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June 9, 2019

Stephen Cook MD, MPH. Medical Director, NYS Office of Health Insurance Programs

New York State’s Health Care Transformation:Delivery System Reform Incentive Payment to Value-Based Payment Programs & the Impact on Asthma Care

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Disclosures

1) Faculty at University of Rochester Medical Center1) Assoc Professor of Pediatrics, Internal Medicine & Center for Community Health

Research from NIH and PCORISee patientsTeach students

2) Medical Director: New York State Department of Health1) Pediatric lead2) First 1000 Days on Medicaid

3) Used to work at TJ’s Big Boy

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How DSRIP & Value Based Payment Programs (VBP) Relate

20132014

20152016

20172018

20192020

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This is what NYS really looks like

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25 Regional Performing Provider Systems

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VBP Transformation: Overall Goals and Timeline

Acronyms: NYS = New York State; PPS = Perform ing Provider System; MCO = Managed Care Organization

April 2017 April 2018 April 2019DSRIP GoalsPPS requested to

subm it growth plan outlining path to

80-90% VBP

> 10% of total MCO

expenditure in Level 1 VBP or above

> 50% of total MCO

expenditure in Level 1 VBP or above.> 15% of total

paym ents contracted in Level 2 or higher

80-90% of total MCO

expenditure in Level 1 VBP or above

> 35% of total paym ents contracted in Level 2 or

higher

NYS Payment ReformBootcamps

Clinical Advisory Groups

VBP Pilots

Goal: To improve population and individual health outcomes by creating a sustainable system through integrated care coordination and rewarding high value care delivery.

April 2020

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How is VBP Different from the Current Payment Structure?

1) Efficiency Component - A target budget is set at the beginning of the year, against which costs (expenditures) are reconciled at the end of the year.

Services may be reimbursed as fee-for-service as they are now, or as a per member per month (PMPM) prospective payment.

2) Quality Component - A percentage of performance measures on the attributed population (those included in the arrangement) must be passed to share in any savings (or to determine the percentage of losses that must be made up).

Source: New York State Department of Health Medicaid Redesign Team. A Path Towards Value Based Payment, New York State Roadmap for Medicaid Payment Reform. NYS DOH VBP website (Link) June 2016 updated version approved by CMS March 2017.

EfficiencyQuality

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Delivery System Reform Incentive Payment (DSRIP) Program

Objectives

• DSRIP was built on the CMS

and State goals in the Triple Aim:

o Improving quality of care

o Improving health

oReducing costs

oQuadruple Aim:oClinician Wellness

Goal: Reduce avoidable

hospital use –Em ergency

Departm ent and Inpatient – by 25%

over 5+ years of DSRIP

Rem ove Silos

Develop Integrated Delivery System s

Enhance Prim ary Care

and Com m unity-

based Services

Integrate Behavioral Health and

Prim ary Care

Source: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/. Accessed May 5, 2016.

DSRIP delivery system changes à VBP

Readiness

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DSRIP Project Implementation• PPS committed to healthcare reform by choosing a set of Projects best matched to the

needs of their unique communities.

• DSRIP Projects are organized into Domains, with Domain 1 focused on overall PPS organization, and Domains 2 - 4 focused on various areas of transformation. All projects contain metrics from Domain 1.

DSRIP Project Organization

Domain 2:System Transformation

e.g. Project 2.a.i - Integrated Delivery System

2 – 4 projects +/- 2.d.i

Domain 4:Population Health

e.g. Project 4.a.iii – Strengthen Mental Health and Substance

Use Infrastructure1-2 projects

Domain 3:Clinical Improvement

e.g. Project 3.d.ii and 3.d.iii –Asthma-related projects

2 – 4 projects

Dom ain 1:Organizational Com ponents

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The New World: Paying for Outcomes not Inputs

S ource : N ew Y ork S ta te D epartm ent o f H ea lth M ed ica id R edes ign T eam . A P a th T ow ards V a lue B ased P aym ent, N ew Y ork S ta te R oadm ap fo r M ed ica id P aym ent R e fo rm . N ew Y ork S ta te D epartm ent o f H ea lth (N Y S D O H ) D S R IP W ebs ite . O rig ina lly P ub lished June 2015 .U pda ted and approved by C M S M arch 2017 . h ttps ://w w w .hea lth .ny .gov /hea lth_care /m ed ica id /redes ign /dsrip /2017 /2017-03-30_cm s_vbp_roadm ap_approva l_ le tte r.h tmhttps ://w w w .hea lth .ny .gov /hea lth_care /m ed ica id /redes ign /dsrip /2017 /docs /2016-06_vbp_roadm ap_fina l.pd f

An approach to Medicaid

reimbursement that rewards value over

volume

An approach to incentivize providers

through shared savings and financial

risk

A method to directly tie payment to

providers with quality of care and health

outcomes

A component of DSRIP that is key to the sustainability of

the program

Value Based Payment (VBP)

Volume of Care(FFS)

Value of Care(VBP)

F F S - F ee fo r S erv ice

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In addition to choosing which integrated services to focus on, the MCOs and contractors can choose different levels of Value Based Payments:

Level 0 VBP* Level 1 VBP Retrospective Reconciliation

Level 2 VBPRetrospective Reconciliation

Level 3 VBP Prospective (requires mature contractors)

FFS with bonusand/or withhold based on quality scores

FFS with upside-only shared savings available when outcome scores are sufficient

FFS with risk sharing (upside available when outcome scores are sufficient)

Prospective capitation PMPM or Bundle (with outcome-based component)

FFS Payments FFS Payments FFS Payments Prospective total budget payments

No Risk Sharing á Upside Only áâ Upside & DownsideRisk áâ Upside & Downside Risk

May 2018

Managed Care Organization and Provider can Choose Different Levels of VBP

Source: New York State Department of Health Medicaid Redesign Team. A Path Towards Value Based Payment, New York State Roadmap for Medicaid Payment Reform. June 2016 updated version approved by CMS March 2017

Acronym Definition: Fee for Service (FFS); Per Member Per Month (PMPM)

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VBP Arrangements• Arrangement Types*

o Total Care for the General Population (TCGP)o Integrated Primary Care (IPC)o Maternity Care o Health and Recovery Plans (HARP)o HIV/AIDS Careo Managed Long Term Care (MLTC)

*Arrangements do not yet include Dually Eligible members

• Two VBP implementation subcommittees were created to focus on:o Social Determinants of Health and Community Based Organizationso Advocacy and Engagemento The full recommendations that came from these Subcommittees are available in the

Department of Health (DOH) VBP Resource Library – New York State DOH VBP website (Link)

HARP

HIV/AIDS

MLTC

Maternity Care

Integrated Primary Care

TCGP

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Asthma Statistics, New York State

Snapshot of Asthma spend in NYS for 2017-2018:

Age Group

Asthma Cohort

% total Asthma Pop

% total Medicaid

ED + IP Spend Non-ED+IP Asthma Spend

Asthma spend % of Total Medicaid Spend for that age group

0-1 24,844 4% .4% $17,097,349 $1,728,738 11.5%

2-11 159,747 26% 2.6% $80,879,220 $40,191,191 15.6%

12-20 97,885 16% 1.6% $76,169,634 $36,033,469 17.9%

21+ 362,984 59% 5.9% $673,225,828 $271,198,849 14.4%

Total 620,450 100% 10.1% $847,372,030 $349,152,246 14.7%

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• 13 Performing Provider Systems (PPS) covering various geographic regions throughout the state selected to address their Medicaid population with asthma via DSRIP initiatives:

• Project 3.d.ii - Expansion of asthma home-based self management program • 8 PPS implementing (6 NYC, 1 Long Island, 1 Capital Region)

• Project 3.d.iii - Implementation of evidence-based medicine guidelines for asthma management

• 5 PPS implementing (1 NYC, 1 Long Island, 1 Capital Region, 1 Hudson Valley, 1 Central NY)

• Associated Performance Measures:• PQI15 (Asthma in Younger Adults Admission Rate) Ages 18-39• PDI14 (Asthma Admission Rate) Ages 2-17• Asthma Medication Ratio (5 – 64 Years)• Medication Management for People with Asthma (5 – 64 Years) – 50% of Treatment Days Covered• Medication Management for People with Asthma (5 – 64 Years) – 75% of Treatment Days Covered

Addressing access to and quality of Medicaid asthma management services via the NYS DSRIP Program

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• Project 3.d.ii - Expansion of asthma home-based self management program • 7 of 8 PPS have completed implementation, with over half passing all project

milestones• 8th PPS has this project due for completion next quarter

• PPS partnering with community-based organizations, Regional Asthma Coalitions, primary care providers, local health departments, among others.

• Project 3.d.iii - Implementation of evidence-based medicine guidelines for asthma management

• 4 of 5 PPS have completed implementation, with all but one passing all project milestones

• 5th PPS has this project due at the close of DY4.

• PPS partnering with primary care providers, specialists, pharmacists, and others.

Progress and Performance through DY3

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DSRIP Mid Point Assessment• Of the 13 PPS implementing Asthma Management projects (3.d.ii and 3.d.iii), four PPS had a

total of six Mid Point Assessment recommendations from the Independent Assessor (IA) for these projects.

1) PPS to develop a corrective action plan to successfully complete the project requirements that the IA determined were not completed by the PPS Speed & Scale commitment date for this project.

• The PPS must provide a revised timeline for the completion of the three project requirements that were not completed by DY2, Quarter 2 as part of this action plan.

2) PPS workforce committee to develop a strategy to recruit Certified Asthma Educators.3) PPS to develop a standard curriculum to train community health workers in asthma home-based

self-management.4) PPS to develop an action plan to educate patients on the benefits of home-based asthma visits

in order to engage patients in the project. • The PPS must also create a plan to expedite the time needed to negotiate with vendors and integrate

home visits into the infrastructure to engage partners in the project.5) PPS should continue to pursue workforce solutions through its identified workforce partners to

foster workforce pipeline for necessary workers with appropriate skillsets.6) PPS should continue to collaborate with the NYS Asthma Regional Coalitions to provide asthma

education certification trainings.

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• Pay-for-Performance in MY3 (most recent period completed)• Asthma Medication Ratio (5 – 64 Years)

• 11 of 13 PPS improved in performance compared to previous year

• 7 of 13 PPS met their MY3 Annual Improvement Target (calculated on gap-to-goal)

• All PPS rate has improved year-to-year

• Medication Management for People with Asthma (5 – 64 Years) 50% of Tx Days Covered

• 9 of 13 PPS improved in performance compared to previous year

• 7 of 13 PPS met their MY3 Annual Improvement Target (calculated on gap-to-goal)

• All PPS rate has improved year-to-year

• Medication Management for People with Asthma (5 – 64 Years) 75% of Tx Days Covered

• 6 of 13 PPS improved in performance compared to previous year

• 4 of 13 PPS met their MY3 Annual Improvement Target (calculated on gap-to-goal)

• All PPS rate has improved year-to-year

Progress and Performance through MY3

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• PQI 15 (Asthma in Younger Adults Admission Rate) ages 18-39

• PDI 14 (Asthma Admission Rate) ages 2-17

• As of October 2015, AHRQ transitioned from using ICD-9 to ICD-10 diagnosis codes for PQI and PDI measures. As such, these measures will not be trended from MY0, and instead, MY3 results will serve as baseline for Pay-for-Performance beginning in MY4.

Progress and Performance through MY3

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Asthma Projects and DSRIP Program’s Transition to Value-Based PaymentsPrevention Agenda Value Based Payment (VBP) Pilot: Asthma and Healthy Homes

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Standard: Implementation of SDH Intervention

“To stimulate VBP contractors to venture into this crucial domain, VBP contractors in Level 2 or Level 3 agreements will be required, as a statewide standard, to implement at least one social determinant of health intervention. Provider/provider networks in VBP Level 3 arrangements are expected to solely take on the responsibilities and risk.” (VBP Roadmap, p. 41)

Description:VBP contractors in Level 2 or 3 arrangement must implement at least one social determinant of health intervention. Language fulfilling this standard must be included in the MCO contract submission to count as an “on-menu” VBP arrangement.

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The SDH Intervention Menu is available at: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_library/docs/sdh_intervention_menu.xlsx

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NYS Medicaid Health Homes • Health Homes are a Care Management model that provide:

• Integration of behavioral and physical health and social supports to provide “Care Management for All”

• Enhanced care coordination and integration of primary, acute, behavioral health (mental health and substance abuse) services,

• Linkages to community services and supports, housing, social services, and family services for persons with chronic conditions

• Adult Health Homes and Health Homes Serving Children use the below Chronic Condition Eligibility Criteria: • The individual must be enrolled in Medicaid and have:

• 2 or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes*) OR

• One single qualifying chronic condition: ü HIV/AIDS or ü Serious Mental Illness (SMI) (Adults) orü Serious Emotional Disturbance (SED) or Complex

Trauma (Children)

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Asthma Education for Health Homes ACP partnered with OHIP to offer an asthma webinar for Medicaid Health Home Care Managers to present:• Asthma basics • Guidelines-based care• Strategies to support

care coordination

The session was attended by over 300 HH care managers.

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Survey of Managed Care Organizations (MCOs) on Coverage and Availability of Asthma Services• Conducted in partnership with Office of Health Insurance Programs’

(OHIP) Division of Program Development & Management• Purpose

• Explore variations and identify barriers

• Methods• Designed to inquire about key elements of the NAEPP EPR-3 guidelines • Three electronic questionnaires were developed

• Pharmacy and durable medical equipment (DME) coverage• Medical coverage and provider support• Health plan support for Medicaid enrollees with asthma.

• OHIP identified the 18 NYS MCO plans, points of contact for each, and distributed the surveys via email.

• 100% response rates for each

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Summary Results: Pharmacy & DME

Type of benefit coverage for medical devicesDME only Pharmacy only Both

Peak flow meters 11% (2/18) 17% (3/18) 72% (13/18)Valved holding chambers 0% 28% (5/18) 72% (13/18)Spacers 0% 28% (5/18) 72% (13/18)

88.9%

38.9%

94.4%

27.8%11.1%

61.1%

5.6%

72.2%

0%20%40%60%80%

100%

Quanti ty l im itsapply

Ov erfi l l datais trac ked

Quanti ty l im itsapply

Underfi ll datais trac ked

Quick R el ief Medic ations Contro l ler Medic ations

Quantity Limits and tracking of medication fills

(n=18)

Yes No

Notifications by the plans that track fill dataQuick Relief Medications

Notifications provided to prescriber? 100% (7/7)Outreach provided to enrollee? 100% (7/7)

Controller MedicationsNotifications provided to prescriber? 100% (5/5)

Outreach provided to enrollee? 100% (5/5)

39%50% 56%

N/A

72% 72%

N/A17% 17%

0%

20%

40%

60%

80%

Peak Flow Meters Valv ed Hold ingCham bers

Spac ers

Medical device benefit coverage limitations

Prior Authoriz ations Quanti ty L im its Costs Lm its

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78%

39% 33%22% 17%

28%

0%

20%

40%

60%

80%

100%

Electron ic reportingon patients' gaps in

care

Training on Q uali tyImprovement (QI)

methodology

Prac tice-spec ifictelephonic

outreach/c arecoord ination support

On-si teengagement/care

coord ination supportprovided in thecl inica l setting

Prom otion of train ingopportun ities on

guide lines

Other

Perc

enta

ge o

f pla

ns

Types of support reported

Supports offered to providers in managing Medicaid patients with asthma (n=18)

33%

94% 94% 94%

0%

50%

100%

Other (Xolai r) Serum /bloodallergy tes ts

Skin al lergy tests Al lergy shots

Perc

enta

ge o

f pla

ns

Type of testing

Types of Allergy Testing and Allergen Immunotherapies Covered

(n=18)

Medical Coverage

67%50% 44%

22% 17%

0%

50%

100%

Extended w ai ttim es

Geographicd is tance

Avai lab lespecia lists

Other No chal lengesPerc

enta

ge o

f pla

ns

Reported Challenges

Challenges linking patients living in HPSAs to asthma specialty care

services (n=18)

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33%

67%

Type of program offered to enrollees with asthma (n=18)

Comprehensive Asthma C areProgram

Health Plan Support for Enrollees with Asthma

Type of services availableComprehensive

Asthma Care Program (n=6)

Case Management

Services (n=12)Coordination of care with the enrollee’s provider(s) 100% 100% Support for referrals to specialist providers (pulm onology, allergy)

100% 100%

Referrals to com m unity-based asthm a services 100% 83%Targeted tobacco cessation support 100% 75% Coordination of care w/ child’s school nurse’s office/SBHC 100% 67% Assistance w identifying healthy housing or com m unicating w landlords

100% 58%

Asthm a Self-m anagem ent education (ASME) N/A* 83% Other 25%

Community-based asthma service referral typeComprehensive

Asthma Care Program (n=2)

Case Management

Services (n=10)Local health departm ent's Healthy Neighborhoods Program 100% 50% Hom e visiting nursing services 100% 70%Com m unity-based hom e environm ental assessm ent for asthm a triggers

50% 50%

Integrated pest m anagem ent services 50% 20%Hom e environm ental rem ediation services 50% 30%Other 0 10%

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Asthma Care Coverage: Key Findings• Plans exhibit variation in coverage and some barriers remain• Quantity and cost limitations on asthma medications and

devices • Tracking data for asthma medication over and underfills and outreach

• Challenges in linking patients in HPSAs with specialists• Comprehensive asthma care management vs. standard case

management services • Eligibility criteria targets enrollees whose asthma is not well controlled• Comprehensive care management is more likely to include NAEPP guidance-

aligned services • Opportunities for alignment with CDC’s 6|18 Initiative

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Prevention Agenda VBP Pilot: Asthma & Healthy Homes

• Multi-Agency “Healthy Homes” Pilot to serve 500 low-Income households in high asthma-burden regions

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NYS Healthy Homes Pilot

• New York State Energy Research and Development Authority (NYSERDA) and DOH joint initiative

• Aims to develop and validate an approach for delivering a comprehensive healthy homes intervention within the context of VBP

• Streamlined integration of services to address home environmental triggers and housing-related hazards to improve asthma health outcomes and avoid home-based injury

• Components include: asthma self-management education, environmental home assessment, and energy efficiency services

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Cost-Benefit Analysis: NYS Funded Healthy Homes for Residents with Asthma, NYS Health Neighborhoods Program

Objective: Evaluate Costs/Savings of Asthma Intervention of State-funded healthy homes program.

Participants: 550 Children, 731 adults with active asthma; 791 households with 448 children and 551 adults with asthma events, previous year

Intervention: Home environmental assessments intervention to address asthma trigger-promoting conditions, and asthma self-management. Conditions reassessed 3-6 months after initial visit.

Results: Per Person savings, medical encounters and medications filled was $1,083 per in-home asthma visit, average cost of visit $302, net savings: $781. Active Asthma Group: $613 savings per visit, net benefit to program $311.

https://www.ncbi.nlm.nih.gov/pubmed/28121775

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NYS “Healthy Homes” Pilot

• Joint initiative with Department of Health (DOH) and the New York State Energy and Development Authority (NYSERDA) to reduce Asthma-related illnesses

• Aims to develop and validate an approach for delivering a comprehensive healthy homes intervention within the context of VBP

• Streamline integration of services to address home environmental triggers and housing-related hazards to improve asthma health outcomes and avoid home-based injury with:

• asthma self-management education

• environmental home assessment• energy efficiency services

• “Healthy Homes” Pilot to serve 500 low-Income households in high asthma-burden regions

• “Healthy Homes” is part of the Health Across All Policies Initiative, aligned with Prevention Agenda priorities and addresses Social Determinants of Health (SDH)

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According to the CDC’s Community Preventive Services Task Force and the

National Asthma Education and Prevention Program, the best Asthma

interventions are…

Multi-component• After diagnosis, a certified

asthm a educator, nurse, or other qualified health worker visits the fam ily at hom e. They conduct asthm a education, self-m anagem ent training, answer questions, refer the fam ily to needed social services, and provide care coordination.

Home-based• A certified, experienced

professional w ill identify and address the hom e’s environm ental asthm a triggers.

Multi-trigger• Rem ediation within the

hom e is directed at elim inating m ultiple asthm a triggers (allergens and irritants) including m ice, cockroaches, dust m ites, excess m oisture and m old, household pets, and tobacco sm oke.

https://www.hud.gov/sites/dfiles/HH/documents/HUD%20Asthma%20Guide%20Document_Final_6%2020%2018.pdf

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Addressing Social Determinants of Health in a VBP Context• Disparities in asthma burden

IncomeHousing quality and exacerbationsImpacts on overall health and productivityLeads to higher health system costs

• Pilot will support VBP Roadmap Requirements by:Level 2 and 3 arrangements include at least one SDH interventionMCOs and VBP Contractors include at least one Tier 1 CBO (non-Medicaid billing) in their Level 2 and 3 arrangementsPilot will build market support and foster provider engagement

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Please send questions and feedback to:asthma@health.ny.govvbp@health.ny.gov

Questions and Discussion

Thank you!