Tennessee Health Care Innovation Initiative. More information available at:

Transcription

1 Tennessee Health Care Innovation Initiative More information available at:

2 Delivery System Transformation Payment Reform is essential since the current health care delivery system as a whole is simply not sustainable. Right now the system is mostly fee-forservice meaning a service is provided and the provider submits a claim for reimbursement. Therefore more services means more payment. Met with more than 100 different groups from across the state in more than 80 meetings between Feb. and Oct Includes providers, payers and other stakeholders Focus on population-based care (preventative) and episodebased care (acute) Three technical advisory groups focused on three initial episodes: total joint replacement, asthma, and labor and delivery Plan to add new episodes every six months Our goal is to pay for outcomes and for quality care, rather than for the amount of services provided value-based care instead of volume-based. This is an issue being examined nationwide and Tennessee is recognized as a leader in this effort. The state is working collaboratively with hospitals, medical providers, and payers to work towards meaningful payment reform. By working together, we can make significant progress toward sustainable medical trends and improving care. The State Innovation Models Initiative provides funding for states to develop and test state-based models for multi-payer payment and health care delivery system transformation with the aim of improving health system performance for residents of participating states. SIM Testing SIM Pre-Testing SIM Design States with SIM Grants

3 To develop Tennessee s health care innovation plan, we have engaged with over 100 different groups in over 80 meetings Stakeholder group A State Innovation Model Public Roundtables B Provider Stakeholder Group C Payment Reform Payer Coalition D Employer Stakeholder Group E Payment Reform Technical Advisory Groups Stakeholders involved Open to the public in person or by conference call. Topics include payment reform and other health policy issues facing the state of Tennessee. Select providers meet regularly to advise on overall initiative implementation State healthcare purchasers (TennCare, Benefits Administration) and major insurers meet regularly to advise on overall initiative implementation Periodic engagement with employers and employer associations Select clinicians meet to advise on each episode of care Meeting rhythm As needed Monthly 2 per month As needed 4-5 per episode

4 Landscape of Medicaid MCO and commercial members Tennessee Medicaid, commercial, and Medicare membership Number of members, Thousands (Percent of total Medicaid and commercial membership) Plans that are actively engaged in payment and delivery system reform initiative (represent 72% of covered lives) A BCBS B United C Amerigroup/ Wellpoint D Cigna E Aetna Other Payers Total 1 TennCare 460 (9%) (11%) 198 (4%) 1,223 (22%) State 2 Employee 150 (3%) 1 126(2%) (5%) Plan 1 3 Commercial Self Insured 510 (10%) 230 (4%) 104 (2%) 554(10%) 136 (3%) 259 (5%) 1,793 (33%) (other) 4 Commercial 511 (10%) 142 (3%) 82 (2%) 46 (1%) 39 (1%) 118 (2%) 939 (18%) Fully Insured 5 Medicare 34 (1%) 70 (1%) 3 (0%) 75 (1%) 1 (0%) 127 (2%) 310 (6%) Advantage 6 Medicare 817 (15%) 817 (15%) FFS Total 1,665 (31%) 1,007(19%) 387 (7%) 801 (15%) 176 (3%) 1,322 (25%) 5,359 (100%) 1 Tennessee Benefits Administration Group Health split per Benefits Administration staff, April Includes CoverTennessee programs, including CoverKids SOURCE: 2012 Health Leaders / InterStudy; State Group Insurance Program 2011 Annual Report

5 Comprehensive risk-based Medicaid managed care, 2011 Penetration of comprehensive risk-based managed care, July 1, 2011: WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS VT NY MI PA OH IN WV VA KY NC TN SC AL GA ME NH MA CT RI NJ DE MD DC TX LA AK FL HI U.S. Overall = 51% 0% (14 states) 1-50% (11 states) 51-65% (10 states) 66-80% (13 states, including DC) >80% (3 states) NOTE: Comprehensive risk-based managed care includes Health Insuring Organizations (HIOs), comprehensive commercial and Medicaid managed care organizations (MCOs), and Program of All-Inclusive Care for the Elderly (PACE). SOURCE: Medicaid Managed Care Enrollment Report, Summary Statistics as of July 1, 2011, CMS, Compiled by the Kaiser Family Foundation

6 Delivery System Reform: Overview Populationbased Basis of payment Maintaining patient s health over time, coordinating care by specialists, and avoiding episode events when appropriate. TN Payment Reform Approach Patient centered medical homes (PCMH) Examples Encouraging primary prevention for healthy consumers and care for chronically ill, e.g., Obesity support for otherwise healthy person Management of congestive heart failure Episodebased Achieving a specific patient objective including all associated upstream and downstream care and cost. Retrospective Episode Based Payment (REBP) Acute procedures (e.g., hip or knee replacement) Perinatal Acute outpatient care (e.g., asthma exacerbation) Some behavioral health Some cancers

7 How retrospective episodes work for patients and providers Patients and providers deliver care as they do today Patients seek care and select providers as they do today Providers submit claims as they do today Payers reimburse for all services as they do today Payers calculate incentive payments based on outcomes after a predefined period Quarterbacks are provided detailed information for each episode which includes actionable data

8 Delivery System Reform: Payment Risk-adjusted costs for one type of episode in a year for a single example provider Risk-adjusted average episode cost for the example provider Cost per episode Average Example provider s individual episode costs Example provider s average episode cost High cost Average cost per episode for each provider Low cost Annual performance across all providers This example provider would see no change. Individual providers, from highest to lowest average cost If average cost higher than acceptable, share excess costs above acceptable line If average cost between commendable and acceptable, no change Acceptable Commendable If average cost lower than commendable and quality benchmarks met, share cost savings below commendable line Gain sharing limit If average cost lower than gain sharing limit, share cost savings but only above gain sharing limit

9 Delivery System Reform: Quality Each provider report will include provider performance on key quality metrics specific to that episode Some quality metrics will be linked to gain sharing, while others will be reported for information only Asthma Exacerbation Follow-up visit rate (linked to gain sharing) Percent of patients on an appropriate medication (linked to gain sharing) Repeat asthma exacerbation rate Inpatient admission rate Percent of episodes with chest x-ray Rate of patient self-management education Percent of episodes with smoking cessation counseling offered Total Joint Replacement (Hip & Knee) 30 day readmission rate (linked to gain sharing) Frequency of post-op DVT/PE (30 days postsurgery) Frequency of post-op wound infection (90 days post-surgery) Frequency of dislocations or fractures (90 days post-surgery) Average length of stay Perinatal HIV screening rate (linked to gain sharing) Group B streptococcus screening rate (linked to gain sharing) Overall C-section rate (linked to gain sharing) Gestational diabetes screening rate Asymptomatic bacteriuria screening rate Hepatitis B screening rate T-day vaccination rate

10 Avg. adj. episode cost ($) # of episodes Delivery System Reform: Reporting Providers will receive several reports from payers: Summary Overview: Total number of episodes (included and excluded) Average cost of care compared to other providers Quality summary Cost summary Key utilization statistics Performance summary Data for all episodes the provider is considered the Quarterback Includes gain sharing and risk sharing eligibility Quality detail: Detail benchmarks for quality metrics across all providers Cost detail: Breakdown of episode cost by care category Benchmarks against commendable providers Episode detail: Cost detail by care category for each individual episode a provider treats Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013 [1. Asthma] A. Episode Summary Overview Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29 Cost of care (avg. adj. episode cost) comparison Episode cost summary Commendable Your average episode cost is commendable Your episode cost distribution (risk adj.) 28 Below $ $500- $ $833- $1167 Acceptable 43 $1167- $ $1833- $ $2167- Above $2500 $2500 Distribution of provider average episode cost (risk adj.) Not acceptable Less than $1,000 $1,000 to $1,750 > $4000 $1,750 Parameters 2,000 1,500 1,000 You Your avg. cost: $ Providers base avg. cost: $1, Total cost across episodes 2. Total # of included episodes 3. Avg. episode cost (non adj.) 5. Avg. episode cost (risk adj.) Commendable You Acceptable Provider base average $235, $317, $1, $1, Risk adjustment factor* (avg.) $ Commendable * Risk adjustment factor calculated for select provider s patient base $1, Acceptable Percentile of providers Not acceptable 4 Commendable cost ($) YOUR GAIN/ RISK SHARE You are eligible for gain sharing Episode quality and utilization summary Quality metrics linked to gain sharing You achieved selected quality metrics 1. Follow-up visit w/ physician 2. Patient on appropriate medication [Period: Start/end dates of period] +$10, x x Your avg. cost ($) 1, Quality metrics not linked to gain sharing 1. Repeat acute exacerbation within 30 days You Number of episodes Gain share standard 61% 55% 77% 70% You Share factor % Provider base average 5% 8% Met standard Preliminary draft of the provider report template for State of TN (for discussion only) All content/ numbers included in this report are purely illustrative

11 Episode cost details 6 Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013 Episode cost breakdown by care category (risk adj.) Total episodes included: 233 Care category Outpatient Professional # of episodes with claims in care category 224 % of episodes with claims in care category 96% 92% Your performance Provider base average Avg. adj. cost per episode when care category utilized Percentile (Quartile) of Providers 0 (first) 25 (second) 50 (third) 75 (fourth) 100 < $85 < $115 < $145 $109 $117 Pharmacy % 51% < $61 < $85 < $107 $91 $100 Emergency department % 91% < $95 < $266 < $350 $274 $303 Outpatient lab 22 10% 12% < $6 < $10 < $15 $9 $11 Outpatient radiology/ procedures 22 10% 11% < $39 < $102 < $160 $91 $126 Inpatient professional 16 7% 5% < $31 < $75 < $120 $36 $90 Inpatient facility 16 7% 5% < $245 < $355 < $654 $264 $411 Outpatient surgery 0 0% 0% 0% 0% $0 $0 $0 Other % 55% < $25 < $83 < $117 $36 $84 Preliminary draft of the provider report template for State of TN (for discussion only) All content/ numbers included in this report are purely illustrative

12 Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013 List of included episodes with cost and quality information Total episodes included: 233 Less than provider base average cost More than provider base average cost

13 Evolution of Population-Based Reform Most medical costs occur outside of the office of a primary care physician (PCP), but PCPs can guide many decisions that impact those broader costs, improving cost efficiency and care quality. The vision for Tennessee s Patient Centered Medical Home (PCMH) program is a team-based care delivery model led by a primary care provider that comprehensively manages a patient s health needs. Specialists Patients & families PCP Ancillaries (e.g., outpatient imaging, labs) Providers are responsible for managing health across their patient panel Coordinated and integrated care across multidisciplinary provider teams Focus on prevention and management of chronic disease Expanded access Referrals to high-value providers (e.g., specialists) Improved wellness and preventative care Use of evidence-informed care Community supports Hospitals, ERs