payment reform quarterly update
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Payment Reform Quarterly Update
August 23, 2016
Agenda
I. Payment Reform
I. P4PII. HHP / Section 2703 III.APM PilotIV.CP3
2
CPCA Payment Reform Strategy
3
CPCA Payment Reform
Strategy
4
Medi-Cal P4P Core Measure Set
© 2016 Integrated Healthcare Association. All rights reserved. 6
Health care measurement important to assess health system performance and improve care delivered
Number and scope of measures providers held accountable for steadily increasing
Lack of alignment across incentive programs creates unnecessary burdens on providers and confusion among consumers
As Medi-Cal enrollment increases and Medi-Cal shifts to managed care, imperative emerging for consistent performance measurement
Performance Measurement Landscape
© 2016 Integrated Healthcare Association. All rights reserved. 7
Medi-Cal P4P Inventory: Program Prevalence
P4P Programs
Of the 20 Medi-Cal managed care plans interviewed, 16 have pay-for-performance programs in place
The P4P programs vary in extent and approach
Overview of Current P4P Activities
Number of Plans
P4P Programs in Place 16
Just Starting 1
Started 2009 - 2013 5
Started 2004 - 2008 3
Started 2003 and before 7
No P4P Program in Place 4
Total 20
© 2016 Integrated Healthcare Association. All rights reserved. 8
Why do we need greater standardization?
Only 1 measure aligns across all programs:
Diabetes HbA1c Testing
California Health & Wellness
Cal Optima
CenCal
Central California Alliance
Health Net
Health Plan of San
JoaquinHealth
Plan of San Mateo
Inland Empire Health
Plan
Kern Health
Systems
LA Care
Partnership
San Francisco
Health Plan
Anthem
Medi-Cal
Only 2 measures align across all programs:
1. Controlling Blood Pressure for People with Hypertension
2. Diabetes: Medical Attention for Nephropathy
Federal Quality Rating
System for Covered
California
CMS & AHIP Core Quality
Measures Collaborative
Medicare Advantage
Stars
IHA Value Based P4P
DHCS External
Accountability Set
Cross Product
Only one measure out of 86 distinct measures align across all programs (based on IHA’s 2014 inventory)
Only two measures align across all measure sets
© 2016 Integrated Healthcare Association. All rights reserved. 9
Reduce unnecessary burdens associated with the lack of
alignment across incentive programs
Enhance provider effectiveness by “strengthening the signal”
–focus improvement efforts and resources
Facilitate the comparability of performance results and
benchmarking statewide
Benefits of a Core Measure Set
© 2016 Integrated Healthcare Association. All rights reserved. 10
Convene an Advisory Committee to provide expertise and guidance across project activities
Identify a core measure set that all plans could adopt as a part of their P4P programs
Develop a menu of additional measures that plans can use to supplement the core measure set at the local level as well as a set of incentive design principles and best practices
Funding – Blue Shield of CA Foundation
Timeline: April 2015 – March 2016
Medi-Cal P4P Core Measure Set
© 2016 Integrated Healthcare Association. All rights reserved. 11
Health Plans Alameda Alliance for Health Anthem Blue Cross California Health & Wellness CalOptima CenCal Health Central California Alliance for Health Health Net Health Plan of San Joaquin Health Plan of San Mateo Inland Empire Health Plan Kern Health Systems LA Care Health Plan Partnership Health Plan San Francisco Health Plan UnitedHealthcare
Standardizing Medi-Cal Advisory Committee
Collaborators American Institutes of Research
Blue Shield of California Foundation
California HealthCare Foundation
California Quality Collaborative
Center for Care Innovations
Center for Health Care Strategies
Health Services Advisory Group
John Snow, Inc.
Provider Representatives
Alameda Health Consortium
AltaMed
CHOC Health Alliance
Community Clinic Association of Los Angeles County
Community Medical Centers
County of San Mateo
Family Care Specialists Medical Group
Hill Physicians
Integrated Health Partners
Omnicare Medical Group IPA
Palo Alto Medical Foundation
San Mateo Medical Center
Santa Clara Valley Health & Hospital System
Santa Rosa Community Health Centers
Shasta Community Health Center
SynerMed
West County Health Center
Associations California Association of Health Plans
California Primary Care Association
CAPG
Local Health Plans of California
Safety Net Institute
California Department of Health Care Services
© 2016 Integrated Healthcare Association. All rights reserved. 12
Medi-Cal P4P Continuum
12
Voluntary Core
Measure Set; shared
specifications and
benchmarks
Voluntary Core & Supplemental
menu of measures;
shared specifications
and benchmarks
Quality based P4P in Medi-Cal; Core and Supplemental measure set
and incentive design
required; payment
amount not required
Quality based P4P in
Medi-Cal; payment amount required
Value based P4P in
Medi-Cal; payment based on
quality and resource use
Voluntary Core and
Supplemental menu of
measures and incentive
design options
IHA’s Standardizing Medi-Cal P4P Project
Current Status Medi-Cal P4P –Uniform/Broad Adoption
COORDINATION / COLLABORATIONLESS MORE
No formal coordination/collaboration;
Variation in performance measurement
& incentive design
© 2016 Integrated Healthcare Association. All rights reserved. 13
Key features of the Core Measure Set:
• No more than 10 measures
• Included in DHCS’s External Accountability Set
• Feasible for a wide array of providers to report using administrative only data
Core Measure Set Overview
CORE MEASURE SET
Domain Measures Steward NQF #
CardiovascularAnnual Monitoring for Patients on Persistent Medications: ACE or ARB NCQA 0021
Annual Monitoring for Patients on Persistent Medications: Diuretics NCQA 0021
Diabetes Care
HbA1c Testing NCQA 0057
HbA1c Control (<8.0%) NCQA 0575
Eye Exam NCQA 0055
Maternity Timeliness of Prenatal Care NCQA 1517
Prevention
Childhood Immunizations, Combo 3 NCQA 0038
Well-Child Visits in 3rd, 4th, 5th, and 6th Years of Life NCQA 1516
Cervical Cancer Screening NCQA 0032
Respiratory Medication Management for People with Asthma – Medication Compliance 75% NCQA 1799
© 2016 Integrated Healthcare Association. All rights reserved. 14
A menu or library of additional measures that plans can use to supplement the core measure set at the local level
Selection Criteria:
1. EAS measures that were not included in the core measure set
2. Additional measures currently included in Medi-Cal P4P programs
3. Measures included in more than one of the other existing performance measurement requirements for Medi-Cal plans and providers, including:
o DHCS EAS
o Covered California’s Quality Rating System
o NCQA Medicaid Managed Care Health Plan Accreditation Standards
o CMS Medicaid Core Measures for Adults and Children
Supplemental Measure Set Overview
© 2016 Integrated Healthcare Association. All rights reserved. 15
Supplemental Measure Set
Access Children and Adolescents’ Access to PCPs NCQA 1390
Behavioral Health /
Substance Abuse
Antidepressant Medication Management NCQA 0105
Follow-Up for Children Prescribed ADHD Medication NCQA 0108
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment NCQA 0004
Cardiovascular Controlling blood pressure for people with hypertension NCQA 0018
Diabetes Care
Blood Pressure Control <140/90 mm Hg NCQA 0061
HbA1c Poor Control >9% NCQA 0059
Medical Attention for Nephropathy NCQA 0062
Maternity Timeliness of Postpartum Care NCQA 1517
Musculoskeletal Overuse of Imaging Studies for Low Back Pain NQCA 0052
Prevention
Adolescent Well-Care Visits NCQA n/a
Adult BMI Assessment NCQA n/a
Breast Cancer Screening NCQA 2372
Childhood Immunizations, Combo 10 NCQA 0038
Chlamydia Screening NCQA 0033
Colorectal Cancer Screening NCQA 0034
Flu Vaccinations for Adults Ages 18-64 NCQA 0039
Human Papillomavirus Vaccine for Female Adolescents NCQA 1959
Immunizations for Adolescents NCQA 1407
Medical Assistance with Smoking & Tobacco Cessation NCQA 0027
Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents: NCQA 0024
Well-Child Visits in the First 15 Months of Life (6 or more visits) NCQA 1392
Respiratory
Asthma Medication Ratio NCQA 1800
Appropriate Testing for Children with Pharyngitis NCQA 0002
Appropriate Treatment for Children with URI NCQA 0069
Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis NCQA 0058
Resource UseAll-Cause Readmissions NCQA 1768
Emergency Department Visits NCQA n/a
© 2016 Integrated Healthcare Association. All rights reserved. 16
• Creation of consensus core, supplemental measure sets
• Active and engaged Advisory Committee, including both plans and providers
• Strong interest from plans not initially involved
• DHCS engagement, including seeking guidance from AC on measure set update
Results to Date
© 2016 Integrated Healthcare Association. All rights reserved. 17
• Core measure set adoption underway – intent to adopt by 6 plans for MY 2017, partial adoption by 7 more
Adoption Efforts to Date
Intent to adopt for MY 2017 Partial adoption for MY 2017
1. Alameda Alliance 1. CalOptima
2. Anthem Blue Cross 2. CalViva
3. California Health & Wellness 3. Health Net
4. CenCal 4. Health Plan of San Joaquin
5. Central California Alliance for Health 5. Health Plan of San Mateo
6. LA Care 6. Partnership Health Plan
7. San Francisco Health Plan
© 2016 Integrated Healthcare Association. All rights reserved. 18
Next Phase of Standardizing Medi-Cal P4P
Create greater measure set alignment across the policy landscape
Support the implementation of the core measure set across all Medi-Cal P4P programs
Spread the adoption of the core measure set to plans not participating on the Advisory Committee
Funding – CMMI (included in Transforming Clinical Practices Initiative grant awarded to PBGH/CQC)
March 2016 – February 2018
© 2016 Integrated Healthcare Association. All rights reserved. 19
Objective: • Identify opportunities for greater measure set alignment across the
policy environment
Planned Activities:• Identify initiatives underway or planned in Medi-Cal & the safety net
• Develop crosswalk of key initiatives to use as a resource toward creating a shared performance measurement strategy
• Summarize findings in an issue brief
• Support DHCS’ EAS update efforts
Timeline: • March 2016 – September 2016
Policy Initiatives -- Measure Set Status
© 2016 Integrated Healthcare Association. All rights reserved. 20
Objective:• To support implementation efforts and create opportunities for
collaboration and learning
Planned Activities:• Convene quarterly Advisory Committee meetings
• Develop timeline and process for adopting new measures to core measure set and complete one update of core measure set
• Explore feasibility of developing benchmarks at provider level
• Explore providing access to IHA’s web-based portal
• Re-survey plans to identify issues and unintended consequences
Timeline:• March 2016 – February 2018
Implementation of the Core Measure Set
© 2016 Integrated Healthcare Association. All rights reserved. 21
Spread Core Measure Set
Objective:• To spread the core measure set to Medi-Cal plans not currently
participating on the Advisory Committee
Planned Activities:• Schedule 1:1 meetings with plan representatives to share information
about project and the core measure set
• Develop resources to support plans with adoption
• Provide technical support to plans interested in developing P4P programs
Timeline:• March 2016 – December 2016
For more information:
Sarah Lally, slally@iha.org
Web: www.iha.org
California’s Health Home Program (HHP)
23
Section 2703
State Option to Provide Health Homes for Enrollees with Chronic Conditions as defined by each state
• Funding for 2 years and requirement to demonstrate savings
• 90% Federal/ 10% State funding
• The California Endowment contributing California’s 10%
HHP
24
State Process
• State submitted a State Plan Amendment (SPA) in March 2016.
• Based on California Concept Paper Final -Health Homes for Patients with Complex Needs final concept paper (3/29/16)
HHP
25
What does the HHP fund?
• Comprehensive care management
• Care coordination
• Health promotion
• Comprehensive transitional care & follow-up
• Patient and family support
• Referral to community and social support services
…services not already funded by Medicaid
* No funding for direct medical or social services.
HHP
• Target Population • The Health Homes Program (HHP) is intended to be an
intensive set of services for a small subset of members who require coordination at the highest levels.
- Individuals with two or more chronic conditions
- Individuals with one chronic condition and at risk for another;
- Individuals with serious and persistent mental illness
• The highest-risk top three to five percent of the Medi-Cal population will be eligible.
HHP• Eligibility Criteria:
1. At least two of the following: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Traumatic Brian Injury, Chronic or Congestive Heart Failure, Coronary Artery Disease, Chronic Liver Disease, Dementia, Substance Use Disorder OR
2. Hypertension and one of the following: COPD, Diabetes, Coronary Artery Disease, Chronic or Congestive Heart Failure OR
3. One of the following: Major Depression Disorders, Bipolar Disorder, Psychotic Disorders (including Schizophrenia)
And the member must also have one of the following:
1) Risk Score of at least three,
2) at least one inpatient visit in the last year, or
3) at least three ED visits in the last year.
HHP• Rollout Schedule:
Counties Physical Conditions and SUD
SMI
Del Norte, Humboldt, Lake, Marin, Mendocino, Napa, Shasta, Solano, Sonoma, Yolo, San Francisco
January 1, 2017 July 1, 2017
Imperial, Lassen, Merced, Monterey, Orange, Riverside, San Bernardino, San Mateo, Santa Clara, Santa Cruz, Siskiyou
July 1, 2017 January 1, 2018
Alameda, Fresno, Kern, Los Angeles, Sacramento, San Diego, Tulare
January 1, 2018 July 1, 2018
*HPP implementation in the following counties is not currently scheduled: Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, El Dorado, Glenn, Inyo, Kings, Madera, Mariposa, Modoc, Mono, Nevada, Placer, Plumas, San Benito, San Joaquin, San Luis Obispo, Santa Barbara, Sierra, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Ventura and Yuba
HHP
29
HHP
30
Logistics• Health Home Program will run through the managed care plans• They will certify and select organizations to be CB-CMEs
(community based care management entities)• CB-CME’s can be:
• Community health center • Community mental health center• Hospital or hospital-based physician group or clinic • Local health department • Primary care or specialist physician or physician group • Substance use disorder treatment provider • Providers serving those that experience homelessness • Providers serving individuals/persons diagnosed with HIV/AIDS • Other entities who meet certification and qualifications of a CB-CME may
serve in this capacity if selected and certified by the MCP
HHP
31
Timeline
• February 2016: Provider Self-Assessment to help MCPs identify potential CB-CMEs
• March 2016: SPA submission to CMS
• Ongoing: Technical Assistance to prepare for program implementation
• October 2016: Rate development
• January 1, 2017: Begin HPP services in first implementation counties
APM Pilot
32
California’s APM
Most Basic
• PPS rate converted to a monthly capitation payment
• Same amount you are receiving today, just paid up front on a monthly basis rather than per visit
• EXAMPLE: $175 PPS x 3 Avg Adult Visits = $525• $525/ 12 member months = $43.75 PMPM
• PPS Rules Gone- billable provider/same day visit restriction/4 walls/etc
Today- PPS
DHCS
Traditional Rate Setting
FQHC
Primary care
capitation
Health Plan Wrap around payment
FFS for mental health
• DHCS sets rates for health plans
• Plans pay primary care capitation to health centers
• Health centers bill state a wrap-around payment
• Annual reconciliation
34
APM Demonstration
DHCS
Traditional Rate Setting
FQHC
APM
Health Plan
Wrap Cap-ChildAdultSPD
Expansion
• DHCS sets rates for health plans• Monthly, plan would tell State
how many medi-cal members are assigned to FQHC in demonstration.
• State would pay the plan an additional “Wrap Cap” for that site(s)• Wrap around payment
becomes a capitation payment that is AID Category specific
• Health center would receive 4 per member per month payments (Child, Adult, SPD, Expansion)
• Rate Adjustment between FQHC and plan.
• Health center receives strictly capitation for all services in their PPS rates for the four aid categories
APM Demonstration
• Plans will have risk corridor (.75%/.75%)• At risk for max of .75% of wrap cap amount. State responsible
for rest.
• Can benefit up to .75% of wrap cap if FQHC had to pay back. State would get rest.
• Possible rate adjustment at end of year• Year 1 – Rate adjustments would be occur if traditional visits
increase by more than 5% or decrease by more than 30%
• Yr 2 –more than 7.5% or decrease of more than 30%
• Yr 3 –more than 10% or decrease of more than 30%
APM Demonstration
• 3 year demonstration with volunteer health centers• Roll out will be staggered
• 3 years starts when the county starts
• Abide by Federal APM– PPS is Floor
• Health centers will continue to:• Have site-specific rates
• Have ability to do scope change (with State)
• Receive annual MEI increases (State to pass to plans)
APM Pilot Timeline
38
2016
• Implementation Detail WGs – Spring • Rate Development• Contracting• Alternative Encounters
• Concept paper – Summer • Will initiate the SPA process
• Invitation/Application to all FQHCs in CA- Fall
• State will select FQHCs- Winter
2017
• Rate setting- Spring
• Launch- October
Current Work
39
APM WG
• Meets monthly
• Non Traditional Services Sub WG currently reviewing list of CPT codes• State wants only non traditional services with an
associated CPT code
• Must be submitted on the 837 file
Goal of CP3
To demonstrate through statewide aggregated data
that under the APM pilot, FQHCs can help bend the
total cost of care curve, improve patient outcomes,
and enhance patient experience while remaining
financially robust.
CP3 Objectives
• Define what it means to be a successful FQHC within a value-based, managed care payment system
• Provide technical assistance and support to demonstration sites within the Alternative Payment Methodology (APM) demonstration
• Utilize the lessons learned within the pilot environment to inform future payment reform transition efforts of all California FQHCs
CP3 Measures of Success
CP3 Measures of Success
APM Demonstration External Evaluation
Measures
Clinical 1. IP Utilization: Admissions2. IP Utilization: All cause
readmissions 3. ED Visits per 1000 members4. Controlling HTN high blood
pressure5. Diabetes Control6. Childhood Immunization Status7. Cervical Cancer Screening8. Colorectal Cancer Screening9. Frequency of Ongoing Prenatal
Care10. BMI Screening & counseling11. TBD – Behavioral Health
Integration metric
Operational 12. Provider/Patient Productivity13. Staff ratio: total non-clinical/total
staff14. Member/care team ratio15. % of patients with at least 1 “touch”
in measurement year16. Total Member touches17. Continuity of Care: % of PC visits
with assigned PCP org18. Clinic staff satisfaction19. Patient Experience/Satisfaction20. Care ratings from assigned Medi-
Cal members21. TBD – Data goal around the ability
to capture social determinants of health
Submitted CP3 Measure Set
CHCC Required Capacities
Population Health Management
Data Management
Financial Management
Population Health Management
• Shifting from patients to assigned members
• Understanding who your patients are and what needs they have
• Using care teams more effectively
• Using the appropriate visit type to manage patients’ needs
• Engaging patients effectively and meaningfully
Data Management
• Foundational Elements• Data leadership & strategy
• HIT (integrated EHR, registry, PMS, accounting software)
• Data analytic expertise
• New Elements• Monitoring eligibility data & payments
• Monitoring encounter data
• Monitoring resource use
• Capturing risk stratification data
• Integrating utilization data from other sources
• Generating meaningful reports
Financial Management
• Ability/tools to plan for and manage capitated payments
• Understanding costs and revenue per site, per member, per service line, per care team/panel, etc.
• Identifying high cost/high utilizing patients
• Modeling for PMPM/budget planning for PMPM
• Ability to operate dual payment systems
Payment Reform Readiness Checklist
Designed to assess gaps and strengths in seven domain areas including: • Population health management• Leadership• Learning organization• Technology• Financial infrastructure• Patient centered care• Access innovations (non-traditional touches)
Payment Reform Readiness Preparation
• Checklist completed by 63 sites; data used to develop implementation plans
• Series of three change management webinars
• Regional Training on Finance and Operational Preparedness• August 18 & 19• September 15 & 16• September 22 & 23
• Data/Rate technical assistance
• Population Health Management Technical Assistance provided through our partner, CCI
• Additional Managed Care (data and finance) TA being developed for roll out later this year.
TA Priorities
• Population Health Management• Empanelment• Panel Management• Access• Stratifying Population• Data Collection & Management (SDOH)
• Managed Care• Monitoring eligibility data• Managing capitation payments• Understanding cost/revenue per site• Data collection & Management (SDOH and non traditional
touches)
How can you stay informed?
• CPCA Weekly Update listserv
• CPCA/CP3 Monthly Steering Committee and Wrap Cap workgroups
• CP3 Monthly Bulletin
• CPCA Website: http://www.cpca.org/index.cfm/health-center-resources/capitation-payment-preparedness-program-cp3/
CPCA Staff Roles
Cindy KeltnerDeputy Director Health Center
Transformationckeltner@cpca.org
Lucy MorenoData Informaticist
lmoreno@cpca.org
Nenick VuAssociate Director of Managed Care
nvu@cpca.org
Tina CanuppAssociate Director of Health Center
Transformationtcanupp@cpca.org
Allie BundenzAssociate Director of Quality
Improvementabundenz@cpca.org
Charlotte ReischeSenior Administrative Assistant
creische@cpca.org
Contact
53
Sara LallyProject Manager, IHA
slally@iha.orgRe: P4P
Meaghan McCammanAssistant Director of Policy
Meaghan@healthplusadvocates.orgRe: PCHH
Andie Patterson Director of Government Affairs
andie@healthplusadvocates.orgre: APM
Cindy KeltnerDeputy Director ofckeltner@cpca.org
Re: CP3
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