adirondack medical home summit 2013: nys reform foster gesten, md, facp office of quality and...
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Adirondack Medical Home Summit 2013: NYS Reform
Foster Gesten, MD, FACP
Office of Quality and Patient Safety
2
Overview
• Medicaid Reform
• Health Exchanges
• Primary Care: PCMH and beyond
• State Innovation Model (SIM)
• Quality and Patient Safety
• Prevention Agenda
3
Overriding Themes
• Integration
• Care Management
• Care and Payment Reform
• Alignment
• Data (to information to action)
• Transparency
• Triple Aim
4
Medicaid Reform
5
Medicaid Reform
• Managed Care for All
– SPMI
– LTC
– Duals
– Foster care
• Care Management for All (that need it)
– Health homes
• Global Cap
• Value Based Benefit Design
– PCI
– Preterm births
– Evidence based review of benefits
6
Health Insurance Exchange
New York State of Health
7
What is NY State of Health?
• Organized marketplace
– One-stop shopping for subsidized and unsubsidized coverage
– Easily compare health plan options
– The only place to check eligibility and apply for financial assistance
– Enroll in qualified health plans
• Two programs
– Individual Marketplace
– Small Business Marketplace
8
Individual Marketplace (58%)
Small Business Marketplace (42%)
Who Will Enroll In NY State Of Health?
Health Plan Marketplace enrollment is estimated to be
1.1 million New Yorkers
9
http://www.nystateofhealth.ny.gov/PlansMap
10
Health Plan Highlights
• Choice of plans in all areas of the State
• Increased competition gives consumers new health plan options
• Premiums for people who buy coverage for themselves and their families decreases by an average of 53%
compared to today’s premiums
• You will not be denied health insurance on the basis of a pre-existing condition
• All plans are required to have adequate networks
11
Required Ten Essential Health BenefitsPreventive services will be offered at no cost to you
1. Ambulatory patient services
2. Emergency room services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance abuse disorders
6. Prescription drugs
7. Rehabilitation and habilitation services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision
12
Financial Assistance
• Many individuals and families will be eligible for financial assistance to reduce the cost of coverage
• Financial assistance is available in 2 forms:
– Tax credits will reduce the cost of premiums for most single adults earning less than $45,960 and for families of 4
earning less than $94,200
– Cost-sharing reductions will lower co-payments and deductibles for single adults earning less than $28,725 and for
families of 4 earning less than $58,875
• Tax credits and cost sharing reductions are estimated at the time of application and applied immediately
13
Primary Care
14
Primary Care
• Medicaid Incentive
– Impact
– Future direction
• Hospital Medical Home Demonstration
• Multi-payer Demonstrations
– ADK
– CPCI
– SIM
15
State Health Care Innovation Plan
• CMMI challenge to states: beyond ‘demo’ and pilot
• Value based model of care/payment covering 80% of population within 5 years
– Multipayer
– ‘transformative’ care delivery and payment innovation
• Disseminate and ‘connect’ demonstrations and innovations
– ACO
– Waivers
– HIT/HIE
– PCMH
• Basis for Testing Grant application (up to ~$60 million)
16
Proximate Goals
• Refine coherent, more detailed plan with internal and external stakeholder
engagement
– Interagency alignment (DFS, DOH, Civil Service, OMH, etc.)
– Payers, providers, associations
• Review with wider set of stakeholders
• Finalize and submit SHIP
• Convert SHIP into application (early 2014)
17
Core Elements
• Care model
• HIT/HIE
• Metrics/reporting
• Payment model
• Transformation support
• Benefit design
• Workforce strategy
18
Quality and Patient Safety
• ‘New’ Office of Quality and Patient Safety
– Hub for department on Q/S initiatives
– Advance use of data for improvement, evaluation, prioritization, transparency,
accountability
• LTC
• Physician practices
– APD
– Sepsis
– Cardiac services, Stroke, Office Based Surgery
19
Make New York the Healthiest State
New York State Prevention Agenda
20
Prevention Agenda 2013-2017
• Goal is improved health status of New Yorkers and reduction in health disparities
through increased emphasis on prevention.
• Call to action to broad range of stakeholders to collaborate at the community level
to assess health status and needs, identify local health priorities and plan,
implement and evaluate strategies for local health improvement.
21
CHAs & CSPs
• Local Health Department Community Health Assessment & Community Health
Improvement Plan
– Due November 15, 2013; covers years 2014-2017
• Hospital Community Service Plans
– Due November 15, 2013, covers years 2013-15
• LHDs and Hospitals asked by Comm. Shah to work together to assess health status, select
common priorities including one to address a health disparity, and develop and implement
a plan to address priorities.
22
Prevention Agenda 2013-2017:
Ad Hoc Leadership Group• Six members of Public Health Committee and other leaders from Healthcare, Business,
Academia, Community-based & Local Health Departments.
23
Background
Ad Hoc Committee considered:
• Urgent Health Issues and Disparities in NYS
• Experience with first Prevention Agenda
• Factors that contribute to health
24
Leading Causes of Death, New York State, 2000 - 2009
Heart Disease, 207/100,000
Cancer, 160/100,000
CLRD, 31/100,000Stroke, 26/100,000
Pneumonia/flu 20/100,000
Unintentional Injury, 20/100,0000
50
100
150
200
250
300
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Rate
per
100,
000
Heart Disease Cancer CLRD
Stroke Pneumonia/Influenza Unintentional Injury
25
Estimated Number of Deaths Due to Modifiable Behaviors, New York State, 2009
0
5,000
10,000
15,000
20,000
25,000
30,000
26,222
22,021
5,071 4,5213,315 2,592 1,748 1,206
Estimates were extrapolated using the results published in:“Actual Causes of Death in the United States, 2000", JAMA, March 2004, 291 (10) and NYS 2009 death data
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2000 2001 2002 2003 2004 2005 2006 2007 2008 20090
50
100
150
200
250
300
350
400
Age-Adjusted* Heart Disease Death Rate per 100,000 by Race/Ethnicity, New York State, 2000-2009
White/NH Black/NH AsianPI/NH Hispanic
* Age-adjusted to U.S. Census 2000 population
27Frieden T., A Framework for Public Health Action: The Health Impact Pyramid.
American Journal of Public Health. 2010; 100(4): 590-595
Framework for Improving Health
28
Five Prevention Agenda Priorities
1. Prevent chronic diseases
2. Promote a healthy and safe environment
3. Promote healthy women, infants and children
4. Promote mental health and prevent substance abuse
5. Prevent HIV, sexually transmitted diseases, vaccine-preventable diseases and
healthcare associated infections
29
For each priority area:
• Focus Areas
• Goals
• Measurable Objectives
• Interventions
• By Sector
• By Health Impact Pyramid
30
http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/indicator_map.htm
31
Statewide Update
• Communities completing community health assessments and community health
improvement plans due November 15th
• Technical assistance being provided by statewide and regional organizations
• Communication tools being distributed to local partnerships for use in engaging
stakeholders
• Meeting with foundations to seek funding to support local partnerships.
32
Priorities identified by Region - September 2013
P2P S2AY Network CNYHSA AHI HCDI HVRHON Nassau-Suffolk0
2
4
6
8
10
12
14
16
2 2
13
2
1
7
15
13
9
4
7
4
2
1 1
2
6
22
1
2 2
4 4
1
2
0
2 2
NA
Prevent Chronic Diseases
Promote a Healthy and Safe Envi-ronment
Promote Healthy Women, Infants and Children
Promote Mental Health and Prevent Substance Abuse
Prevent HIV, STDs, Vaccine Preventable Diseases and Healthcare Associated In-fections
Other
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