primary care in the new normal part 2: managing the full
TRANSCRIPT
Primary Care in the New NormalPart 2: Managing the Full Continuum of Care Under a Total Cost of Care APM
Ohio Association of Community Health CentersDate
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OBJECTIVES
1. Assure recognition of the national nomenclature that categorizes alternative payment models.
2. Increase appreciation for how different categories of alternative payment models can be synergistic.
3. Foster the development of clinical and care management models of care that improve patient experience, patient outcomes and reduce low-value health care utilization and cost.
4. Enhance a vision of Ohio CHCs working together to successfully pursue value-based payment
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SHARED STAKEHOLDER THINKING
Improve health care access
Focus on population health, high value
care, and improving patient outcomes
Increase provider satisfaction and
strengthen the primary care workforce
Incent innovative team-based care
models
Reduce potentially avoidable inpatient and ED utilization
Expense neutrality for payers, revenue enhancement for primary care providers
For Public Release
The framework situates existing and potential APMs into a series of categories.
APM Framework Nomenclature
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For Public Release
CMS and State Payment Improvement Initiatives
Delivery System Transformation
Payment System Transformation
Payment Reform without Practice
Transformation doesn’t
change outcomes.
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CHOOSING A PAYMENT STRATEGY THAT UNDERWRITES BETTER
PATIENT OUTCOMES
A Bigger Piece of the Cake (Market Share)
Preserving Revenue• Fee-for-
service PPS or Capitated APM
Icing on the Cake• CM fee • PCMH• P4P • Shared
savings• Partial
capitation for non-PCP services
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NEW THINKING: PERHAPS THE STEPS ARE OUT OF ORDER
Copyright © 2020 Health Management Associates, Inc. All rights reserved. PROPRIETARY and CONFIDENTIAL
Prov
ider
Fin
anci
al R
isk
Provider Integration and Accountability
Fee For Service
Incentive Payments
Pay for Performance
(P4P)
Bundled/Episodic
PaymentsUpside Shared Savings
Two Way Shared Savings
Partial Capitation
Full Capitation
Cat 2: FFS w/ payment linked to quality and
value
Retrospective Payments
Provider at Risk
Prospective Payments
Cat 3: APM built on FFS Cat 4: Population-based payments
Cat 1: FFS w/ no link to quality
Cost-based Contract
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THE QUESTIONS FQHCs ARE ASKING
Can’t I just keep living on the first floor (or go back to the basement)?
Can I wait for the elevator?
How badly can I get hurt if I fall climbing the stairs?
Is this the only set of stairs and if so, can I skip some steps?
Do I really have to make it to the top?
Does the railing go to the top?
Should I hold someone’s hand on the way up and if so, who’s?
11Medical Home Network | ©2020 All Rights Reserved | Proprietary & Confidential
Medical Home Network ACO: Enhancing Patient Care, Driving Value & Improving Outcomes
Enables members to drive cultural transformation & advance an integrated, practice-level model of care
Medical Home Sites
hospitals
566
183Care Managers
136k
PCPs
117
patients
6
MHN ACO, LLC established in 2014
• 11 FQHCs
• 3 Hospital systems
• Wholly provider-owned entity
• Unique egalitarian governance model
• Delegated for Care Management
• At Risk for Total Cost of Care
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LAN CATEGORY 2A: THE HEALTH HOME PROGRAM
Required CM Services
Comprehensive care management
Care coordination
Health promotion
Comprehensive transitional care
Individual and family support
Referral to community and support services
Payment is for 6 components of “health home” care coordination services and NOT direct treatment
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Medical Home Network:
The Impact of Delegating Care Management to Practices
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LAN CATEGORY 2A: DELEGATED, NCQA CERTIFIED CARE MANAGEMENT
Reassessment
Identify & Stratify
Engage & Connect
Moderate & High Risk
Plan & Support
Follow Up & Reassess
Risk
Transition to
Low-Risk Reevaluation
in Response to
Triggers
Health Risk
Assessment
(HRA)
Care Plan
Comprehensiv
e Risk
Assessment
(CRA)
Medication
Reconciliation
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A Consistent and Accountable Model of Care
© 2020 All Rights Reserved Proprietary Confidential
Medical Home Network:
Driving Health Outcomes by Reducing Adverse Social Drivers of Health
MHN OUTCOME 37.4% reduction in total social risk factors impacting health
Source: Jones A, et al., J Community Med Public Health Care 2017, 4: 030. Evaluation criteria: Most recent HRAs for
ACO members with 12+ months continuous enrollment and minimum of 2 HRAs at least 30 days apart.
Social Risk Factor Reduction of High Risk and Medium Risk Adults in Care
Management
3,315 members, July 2014 – June 2018
Social Risk FactorInitial
HRA
Latest
HRA
%
Change
Predictive of
Future Cost
and/or
Utilization*
Total Social Factors 11,124 6,963 -37.4%
Rates overall health as Fair or Poor 2,019 1,578 -21.8% ✓
Difficulty making appointments 685 396 -42.2% ✓
Difficulty getting to appointments or filling
prescriptions
1,396 885 -36.6%✓
Untreated Depression 1,172 511 -56.4%
Untreated Drug/Alcohol Use 304 156 -48.7% ✓
Difficulty securing food, clothing, or housing 1,717 868 -49.4% ✓
Currently homeless or living in a shelter 126 68 -46.0% ✓
Difficulty paying for meds 1,000 270 -73.0% ✓
Does not feel physically or emotionally safe at
home
213 143 -32.9%
Refused Smoking Cessation program 607 226 -62.8%36
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© 2020 All Rights Reserved Proprietary Confidential16
MHN uses AI to identify the rising health risk population
RISK STRATIFICATION
Whole-person care, with dynamic daily AI risk stratification
BUILDING ON A PROVEN MODEL: 37.4% reduction in total social risk factors impacting health1
Untreated depression | Difficulty securing food, clothing or housing | Difficulty paying for meds | Difficulty making appointments or filling prescriptions | Untreated drug / alcohol use | Etc.
Dynamic, daily AI health risk stratification
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Real-Time Connect Alerts & Communication
AI / Machine Learning
Warm Handoffs
Ambulatory Visits
Hospital Relation-
ships
Patient Engagement
TRANSITIONS OF CARE WORKFLOWS
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The Results21% Decrease in 30-day the Readmission Rate
TRANSITIONS OF CARE WORKFLOWS
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TRANSITIONS OF CARE WORKFLOWS
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CARE COORDINATION WORKFORCE DEVELOPMENT
MHN GOAL: MHN wanted to support the development of a capable, professional, practice-level care coordination workforce
INTERVENTION: MHN created a care coordination certification program
THE OUTCOME: MHN’s care coordination certification program standardizes the care coordination role and equips staff to meet the demands of working with challenging populations.
EDUCATION
CLINICAL▪ Diabetes▪ Asthma▪ Heart Failure▪ COPD▪ Obesity▪ Myocardial
Infarction
BEHAVIORAL▪ Depression &
Anxiety▪ Homelessness▪ Trauma Informed
Care▪ Substance Abuse▪ Suicide
Prevention ▪ Domestic
Violence
MOTIVATIONAL INTERVIEWING▪ Techniques to engage
patients in decision-making and in their care
▪ Training to effectively work with patients on behavior change and therapy compliance
CERTIFICATION PROCESS
1. Attend MHN trainings and 10-12 education sessions2. Participation in facilitated group discussion3. Complete self-study and pass written test4. Validate competency using live simulation with patient actors
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CATEGORY 2C: PAY FOR PERFORMANCE
• Choose a set of metrics that has direct financial implications for the health plan (premium withhold, member auto assignment)
• Understand the magnitude of potential financial impact on the health plan
• Agree on a manageable number of metrics
• Choose metrics that you can impact (room for improvement, access to timely information, able to impact with CM and/or clinical model)
• Agree on attribution methodology
• Gauge current performance vs. target performance
• Require at least monthly updates to a provider portal that allows identification of patients out of compliance with the metric
• Agree on a hybrid approach to measuring performance or at least a reconciliation and appeal mechanism
• Negotiate tiered payment based on improvement and attainment
• Negotiate a payment potential adequate to engage PCPs
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CATEGORY 2C: PAY FOR PERFORMANCE
✓ Start the program in year one using statewide benchmark as baseline
✓ Do not be subject to outcomes for members being transferred to the provider from other PCPs when it is too late to impact performance
✓ Do not let your payment be held hostage to total plan performance
✓ Avoid replacement of P4P as assume category 3 or 4 APMs
✓ Try not to allow P4P costs be counted as a cost in category 3 or 4 APMs when there is a separate source of revenue (i.e. premium withhold)
✓ Don’t allow plan to terminate the APM mid year
✓ Agree on detailed terms before signing a contract
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Improvement and attainment of performance targets
Attainment Goal (75th percentile) 80%
Improvement Goal over Baseline 5%
Baseline Score Performance Target
FQHC #1 40% 42%
FQHC #2 60% 61%
FQHC #3 90% 80%
APM QUALITY METRICS EXAMPLE OF PERFORMANCE TARGETS
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APM QUALITY METRICS EXAMPLE: CT PCMH+ PROGRAM
1. Maintain Quality points are awarded if a Participating Entity's (PE's) 2018 rate is greater than or equal to its 2017 rate.2. Improve Quality points are awarded for a PE's 2018 improvement trend over 2017 on a sliding scale based on the participating entities improvement trend.3. Absolute Quality points are awarded for a PE's ability to reach 2018 Absolute Quality targets.4. DNQ (Does Not Qualify) values occur when a denominator count is less than 30.
Quality Measures
Maintain
Quality
Improve
Quality
Absolute
Quality
Quality
Points
Points
Possible
Adolescent Well-Care Visits 1.0 1.0 1.0 3.0 3.0
Avoidance of Antibiotic Treatment in Adults
with Acute Bronchitis 1.0 0.0 0.0 1.0 3.0
Developmental Screening in the First Three
Years of Life 1.0 1.0 1.0 3.0 3.0
Diabetes HbA1c Screening DNQ DNQ DNQ 0.0 0.0
Emergency Department Usage 1.0 1.0 0.0 2.0 3.0
PCMH CAHPS 0.0 0.0 0.0 0.0 3.0
Prenatal Care DNQ DNQ 0.0 0.0 0.5
Postpartum Care DNQ DNQ 0.5 0.5 0.5
Well-child Visits in the First Months of Life 0.0 0.0 0.0 0.0 3.0
Total Points 9.5 19.0
Aggregate Quality Score (Total Quality Points/Total Possible Points) 50%
CATEGORY 3A: APM WITH UPSIDE GAINSHARING; DISCUSS AND AGREE ON
• Define population eligibility types for inclusion • Attribution methodology• Minimum attributed membership• Service inclusion• Accounting for cost of the care management fee and
Category 2 APM funds • Basis for the benchmark spend (percentage of
premium, historical spend)• Annual trending of the benchmark spend• Frequency of resetting the benchmark spend
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DECISION: SERVICE ACCOUNTABILTY
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Primary Care
Provider
Specialty Care
Outpatient Hospital Care
and ED
Inpatient Hospital
Acute CarePharmacy
Long Term Acute
Hospital Care
Inpatient Rehab
Hospital Care
Skilled Nursing
Facility Care
Post Acute and LTC Bundling
Total Cost of Care Bundle
Ambulatory Care Acute Hospital Bundling
Ambulatory Care Services
▪ What bundle of services can I manage and what do I want to be accountable for now versus over time?
CATEGORY 3A: APM WITH UPSIDE GAINSHARING
• Risk adjustment methodology• Individual stop loss• Split of savings between payer
and provider• Savings corridors if any (minimal
and maximum savings ratios)• First dollar savings• Claims runout/IBNR• Quality parameters and
performance targets for accessing savings
• Impact of quality score on savings
• Multi-payer alignment
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CATEGORY 3B OR 4: RISK MITIGATION STRATEGIES
• Demonstrate ability to generate shared savings before progressing to shared risk
• Assure panel size is enough to minimize the impact of statistical variation in performance
• Negotiate a minimal loss ratio (MLR)
• Negotiate stop loss and risk corridors
• Consider clinical and financial integration with non-PCP partners
• Take risk only for services you can reasonably impact
• Build an adequate reserve pool
• Take a multi-payer approach
• Act now as if you were taking capitated risk
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CALCULATION OF A CAPITATED FQHC APM
(PPS Rate in Baseline Year) x (# of Billable Encounters for Empaneled Medicaid Members in Baseline Year)
# of empaneled Medicaid Member Months in Baseline Year
= PER MEMBER PER MONTH APM RATE*
*Rate is inflated annually by current trend rates; broken into State and MCO portions
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• Market share
• Geographic coverage
• Network performance across the continuum of care
• Preferential MCO relationships
• Single signature
• Willingness and ability to assume financial accountability
CREATING IPA CONTRACTING LEVERAGE
Delivery System Transformation
Payment System Transformation
Payment Reform without Practice
Transformation doesn’t
change outcomes.
3232
FRAMEWORK FOR CREATEING A SUCCESSFUL CLINICALLY
INTEGRATED NETWORK
Governance and
Committee Structure
Practice Transformatio
n and Care Management
Work Force Development
Communication &
Connectivity
Care Management
Platform, Analytics and
Reporting
Patient Engagement
Value-Based Payment
7 Key Building Blocks to Population Health and Value-based Care
© Copyright Medical Home Network 2009-2020 | All Rights Reserved | Proprietary & Confidential
Clin
ical
Co
mm
itte
e
Behavioral Health Workgroup
Transitions of Care Workgroup
ED Utilization Workgroup
Quality Workgroup
Specialty Care Workgroup
Care Management Workgroup
Complex CM Workgroup
Pharmacy Work Group
3333
Highly Engaged Clinical Committee and Workgroups
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Use Of E-consult System To Meet Specialty Care Needs
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Recommendation: Explore use of an e-consult system to meet patient specialty care needs.
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CONNECTIVITY, DATA ANALYTICS AND TIMELY REPORTLY
© Copyright Medical Home Network 2009-2020 | All Rights Reserved | Proprietary & Confidential
Primary Care in the New NormalPart 3: A Menu of National FQHC Models and the Ohio Selection Process
Ohio Association of Community Health CentersDate