ACOs, CCOs: Challenges & Opportunities. Speakers

Transcription

1 ACOs, CCOs: Challenges & Opportunities 2014 Compliance Institute Wednesday, April 2 San Diego, CA Speakers Chris Apgar CEO and President, Apgar and Associates, LLC Dick Sabath Compliance Officer, Trillium Community Health Plan Dawn Bonder President and CEO, Health Republic Insurance Company 2 1

2 Case Study of Oregon *Portland *Eugene 3 Coordinated Care Organizations A new locally controlled way to provide Medicaid services in Oregon that includes: Integration of behavioral, mental, physical & oral health Non-Emergent medical transportation Reimbursement models that incentivize positive patient outcomes CCO accountability for the health of the population served Partnership among health care providers, health systems, community members and patients Remember: More Medicaid patients in

3 ACCOUNTABLE CARE ORGANIZATION VERSUS COORDINATED CARE ORGANIZATION 5 Definitions ACO Organization of providers that shares responsibility for providing care to patients, is accountable for the care of beneficiaries assigned to it. CCO Community based organization using patient centered primary care homes, fixed global budgets, efficiency and quality improvements to reduce costs. 6 3

4 Major Differences ACO Specifically addressed in the Affordable Care Act (ACA) Rules issued to help guide interpretation of key provisions CCO Not provided for in the ACA No rigid framework for implementation Mostly state endeavors right now (Oregon) 7 Organization & Governance ACO Vertically integrated organizations of care Minimum: composed of primary care physicians, hospital and specialists Governed by providers, suppliers of services and beneficiaries Governing board must be responsible for measuring and improving performance CCO May function as single corporate structure or network of providers Consumers will play a role in governing the organizations Governed by a majority interest of persons that share Financial risk Providers The community Local Government 8 4

5 Payment & Risk ACO Based on shared savings and shared loss model Benchmark on estimate of what total expenditures for beneficiary group would have been without the ACO ACO gets shared savings if cost is lower ACO must pay if higher CCO Based on global budget with shared savings if performance standards are met Oregon Each CCO receives global budget to cover all services Directors decide how the money is parceled out 9 Providers ACO Primary Care Providers may only participate in one ACO Hospitals/other providers may participate in more than one May involve nontraditional health providers, such as Public health Wellness programs Providers held directly responsible for the health of their patients Evaluated based on their effectiveness, efficiency & quality of care in treating patients CCO May participate in more than one CCO Emphasis on hiring Community Health Workers Emphasis on prevention and nonmedical components to health Housing Transportation 10 5

6 Quality ACO Beneficiary experience of care survey required CCO Consumer and caregiver satisfaction considered 11 Beneficiaries ACO Not required to stay in network Minimum of 5,000 members CCO No requirements 12 6

7 Special Considerations ACO Strong emphasis on primary care and reducing overall costs of care CCO Align and integrate the care of duals Oregon counties are the local mental health and public health authorities CCOs will be required to have formal, contractual relationships with the county(ies) in which they operate

8 Covered Entity? Coordinated Care Organization (CCO) means an entity that has been certified by the Authority to provide coordinated and integrated health services. CCO CONTRACT Exhibit E.6 HIPAA Compliance The parties acknowledge and agree that each of OHA and the Contractor is a covered entity for purposes of privacy and security provisions of the Health Insurance Portability and Accountability Act and the federal regulations implementing the Act (collectively referred to as HIPAA). OHA and Contractor shall comply with HIPAA to the extent that any Work or obligations of OHA arising under this Contract are covered by HIPAA. Contractor shall develop and implement such policies and procedures for maintaining the privacy and security of records and authorizing the use and disclosure of records required to comply with this Contract and with HIPAA. 15 CURRENT CHALLENGES 16 8

9 HIPAA Information sharing for improved care (authorized by ORS ) A CCO, its provider network and programs administered by DHS for adults and persons with disabilities must share member information for purposes of: service and care delivery, coordination, service planning, transitional services and reimbursement, improving the safety and quality of care, lowering the cost of care, and improving the health and well being of the CCOs members. 17 HIPAA (cont.) Information may be shared within the CCO and the CCO provider network for the purpose of allowing the CCO to provide whole person care. Information that may be shared without member authorization includes diagnosis of HIV, other physical health diagnoses and mental health diagnoses. Information about members may be shared between CCOs, OHA and DHS for the purpose of administering the laws of Oregon. 18 9

10 HIPAA (cont.) In network provider mandate for information sharing (authorized by SB 1580 (2012)) Except for psychotherapy notes, protected health information MUST be disclosed by health care providers participating in a CCO without member authorization: To other health care providers participating in the CCO for treatment purposes, To the CCO for health care operations and payment purposes, permitted by ORS ; and To public health entities as required for health oversight purposes. 19 HIPAA (cont.) But: CCOs and their providers must comply with HIPAA and 42 CFR Part 2 (authorization needed for disclosure of treatment records of substance abuse treatment providers). Mandated disclosures under state law do not override the federal protections for drug and alcohol records found in 42 CFR Part 2 or for educational records

11 Metrics Incentive Measures CCOs are required to provide based line data and show improvements in care through data as incentivized payment mechanism CCO Incentive Measure Benchmarks Measure 2013 Benchmark 2014 Benchmark 2014 Improvement Target Adolescent well care visits 53.2% 2011 National Medicaid 75th percentile (admin data only) 57.6% 2013 National Medicaid 75th percentile (admin data only) Minnesota method1 with 3 percentage point floor. Alcohol and drug misuse (SBIRT) Ambulatory care: emergency dept. utilization CAHPS: Access to Care 13% Committee consensus. 44.4/1,000 member months 2011 National Medicaid 90th percentile 87% Average of the 2012 National Medicaid 75th percentiles for adult and child rates. 13% unless CCOs demonstrate higher performance in Review in Q /1,000 member months 2013 National Medicaid 90th percentile 88% Average of the 2013 National Medicaid 75th percentiles for adult and child rates. Minnesota method with 3 percentage point floor. Minnesota method Minnesota method with 2 percentage point floor

12 2014 CCO Incentive Measure Benchmarks (cont.) Measure 2013 Benchmark 2014 Benchmark 2014 Improvement Target CAHPS: Satisfaction with Care Colorectal cancer screening Developmental screening Early elective delivery Electronic Health Record Adoption 84% Average of the 2012 National Medicaid 75th percentiles for adult and child rates. n/a improvement target only 50% Committee consensus. 5% or below Committee consensus. 49.2% Federal benchmark for EHR adoption by % Average of the 2013 National Medicaid 75th percentiles for adult and child rates. To be determined staff researching Medicaid benchmarks. Minnesota method with 2 percentage point floor. To be determined. 50% Committee consensus. Minnesota method. 5% or below Committee consensus 72% Committee consensus, based on highest performing CCO in July Minnesota method with 1 percentage point floor. Minnesota method with 3 percentage point floor CCO Incentive Measure Benchmarks (cont.) Measure 2013 Benchmark 2014 Benchmark 2014 Improvement Target Follow up after hospitalization for mental illness 68% 2012 National Medicaid 90th percentile 68.8% 2013 National Medicaid 90th percentile. Minnesota method with 3 percentage point floor. Follow up for children prescribed ADHD medication (initiation rate) Mental and physical health assessments for children in DHS custody Patient Centered Primary Care Home (PCPCH) enrollment 51% 2012 National Medicaid 90th percentile 90% Committee consensus. Goal: 100% of members enrolled in Tier 3 PCPCH Timeliness of prenatal care 69.4% 2012 National Medicaid 75th percentile, admin data only. 51% 2013 National Medicaid 90th percentile 90% Committee consensus. Goal: 100% of members enrolled in Tier 3 PCPCH 90% 2013 National Medicaid 75th percentile Minnesota method. Minnesota method with 3 percentage point floor. n/a Minnesota method

13 Innovator Agents Help Oregon Health Authority and Coordinated Care Organizations achieve the goals of the triple aim Critical in linking the needs of OHA, the community and the CCO Inform OHA of opportunities and obstacles related to system and process improvements Assist and support the CCOs in developing and implementing their transformation plans Help the CCO in developing strategies to support quality improvement and the adoption of innovations in care 25 Innovator Agents (cont.) Attend Community Advisory Council meetings to provide guidance for the development of the CCOs Community Health Assessment Assist the CCO in gathering, managing and using data to target areas of local focus for improvement and accelerate quality improvement Share best practices with all other Innovator Agents Engage with community partners and elected officials as needed to build partnership and support effective innovation 26 13

14 Delegated Contracts Behavioral Health Integrating primary and behavioral health care was initially a big focus of Oregon s coordinated care organizations Patients with severe mental health illnesses and problems with substance abuse are a high priority population to treat They tend to be less likely to access primary care They leave physical health conditions untreated Frequently use the emergency room Represent high costs to the health care system 27 Delegated Contracts Behavioral Health (cont.) Define core attributes of the patient centered primary care home Establish a simple and uniform process to identify patient centered primary care homes that meet the core attributes Develop uniform quality measures (including acute-care hospital and ambulatory measures) that build from nationally-accepted measures and allow for standard measurement of performance Develop policies that encourage the retention of, and the growth in the numbers of, primary care providers Community Health Workers 28 14

15 Delegated Contracts Alcohol & Drug Residential Services Transition to CCOs July 1, 2013 Coordinated care organizations are replacing a fragmented system of care that relied on different groups to provide physical health, mental health and addictions care Alcohol and drug residential treatment services are delivered to individuals who are in need of 24-hour supervision, treatment and care 29 Delegated Contracts Alcohol & Drug Residential Services (cont.) To support, stabilize, and rehabilitate individuals so they can to return to independent community living The capitation rate and contract includes provision of medically managed detox Individuals must detox before they enter residential treatment 30 15

16 Delegated Contracts Dental Care Organization 8 of the 16 CCOs have integrated multiple Dental Care Organizations (DCO) into their CCOs. CCOs cannot delegate oversight and monitoring Quality Improvement activities. CCOs cannot delegate adjudication of final appeals in Member grievance and appeal process. 31 Delegated Contracts Non-Emergent Medical Transportation (NEMT) CCOs have integrated Non-Emergent Medical Transportation as service offering. NEMT brokerages vary across the state. Some face provider access issues in transportation philosophy. Notice of Action denial directly to hearing w/out appeal Volunteers making ride eligibility decisions Untrained call center personnel Medical reason for appointment Unmet transportation needs 32 16

17 PRACTICAL TOOLS TO CURRENT CHALLENGES 33 HIPAA Solutions Assist working partners, such as behavioral health and Non-Emergent Medical Transportation, Comprehend HIPAA, and Understand the application of HIPAA within the CCO through training and agreements

18 Quality Metrics Solutions Base line data that is accurate Understand how best to show improvement in care Make quality care accessible Eliminate health disparities 35 Behavioral Health and Alcohol & Drug Residential Services Solutions Co-location of Behavioral and Physical health care coordination services Integration of Community Health Workers in to BH and PH care coordination teams Multi-disciplinary monthly meetings 36 18

19 Dental Care Solutions Work in collaborative, cooperative environment Work out processes for appeals and grievance reporting Assess compliance efforts Offer suggestions to improve or strengthen compliance programs 37 Non-Emergent Medical Transportation Solutions Conduct Risk Assessments Review Contract Provisions Offer Assistance and Share Best Practices Share and Explain Performance Expectations Educate Brokerage on Practical HIPAA Impacts 38 19

20 FUTURE CHALLENGES 39 Mental Health Residential Treatment Systems Anticipated transition of Mental Health Residential Treatment from Oregon Health Authority to CCOs Projected Transition Schedule: Meetings between May and August 2014 Active Transition to CCOs July 1,

21 Mental Health Residential Treatment Systems (cont.) Medicaid-funded personal care, habilitation, and mental health rehabilitative services Includes coordination and administration of Oregon s home and community-based services 41 Public Employee Benefit Board (PEBB)/ Oregon Educators Benefit Board (OEBB) Contract for and administers medical and dental insurance programs for state employees and their dependents budget PEBB is $1.54 billion OEBB $1.64 billion Budget was constructed to reflect a per-employee growth rate of: 4.4% % % Growth rates are consistent with Oregon s Medicaid waiver 42 21

22 Public Employee Benefit Board (PEBB)/ Oregon Educators Benefit Board (OEBB) (cont.) Vision: Improve the health of all members Increase quality of care for all members Lower or contain cost of care 43 PRACTICAL TOOLS TO FUTURE CHALLENGES 44 22

23 Mental Health Residential Treatment Systems Solutions Foster Care is highly unionized Multiple contracts Compliance challenged Read Mental Health Residential Treatment System Transition to CCOs (FAQ format) Look at charters 45 Public Employee Benefit Board (PEBB)/ Oregon Educators Benefit Board (OEBB) Solutions Inflation in health care costs and trend drive program costs Has older population Biennial health risk survey shows both groups have: Lower than average overweight or obese membership About 10% of population with chronic conditions Majority have sedentary occupations Health system transformation requires: Rapid, systemic changes in structure and administration Management of simultaneous federal and state requirements for modifications to delivery system Membership PEBB approximately 150,000, OEBB 170,00 Governor s vision is for PEBB/OEBB to be in the CCOs 46 23

24 Questions & Answers 47 24