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ALIGNING PAYMENT WITH PATIENT-CENTERED CARE AND VALUE-BASED PAY

Craig HostetlerMPCA Annual Conference

August 5th, 2013

Why Are We Doing This?

Why Take the Risk?

Our stakeholders wanted something better

Patients

Payers

Providers & support staff

Recruitment getting harder

Increased pressure

Transparency and accountability increasing

Payment moving from volume to value

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Policy Environment

Policy Environment in Oregon

Legacy of innovation Oregon Health Plan

Legislature has worked well together

Oregon Health Authority

Created in 2009 Led by nine-member board Consolidates most state health

care programs: Public Health, Oregon Health Plan,

Healthy Kids, employee benefits, public-private partnerships

Purchasing power to affect cost, quality, access

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Coordinated Care Organizations

Oregon’s version of ACOs for Medicaid Key elements: PCMH – Needs to address access and quality Local control CoordinationHealth equityMetrics/performance measuresGlobal budgets (pmpm) & shared savings

Value-based pay the burning platform

Pressure from State

State knows our clinics well Questions our value for

enhanced rate Pressure to align more with

value-based payment reform Become part of local solution:

Include enhanced rates in CCO global budget

Pressure from CMS

FQHC wrap not part of CCO global budget

CMS wants wrap growth < 3.4% New patients counted against

growth limit Exceptions:NAP Federally initiated service expansions Change in Scope

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National Pressure

Medicaid Directors questioning value of enhanced reimbursement

CMS is asking same question of BPHC CMS and Medicaid Directors want:

Alignment with value-based pay, and/or Movement away from FFS

Pressure way up in the last 12 months

Partnering with Medicaid

Pressure on the Current Payment System

Health care cost increases not sustainable

State budget deficit in Oregon

Reformed health system needs as its foundation: Primary care Prevention Wellness

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Starting the Conversation with Medicaid

Our missions are aligned Payment reform should make

primary care more effective Value-based pay makes sense Must account for behavioral

and socio-economic barriers Let’s work together on a

bridge to value-based pay

Adjusting/Stratifyingfor Patient Complexity

Not adjusting could increase disparities Hong et. al., “Relationships Between Patient Panel Characteristics

and Primary Care Physician Clinical Performance Rankings,” Journal of the American Medical Association, 9/8/10.

Chien et.al., “Do Physician Organizations Located in Lower Socioeconomic Status Areas Score Lower on P4P Measures?,” Journal of General Internal Medicine, 12/13/11

Paying for health homes in the safety net Long A., Phillips K., Hoyer D., ”Payment Models to Support Patient-

Centered Medical Home Transformation: Addressing Social, Behavioral, and Environmental Factors,” Qualis Health, 8/11.

Not adjusting could penalize safety net Tyo et. al., “Methodological Challenges for Measuring Primary Care

Delivery to Pediatric Medicaid Beneficiaries Who Use CHCs,” American Journal Of Public Health, 2/13.

APM Model

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Alternative Payment Methodology

States have Alternative Payment Methodology (APM) option

APM must pay at least as much as PPS

FQHCs/RHCs can keep PPS or transition to APM

Goal and Intent

2010: PCMH clinics asked OPCA for methodology to better align with model Current reimbursement is a barrier to medical

home transformation Provider team retention issue

Goal of APM: De-link payment from the traditional, face-to-face, patient-provider encounter

Building the Will to Transform

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Removing the Biggest Barrier

Provider satisfaction and patient outcomes started improving, BUT Providers were becoming

dissatisfied

Providers still have F2F visit targets Additional PCMH responsibilities

lengthening their day

Basic APM Construct

Convert PPS into a bundled, pmpm rate CCO will pay a pmpm rate comparable to any

primary care provider State will pay a pmpm wraparound based on

prior year’s wraparound payments PCPCH payments, Pay for Performance or other

bonus payments are separate

Oregon’s APM Process

Fall 2010 Initial meetings between CHCs, OPCA and state

November 2010 Board and full membership engaged

Spring 2011 MCO engaged

Spring 2011 – June 2012 Model developed – Laura Sisulak, Curt

Degenfelder, Don Ross, CHCs

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Oregon’s APM Process, cont’d

June 2012 SPA submitted to CMS

September 2012 SPA approved

March 1, 2013 “Go Live”

APM

Budget-neutral Includes:

Physical health services Mental health services after one year Dental services

Will be more difficult, but intended to be carved in

Inpatient care/prenatal/deliveries carved out All sites, all patients (managed care and open card) Three-year commitment from both parties Change in Scope process - similar to PPS

Oregon PPS Change in Scope

Pretty Robust “PCMH Implementation” EMR ongoing costs Change in patient mix Provider mix fluctuation Services mix fluctuation, including enabling

services that don’t require a F2F visit Addition of services out of scope

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APM , cont’d

Clinics to provide: Process and outcome data to the state “Touches” with the patient

Demographic data will be collected OCHIN has been an outstanding partner State/CCO to provide total patient cost info Aligning with other state reform efforts (e.g.,

PCMH, CCO) CHCs join based on readiness MOU with the state is key

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APM, cont’d

Attribution To be developed and paid on current users for

Day 1 18 month look back Add patients through F2F visit with

licensed professional Thorough intake:

Medical history Problem Rx list

At minimum

Next Steps with APM

March 1, 2013 was our “go live” Submit/analyze quarterly data Track financial impact Add clinics to pilot Add mental health (and

eventually dental)

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Non-Visit Based Care

We’re re-imagining how the medical home would be structured if we eliminated the incentive to “crank” visits

What Have We Learned?

Lessons Learned

Framing conversation with Medicaid critical

APM took longer than we expected

Attribution issue

Competing priorities for state

We need to get a lot better with data: Tracking

Reporting

Using

A good offense can be more effective than a good defense, but you need both

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Elements of Risk We Shouldn’t Underestimate

CHC work for each patient may increase while payment remains the same

Transparency in data (cost, quality and access) shortens bridge to value-based pay

Little time remains to adjust for behavioral and socio-economic barriers

Elements of Risk We Shouldn’t Underestimate, cont’d

Oregon’s focus on short-term cost-cutting It’s alarming Everything else appears

secondary Our data needs to be

cleaner yesterday Must focus on showing

CHC value in a managed care and ACO/CCO environment

Social Determinants

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Game, Set and Match

Bridging to value-based pay must take psychological and socio-economic complexities into account

Focusing Adjustmentson What Matters

Social circumstances

15%

Environmental exposure

5%

Health care10%

Behavioral patterns40%

Genetic predisposition

30%

Source: McGinnis J.M., Williams-Russo P., Knickman J.R. “The Case for More Active Attention to Health Promotion,” Health Affairs 2002;21(2):78-93.

Reasons: Many safety-net

providers not penalized Denver Health

Need to hold all hospitals accountable for the same outcomes

Medicare gave grants to these hospitals

No adjustment for social determinants

Medicare Readmission Penalties

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Does This Sound Familiar?

“We all should target the same outcomes, period.”

“Providers need to be held accountable, not given excuses.”

“Psycho-social characteristics show up in medical complexity, so it would be double counting.”

“If clinic X can meet the health outcome benchmarks without adjustments, why can’t they all?”

Addressing Naysayers

Target the same outcome…and: Safety net clinics need more time & resources

Clinic choices without psycho-social adjustments: Improve/add services Limit seeing complex patients

To hold providers accountable: Stratify patients Hold providers accountable for patients with

similar barriers

Addressing Naysayers, cont’d

Stratified patients Same high blood pressure or

glucose readings Different psycho-social barriers

Producing outcomes through fundraising

“Deal with the Devil” BUT, we need to get our

house in order

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What Can We Do?

Taking Charge

Value perceptions of CHCs Cost, quality and ACCESS (CHC focus on quality vs. access) Complete/share complexity research and link to cost studies

Research issue nationally Determine three-five SDOH to standardize and collect

Most impact on PCMH work and health outcomes Standardize and collect data on enabling services Develop ROI nationally

Payment reform Develop payment strategy for state Advocate for risk adjustments beyond medical Determine payment methodologies to support continuation of

enabling services in CHCs

Current Research

Cost comparisons: CHC vs. non-CHC (All Payers) In process

Complexity comparisons: CHC vs. non-CHC 500 charts reviewed

Looking for chart notes that would indicate: Social and environmental circumstances Enabling services delivered

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Preliminary Results

CHC patients have more extreme barriers Higher SPMI Homelessness Unstable social situations

CHC patients have higher rates of chronic conditions CHCs invest more in supporting social issues

Housing, access to food, linking to other benefits (food stamps, alcohol & drug services)

CHC patients have less of a social support network CHCs invest less in wellness

Nutrition takes a back seat when patients are homeless

Coordinated Care Organizations

Designing incentive programs No ability to risk adjust for

social determinants of health Community Advisory Councils

Will they have teeth? Short-term cost reduction vs.

system transformation

Provisions of SB 1522

CCOs to account for psychological & social barriers Quality measures Payment

All providers to meet same outcomes For providers treating complex patients:

Measurement/payment stratified for extra time & resources required

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Get Our House in Order

Bring up low

performers

Get clean data

Work With Your PCA

Data to promote and improve CHC value

Research Payment reform PCMH has to be about

transformation

Questions

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Thank You

Craig HostetlerOregon Primary Care Association

503-228-8852 x 227chostetler@orpca.org