5/3/2016. Value-Based Purchasing in Minnesota Medicaid AGENDA

Transcription

1 Value-Based Purchasing in Minnesota Medicaid Gretchen Ulbee Manager, Special Needs Purchasing, Health Care Administration Minnesota Department of Human Services May 11, 2016 AGENDA What is Value-Based Purchasing? Why Value-Based Purchasing? Examples of Value-Based Purchasing Medicare ACO demonstrations Minnesota Medicaid Examples Integrated Health Partnerships Integrated Care System Partnerships How can I get involved? Minnesota Landscape: Medicaid Managed Care Medicaid managed care for seniors IHP and ICSP for seniors Medicaid managed care for people with disabilities IHP and ICSP for people with disabilities Resources Value-based purchasing is an umbrella term for financing strategies that attempt to reward providers for high quality, good outcomes, and population-based approaches. In fee-for-service, the financial incentive is to simply provide more services for more pay. Value-based purchasing tries to shift the financial incentive to reward providers who invest in staff training, care coordination, taking extra time with the sickest people, and working to prevent problems before they become more costly 3 1

2 Pay-for-performance providers get bonus payments or a share of an incentive pool for hitting quality targets PMPM fee for Care Coordination providers are paid a set fee each month to managed care for a group of patients Total Cost of Care or Accountable Care Organization (ACO) provider system is paid fee-for-service all year for caring for a group of patients. Actual expenditures are then compared to what care would have cost for the patients. Provider system shares in gains and may pay for losses. Capitation and subcapitation (Managed care) 4 Over one million, or 1 in 5 Minnesotans rely on Medical Assistance and MinnesotaCare for access to health coverage and care. The quality, health outcomes long-term sustainability of these programs is of paramount concern. State spending for Medical Assistance and MinnesotaCare is approximately $5.0 billion for 2016 (approximately $4.9 billion projected for Medical Assistance and $162 million for MinnesotaCare) Medical Assistance is projected to be approximately 21% of the State general fund budget in 2016, with annual cost growth of approximately 6%. Approximately 70% of the state Medical Assistance spending is on health care and long term care for the elderly and individuals with disabilities. Financing should encourage reducing cost and improving quality. Care should be centered around patients and their families. 5 Fiigures from the 2015 Health Care Financing Task Force final report. Medicare Shared Savings Program (CMS) Eligible providers, hospitals, and suppliers participate in ACOs to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. Advance Payment ACO Model provides supplemental support from CMMI to physician-owned and rural providers for start-up resources to build the infrastructure (e.g., staff, improving information technology systems, etc.) Minnesota MSSP sites: Essentia and HealthEast Pioneer ACO Model (CMMI) For early adopters of ACOs Designed to support organizations with experience operating as ACOs or in similar arrangements in providing more coordinated care to beneficiaries at a lower cost to Medicare. The Pioneer ACO Model will test the impact of different payment arrangements in helping these organizations achieve the goals of providing better care to patients and reducing Medicare costs. Minnesota Pioneer ACO sites: Fairview, Park Nicollet, and Allina 6 Fiigures from the 2015 Health Care Financing Task Force final report. 2

3 HCBS Quality Improvement Requirement rate increases tied to submission of quality improvement plans HCBS Performance-based Incentive Payment Program (PIPP) grants to implement quality improvement projects Health Care Home: Additional payments to clinics certified by MDH Behavioral Health Home: PMPM for care management 7 IHP or Integrated Health Care Partnerships state total cost of care agreement with provider systems; gain sharing and some loss sharing ICSP or Integrated Care System Partnerships agreements between managed care plans and providers or provider systems 8 The IHP is accountable for its attributed Medicaid enrollees total cost of care. Both FFS and MCO recipients are attributed using past provider encounters TCOC is defined as a subset of Medicaid services health care organizations can reasonably expect to impact. Generally includes inpatient, outpatient, physician/professional, mental health, chemical health Generally excludes dental, supplies, transportation, long-term services Gain/loss sharing payments are made annually based on riskadjusted total cost of care performance. 9 3

4 Builds from current managed care organization/care system contracting arrangements Proposals are subject to state contract requirements for care coordination, quality metrics, financial performance measurement and reporting Tied to a range of quality metrics: Clinical work group developed quality measure options; can propose alternatives Measures differ between systems based on population services, setting of care, geographic area 10 Know your strengths and the value you bring for patients Know your client s eligibility: Medicare? Medicaid? both? Know your payors and benefits coverage: Medicare (FFS, ACO, managed care) Medicaid (FFS, managed care, IHP, ICSP) Integrated Medicare-Medicaid plan (FFS, managed care, IHP, ICSP) Explore innovative relationships with health plans, ACOs and clinic systems 11 Roughly 891,000 Minnesotans receive coverage through Medicare In 2014: Full benefit dually eligibles: 118,000 (56,000 seniors 62,000 PWD) Total Medicaid seniors 65+ : 59,000 (95% dual) Total Medicaid people with disabilities: 125,000 (50% dual) Partial benefit Medicaid (Medicaid covers only Medicare cost sharing): 10,

5 Medicaid managed care for families, children, adults: 647,019 MinnesotaCare: 76,702 90% Medicaid seniors enrolled in managed care under two options: Minnesota SeniorCare Plus (MSC+): 13,677 enrollees (coordinates Medicare, enrollment mandatory) Minnesota Senior Health Options (MSHO): 35,291 enrollees (integrates Medicare, enrollment voluntary) Special Needs BasicCare (SNBC): For people with disabilities, 40% (50,150) enrolled, all behavioral and physical health, home health aide and skilled nurse visit, not MLTSS 13 Medicaid seniors are required to enroll managed care Goal is to focus on improved management of chronic conditions, appropriate utilization of services and control of costs. Services provided include all Medicaid services including Long Term Services and Supports (LTSS), HCBS waiver services, 180 days nursing facility care, in all settings and levels of care MSHO achieves integration of Medicare by contract and allows coordination of benefits across programs. Combines Medicare (including Part D) and Medicaid services 14 Aligned capitated financing supports innovation and payment reform Integrated member materials, one enrollment form, aligned enrollment dates, one card for all services State MLTSS assessment tool integrates Health Risk Assessment (HRA) into assessment process All members are assigned individual care coordinators. The State sets uniform standards, audit protocols and criteria for care plans, face to face assessment and care coordination Flexible care coordination delivery models High degree of collaboration among SNPs and State on member materials, PIPs, care coordination, benefit policy, demo decisions, etc. through multiple joint workgroups 15 5

6 People over age 65 are excluded from IHP because the majority are eligible for Medicare All seniors managed care plans must develop and report on ICSP initiatives Managed care benefits include almost all Medicaid services, including 180 days nursing facility payment 16 Plan All-Cause Readmissions (PCR) The number of acute inpatient stays during the measurement years that were followed by an acute readmission for any diagnosis within 30 days and the predicated probability of an acute readmission Inpatient Utilization- General Hospital/Acute Care Summarizes utilization of acute inpatient care and services in the following categories: Total inpatient, Medicine, Surgery, and may also be disease specific rather than general hospitalizations Advanced Care Planning/ POLST Percentage of members age 65 or greater who have evidence (i.e.- documentation) of advanced care planning in their medical record at their health care home clinic or nursing facility across a 12 month period 17 SNBC is a voluntary statewide managed care program for people Participating health plans; two plans have D-SNPs 49,751 total enrollees. Of these 791 are in fully integrated SNBC. An additional 26,482 duals are in the Medicaid-only program. Emphasis on preventive, primary and behavioral health care Health plans provide care coordination/navigation assistance 100 days NF; no HCBS waiver services, home care nursing or PCA but does include home health aide and skilled nurse visit 18 6

7 Use of High Risk Medications in the Elderly (DAE) Percentage of Medicare members 66 years of age and older who received at least one or two high risk medications Medication Reconciliation Post Discharge (MRP) Percentage of discharges for members 66 years of age and older for whom medications were reconciled on or within 30 days of discharge 19 Duals are excluded from IHP, but about half of people with disabilities on Medicaid are not yet Medicare eligible All SNBC managed care plans must develop and report on ICSP initiatives Managed care benefits are more limited than Seniors benefits; items not covered under the health plan are paid under Medicaid fee for service 20 Plan all-cause readmissions (PCR) The number of acute inpatient stays during the measurement year followed by acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission Anti-Depressant Medication Management (AMM) Percentage of participates 18 and older with major depression dx; newly treated with anti-depressant medication and remained on treatment Medication Reconciliation Post discharge (MRP) Percentage of discharges for members 66 years and older for whom medications were reconciled on or within 30 days of discharge. 21 7

8 Gretchen Ulbee, Manager of Special Needs Purchasing, DHS Income and eligibility chart for Medicaid, MinnesotaCare, Medicaid for Employed Persons with Disabilities, Tax Credits MN Health Care Financing Task Force Report _tcm pdf

9 25 26 Thank you! 9