MaineCare Value Based Purchasing Initiative
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1 MaineCare Value Based Purchasing Initiative The Accountable Communities Strategy Jim Leonard, Deputy Director, MaineCare Peter Kraut, Acting Accountable Communities Program Manager
2 Why Value-Based Purchasing In Maine? Success of Emergency Department Pilot project Move away from insurance model managed care philosophy Need to establish quality measures Focus on quality and cost Hold providers accountable Manage to the measures Will allow us to address current challenges Aligns with other programs Opportunity for local intervention Population health 2
3 AHRQ s Key Elements of Value-Based Purchasing Contracts that clearly spell out the responsibilities of purchasers with selected insurance, managed care, and hospital and physician groups as suppliers Information to support the management of purchasing activities Quality management to drive continuous improvements in the process of health care purchasing and in the delivery of health care services Incentives to encourage and reward desired practices by providers and consumers Education to help employees become better health care consumers 3
4 Maine s VBP Strategy's Focus: Three Major Components Create Accountable Communities Improve Transitions of Care ED Collaborative Care Management Initiative Health Homes focus Learning opportunities Payment reform discussion Strengthen Primary Care Health Homes Initiative Patient-Centered Medical Homes Community Care Teams Reform of Primary Care Provider Incentive Payment program 4
5 Maine s Accountable Communities: Our Definition An entity responsible for population s health and health care costs that is: Provider-owned and driven Characterized by community collaboration and a strong consumer component Includes shared accountability for both cost and quality In traditional managed care, a managed care organization is responsible for care and cost that is delivered through providers 5
6 Accountable Communities Shared Savings/ Losses Models 6
7 Accountable Communities Shared Savings/ Losses Models Choice of two models: 1. Model I - requires minimum of 1000 Members Share in a maximum of 50% of savings, based on quality performance, with cap at 10% of TCOC No downside risk in any of the three performance years 2. Model II - requires minimum of 2000 Members Share in a maximum of 60% of savings, based on quality performance, with cap at 15% of TCOC No downside risk in first performance year. Liable for 40-60% of losses, based on quality performance, in years two and three, with cap at 5% of TCOC in Year 2 and 10% of TCOC in Year 3 7
8 Maine s Accountable Communities: The Basic Components Providers work together and may share in any savings achieved The amount of shared savings depends on performance on quality measures Open to any willing and qualified providers statewide (through application process) Possible to have multiple Accountable Communities in one geographical area Members retain choice of providers Maximize measure alignment with other ACOs initiatives Flexible design encourages innovation 8
9 Who Can Be an Accountable Community, and What Are the Requirements? One or multiple provider organizations represented by a Lead Entity. Lead Entity does not need to be a provider. Include providers that directly deliver primary care services and meet PCCM requirements Include at least one provider of services under each of the following three categories, if there is such a Provider serving Members in the AC s Service Area: Chronic Conditions Developmental Disabilities Behavioral Health 9
10 Who Can Be an Accountable Community, and What Are the Requirements? Detail for last bullet on previous slide Chronic Conditions Health Home Practices or Community Care Teams, Providers of Targeted Case Management (TCM) services for children with chronic health conditions, or Providers of TCM services for adults with HIV Developmental Disabilities Providers of TCM for children with developmental disabilities, or Providers of TCM for adults with developmental disabilities Behavioral Health Behavioral Health Home Organizations Providers of Community Integration Providers of TCM for children with Behavioral Health Disorders Providers of TCM for adults with Substance Abuse Disorders 10
11 Who Can Be an Accountable Community, and What Are the Requirements? Have relationships or policies to ensure coordination: with all hospitals in the AC s Service Area with at least one Public Health Entity, if there is such a Public Health Entity that serves Members in the AC s Service Area. If the AC includes a Health Home Practice, invite the HHP s partner(s) (i.e., Community Care Team and/or Behavioral Health Home Organization) services to participate in the AC. Include two MaineCare members in Governance 11
12 What could an Accountable Community look like? 12
13 Attribution Methodology Members with 6 mo continuous eligibility or 9 mo non-continuous eligibility 1. Members enrolled in a Health Home Practice that is part of an Accountable Community 2. Members not captured in step 1 who have a plurality of primary care visits with a primary care provider that is part of an AC 3. Members not captured in steps 1 or 2 who have 3 or more ED visits with a hospital that is part of an AC. 13
14 Accountable Communities Shared Savings/ Losses Models 14
15 Total Cost of Care (TCOC): General Acute Inpatient Psychiatric Inpatient Inpatient Inpatient Psychiatric General Acute Outpatient Outpatient Psychiatric Outpatient Physician -- Primary Care Physician -- Specialty Outpatient Psychiatric Core Services Physician, Physician Assistant, Nurse Practitioner, Nurse Midwife, Federally Qualified Health Centers, Rural Health Centers, Indian Health Services Physician, Physician Assistant Mental Health Laboratory/ Radiology Long Term Care Durable Medical Other Pharmacy School Health Centers, Behavioral Health Services, Rehabilitative and Community Support Services Lab & Imaging Services Hospice, Home Health Durable Medical Equipment School Health Centers, Ambulance, Dialysis, Early Intervention, Family Planning, Occupational & Physical and Speech Therapy (including services provided in schools and at Nursing Facilities), Chiropractic Services, Optometry, Audiology, Podiatry Pharmacy 15
16 Total Cost of Care (TCOC): Optional Services Adult Family Care Home Long Term Care Services and Supports* Assisted Living Services Children's PNMI Day Health Dental HCBS Waiver Services ICF-MR Long Term Care Nursing Facility Personal Care Private Duty Nursing -- Adult/Children Long Term Care Services and Supports* Children's PNMI Long Term Care Services and Supports* Dental Long Term Care Services and Supports* Long Term Care Services and Supports* Long Term Care Services and Supports* Long Term Care Services and Supports* Long Term Care Services and Supports* Long Term Care Services and Supports* *excluding Home Health, Hospice, and PT, OT and Speech provided at Nursing Facilities, which are all core 16
17 Data Adjustments To calculate benchmark TCOC, baseline year TCOC amount is adjusted for: Policy changes Trend Risk To minimize variations from one year to the next due to AC members with large claims, total annual claims for any individual Member in excess of the following claims caps will not be included in benchmark or actual TCOC : members: $50, members: $150, members: $200,000 17
18 Accountable Communities Shared Savings/ Losses Models Choice of two models: 1. Model I - requires minimum of 1000 Members Share in a maximum of 50% of savings, based on quality performance, with cap at 10% of TCOC No downside risk in any of the three performance years 2. Model II - requires minimum of 2000 Members Share in a maximum of 60% of savings, based on quality performance, with cap at 15% of TCOC No downside risk in first performance year. Liable for 40-60% of losses, based on quality performance, in years two and three, with cap at 5% of TCOC in Year 2 and 10% of TCOC in Year 3 18
19 Shared Savings and Loss Details Minimum savings to qualify for savings/loss payment 19
20 Model I & II Shared Savings Example For Accountable Community ABC Benchmark TCOC for Yr 1: $500 PMPM Actual TCOC for Yr 1: $390 PMPM Savings = $110 PMPM, exceeds 2% threshold, so AC is eligible for shared savings payment In example below, assume 95% quality score model 1 model 2 pre-cap shared savings payment $110 * 50% * 95% = $52.25 $110 * 60% * 95% = $62.70 compare to cap $500 * 10% = $50 $500 * 15% = $75 shared savings payment $50 $
21 Model II Shared Loss Example For Accountable Community XYZ, Years 2 & 3 Benchmark TCOC for Yr 1: $500 PMPM Actual TCOC for Yr 1: $570 PMPM Loss = $70 PMPM, exceeds 2% threshold, so AC is liable for shared loss payment In example below, assume 95% quality score year 2 year 3 pre-cap shared loss payment $70 * [1 - (60% * 95%)] = $30.10 $70 * [1 - (60% * 95%)] = $30.10 compare to cap $500 * 5% = $25 $500 * 10% = $50 shared savings payment $25 $
22 Quality Measures: 16 Core, Choose 2 of 5 Elective AT-RISK POPULATIONS (30% OF QUALITY SCORE) CORE: Diabetes - Glucose Control (HbA1c Control) (adults). Year 1: Percentage of AC Primary Care Providers for whom Glucose (HbA1c) results for Members age 18 and over have been reported to the State s Health Information Exchange Years 2 & 3: Percentage of Members ages 18 to 75 years of age with diabetes mellitus who had HbA1c < 8.0 percent CORE: Diabetes- Eye Care. Percentage of Members years of age with diabetes (type 1 or type 2) who had a retinal eye exam performed within past 1-2 years. CORE: Follow-Up After Hospitalization for Mental Illness. Percentage of discharges for Members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days of discharge. CORE: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment.*Percentage of adolescents and adults Members with a new episode of alcohol or other drug (AOD) dependence who received the following: Initiation of AOD treatment. Engagement of AOD treatment. CORE: Asthma- Medication Management Percentage of Members ages 5-64 who were identified as having persistent asthma and were appropriately prescribed controller medication. ELECTIVE: Diabetes (HbA1c Testing) (adults). Percentage of Members years of age with diabetes (type 1 or type 2) who had a Hemoglobin A1c test in the measurement year. ELECTIVE: Diabetes- Nephropathy. Percentage of Members years of age with diabetes with nephropathy screening within previous 12 months. ELECTIVE: Use of Spirometry Testing in the Assessment and Diagnosis of Chronic Pulmonary Disease (COPD). Adults with a new (within the measurement year) diagnosis or newly active COPD who received Spirometry testing to confirm the diagnosis. Spirometry testing must occur 730 days (2 years) prior to or 180 days after the diagnosing event. Age 42 and older. 22
23 Quality Measures CARE COORDINATION/ PATIENT SAFETY (30%) CORE: Prevention Quality Indicator (PQI #92). Prevention Quality Indicator (PQI) composite of chronic conditions per 100,000 population, ages 18 years and older CORE: Pediatric Quality Chronic Composite (PDI #92) Pediatric Quality Indicators of chronic conditions per 100,000, ages CORE: Non-emergent ED Use. Maine ED study developed list of 14 diagnoses identified as preventable. CORE: Percent of Primary Care Providers who Successfully Qualify for a Health Information Technology EHR Program Incentive Payment. CORE: Plan- All Cause Readmission. For Members 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days ELECTIVE: Use of High-Risk Medications in the Elderly The percentage of Members 66 years of age and older who received at least one high-risk medication 23
24 Quality Measures PATIENT EXPERIENCE (10%) CORE: Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician & Group Surveys Version: 12-Month Survey with Patient-Centered Medical Home (PCMH) Items (child and/or adult version as appropriate) PREVENTIVE HEALTH (30%) CORE: Adolescent Well-Care Visit (12-21). Percentage of Members who were years of age and who had at least one comprehensive well-care visit with a PCP or OB/GYN during the measurement year. CORE: Developmental Screening - First Three Years of Life CORE: Well-Child Visits ages 0-15 months percent of children with 6 or more well child care visits in the first 15 months CORE: Well-Child Visits ages 3-6 percent of children 3-6 years old with at least one well child visit per year CORE: Well Child Visits ages 7-11: percent of children 7-11 years old with at least one well child visit per year. ELECTIVE: Breast Cancer Screening Measure: Percentage of female Members year of age who had a mammogram to screen for breast cancer. 24
25 Quality Measures AC Performance Level Quality Points per Measure EHR Meaningful Use Points per Measure 90+ percentile or percent 2 points 4 points 70+ percentile or percent 1.7 points 3.4 points 50+ percentile or percent 1.4 points 2.8 points 30+ percentile or percent 1.1 points 2.1 points <30 percentile or percent No points No points 25
26 Data Feedback to Providers Reports to Accountable Community providers will include the following: Utilization report (monthly) Attributed member roster (quarterly) Actual TCOC (quarterly) broken out by practice and service category Performance on quality measures (quarterly), including list of which members are in numerator and denominator of each measure (All reports use most recent 12 months of data at the time the report is generated) 26
27 Where Are We Now? State Plan Amendment approved this past summer Round 1: In process of finalizing contracts with five ACs, covering 30,000 Members: Beacon Community Care Partnership of Maine Kennebec Region Health Alliance MaineHealth ACO York Hospital Round 2: Currently determining process and timeframe. Goal is start date approximately one year from now. 27
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