department of vermont health access the vermont approach to building an integrated health system...

Department of Vermont Health Access

The Vermont Approach to Building an Integrated Health System

Creating “Accountable Care Partners”Based on Shared Interests

State Health Research and Policy Interest Group Meeting

June 11, 2011

Richard SluskyDirector, Payment ReformDepartment of Vermont Health Access

H.202: Universal and Unified Health System: “The Path to Single Payer”

• Delivery system reform

• Payment reform

• Integrated health information technology

• Multi-payer claims data base

• Health insurance exchange

• Financing Plan

• Green Mountain Board



MedicaidMedicareBlueCrossMVPCignaSelf Insured

Advanced Primary Care

NCQA StandardsPatient Centered CareAccessCommunicationGuideline Based CareUse of Health IT

Advanced Community Support

Community Health TeamsMCAID CCsSASH Teams

Fee for Service (Volume)

PPPM # 1 - NCQA ScoreStandards

Payment Reform Delivery System ReformFinancing

Shared Costs

State Role: Designing & Promoting New Payment Methods

Phase I – Blueprint for Health


Multi-insurer Payment ReformsPhase I – Blueprint for Health

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

•Medicaid•Commercial Insurers•Medicare


Multi-insurer Payment ReformsPatients with 2+ Chronic Conditions

Phase II – PCP/Specialists

Insurers

• Community Health Teams

• Shared costs as core resource

• Consistent across insurers

• Minimizes barriers

• PCP/specialist partnership• Equal payment to

PCP/Specialist• Includes all payers• Promotes coordination

/collaboration

Payment based on reductionin total cost of care, avoidable services, quality performance, patient engagement

+ +

•Medicaid•Commercial Insurers•Medicare?


MedicaidMedicareBlueCrossMVPCignaSelf Insured

Advanced Community Support

Community Health TeamsMCAID CCsSASH Teams

Specialized Services

HospitalsSpecialty CareTargeted ServicesMental Health ServicesSubstance Use ServicesFamily ServicesSocial ServicesEconomic ServicesLong Term CareNursing Homes

Payment Reform Delivery System ReformFinancing

Fee for Service (Volume)

PPPM # 2 - Outcome, Quality, and Patient Centered Measures

Phase IIBlueprint and PCP/Specialists


Payment Based on Shared Interests: PCPs & Specialists

Adjustable outcomes based payment – ongoing refinement

First shared interest$PPPM payment

6 moBaseline

Continue current FFS

12 mo

Decreased FFS

Adjust Payment Dials

Total new FFS + $PPPM > baseline FFS

Measure results

Second shared interest$PPPM payment

Measure results

HEALTH CAREPROVIDERSINCLUDED

EXAMPLES OFCOST REDUCTIONOPPORTUNITIES

Improved Outcomesand Efficiency for Major Specialties

Major Specialists(Cardiology,

Orthopedics, Etc.)

Greater Efficiency & Improved Outcomes

for Inpatient CareOther Specialists

Hospitals

Level 2FFS, CHT’s, PMPM

Level 3Bundled

Level 4Global (ACO)

Level 5 Cost based payments grants

PrimaryCare

Practice

PrimaryCare

Practice

PrimaryCare

PracticePrevention &

Early Diagnosis

Appropriate Use of Testing/Referral

Reduction in Preventable ER

Visits & Admissions

Better Management of Complex and

Low-Income PatientsSafety-Net Programs

Public Health

Phase IIIIntegrated Medical & Social Svcs

© 2010 Center for Healthcare Quality and Payment Reform, Network for Regional Healthcare Improvement

FQHC’s

FQHC’s

FQHC’s

State Role: Fostering the Use of Accountability Measures

Four Dimensions of Performance Measurement

• Reduction in growth of total cost of care• Reduction in avoidable services:

– ED visits– Inpatient admissions/readmissions– Imaging– Laboratory tests

• Improvement in adherence to quality performance standards– Process measures– Outcome measures

• Improved patient experience and engagement


State Role: Designing and Promoting Data

• Vermont Information Technology Leaders (VITL)

• Medicity (Gathering/Organizing)

• Onpoint (Gathering/Organizing)

• University of Vermont (Analyzing)

• Docsite (Reporting)



State Role: Supporting a Continuum of Care and the Role of Medical Homes

• Primary & specialty care providers share common goals & interests

• Encourages provider relationships as “Accountable Care Partners”

• Incentive to help patients be followed in a medical home

• Incentive for well coordinated health services (communications, transitions)

• Incentives are balanced and payment is optimized by collectively improving quality, prevention, control of costs

• Patient centered not organization centered (payment follows patients)

• Incentive to meet needs & engage patient in ongoing care

• Levels out the roles of primary & specialty care (equal payment for coordinated and effective care)





• Builds on established (and successful) payment methodologies in the Blueprint (Quality based on NCQA score, CHTs in place)

• Builds on established measurement capabilities• Does not require new organizations or administrative

entities• Promotes shared interests across all providers within a

practice (in addition to promoting shared interests across primary and specialty care)



• Payment based on goals that are shared by most / all stakeholders (patients, families, providers, insurers, businesses)

• Payment streams & methods are applicable in any financing system (multiple payers, private & public, single payer)

State Opportunities for ACO/ACP Development

ACO• FFS Payment• Shared Risk• Retrospective Attribution

of Patients• Requires Organizational

Structure• 65 Quality Measures]• Requires 50% of PCP’s

to meet meaningful use criteria

ACP• FFS & Enhanced Payment Based

on Value• Initial Upside Only – Performance

Risk Increases as FFS is Reduced• Prospective Attribution Based on

Historical Usage• No New Org Structure Required• Measures Four Dimensions of

Performance• Requires Data Submission in

Several Formats Based on Provider Capabilities


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