Better Health for the Population. Better Care for Individuals. Lower Cost Through Improvement

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Ruth Sherman
8 years ago
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3 Better Health for the Population Better Care for Individuals Lower Cost Through Improvement

4 THE NEW HEALTH CARE HEALTH CARE AT A CROSSROADS: CAN CCOs HELP FIND THE WAY? Traditional health care is good at focusing on what happens at the point of care. They screen, treat, or manage symptoms of illness and try to achieve good quality and health outcomes; ideally at a reasonable cost. CLINICAL WORK TREATMENT: Ways to treat or cure it PREVENTION: Ways to keep it from happening in the first place PALLIATIVE CARE: Ways to manage suffering & ease the way QUALITY HEALTH COSTS Health care is increasingly being called to think more broadly about what drives the triple aim outcomes.

5 THE NEW HEALTH CARE HEALTH CARE AT A CROSSROADS: CAN CCOs HELP FIND THE WAY? HEALTH SYSTEMS HOW THE ORGANIZATION & DELIVERY OF CARE SHAPES OUTCOMES CLINICAL WORK HEALTH POLICY Coverage, access, regulatory & accountability structures, etc STRUCTURE OF CARE Medical home, whole-person care, shared decision making, etc PAYMENT & FINANCE Bundled payments, risk sharing, ACO movement, cost effectiveness, etc CONNECTED SYSTEMS Public health, social services, informal care networks, etc TREATMENT: Ways to treat or cure it PREVENTION: Ways to keep it from happening in the first place PALLIATIVE CARE: Ways to manage suffering & ease the way QUALITY HEALTH COSTS For instance, we know that the organization, delivery, and financing systems behind health care shape the impact different clinical strategies will have when deployed in the world. So do the interconnected systems that lie outside health care but profoundly shape health care outcomes.

6 THE NEW HEALTH CARE HEALTH CARE AT A CROSSROADS: CAN CCOs HELP FIND THE WAY? Likewise, environments and other social determinants of health play a profound role in shaping outcomes. How can health care embrace the complex future and shift its way of thinking? How can we develop a health care system that embraces this future?

7 WHAT ARE CCOs? CCOs WERE DEVELOPED AS ONE POSSIBLE SOLUTION BACKGROUND : $860 M gap in Medicaid funding -- translated to 30% reduction in payments. Old solutions: Reduce payments (provider rates) Reduce number of people covered (enrollment) Reduce the benefits covered (Prioritized list) New solution: Change the way that care is organized, connect health care to population health. ESSENTIAL FEATURES A network of providers and plans in a region that provides integrated care to Medicaid members. Full risk under a single global budget that grows at a fixed rate Responsible for delivering physical health care, mental health care, addictions treatment, and dental care Performance-based incentive (2% withhold for quality) no making it by throwing people under the bus.

8 WHAT ARE CCOs? THE PROMISE OF CCOs AS A BRIDGE BETWEEN HEALTH CARE & PUBLIC HEALTH Theoretically, the CCO model could be the thing that finally breaks down the artificial distinction between health care & public health. CCOs create THE ARCHITECTURE FOR CHANGE: New rules for sharing data to allow for care integration. Anti-trust exemptions to allow competitors to come together to manage a population s outcomes together. Community advisory board required. New flexibility in how health care dollars can be spent & how risk can be allocated. THE INCENTIVE FOR CHANGE: Global budget means the $ are fixed, so the incentive for every part of the system to maximize at the expense of every other is less. Tying global budget to quality means its not all about lower costs. Risk sharing means providers have a reason to care about managing health rather than just delivering services.

9 THE CHALLENGES CHALLENGE #1: PRESSURES FROM OREGON S $1.9 BILLION WAGER BACKGROUND Federal Investment of $1.9 Billion over 5 years to support costs of transformation. In return, Oregon must: Cut cost growth by 1 % point after two years, then 2%. Measurably improve quality & access. Demonstrate that CCOs were what drove these changes. If Oregon fails, they have to pay the money back. THE CATCH FOR PUBLIC HEALTH This investment helped kickstart CCO transformation, but it also brings with it intense pressures that may hamper the ability of CCOs to realize the original vision as transformative entities. Early focus is on achieving cost goals and hitting quality metrics. The quality metrics chosen were safe, traditional health care metrics not population health measures.

10 THE CHALLENGES CHALLENGE #2: STRUCTURES ARE SET UP TO WORK ON SHORT TERM STRATEGIES There are basically two paths for CCOs to make it under global budgets. They need outcomes in a couple of years which path are they set up to move down in such short notice? CCO STRUCTURES Are Health Care Structures POTENTIAL STRATEGIES GOALS GOVERNANCE & LEADERSHIP STRATEGIES/MODEL OF CARE ORGANIZATIONAL CULTURE FINANCE & PAYMENT SYSTEMS COMMUNITY ENGAGEMENT MEASUREMENT & IMPROVEMENT SYSTEMS OPTIMIZE DELIVERY SYSTEM The right care, in the right place, at right time. Global budget goes further if care is more efficiently delivered. POPULATION HEALTH Make people healthier so they need less care. Global budget goes further if less care is used. TRANSFORMATION GOALS Better Care Better Health Lower Costs

11 THE CHALLENGES CHALLENGE #3: EVERY CCO HAS VERY DIFFERENT GOVERNING & FINANCIAL STRUCTURES Oregon Health Authority Contract PacificSource Health Plan Accepts all Risk SUBCAPITATION HOSPITAL IPA BEHAVIORAL HEALTH PROVIDERS SAFETY NET CLINICS Some CCOs subcapitate risk to providers, creating a reason for population health to matter to everyone in the system.

12 THE CHALLENGES CHALLENGE #3: EVERY CCO HAS VERY DIFFERENT GOVERNING & FINANCIAL STRUCTURES Oregon Health Authority Contract Health Share (2% administrative skim) Others basically have the old system -- a new layer of coordination at the top, but plans still bear the risk. Mental Health Funds DENTAL RAES Physical Health Funds MENTAL HEALTH RAE PHYSICAL HEALTH RAE PHYSICAL HEALTH RAE MENTAL HEALTH RAE MENTAL HEALTH RAE PHYSICAL HEALTH RAE PHYSICAL HEALTH RAE

13 THE CHALLENGES CHALLENGE #4: THE MEDICAL MODEL MAY RESTRICT THE SHAPES IDEAS CAN TAKE When population health ideas are run through CCOs, what comes out often looks very much informed by the medical model: WHAT S BEING DONE? Improve screening rates so we can get people into treatment earlier. IDEA: BETTER PREVENTION WHAT S GETTING LESS TRACTION? Address root causes like built environments, social connectivity, social determinants of health, housing stability, food environments, etc. WHAT S BEING DONE? CHWs are care managers. They re professionals based in clinics working with high utilizers. IDEA: COMMUNITY HEALTH WORKERS WHAT S GETTING LESS TRACTION? CHWs are from local communities and work as peer to peer change agents. They focus on community problems, not health system problems.

14 THE RESULTS WHAT KINDS OF THINGS ARE CCOs DOING? Most transformation efforts look a lot like tinkering with the old model. WHAT ARE CCOs WORKING ON? RESULTS FROM AN EARLY INVENTORY HIGH UTILIZERS Focus on highest cost patients in attempt to stabilize their health and reduce their costs. Right care, right place, right time. RISK SCORING/IDENTIFICATION Stratify patients by risk of being a high cost member and then try to intervene. TRAUMA INFORMED CARE Efforts to build care models informed by life course and trauma research PROVIDER RISK & PAYMENT Working on ways to share risk & tie payment to performance, esp for hospitals/providers. STANDARDIZE PROCESSES Try to introduce efficiencies in system by standardizing things like handoffs, discharges, etc. HOUSING WORK Efforts to understand the impact of stable housing with integrated services on health care costs. ALIGNING INCENTIVES Payments moving from FFS within CCOs to bundled payments & similar. NEW WORKFORCE Nontraditional health workers (CHWs, etc) but typically with a medical model focus. CONNECTED IT SYSTEMS Work to connect the information systems for better population management.

15 EARLY EVALUATION RESULTS EARLY FINDINGS SHOW IMPACTS IN ACCESS & QUALITY OF CARE, NOT PREVENTION An early study of CCO performance suggests impacts in traditional health care measures access, quality, utilization but few gains in screenings or other health measures. HEALTH CARE ACCESS Members in CCOs had better improvements in access to medical care, especially mental health care than non-cco members. UTILIZATION OF CARE CCO members used more primary care and had fewer Emergency department visits than non-cco members. QUALITY OF CARE Members in CCOs had improvements in ratings of care quality and better connections to personal care providers. PREVENTIVE SCREENINGS CCO members didn t do any better than nonmembers on preventive screening rates. HEALTH OUTCOMES CCO members didn t report significantly different health outcomes than non-cco members. CARE COORDINATION CCO members reported better coordinated care than non-cco members.

18 Needs, Priorities, Opportunities COMMUNITY COMMUNITY HEALTH WORKERS HEALTHY LIVING COLLABORATIVE Local Priorities Local Control Local Action Enabling Resources & Responses External Forces Larger Systemic Barriers Funding, Technical Assistance

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24 C.H.E.F Thank You

Summary of the Final Medicaid Redesign Team (MRT) Report A Plan to Transform The Empire State s Medicaid Program

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