORKS

I. Gain insight into payment systems that exist in

Connecticut

II. Receive feedback from payers regarding the

incorporation of CHW roles in healthcare reform models

III. Gain insight of outcome measurements that payers

would consider for CHW payment.

IV. Assess payer perception of feasibility of providing

payment for CHWs

OBJECTIVE

Literature review CHW payment methods in other states CHW roles in alignment with PPACA and SIM Sustainable payment methods recommended through

PPACA/SIM

Interests and guidance from SWAHEC and advisors Collaboration on project mission Conferences/CHW meeting to gain insight Key informant contacts

Interviews with: 1 National private payer 1 State private payer (multi-company representative) 3 Medicaid representatives 1 State representative offi cial

METHODS

METHODS

Transcribed and coded responses

Coding themes:

1. Payment Methods (e.g. value-based payment, bundled payment, grants)

2. Reform Program Models (e.g. P4P, Medical Homes, ACOs)3. Funding Source (Medicare, Medicaid, Commercial Payers)4. Roles of CHWs (e.g. Care Management and Care

Coordination)5. Health Reform (ACA, SIM)6. Performance Measurements7. Other State Models8. Quotes

Short-term grants and funding are the current sources of compensation in Connecticut

States including New York, Arizona, Tennessee, and Washington pay CHWs through management fees in Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs) within Federally Qualified Health Centers (FQHCs)

New Jersey CHWs operate within FQHCs through practices known as CAMcare and Camden Coalition

Texas, Arkansas, Oregon and Minnesota have Medicaid programs that provide CHWs with sustainable funding

RESULTS

Current Payment Methods for CHWs

PPACA and SIM-CT encourage the role of CHWs in PCMHs and ACOs

CHWs play the roles of health coaches, health literacy advocates, and care coordinators in ACOs of several states

CT Medicaid is in process of implementing CHW roles within Advanced Medical Homes

Highest level of interest was shown for  P4P, PCMHs/AMHs, and ACOs

Public and national private payers agree that CHWs are important for cost containment

RESULTS

Roles of CHWs in Delivery System and Payment Reforms

Five out of six key informants showed interest in value-

based payment and agreed that CHWs should not be reimbursed through fee-for-service

State private payers did not see an issue with fee-for-service being a problem for sustainability of CHWs nor in the healthcare system

RESULTS

Sustainable Payment Methods Preferred by Payers

“Get away from fee-for-service.”- Medicaid Representative

“The state will pay for a package of services and the provider has the option to include community health workers in the provision of those services, but it's not a direct payment [...] specifically for CHW services.”

-- Medicaid Representative

Half of the sample expressed that global payment is the optimal sustainable method

RESULTS

Sustainable Payment Methods Preferred by Payers

“The strategy to adopt is to say payers are already advancing money that enables practices to expand their team to include care coordinators.”

- State Representative Official

“There’re a lot of different variations on how [CHWs] are paid [...].It’s usually some kind of a bundle payment either for an episode or sort of global payment for all the health needs of the covered population.”

- Medicaid Representative

CT Medicaid is in nascent stages of implementing enhanced-fee-for service and performance payments for CHWs employed in Advanced Medical Homes (AMHs)

RESULTS

Sustainable Payment Methods Preferred by Payers

“Medical Homes is a building block for ACOs. It’s certain that the proliferation of Medical Homes is conducive to the deployment of CHWs.”

- State Official Representative

State private payers showed no interest or were non-responsive to recommend sustainable payment methods for CHWs

All payers agreed CHWs should receive sustainable funding but do not foresee implementation in the near-future

RESULTS

Medicaid Payer 3

Medicaid Payer 2

Medicaid Payer 1

National Payer

State Private Payer

SIM-CT RepresentativeEnhanced Fee-For-Service

Value-based Payment

Bundled Payment

Global Payment

Fee-For-Service*

Number of Responses

*Not recommended by any key informants

Sustainable Payment Methods Recommended by Key Informants

CHART FROM CODING

Medicare and Medicaid measure care experience to evaluate CHW impact in CT healthcare programs

Payers recommended using health outcomes, such as quality of life, chronic illness management, appropriate utilization of services, hospital readmission rates, return on investment, and health literacy as measurements

Key informants expressed concern that P4P may not be an accurate measure of CHW value and effi cacy of performance.

RESULTS

Measurement Outcomes used to evaluate CHW services

CHWs should be employed in health reform programs to realize the goals of the Triple Aim

Connecticut should refer to Oregon as a reference for payment models since it has a similar healthcare system

CT should consider global payment or value-based payment for sustainable funding of CHWs

RECOMMENDATIONS

Recommendations for Connecticut’s CHW Initiative

Providers should be interviewed regarding their perception of sustainable payment approaches for CHWs since they directly work with and employ CHWs

Likert Scale in future studies should be used  to allow for interest level of interviewees to be more clearly determined

List of existing payment methods recommended through PPACA and SIM-CT and case examples of cost-saving CHW interventions should be provided to interviewees, especially state private payers

RECOMMENDATION

Recommendations for future studies

Our study revealed that the goals of SIM-CT align with PPACA and encourage the roles of CHWs in health reform programs, as they embody the goals of the Triple Aim.

On a national level, Medicare is using and encouraging the use of CHWs in many ACO pilots.

In Connecticut, Medicaid and SIM are in the process of implementing CHWs through a value-based payment in the AMH model.

CONCLUSION

VOLUME TO VALUE BASED PAYMENT

Our study showed that various states, especially SIM states, are encouraging or have already implemented, CHW sustainable payment programs or are using a Medicaid funds.

Connecticut should consider the design of successful programs in other states in the development of its CHW workforce. Oregon was noted as a valuable reference for Connecticut’s future payment models, as the two states share similar healthcare systems.

Seemingly the most preferred way to incorporate CHWs into healthcare delivery is through the use of global or value-based payment methods.

CONCLUSION

Health-in-all policies is defi ned as collaborative approach to improving the health of all people with participation from multiple sectors, including payers.

CHWs are an integral sector to help accomplish social determinants of health which is now known as health-in-all policies.

The Trust for America’s Health estimates that $10 per person per year for prevention of chronic illness in proven community-based programs could save our country more than $16 billion annually in fi ve years – a return of $5.60 for every dollar spent.

Within these programs, CHWs often address a patient’s basic needs such as promoting economic stability, transportation access, environmental, and educational attainment.

Work of CHWs could also result in a decrease of chronic illness and unnecessary ER visits. CHWs are, therefore, a necessary work force for the health in all policies framework.

HEALTH-IN-ALL POLICIES

In June 2011, law RIGL 23-64.1 directed the establishment of a Commission of Heath Advocacy and Equity.

Requires a cross-section of state agency and community members to focus on the social determinants of health, and prepare biennial reports with public participation.

The law will serve to remind the government and the public that objectives for the well-being of the population are best achieved when all sectors include health as a key component of policy development.

CASE STUDY:HEALTH IN ALL POLICIES - RI

Overall, most public and national private payers support the idea of providing funds for CHW services but it will not be in the short-term that sustainable payment methods can be realized.

CONCLUSION

Special thanks to our preceptor, Meredith Ferraro of SW AHEC, and to Elaine O’Keefe and Mary Ann Booss of the Offi ce of Public Health Practice at Yale University for providing contacts, information about CHW conferences, and their passionate devotion to our project.

We also thank our instructor, Dr. Debbie Humphries, for her endless support and guidance, as well as our TA, Benjamin Clopper, for his assistance and collaboration on this project.

We are also grateful for the time and contribution of our key informants.

ACKNOWLEDGEMENT

Q u e s ti o n s ?

CONCLUDING REMARKS

1. http://www.swctahec.org/2. Association Public Health America. (2014). Community Health Workers. 2014, from http://www.apha.org/membergroups/sections/aphasections/chw/ 3. .National Peer Support Collaborative Learning Network. (2013). Opportunities for Peer Support in the Aff ordable Care Act (pp. 16). Leawood,KS: Peers for Progress.4. State of Connecticut. (2013). Connecticut Healthcare Innovation Plan (Vol. 225). Connecticut: State of Connecticut.

REFERENCE