health reform in vermont - csg knowledge...
TRANSCRIPT
Steve MaierHealth Care Reform Manager
Vermont Division of Health Care [email protected]
1/11/2011 1
Health Reform in VermontTransforming to a High Value and Affordable Health Care System
Vermont Context• 620,000 total population
• 13 Hospital Service Areas define ‘community systems’
• Payers: 3 major commercial+ 2 public
• History of collaboration: multi-partisan and multi-stakeholder
Health Reform in Vermont Transforming to a High Value and Affordable Health Care System
COVERAGE Reform
CARE Reform
INSURANCE Reform
PAYMENT Reform
FINANCING & COST Reform
INFRASTRUCTURE Reform
CARE reforms for all Vermonters include:
Advanced Primary Care foundation (PCMHs + CHTs)
Multi-Insurer Payment Reforms
A focus on prevention (public health health care delivery)
A statewide health information exchange
An evaluation infrastructure to support ongoing improvement
Facilitators & support for a learning health system
CARE Reform =
7
Vermont’s Administration and Legislature have consistently supported CARE Reform
2003 Blueprint launched as a Governor’s Initiative
2005 Implementation of Chronic Care Model2006 Blueprint codification as part of sweeping
reform legislation2007 Blueprint leadership and Integrated Pilots2008 Community Health Team structure and
insurer mandate2009 Accountable Care Organization Exploration2010 Statewide Expansion
“a program for integrating a system of health care for patients, improving the health of the overall population, and improving control over health care costs by promoting health maintenance, prevention, and care coordination and management.”
VT Act 128 - 2010
VT Blueprint for Healthfor all Vermonters
Health IT Framework
Evaluation Framework
Medical Home
Hospitals
Public Health Programs & Services
Community Health TeamNurse Coordinator
Social WorkersNutrition Specialists
Community Health WorkersMCAID Care Coordinators
Public Health Specialist
Specialty Care & Disease Management Programs
A foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of services
Multi Insurer Payment Reform that supports a foundation of medical homes and community health teams
A health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry
An evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impact
Mental Health & Substance Abuse
Programs
Medical Home
Medical Home
Medical Home
Social, Economic, & Community Services
Healthier Living Workshops
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Multi-insurer Payment Reforms
Insurers
•Community Health Teams•Shared costs as core resource•Consistent across insurers•Minimizes barriers
•Patient Centered Medical Home•Payment to practices•Consistent across insurers•Promotes quality
•Fee for Service•Unchanged•Allows competition•Promotes volume
+ +
•Based on NCQA PPC-PCMH Score•$1.20 - $2.49 PPPM•Based on active case load
•5 FTE / 20,000 people•$ 350,000 per 5 FTE•Scaled based on population
•Medicaid•Commercial Insurers•Medicare?
YES!!
$0.00
$0.50
$1.00
$1.50
$2.00
$2.50
$3.00
0 10 20 30 40 50 60 70 80 90 100
$ P
PP
M p
er p
rovi
der
NCQA PCMH Score
Requires 5 of 10 Must Pass Elements
Requires 5 of 10 Must Pass Elements
All insurers pay enhanced payment based on a practices score as a patient centered medical home
NCQA PCMH standards and scoring methods are used to score practices as a medical home
Payment changes with each 5 point change in the NCQA PCMH score (score ranges from 0 – 100 points)
Designed to incent ongoing iterative improvement, and to provide a disincentive for moving backwards
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Patient Centered Medical Homes
Multi-insurer payment reform
Health Information Infrastructure
Evaluation Infrastructure
AM
PC
Foundation
General population
SubPopulation
SubPopulation
SubPopulation
Community Health Team
Advanced Model of Primary CareA Foundation for integrated services
Patient Centered Medical Homes
Multi-insurer payment reform
Health Information Infrastructure
Evaluation Infrastructure
AM
PC
Foundation
General population
SubPopulation
SubPopulation
SubPopulation
Community Health Team
Advanced Model of Primary CareA Foundation for integrated services
Tool
s (e
.g. H
RAs
)
Targ
eted
Inte
rven
tions
Bes
t Pra
ctic
es
Gui
delin
e ba
sed
care
Patient Centered Medical Homes
Multi-insurer payment reform
Health Information Infrastructure
Evaluation Infrastructure
AM
PC
Foundation
General population
SubPopulation
SubPopulation
SubPopulation
Community Health Team
Advanced Model of Primary CareA Foundation for integrated services
Targeted Services
Specialty Care
Disease Management Programs
Case Management
Social Services
Economic Services
Community Health Team
Patient Centered Medical Homes
Multi-insurer payment reform
Health Information Infrastructure
Evaluation Infrastructure
AM
PC
Foundation
Advanced Model of Primary CareA Foundation for integrated services
Targeted Services
Specialty Care
Disease Management Programs
Case Management
Social Services
Economic Services
General population
SubPopulation
SubPopulation
SubPopulation
Advanced Primary Care PracticesNCQA Criteria for PCMH recognition
Blueprint Central Registry
Patient tracking - Access to searchable and actionable data
Care Management - Use of evidence based guidelines
Patient Management Support - Identify patients with unique needs
Test tracking - Managing results/alerts
Performance Reporting - % of patients meeting various guidelines
NCQA PCMH Points
Average PPPM
Payment
0 0.00
5 0.00
10 0.00
15 0.00
20 0.00
25 1.20
30 1.28
35 1.36
40 1.44
45 1.52
50 1.60
55 1.68
60 1.76
65 1.84
70 1.92
75 2.00
80 2.07
85 2.15
90 2.23
95 2.31
100 2.3917
Priorities
Transformation vs. Research
Don’t interfere with health services …. But
Build a learning health system…
with continuous improvements
Evaluation & Results
Building a Learning Health System
Do meaningful & useful evaluation
Provide data as part of routine operations
Support a broad array of meaningful metrics
Create flexible & dynamic reports
Organize processes & people to use information to make improvements
Data Sources Categories of Measures
Reporting
Central Registry Clinical ProcessesHealth Status
Web basedFlexible & dynamic
Multi-Payer Claims Database Resource UtilizationExpenditures
Standard ReportsWeb based Flexible & dynamic
Chart Reviews Clinical ProcessesHealth Status
Standard Reports
NCQA Scoring Clinical ProcessesPCMH Standards
Standard Reports
Public Health Registries Population levelRisk FactorsGuide planningTrack change
Standard Reports
Patient Handout
Basic Outreach Report
Distributions vs. Averages
Group 1Good Disease
Control
Group 2Intermediate
Disease Control
Group 3Poor
Disease Control
Average = 7.46 Average = 7.36
Burlington Cohort: Total Admission Rate
0.0
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10AesculapiusCohortAdmission RatePer Thousand:Pre-MedicalHomeImplementation
AesculapiusCohortAdmission RatePer Thousand:Post-MedicalHomeImplementation
Linear(AesculapiusCohortAdmission RatePer Thousand:Pre-MedicalHomeImplementation)Linear(AesculapiusCohortAdmission RatePer Thousand:Post-MedicalHomeImplementation)
Start MAPCP Pilot
Rate of change = 8.4% decrease
y = 0.0609x + 4.804R2 = 0.229
y = -0.0042x + 7.1R2 = 0.0009
Burlington Cohort: ER Visit Rate
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-06
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Aesculapius CohortER Visit Rate PerThousand: Pre-Medical HomeImplementation
Aesculapius CohortER Visit Rate PerThousand: Post-Medical HomeImplementation
Linear (AesculapiusCohort ER VisitRate Per Thousand:Pre-Medical HomeImplementation)
Linear (AesculapiusCohort ER VisitRate Per Thousand:Post-Medical HomeImplementation)
Start MAPCP Pilot
Rate of change = 15.0% decrease
y = 0.146x + 13.167R2 = 0.2974
y = 0.0135x + 16.164R2 = 0.003
St. Johnsbury Cohort: ER Visit Rate
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Corner Medical CohortER Visit Rate PerThousand: Post-CCT
Corner Medical CohortER Visit Rate PerThousand: Pre-CCT
Linear (Corner MedicalCohort ER Visit Rate PerThousand: Pre-CCT)
Linear (Corner MedicalCohort ER Visit Rate PerThousand: Post-CCT)
y = 0.3248x + 41.454R2 = 0.2165
y = -0.5203x + 69.572R2 = 0.4655
Start of MAPCP Pilot
Rate of change = 21.8% decrease
St. Johnsbury Cohort: Total Hospital Admissions Rate
0.0
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Corner Medical CohortAdmission Rate PerThousand: Post-CCT
Corner Medical CohortAdmission Rate PerThousand: Pre-CCT
Linear (Corner MedicalCohort Admission RatePer Thousand: Pre-CCT)
Linear (Corner MedicalCohort Admission RatePer Thousand: Post-CCT)
Start MAPCP Pilot
y = 0.0784x + 5.6467R2 = 0.2769
y = -0.0417x + 9.6114R2 = 0.0871
Rate of change = 19.1% decrease
*At each site, an active APCP cohort was selected (patients with a visit in the APCP between the start date of the pilot and a defined time period). Monthly rates of ED visits and IP admissions (all cause) for the APCP cohorts were evaluated during two time periods, the 2 years prior to the start of the pilot, and the time period since the start of the pilot. Each chart displays the two different data series and trend lines for the same cohort. The findings suggest a change in gross directionality of hospital encounter volumes, and are suggestive of change with a trajectory that is sustained over time making it unlikely to be a Hawthorne effect. The results are not predictive, but do display early trends with simple linear regression methods.
Vermont MAPCP Preliminary DataTrends in hospital based care per 1000 (pre/post start of MAPCP pilots)*
$200,000,000
$250,000,000
$300,000,000
$350,000,000
$400,000,000
$450,000,000
1 2 3 4 5
ANN
UA
L C
HAN
GE
IN
HEA
LTH
CAR
E EX
PEN
DIT
UR
ES
YEARS
IMPACT OF INTEGRATED HEALTH SYSTEM-POTENTIAL COST AVOIDANCE ACROSS TOTAL POPULATION
INCREMENTAL EXPENDITURES WITHOUT INTEGRATED HEALTH SYSTEM
INCREMENTAL EXPENDITURES WITH INTEGRATED HEALTH SYSTEM
28.7%
Target Population% of VT Population# CHTs
42,1796.7%
2
126,28620%
6
316,66250%16
508,1780%25
637,130100%
321/11/2011 27
$4,000,000
$4,500,000
$5,000,000
$5,500,000
$6,000,000
$6,500,000
1 2 3 4 5
TOTA
L AN
NU
AL
EXPE
ND
ITU
RES
YEARS
IMPACT OF INTEGRATED HEALTH SYSTEM-POTENTIAL COST AVOIDANCE ACROSS TOTAL POPULATION
(000'S)
EXPENDITURES WITHOUT INTEGRATED HEALTH SYSTEM
EXPENDITURES WITH INTEGRATED HEALTH SYSTEM
1.9%
Target Population% of VT Population# CHTs
42,1796.7%
2
126,28620%
6
316,66250%16
508,1780%25
637,130100%
321/11/2011 28
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Health Care Reform 2010 and BeyondConvergence and Opportunity
Vermont Act 128 – Statewide expansion of medical homes, community health teams, and mandated multi-insurer payment reforms
Affordable Care Act – Comprehensive insurance reforms for increased accountability, lower costs and enhancing the quality of health care (Sections 3502 and 3503)
Multi-payer Advanced Primary Care Practice demonstration –Medicare to join state led multi-insurer payment reforms that support an advanced model of primary care
July2008
Jan2009
July 2009
Jan 2010
July 2010
Jan2011
July 2011
Jan 2012
July 2012
Jan 2013
July 2013
Pilot # 1 St Johnsbury HSA St Johnsbury HSA Expansion
Pilot # 2 Burlington HSA Burlington HSA Expansion
Readiness Pilot # 3 Barre HSA Barre HSA Expansion
Readiness HSA # 4 Rollout
Readiness HSA # 5 Rollout
Readiness HSA # 6 Rollout
Readiness HSA # 7 Rollout
Readiness HSA # 8 Rollout
Readiness HSA # 9 Rollout
Readiness HSA # 10 Rollout
Readiness HSA # 11 Rollout
Readiness HSA # 12 Rollout
Readiness HSA # 13 Rollout
Implementation Phase Demonstration Phase (Medicare?)
Target Population% of VT Population# CHTs
42,1796.7%
2
126,28620%
6
316,66250%16
508,1780%
25
637,130100%
32
Blueprint Integrated Health System - Proposed Expansion
1/11/2011 30
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State & Federal PartnershipsExample - Health information & quality infrastructure
National Guidelines & Measures(NIH, Task Force, AHRQ)
Guideline based Data Dictionary
•Clinical process data elements
•Health status data elements
•Aligned measure set
•Aligned answer options
Reporting & Evaluation
• Registry reports
Outreach
Performance
• Claims database reports
Clinical Tracking Systems
•EMR Templates
•Registry visit planners
•Outreach reports
•Interfaces & data transfer
Guideline Based Health Services
•Individual patient care
•Population management
•Coordinated health services
•Emphasis on prevention
Guideline Based QI
•Comparative Evaluation
•Provide reports & data
•Coaching & facilitation
•Shared learning
Learning Health System
Ongoing Refinement
State Led Health Reforms
Federal Funding & Guidance(ONC, CMS)
Future Challenges & Opportunities
COVERAGE Reform
CARE Reform
INSURANCE Reform
PAYMENT Reform
FINANCING & COST Reform
INFRASTRUCTURE Reform
Future Challenges & Opportunities
• Health care costs• Maximize benefits to VT of federal reform • Health care workforce • Payment reform – ACOs • Sustainable financing • System design options - one single-payer
option, one public-insurance option, and one other – Dr. William Hsiao, Harvard
Future Challenges & Opportunities
1/11/2011 35
Conclusions: We propose the establishment of ethics committees to review all future redisorganizationproposals in order to put a stop to uncontrolled, unplanned experimentation inflicted on providers and users of the health services.
A surrealistic mega-analysis of redisorganization theories
Oxman AD, Sackett DL Chalmers I, Prescott TE. J R Soc Med 2005;98:563-568
Make Time to Listen
Susan W. Besio, Ph.D.CommissionerOffice of Vermont Health AccessVermont Health Care Reform [email protected]
Hunt BlairDirectorVT Healthcare Reform Div.State Health IT Coord.(802) [email protected]
Steve MaierHealth Care Reform ManagerVT Healthcare Reform Div.(802) [email protected]
Diane HawkinsExecutive Staff Assistant (802) [email protected]
Craig Jones, MDDirectorVT Blueprint for Health(802) [email protected]
Christine OliverDeputy CommissionerVT Banking, Insurance, Securities and Health Care Administration(802) 828-2900 [email protected]
Vermont Health Care Reformhttp://hcr.vermont.gov