Idaho Medicaid and Service Delivery Model - Plans to Work together

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1 Abstract Idaho Comprehensive Health Care Innovation Planning Grant Idaho Medicaid is one of the largest healthcare payers in Idaho, growing 75% over the last decade from 130,000 to 230,000 enrollees. Idaho Medicaid has experienced unsustainable growth in participants and costs at a time when budget pressures have been severe. Additionally, 100% of Idaho is a federallydesignated shortage area in mental health care, and 96.7% of Idaho is a federally-designated shortage area in primary care. Through House Bill 260, passed in 2011 and subsequently codified into State law, the Idaho Legislature directed the Department of Health and Welfare to begin studying Medicaid managed care approaches. Currently, Medicaid and other organizations across Idaho, such as the Idaho Health Data Exchange and the North Idaho Health Network, are implementing innovative health care initiatives that are poised to become part of the solution for a sustainable and integrated health care system in Idaho. These and other stakeholders are eager to collaborate to mature their capacities within an accountable, integrated system of health care that is sustainable. Therefore, Idaho proposes to engage a broad group of stakeholders in a comprehensive statewide analysis of the current health care system to identify approaches already in place that can support successful transformation to a new payment and service delivery model. Stakeholders, many of whom are already engaged, will drive the process as advisors, work groups, and focus group constituents. A professional consulting company with expertise in health care transformation will be hired to work with the stakeholders to solicit input, facilitate the process, and draft the Comprehensive Health Care Innovation Plan, as well as the related proposal for the Model Testing phase of this transformation process. This process will include developing cost savings estimation and monitoring plans. The cost for this process will be $3 million. The resulting plan will serve as the blueprint for integrating Idaho s patient-centered medical homes into the rest of the health care system and transforming the system to a new model. Idaho proposes to adapt, where applicable, the Community Care of North Carolina service delivery model in developing its Medicaid managed care program. North Carolina created a nationally-recognized Medicaid model of primary care networks that support the patient-centered medical home at both the state and local levels. Idaho s Community Care Network model would be network-based, support the needs of primary care practices and enhance communication and coordination of care throughout the health care continuum. Patient care would be managed in a primary care setting through patient-centered medical homes, the foundation that is currently being developed in Idaho. Regional, private, not-for-profit, community care networks would be developed by local providers. The regional network would link the local health care system through partnerships with hospitals, primary care providers, county health and social service agencies, and other stakeholders that may vary from network to network. The end goal of Idaho s transformation to a new Community Care Network model is to achieve the triple aim, laid out by the Centers for Medicare and Medicaid Services, of improved health, improved healthcare and lower costs for all Idahoans, including Medicaid and Children s Health Insurance Program (CHIP) participants.

2 Idaho s Comprehensive Health Care Innovation Plan Design Strategy A. State Health Care Innovation Plan Design Strategy 1. State s strategy for completing the work: In 2011, the Idaho Legislature passed House Bill 260 instructing Medicaid to explore managed care options. As a result, Idaho Medicaid is initiating three large managed care programs; 1) one for primary care (Health Homes), 2) one for mental health services, and 3) one for Medicare- Medicaid dually eligible participants. Also, Governor C. L. Butch Otter s Idaho Medical Home Collaborative is currently piloting a medical home initiative that is a multi-payer model that includes Medicaid, Blue Cross of Idaho, PacificSource, and Regence Blue Shield of Idaho. In addition, public and private organizations across Idaho are implementing innovative health care initiatives that are poised to contribute to the development of an integrated health care system in Idaho and stakeholders have expressed an eagerness to collaborate to mature their capacities within a supportive integrated system that meets the triple aim of improved health, improved healthcare, and lower costs. Therefore, Idaho proposes to engage these and other stakeholders in a comprehensive statewide analysis of the current health care system to develop a new payment and service delivery model. To pursue the work of transforming health care in Idaho, Idaho has studied innovative payment and service delivery models in other states, and has identified a community care management network model that has been well received by Idaho stakeholders and fits with Idaho s values. Idaho s next step is to develop a Comprehensive Health Care Innovation Plan to enable the work of transformation to a sustainable service delivery model. Idaho State Innovation Model Design Grant P a g e 1

3 Idaho s process for designing the new payment and service delivery model will include a comprehensive statewide analysis of the current system to identify approaches already in place that can support successful transformation. This needs assessment will involve a gap analysis and will require identifying development opportunities and strategies that aligned with a community network model design. At its foundation, the model will describe (1) how patient centered medical homes will be effectively integrated within the larger health care delivery system, (2) how Idaho will build and sustain a long-term integrated patient-centered system using electronic health records to improve care coordination and management, (3) how the recommended system of managed care will support an accountable delivery system with improved health outcomes, and (4) how successful implementation will be evaluated, including how improved health care, community-level health outcomes, and cost savings will be measured. Idaho proposes to complete this work in partnership with an existing stakeholder group, the Governor s Idaho Medical Home Collaborative (referred to as the Collaborative below). The Collaborative has demonstrated prior success in developing a medical home pilot project for Idaho that is aligned with Medicaid s Health Homes program developed under the authority of the Affordable Care Act, Section The Collaborative is provider/payer-led and has broad representation including both public and private insurers that serve the majority of Idaho beneficiaries (Blue Cross of Idaho, Medicaid, PacificSource, and Regence Blue Shield of Idaho). The Collaborative has expressed support for this proposal (please see their attached letter of support), and has responded positively to the proposed community care network model. The Collaborative s Medical Home Pilot project launches January 1, 2013, and will be the primary focus of that group for the next two years. The Collaborative will serve in an advisory capacity for planning activities for Idaho s new payment and service delivery model. A Idaho State Innovation Model Design Grant P a g e 2

4 workgroup will be established to meet regularly to guide the planning work, and will advise and seek input from the larger Collaborative. This core workgroup currently exists as the Integrated Delivery System Advisory Workgroup, with representatives of the Idaho Medical Association, the Idaho Hospital Association, the Idaho Primary Care Association, Medicaid, the Idaho Academy of Family Physicians, and Rural Health. Members of this workgroup will be expanded to reflect the broader reach of this new initiative. Stakeholders will drive the design work at all levels. With guidance and direction from the core stakeholder workgroup described above, subject-matter stakeholder work groups with broad representation will meet regularly. Four key areas of focus have been identified, which will result in four subject-matter workgroups: (1) network structures and integration with medical homes, (2) data interconnectivity and analysis (3) quality improvement systems, and (4) multipayer reimbursement strategies. The core workgroup will focus on creating a public policy framework for an integrated managed care system. The subject-matter workgroups will study their respective topic areas and help develop the statewide needs assessment content. They will use subject-matter expert consultants as needed and will help conduct a coordinated gap analysis. They will integrate information from statewide focus groups, and make recommendations for the plan. Service delivery stakeholders will participate in focus groups statewide to provide input and feedback. Participants will be recruited through outreach efforts by membership associations and the outreach processes already established by the Health Districts. While the identified stakeholder groups will provide leadership, conduct analysis, and collaborate on the final model design, a professional consulting company experienced with Idaho State Innovation Model Design Grant P a g e 3

5 facilitating health care transformation will be engaged to manage the process and to draft the model design plan under the direction of the core and subject-matter workgroups. The consulting company will facilitate the work groups and conduct the statewide focus groups. The consultants will be subject matter experts in the areas that the work groups are focused, or will be responsible for helping identify experts that can provide assistance. They will also have expertise in group facilitation and conducting focus groups. These consultants are essential for keeping the stakeholder groups focused and working toward the goals in the short timeline. The core workgroup and subject-matter workgroups will review recommendations and facilitate integration across the work areas with the assistance of the consultants. Under their direction, the consultant will draft both the Model Design Plan and the Model Testing proposal, which will become due in Spring of The consulting contract will be monitored by the Project Manager who is a current Medicaid employee. Under the direction of Medicaid administration, which will manage the grant and contracts, and the stakeholder leadership group, the Project Manager will work with the consultants to develop the project implementation and monitoring plan. Additional Medicaid staff will be involved in business systems development and data analysis for the project. The structure of this implementation plan is illustrated below in Figure 1: Organization Structure for the Performance of the Model Design Grant (see Project Organization). 2. Idaho s Payment and Service Delivery Model: Background: In December 2011, a Medicaid managed care forum was jointly hosted by the Idaho Department of Health and Welfare, the Idaho Primary Care Association, Idaho Medical Association, and the Idaho Hospital Association to begin discussing how the Medicaid program Idaho State Innovation Model Design Grant P a g e 4

6 could implement managed care in Idaho. Participants, including hospital CEO s, community health center CEO s, and physicians conveyed a consistent message that reflects the values of a patient-centered medical home integrated within the larger health care delivery system. The recommended system of managed care supports an accountable delivery system with improved health outcomes. The foundation would be built on an integrated patient-centered system using electronic health records to improve care coordination and management. This private-public collaboration resulted in identifying an opportunity to explore an acclaimed model based on community care networks. The provider associations and Medicaid (currently the core workgroup identified in this proposal) jointly applied to the National Academy for State Health Policy for a grant to study the Community Care of North Carolina model and identify how it could be adapted to Idaho Medicaid s managed care program. North Carolina created a nationally-recognized Medicaid model of primary care networks that support the patient-centered medical home at both the state and local levels. The core workgroup s current priorities to improve patient outcomes align well with those identified in their National Academy for State Health Policy application: 1. Establish a model to support medical home integration with other aspects of the care system to improve health outcomes and access via care management and coordination. The system design must work well in both the urban and rural setting. 2. Create a strategy and model for developing an actionable informatics/data system that includes clinical and utilization data to improve health outcomes and reduce costs. Idaho State Innovation Model Design Grant P a g e 5

7 3. Create evidence-based standards for internal practice management to address the needs of high-risk and high-cost populations statewide, and provide resources to support transformation toward these standards in community settings. 4. Develop multi-payer reimbursement strategies for the integrated health care system. 5. Create a public policy framework for a community care system to guide implementation of an integrated managed care approach in Idaho. The Idaho core workgroup s application was accepted. The five member workgroup, consisting of representatives from the Department of Health and Welfare, the Division of Medicaid, the Idaho Primary Care Association, the Idaho Academy of Family Physicians, the Idaho Hospital Association, and the Idaho Medical Association, traveled to North Carolina with other states to study the Community Care of North Carolina model. The workgroup participated in an intensive two-day workshop to identify how the model might be adapted to Idaho s unique needs. The Community Care of North Carolina model, which developed over a 25 year period, has a proven track record of providing better care, with better health outcomes, at reduced costs. It is an innovative model that, based upon lessons learned, can be adapted to this new age of provider-driven health care reform. Since Idaho is new to managed care, it has seized the opportunity to observe past and current managed care efforts in numerous states and evaluate the model that will work best for successfully developing Idaho s Community Care Network Model. Key Components of Idaho s Community Care Network Model: The workgroup suggests a model of patient care management that will be network-based, supports the needs of primary care practices, and enhances communication and coordination of care throughout the health care continuum. Regional private not-for-profit community care networks will be developed by local providers. The regional network will link the local health care system through partnerships with Idaho State Innovation Model Design Grant P a g e 6

8 hospitals, primary care providers, county health and social service agencies, and other stakeholders that may vary from network to network. Patient care will be managed in a primary care setting through patient-centered medical homes, the foundation that is currently being developed in Idaho. Each Medicaid enrollee will select a primary care provider who provides direct primary and preventive care, makes referrals, and coordinates after-hours care. Each local network will hire care managers who help the primary care providers coordinate the medical needs of particularly complex patients. The networks will also develop systems for information exchange (informatics) that facilitate and support the care of patients throughout the continuum. The networks will improve population health outcomes, decrease emergency room use, and decrease the cost of health care. Goals and Principles of Idaho s Community Care Network Model: The Idaho Community Care Network Model will provide community-based, coordinated care with an emphasis on wellness and preventive care for most patients, while emphasizing disease management strategies for individuals with special health needs. The goals of the model are consistent with the Centers for Medicare and Medicaid Services (CMS) Triple Aim to provide improved health, improved healthcare, and lower costs. These goals have also been consistently expressed in various sections of Idaho Code, which direct the State s Medicaid program to evolve toward managed care. The Idaho Community Care Network Model concept is built on principles of partnership, long-term commitment, provider-directed patient-centered medical homes, and evidence-based quality improvement. The proposed model supports key attributes of a high performance health care delivery system that ensures: Idaho State Innovation Model Design Grant P a g e 7

9 Clinically relevant patient information is available to all providers at the point of care. Patient care is coordinated among multiple providers, and transitions across care settings are actively managed. Providers (including all members of the health care team) both within and across care settings are accountable to each other. Patients have easy access to appropriate care and information, even after working hours. Providers have clear accountability for the total care of patients. Members of the system are continuously innovating and learning in order to improve the patient s experience and the quality and value of health care delivery. Provider incentives move from volume to value. 3. Existing Waivers, Affordable Care Act Implementation and Other State Initiatives: Legislation for Managed Care in Idaho: As one of the largest healthcare payers in Idaho, Idaho Medicaid currently has 230,000 enrollees, growing 75% over the last decade from 130,000. Idaho s Medicaid program has experienced unsustainable growth in participants and costs at a time when budget pressures have been severe. In addition to this recent growth, Medicaid eligibility provisions defined in the Patient Protection and Affordable Care Act would permit the addition of between 97,000 and 111,000 newly eligible participants to the State s Medicaid program in The current design of the State s Medicaid program, which is primarily based on fee-for-service arrangements, does not provide appropriate incentives and can be improved by incorporating managed care tools (Idaho Code (1)). Through House Bill 260, which was passed and subsequently codified into State law, the 2011 Idaho Legislature directed the Department of Health and Welfare, Division of Medicaid to Idaho State Innovation Model Design Grant P a g e 8

10 begin studying Medicaid managed care options. The direction from the Idaho Legislature is to improve the current health care delivery system by incorporating managed care tools, including contracting based on gain sharing, risk-sharing or a capitated basis, with the objective of moving towards an accountable system of care that results in improved health outcomes, increased participant accountability/responsibility for their care, and improved business practices for providers. Additionally, the Legislature directed that a plan for managed care focused on high cost populations with specific elements that include: Medical home development with a focus on populations with chronic diseases; Approaches that improve coordination of care for high cost, high risk populations that lead to improved outcomes and lower costs; and Elimination of duplicative practices that result in unnecessary utilization and costs. Governor s Health Care Summit and Select Committee: In 2007, Governor C. L. Butch Otter convened a Health Care Summit of health care leaders from around the State to address health care issues in the State. At the end of the summit, several key recommendations to the Governor had been identified, including the need to develop the patient centered medical home model. In response to these recommendations the governor appointed a Select Committee on Health Care which toured the State, taking input regarding our current health care system and recommendations regarding how it could be improved. The final report of the Select Committee to the Governor again identified the patient centered medical home model as critical to building a health care system that could address the triple aim of improved health, improved healthcare and lower costs. Idaho State Innovation Model Design Grant P a g e 9

11 Safety Net Medical Home Initiative: In 2009, the Idaho Primary Care Association (IPCA), at the request of the Governor s Select Committee, successfully applied for the Safety Net Medical Home Initiative, offered by Qualis Health and funded through the Commonwealth Fund. Through this four-year grant, 13 safety clinics have developed the patient centered medical home model for low-income and rural patients. At this point in time, 11 of the 13 clinics participating in the Initiative have successfully received recognition from the National Committee for Quality Assurance (NCQA) as patient centered medical homes. These are the first primary care clinics in Idaho to receive this national recognition. Governor s Idaho Medical Home Collaborative: One of the goals of the IPCA Safety Net Medical Home Initiative was to convene policy makers, payers and providers to address new medical home payment methods and to consider how to spread the model to other providers. The safety net clinics, in partnership with the State s private primary care physicians, worked with the Governor to issue an Executive Order establishing the Idaho Medical Home Collaborative in the Fall of The Collaborative is a broad-based, provider/payer-led, multi-payer stakeholder group (the members are listed below under stakeholders). In its advisory capacity, the Collaborative makes recommendations to the Governor for model design and encourages collaboration among public and private payers on appropriate reimbursement methods and aligned incentive support. The payers, including Medicaid, Blue Cross of Idaho, Regence Blue Shield of Idaho, and PacificSource represent a preponderance of beneficiaries in Idaho. Over the past two years, the Idaho Medical Home Collaborative has established a definition for medical home in Idaho, identified common quality measures for primary care providers, and developed a pilot project for primary care providers interested in transforming their practices to medical homes. The work of the Collaborative has culminated in the Idaho Medical Home Collaborative Idaho State Innovation Model Design Grant P a g e 10

12 Pilot project, which will launch on January 1, Participating primary care providers will receive quality improvement support from project staff, will be required to reach and maintain NCQA recognition at Level 1, and will submit quarterly clinical quality and outcome data for progress monitoring of the program. As a multi-payer pilot, participating providers will receive supplemental payments, for care coordination and management for chronically ill patients, ranging from $15 per member per month (PMPM) to $43 PMPM, depending on the payer. The insurance payers have aligned with the requirements of the pilot to the extent possible in order to provide a uniform set of requirements and to reduce the burden on participating providers. The voluntary pilot will involve approximately 30 practices, including many of the clinics that participated in the Safety Net Initiative. Eligibility will be based upon readiness to transform to a medical home, to submit clinical quality data, and to meet the requirement of at least level-1 recognition from NCQA within the two years of the pilot. The Collaborative achieved this significant milestone of creating the Pilot by assigning three work groups of interested Collaborative members and other community stakeholders. The work groups meet regularly to achieve assigned outcomes, and report to the full Collaborative membership at monthly meetings. In 2010, two workgroups were established. The Practice Transformation workgroup developed the medical home implementation model to reflect the medical home definition developed by the Collaborative. The Payer work group was charged with developing an aligned multi-payer reimbursement strategy for the pilot project. In 2011, the Collaborative got additional traction from Idaho Medicaid. Medicaid staff was hired to facilitate the development and implementation of the Medicaid Health Homes project Idaho State Innovation Model Design Grant P a g e 11

13 under the authority of the Affordable Care Act, Section The Collaborative raised funds to pay for some of the staff time to support the continued development and implementation of the Collaborative Pilot. In particular, it was important to align the Medicaid Health Homes project requirements with those of the Idaho Medical Home Collaborative Pilot project. The Medicaid project staff, a project manager and two quality improvement specialists, was instrumental in that effort, as they were able to keep the work going between stakeholder meetings, and to staff additional work groups. Shortly after their hire, two additional Collaborative work groups were established. The Data Work Group was charged with identifying a set of required clinical quality measures that align with other national and local programs and initiatives and that support quality improvement for serious chronic health conditions identified in the Affordable Care Act. The Communication Workgroup was charged with developing the Pilot project website and other communication tools. The Collaborative has gained much momentum, and will be a significant stakeholder presence in the development of a state innovation plan. Due to the Collaborative s success in developing the Idaho Medical Home Pilot project, its working model will be adapted for the State Innovation Model Design grant work. Idaho Medicaid s Health Homes: Under the Health Home Authority (Section 2703) of the Affordable Care Act, Medicaid recently submitted a State Plan Amendment to implement a patient-centered medical home model, Health Homes, as an enhancement of Healthy Connections, the current Primary Care Case Management System. Implemented in 1992, Healthy Connections is managed by a statewide team with representatives located in each of Idaho s seven regions. It is currently mandatory that Medicaid recipients utilize a primary care Idaho State Innovation Model Design Grant P a g e 12

14 provider in 42 of Idaho s 44 counties. In 2011, Medicaid restructured the Healthy Connections Case Management payment to providers to include an incentive payment for offering extended office hours. Medicaid s Health Home initiative will augment Healthy Connections with a supplemental case management payment of $15.50 per-participant-per-month for those with serious and chronic diseases. Idaho Health Homes has the potential to reach approximately 43,000 Medicaid participants with chronic diseases. Through improved care management, the Health Homes program is expected to improve the health outcomes and healthcare in Idaho, particularly for seriously and chronically ill Medicaid participants, and to decrease costs associated with unneeded or duplicative services. Health Home providers will receive quality improvement support from Medicaid staff, and will be required to provide extended office hours, reach and maintain NCQA recognition at Level 1, and to submit quarterly clinical quality and outcome data to Medicaid for progress monitoring of the program. The Medicaid Health Homes program will launch on January 1, 2013, and as suggested above, was developed in tandem with the Collaborative in order to foster alignment with the multi-payer medical home pilot and reduce burden on Health Homes providers who might also participate in the pilot. The patientcentered medical home is the foundation upon which the proposed payment system and delivery model will be built. Idaho Medicaid s Children s Healthcare Improvement Collaboration (CHIC): Under the Children s Health Insurance Program Reauthorization Act, and in partnership with the State of Utah, Idaho Medicaid s Children s Healthcare Improvement Collaboration has integrated evidence-based practice for asthma, team-based care coordination, and the use of data to monitor and inform patient care into eight pediatric practices (20 physicians). Recently, the CHIC initiative launched a Pediatric Patient-Centered Medical Home Demonstration Project. The Idaho State Innovation Model Design Grant P a g e 13

15 project includes three large Idaho practices with an average Medicaid participant base of 54%. Two of these practices have also applied for the Idaho Medical Home Collaborative Pilot project. Behavioral Health Managed Care: Idaho Medicaid is in the process of transforming its behavioral health services (mental health and substance use disorder services) to a managed care delivery system. Medicaid will procure a single managed care entity to provide a Prepaid Ambulatory Health Plan for behavioral health services statewide. Developing a behavioral health managed care program is a statewide effort of Medicaid staff, behavioral health and medical providers, community partners, participants and families. Medicare-Medicaid Care Coordination for Dually Eligible Participants: In January of 2014, Idaho Medicaid will also participate in a demonstration project that will coordinate the full spectrum of Medicare and Medicaid benefits for Medicare-Medicaid dually eligible participants. Participating health plans will receive a capitated per-member-per-month payment. In return for the payment, plans will pay a care management team and providers to coordinate and cover all Medicare and Medicaid benefits the individual qualifies for. Over 17,000 people in Idaho are dually eligible. Quality measures will be collected and reported in order for the health plans to receive the maximum payment, thereby aligning the health plans interests with the beneficiaries interests for quality health care. Quality requirements will be integrated and will include measures currently used by both Medicare and Medicaid. All participating plans must report on specified measures related to long-term supports and services. The State will use reported measures to assess plan performance and outcomes and to allow quality to be evaluated and compared with other plans in the model. Idaho State Innovation Model Design Grant P a g e 14

16 Medicaid s Electronic Health Record Incentive Program was launched in July of 2012 and is currently making payments to providers for adopting, implementing, or upgrading to a certified electronic health record system. Those who have registered to date include 20 of Idaho s 44 hospitals, three of which have received payments totaling $2,359,611. Among other eligible providers, 188 have registered, 15 of which have received payments totaling $148,750. At least a quarter of those registered professionals are from Federally Qualified Health Clinics and Rural Health Clinics. By July of 2013, the Idaho Medicaid Incentive Program will begin accepting attestations for Stage 1 meaningful use. It will continue to help build the supports for chronic disease management and data sharing that underpin the network concept of interconnectivity through Other State Health Initiatives: The Idaho Health Professions Education Council: was created by an executive order from Governor C. L. Butch Otter in February The Council includes healthcare organizations, Idaho colleges and universities, and the public at large. The Council s charge includes: Conducting a health workforce analysis; Assessing the State s capacity for training healthcare professionals; Advising the Governor and legislature on health workforce issues; Recommending strategies to address healthcare provider shortages in rural areas. The Council creates strategies and recommendations to enhance health workforce development in urban and rural areas of Idaho. The Council s current efforts include increasing primary care and internal medicine residency opportunities and enhancing access to advanced nursing degrees. Currently, 100% of Idaho is a federally-designated shortage area in mental Idaho State Innovation Model Design Grant P a g e 15

17 health care, 96.7% of Idaho is a federally-designated shortage area in primary care, and 95.7% of Idaho is a federally-designated shortage area in dental health care. Nationally, Idaho ranks 48 th and 49 th for the rate of physicians in primary care and overall rate of physicians in patient care per 100,000 citizens. Idaho has 45 certified Rural Health clinics, many of which are very small practices located in remote locations. These practices do not have the technical or financial resources, or the patient volumes to hire practice-specific care coordinators. It will be challenging for our state to develop a system of shared supports and create a reimbursement and incentive model that can sustain this type of delivery system. The Council s charge is wellaligned with Idaho s State Health Care Innovation Planning, as their workforce analysis can be used as a component of the gap analysis. Their recommendations will influence capacity and health workforce needs in Idaho. Idaho Health Data Exchange: In 2006, legislation created the Idaho Health Quality Planning Commission. By 2007, the Idaho Health Data Exchange (referred to as the Exchange below) was established and hospitals and public and private payers were the first to join. It is statewide, connecting participating healthcare providers and organizations throughout Idaho to share clinical information and to improve the quality of care. Currently, seven labs, five hospitals in eight locations, and a growing number of providers participate through six electronic medical record vendor connections. Current services include Virtual Health Record and access to community-wide view, interoperability to electronic medical record vendors (for hub-to-hub connections), and support and training for members. Participation continues to grow; there are more than 550 authorized users, and over 120 electronic medical record connections with physicians and support staff, while more than 430 physicians and support staff participate in virtual health records. The Idaho State Innovation Model Design Grant P a g e 16

18 Exchange has over 1.5 million patient records in its database. Current benefits to providers include access to health information for transition of care, enabling providers to meet Meaningful Use requirements for electronic exchange of clinical information, and improved administrative efficiencies such as chart note preparation, filing, insurance and electronic prescribing. For hospitals, the Exchange offers an information technology solution to connect disparate hospital systems, and permits electronic data exchange (e.g., labs, transcripts, radiology, ADT) between other providers and facilities. For labs, the Exchange enhances lab results delivery, ensures patient safety and prevents duplicative lab costs. For payers, it helps reduce total costs by improving quality and coordination of care, avoiding duplicative tests, emergency room visits, and hospital readmissions, and incentivizes e-prescribing. Wellness programs are also supported by strengthening the physician/patient relationship, and providing patient education and access to personal health records. The Exchange is funded by member fees. In 2010, it received a $5.9 million American Recovery and Reinvestment Act grant to develop a 5-year sustainability plan. It is currently pursuing a hyper-growth strategy. It seeks to expand its provider base and mature with improved technology, analytics and reporting, and making connections with public health. In Idaho, the Idaho Health Data Exchange can play a critical role in the development of statewide interconnectivity and data informatics, and an accountable quality improvement system. As their letter of support indicates, the Exchange is supportive of the State Health Care Innovation planning grant application. North Idaho Health Network: Providers in North Idaho established a provider network in 1994 as a defensive move to health management organizations that were coming to the area. The Idaho State Innovation Model Design Grant P a g e 17

19 North Idaho Health Network (referred to as the Network below) is a not-for-profit 501C3 organization that collects membership fees and manages a shared-savings program. Physicians from all five northern counties and all five hospitals in the region participate, including 100% of the primary care providers. The Network also partners with the largest commercial payers in Idaho. Over 97% of the physicians (>300) in the region participate and share a role in management. The Network is run by a board of directors and has an executive director and medical director. A medical management team oversees the day to day operations, and subcommittees help direct the network: the Pharmacy & Therapeutics Committee, the Primary Care Forum, the Specialty Forum and mostly service line committees that deal with specific clinical issues. The specialty forum meetings are held electronically via webcast. As mentioned above, Idaho is a rural State and a federal shortage area for healthcare providers. Networks such as the North Idaho Health Network may be instrumental in attracting new graduates to rural areas. The Network is currently testing a pilot program that offers independent providers Network staff resources to help them achieve medical home certification. The pilot has raised interest and five independent physicians are participating. The North Idaho Network resonates well with the Idaho Community Care Network Model concept, and it will be instrumental in accelerating the development and implementation of a statewide innovation plan. As the attached letter of support indicates, the Network leadership is supportive of the planning grant, and it is currently considering how to restructure itself to strengthen the clinical care by becoming clinically integrated. Idaho State Innovation Model Design Grant P a g e 18

20 In conclusion, public and private organizations across Idaho are maturing innovative health care initiatives that are poised to contribute to the development and implementation of an integrated health care plan in Idaho. Stakeholders have demonstrated their eagerness to collaborate in the transformation of Idaho s health care system into an integrated system that meets the triple aim of improved health, improved healthcare and lower costs. This planning grant is a timely opportunity, as it will permit Idaho to bring a broader spectrum of stakeholders to the development process that has already been started, and it will enable the use of a professional facilitation firm with experience in healthcare transformation processes to accelerate progress. B. Stakeholders Governor s Idaho Medical Home Collaborative: This group will serve as advisors to the Governor and to the Innovation planning teams. As such, this group may be further expanded. The team of public and private stakeholders involved in the Collaborative includes leaders from the Department of Health and Welfare, Medicaid, public health, and private sector health care experts from hospitals, state medical associations, residency programs, physicians, community health centers, behavioral health, dentists, state universities, commercial health insurers and legislators. This team of stakeholders has worked together since 2010 and will continue to be involved as Idaho s practice transformation efforts continue. Integrated Delivery System Advisory Group: With regard to the Innovation Plan, this group will serve as advisors to the Idaho Medical Home Collaborative, and to the work groups. It will direct the work of the planning grant. It consists of the team that visited North Carolina, which will receive technical assistance from the North Carolina Infrastructure for Maintaining Primary Care (IMPaCT), supported by the Agency for Healthcare Research and Quality and The Idaho State Innovation Model Design Grant P a g e 19

21 Commonwealth Fund. This group will also serve as the public policy workgroup. The current members of the Integrated Delivery System Advisory Group include: Paul Leary Medicaid Administrator Idaho Department of Health &Welfare Denise Chuckovich Deputy Director IDHW, Division of Medicaid, Behavioral Health and Managed Care Services Larry Tisdale Vice President, Finance Idaho Hospital Association Susie Pouliot CEO Idaho Medical Association Neva Santos Executive Director ID Academy of Family Physicians Mary Sheridan Health Policy Supervisor IDHW Office of Rural Health Subject-matter workgroup stakeholders: These will be a combination of advisory group members and others identified through outreach to State and local agencies, tribal governments, academic experts, community service and support organizations, IT coordinators, community health organizations, social service organizations, health care advocates, etc. Similarly, the work groups of the Idaho Medical Home Collaborative were open to interested stakeholders. Constituent focus groups: will vary depending on the topic: 1) network structures and integration with medical homes; 2) data interconnectivity and analytics; quality improvement systems; and multi-payer reimbursement strategies. Because the focus of the innovation plan will be to integrate medical homes into the larger health services system, those focus groups will include primary care providers, clinic administrators and other staff, consumers, and other health service delivery organizations. C. Public and Private Payer Participation Since 2010 Idaho s Medical Home Collaborative (IMHC) has done a great deal of work to bring Idaho s major payers together to develop a multi-payer reimbursement model. The Collaborative has a reimbursement workgroup that Medicaid and the private payers participate in Idaho State Innovation Model Design Grant P a g e 20

22 regularly. This group has identified a multi-payer strategy for the Collaborative s medical home pilot that kicks off January 1, As an extension of the work they are currently doing within the Collaborative, public and private payers will participate in the innovation planning. The private payers have provided letters of support. These payers include Blue Cross of Idaho, PacificSource, and Regence Blue Shield of Idaho. Together with Medicaid, these payers insure a preponderance of the beneficiaries in Idaho. They will participate as stakeholders on both advisory and workgroups to help design the model. One work group in particular will focus on the multi-payer strategies that will be employed in the future. They will also help develop the financial analysis specifications for cost savings analysis associated with the model. We recognize that a true multi-payer effort must have Medicare at the table and have made unsuccessful attempts in the past to reach out to Medicare to join the IMHC. We look forward to assistance from CMS to facilitate Medicare joining our efforts here in Idaho, should we receive the planning grant. D. Project Organization Organization and Administration within Medicaid: As endorsed by Idaho s Governor, the grant will be administered by Medicaid. There will be two Medicaid project sponsors: Paul Leary, the Idaho Medicaid Administrator; and David Simnitt, the Medicaid Deputy Administrator. Mr. Leary will be the primary link between this grant initiative and the executive management team in the Department of Health and Welfare. This is key to ensuring department-wide awareness of this effort and for identifying program areas where communication will be a priority. Mr. Leary will ensure coordination of efforts here and in other department efforts Idaho State Innovation Model Design Grant P a g e 21

23 related to claims based data analyses and any proposed business systems changes associated with the planning grant. Mr. Leary was a member of the team that visited North Carolina and proposed the network community care conceptual model. As such, he is also a member of the Integrated Delivery System Advisory Stakeholder Group, where the project s objectives and direction will originate. During the first few months of the grant period, under the direction of Mr. Leary and Mr. Simnitt, stakeholder and consultant input will focus on development of the project plan. Mr. Simnitt will also manage the hiring process for new staff and will have supervisory responsibility for the Project Manager. The Project Manager will work closely with Mr. Leary and Mr. Simnitt to develop the Request for Proposals to fill the consultant contract. Project Organization for Performance of the Grant: Stakeholders will drive the planning process and the drafting of the Innovation Plan (see Figure 1 below). Advisory Stakeholders will include the Governor s Idaho Medical Home Collaborative and the core workgroup (the Integrated Delivery System Stakeholder Advisory and Workgroup) that directs the planning work. The core workgroup was instrumental in developing the initial Idaho Community Care Network model. The project manager, Julie Wall, will monitor the grant, and facilitate the Consultant s work. The Consulting firm will be identified via a Request for Proposals process managed by Ms. Wall. The consultant will facilitate at least four volunteer stakeholder work groups, and conduct stakeholder constituent focus groups throughout the State. The consultant firm will have facilitation and project management expertise, and also subject matter expertise in the transformation of health systems. The firm will engage other national and local subject matter experts, as needed to support the work of the work groups. Under the direction of the Integrated Delivery System advisory stakeholder group, the Consultant firm will synthesize the information from the work and draft the State Health Care Innovation Plan, as well as the Model Testing proposal that will become due in Spring of The consultant Idaho State Innovation Model Design Grant P a g e 22

24 facilitation will be essential for keeping the work moving over the short timeframe, and for keeping stakeholders motivated and engaged. Figure 1: Project Organization for Performance of the Planning Grant Advisory Group Project Facilitation and Management Subject Area Work Groups Constituent Group Input Network Structures & Integration with Medical Homes Regional Focus Group Governor s Idaho Medical Home Collaborative Integrated Delivery System Stakeholder Advisory and Work Group State Project Management Staff Consulting Company Data Sharing Inter-Connectivity, Analytics and Reporting Quality Improvement System Regional Focus Group Regional Focus Group Stakeholders Consultants State Staff Multi-Payer Reimburseme nt Strategies Regional Focus Group Idaho State Innovation Model Design Grant P a g e 23

25 E. Provider Engagement Idaho s providers are currently fully engaged in the Idaho Medical Home Collaborative. The Collaborative will continue to meet over the next two years as the Medical Home Pilot project is implemented in January, 2013, and has expressed its enthusiasm for the innovation planning work, as indicated by their letter of support. Active outreach through provider associations, and existing health district outreach pathways, will invite providers to serve on work groups and focus groups. Their participation in these groups will be crucial to a successful model that has the medical home as its foundation. As noted above, at the public-private managed care forum sponsored by the Department of Health and Welfare, Division of Medicaid in 2011, providers conveyed a consistent message that reflects the values of a patient centered medical home integrated within the larger health care delivery system. Additionally, since their return from their intensive learning visit to North Carolina, the Community Care Network team has given informational presentations to the major associations (Idaho Primary Care Association (IPCA), Idaho Medical Association (IMA), Idaho Hospital Association (IHA), Idaho Academy of Family Physicians (IAFP), the Governor s Idaho Medical Home Collaborative (IMHC), and the Idaho Legislative Health Care Task Force). These groups have been supportive of the proposed conceptual model. In sum, all of the provider groups are currently champions of the State s and others health care transformation efforts. Idaho State Innovation Model Design Grant P a g e 24

26 Grant Implementation Plan and Timeline: A high-level plan is included below. The Project Manager will write a Request for Proposals to identify and contract with a professional consulting company, and will then work with the consultant to develop a detailed project plan. Idaho Medicaid has already engaged a broad range of stakeholders as advisors, and will expand those groups further to engage additional stakeholders. The advisory group(s) will in turn recruit subject-focused stakeholder work teams, who will advise for the constituent focus groups conducted in each region of the State. Using this facilitated work group and advisory structure, the comprehensive statewide needs assessment will be conducted. The work group activities, as well as the focus groups, will be led and facilitated by the contracted professional consultants. The consultants will have both the facilitation skill set and related subject matter expertise (or can identify and involve needed subject matter experts) to successfully manage the group processes. This combination of skills will ensure that work groups and focus groups remain engaged, and goal-oriented so that the information that is gathered may be synthesized and integrated into recommendations that can be effectively presented to the advisory group. The sub-goals of the work will be to evaluate what resources and structures are already in place, and to conduct a gap analysis to identify development opportunities and strategies. The advisory group will review recommendations and facilitate integration across the work areas with the assistance of the consultants. Under the direction of the Integrated Delivery System Advisory group, the comprehensive health care innovation plan that emerges from this work will be drafted by the consultant during the process and completed by the 6-month due date. As an extension of the plan, the consultants will also draft the core proposal for the Model Testing grant to be submitted in the Spring of Idaho State Innovation Model Design Grant P a g e 25