Ron Stock MD MA Oregon Rural Health Conference October 24, 2013

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1 Ron Stock MD MA Oregon Rural Health Conference October 24, 2013

2 Provide a historical context for healthcare reform including the 2010 Patient Protection & Accountable Care Act Connect what is known to improve health outcomes to service delivery policy at the state and national level Outline Oregon healthcare reform activities that will impact Oregonians, including the CCO, primary care medical home, dual eligible beneficiaries and long term care

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4 1935: New Deal 1948: Truman Fair Deal program fails 1965: Medicare & Medicaid established under Social Security Act; The Great Society 1972: Add- 1)speech, PT, chiropractic; 2) HMO s; 3)Young people w/disabilities; 3) ESRD 1982: Hospice 1997: Balanced Budget Act; Part C Medicare Advantage and PACE program 2003: Medicare Modernization Act - Part D drug

5 Individual mandate, health insurance exchange, and Medicaid expansion Reduced payments to Medicare Advantage and some hospitals/clinicians Created Independent Payment Advisory Board (IPAB) Phasing out the Part D donut hole Fraud and abuse Preventive services: Annual Wellness Exam Center for Medicare and Medicaid Innovation (CMMI)

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7 Chronic Care Model Community Resources and Policies Health System Health Care Organization Self- Management Support Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

8 1. Improving the individual experience of care; Better care 2. Improving the health of populations; Better health 3. Reducing the per capita costs of care for populations; Lower costs Berwick et al. Health Affairs, 27(1): , 2008

9 Coordinated Care Interventions The Medicare Coordinated Care Demo (MCCD) Patient-centered primary care medical home Transitional Care Interventions Self-Management Education Interventions Chronic Disease Self-management program Shared Decision-Making Healthcare Information Systems -Brown et al. The Promise of Care Coordination, Mathematica Policy Research, March, 2009

10 Key Components of Success: Targeting In-Person Contact Access to Info on Hospital & ED Admits Close interaction between CC s and PCP s Services provided, eg med management, social work support, ADL assistance, transportation, address social isolation Staffing: RN role vs SW role

11 Keys to success to reduce hospitalizations: 1.Focus on high risk patients 2.Face to face contact w/ patients 3.Care Manager face to face contact w/ physicians 4.Patient Education 5.Managing care setting transitions 6.Communication hub role of CM 7.Medication management

12 The Innovation Center was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). Congress created the Innovation Center for the purpose of testing innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care for those individuals who receive Medicare, Medicaid, or Children s Health Insurance Program (CHIP) benefits. Aims: Test new payment and service delivery models; Evaluate results and advance best practice ; Engage a broad range of stakeholders to develop new models

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14 To support Health System Transformation, the Oregon Health Authority needs to transform itself Partner with Coordinated Care Organizations (CCO)to increase the rate and spread of innovation needed to achieve triple aim. Spread elements of the coordinated care model to other payers

15 Transformation Center will house: Innovator Agents Learning Collaboratives Data & Analytics Technical assistance and infrastructure support Conferences and workshops, communications, outreach and networking Council of Clinical Innovators; Clinical standards & supports Regional Health Equity Coalitions Promotion of patient-centered primary care homes, use of nontraditional health workers and elements of the CCO model

16 Coordinated Care Organizations (CCO) Patient-Centered Primary Care Medical Home State PCPCH PCPCH Institute FQHC Advanced Primary Care Practice Demo Comprehensive Primary Care Initiative Independence at Home Demonstration Community-based Care Transitions Program Grants: TopMed; OPIP; ORPRN; Health Commons; SIM grant

17 An organization of providers that is accountable for the care of the Medicare Beneficiaries assigned to it. ACO s will have a strong emphasis on Primary Care and reducing overall costs. Shared savings model Community based Governance (Board, CAP, CAC) patient centered primary care homes fixed global budgets efficiency and QI to reduce costs for Oregon Medicaid 17 Incentive Measures CCOs align and integrate Oregonians eligible for both Medicare and Medicaid to reduce admin costs. ACO CCO

18 Local health entities that deliver health care and coverage for people eligible for Medicaid (the Oregon Health Plan). Local control One point of accountability Global (single) budget fixed rate of growth Expected health outcomes Health Equity Integrate physical and behavioral health Community health workers Focus on prevention Reduced administrative overhead Electronic health records Patient-Centered Primary Care Homes* *CCOs required to include recognized clinics in their networks of care to the maximum extent feasible 18

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20 HB 2009 established the PCPCH Program: Create access to patient-centered, high quality care and reduce costs by supporting practice transformation Key PCPCH Program Functions: PCPCH recognition and verification Refinement and evaluation of the PCPCH Standards over time Communication and provider outreach Coordination across OHA divisions, CCO development and health reform initiatives Restructure primary care payment to align with the PCPCH framework Technical assistance development

21 Based on the Oregon Health Policy Board s Action Plan: All OHA covered lives (almost 900, 000) receive care through a Patient-Centered Primary Care Home - Includes Medicaid, public employees, Oregon educators, Oregon high-risk pool, Family Health Insurance Assistance Program, and Healthy Kids 75% of ALL Oregonians have access to quality care through a PCPCH by 2015 Spread to private payers and Qualified Health Plans via the Exchange

22 Tier 3: Advanced Primary Care Home Proactive patient and population management Accountable for quality outcomes Tier 2: Intermediate Primary Care Home Demonstrates performance improvement Additional structure and process improvements Tier 1: Basic Primary Care Home Foundational structures and processes

23 Date # Recognized Tier 1 Tier 2 Tier 3 10/21/ % 23.70% 74.94%

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25 Current minimum criteria to become a PCPCH will remain the same More options available for clinics to achieve PCPCH recognition and higher Tier levels Application renewal cycle expanded from annually to every two years (effective September 3, 2013) - Clinics can reapply every 6 months if they meet a higher tier or score New opportunity for primary care homes to become Tier 3 star performers

26 2014 PCPCH Standards are available on the web CPC practices will be well-positioned to meet many of the additional menu of standards/measures Patient-Centered Primary Care Institute (PCPCI.org) is an additional resource for technical assistance Tools/Webinars/online learning/learning collaboratives for clinics/leaders/ta providers Work with CCOs/Transformation Center to engage/support PCPCHs Continuing to engage payers inside and outside the OHA to support recognized PCPCHs and align initiatives. PEBB/OEBB CoverOregon - Insurance Exchange Aetna PCPCH payment incentive program launched

27 Launched in 2012 Public-private partnership Broad array of technical assistance for practices at all stages of transformation Ongoing mechanism to support practice transformation and quality improvement in Oregon

28 Four year, multi-payer collaboration between CMS and statewide private payers; Redesign of the primary care practice Seven (7) demonstration regions/ markets (AR, CO, NY, OH, KY, NJ, OK, OR) New payment model Monthly per-member-per month (PMPM) management fee In years 2-4, potential to share in savings

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30 67 Primary Care Practices 552 Providers 5 Payers: CareOregon, TualityHealth, Providence, Regence BC/BS, OHA Estimated 48,000 beneficiaries served

31 Risk-stratified Care Management; Access and Continuity; Planned Care for Chronic Conditions and Preventative Care; Patient and Caregiver Engagement; Coordination of Care Across the Medical Neighborhood.

32 1. Provide care management for high risk patients. 2. Provide 24/7 patient access guided by the medical record. 3. Assess and improve patient experience of care. 4. Use data to guide improvement in care at the provider/care team level. 5. Demonstrate active engagement and care coordination across the medical neighborhood 6. Improve patient shared decision-making capacity.

33 1. Time (finding time; deadlines; length of time provided) 2. My patients (attributing the right ones, risk stratification) 3. My team (staffing, budgeting, transforming) 4. Metrics and measuring success (reports, baseline metrics, harmonization) 5. Competing priorities (other projects, new responsibilities)

34 Subtitle Jan 1, 2014, all CCO s will be required to offer a Medicare Advantage plan Not required to enroll in the CCO Pushing CCO s to be more attractive Improvement initiatives beginning to make it easier to submit claims Better member communication; address grievances

35 LTC carve out Shared Accountability for Long Term Care (LTC) Memorandum of Understanding CMS/LTC/CCO Study Group- An exploratory stakeholder process that will result in a report to the Centers for Medicare/Medicaid Services (CMS) regarding the integration of DHS Medicaid-funded Long-Term Care (LTC) for the aged or people with disabilities into the Coordinated Care Organizations (CCO) global budgets.

36 Care coordination throughout the system Alternative payment methodologies Integration of physical, behavioral, oral health Community-based focus Flexible services Testing, accelerating and spreading innovation

37 Horses out of the barn Beginning to see changes at the practice level What s so different now? Workforce

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