A. Description of the State Health Care Innovation Plan Testing Strategy

Transcription

1 IV. Project Narrative A. Description of the State Health Care Innovation Plan Testing Strategy The Minnesota Accountable Health Model (Minnesota Model or the Model) Track One testing strategy builds on Minnesota s tradition of collaboration and the state s commitment to work with consumers, payers, public health and health care communities to reform our delivery and payment systems. Our approach will provide needed resources and investments to accelerate Minnesota s care delivery transformation to achieve the Triple Aim of improved population health, improved patient experience, and lower costs. Minnesota has made significant progress toward the Triple Aim through dramatic transformations in care delivery models, spearheaded by home grown innovations led by our early innovator integrated provider systems and payer partners. Despite this progress, Minnesota needs to address gaps and barriers in data infrastructure, provider practice patterns, service integration and consumer engagement in order to drive system-wide transformation that will impact the preponderance of care in the state. These gaps are most pronounced among smaller, independent and safety net providers, especially in rural areas. These gaps are described in more detail the Innovation Plan and will be addressed in the testing model through investments and resources for health care systems and communities, focused on small, rural and safety net providers. The Minnesota Model will test the next logical step toward providing and paying for value-based care and achieving the Triple Aim by expanding Accountable Care Organizations (ACOs) in collaboration with other payers. The Minnesota Model will build upon the current Minnesota Medicaid ACO models the Health Care Delivery Systems (HCDS) and the Hennepin Health demonstration projects to increase the percentage of Medicaid enrollees and 1

2 other populations included in ACOs under shared savings/shared risk payment arrangements. These ACOs will focus on the development of integrated community service delivery models and coordinated care models, building on Hennepin Health and Minnesota s Health Care Homes program, that bring together health care, behavioral health, long term supports and services, and community prevention services that are coordinated and centered around patient needs. The Minnesota Accountable Health Model will build upon ACOs under the HCDS and Hennepin Health demonstrations and other payers as the basis for testing: 1) How does expanding the number of people covered by and the scope of services included in Medicaid ACOs improve patient health and decrease costs, when implemented in alignment with Medicare and commercial ACOs? The Medicaid ACO model (HCDS) was specifically designed to align with Medicare (Pioneer ACO and Shared Savings) and private payer ACO models in the State with the premise that consistency in the State s ACO models will drive delivery system transformation. We expect that the alignment and expansion of ACOs will benefit all populations statewide, while also improving health outcomes for Medicaid beneficiaries, specifically. Under the Model, the state will expand the range of services for which Medicaid ACOs are accountable to include mental health and long term supports and services, including patients with more complex health needs. The Hennepin Health demonstration has begun to develop an integrated delivery model that serves high-risk and high-need adults, but barriers still exist that prevent more providers and organizations across the state from entering into these models. 2) Can investments in infrastructure for data analytics, health information technology, practice facilitation, and quality improvement accelerate adoption of ACO models and remove barriers to integration of care (including behavioral health, social services and long-term services 2

3 and supports), especially among smaller, rural and safety net providers? Minnesota will provide intensive investments in electronic health record/hit adoption, secure information exchange, data analytics, practice facilitation, development of risk adjustment methodologies, and quality improvement to remove barriers to integration of care across settings for complex, high-cost patients. Minnesota will track rates of health information exchange, quality improvement and care coordination to assess the impact of these investments. 3) How are health outcomes and costs improved when ACOs adopt Community Care Team and Accountable Communities for Health models to support integration of health care with non-medical services, compared to those who do not adopt these models? Three Community Care Teams are at work in Minnesota. They will be expanded to up to fifteen Accountable Communities for Health, focused on inclusion of non-health care providers in ACOs, integrating care, building on the patient-centered Health Care Home model and strengthening population health. Their quality, cost, and health information exchange results will be compared to providers/ communities without such models. 1. Models purpose The purpose of the Minnesota Accountable Health Model is to provide Minnesotans with better value in health care through integrated, accountable care supported by innovative payment and care delivery models that are responsive to local needs. The Model will create an environment in which the following vision for delivery system transformation can be achieved: a. Every patient receives coordinated, patient-centered primary care; b. Providers are held accountable for the care provided to Medicaid enrollees and other populations, based on quality, patient experience and cost performance measures; 3

4 c. Financial incentives are fully aligned across payers and the interests of patients, through payment arrangements that reward providers for keeping patients healthy and improving quality of care; and, d. Provider organizations effectively and sustainably partner with community organizations, engage consumers, and take responsibility for a population s health through Accountable Communities for Health that integrate medical care, mental/chemical health, community health, public health, social services, schools and long term supports and services. Current Minnesota initiatives in both the public and commercial markets, and similar national models, are based on the concept of accountable care. Our testing model builds on these initiatives by addressing gaps and barriers in the system to facilitate further integration of care within and beyond health care and across traditional funding and service delivery silos, to meet the needs of the whole person. The Model is built on the understanding that 70 percent of health is determined by factors outside of the health care system. The Model holds providers accountable through a total cost of care payment model for services provided to their patients inside and outside of their system, and moves towards integration of health care with other systems that impact the health of populations, such as mental health, chemical health, community health, public health, social services, schools and long-term supports and services. Rather than simply cutting costs through decreasing access or services, Minnesota will save money in the health care system and improve health by realigning providers incentives towards quality and efficiency and away from volume and providing more coordinated, prevention-oriented care. Ultimately, the Minnesota Model will begin to move providers and communities towards the vision of shared accountability for the total cost of health of a population, and partnerships to improve population health. 4

5 The Minnesota Accountable Health Model will be based on expansion and support of ACO models through the Medicaid Health Care Delivery System (HCDS) demonstration, which builds on other payers total cost of care or shared savings/risk arrangements, including Medicare Pioneer ACO and Shared Savings Programs and ACOs established by private payers in Minnesota, as well as with Minnesota s patient-centered Health Care Home program. The Minnesota Model will also increase community engagement and integration of care across the medical, behavioral, social service and other realms by testing Accountable Communities for Health, in conjunction with these new payment and care delivery models. The Minnesota Model will create financial incentives for delivery system innovation and secure exchange of data, to bring better integration and coordination of care across the spectrum of services. Throughout the testing period, Minnesota will focus resources on developing and improving quality metrics that can support rapid cycle improvement, to assure that improvements in health as the result of the model s implementation can be adequately assessed. 2. Scope of the Models Phase One (January June, 2013): Fully implement and prepare for testing nine ACO contracts under the Medicaid HCDS demonstration, in alignment with other payers and the State s ACO early innovators. The nine ACO contracts include the following organizations in Table One: 5

6 Table One: Health Care Delivery Systems Demonstration Organization Geographic area CentraCare Central MN, north of Minneapolis/St. Paul Children s Hospital Minneapolis/St. Paul Metro Essentia Health* Duluth/NE MN Fairview* Minneapolis/St. Paul Metro FQHC Urban Health Network or FUHN (10 FQHCs) Minneapolis/St. Paul Metro Mayo Southeast MN North Memorial Minneapolis/St. Paul Metro Northwest Metro Alliance (Allina*/HealthPartners) Minneapolis/St. Paul Metro *denotes organizations also participating in Medicare Pioneer ACO/Shared Savings programs As a condition of participation, ACOs will include all non-dually eligible Medicaid patients attributed to them in the demonstration, including both fee-for-service recipients and managed care enrollees. Medicaid Managed Care Organizations (MCOs) will participate in the HCDS demonstration in collaboration with the state to create consistency of financial incentives at the provider system level for the Medicaid population. Once these nine ACO contracts are fully implemented, 159 (21%) of Minnesota s primary care clinics and more than 2,500 providers will be operating under total cost of care contracts, covering approximately 25% of the non-dual Medicaid population. Phase Two (July 2013 June 2014): Expand ACOs under the Medicaid HCDS demonstration in conjunction with other payers, and provide infrastructure support for measurement, quality improvement, data exchange and practice transformation. In Phase Two, Minnesota will award a second round of ACO contracts under the HCDS demonstration to expand the number of Medicaid enrollees and other populations served by existing ACOs and adding new ACOs to the HCDS demonstration. This phase will specifically focus on furthering integrated delivery models (e.g. Hennepin Health) through the expansion of services ACOs are accountable for to include mental health and long-term supports and services, and providers that 6

7 serve complex populations. Multi-payer alignment will occur through initiatives such as common measurement tools across payers, improved data exchange capacity at the provider level, aligning payment and risk adjustment methodologies for complex populations, and ongoing model development with a Multi-payer Consultation Group. The primary goal in Phase Two is to expand the number of providers operating as or as partners with ACOs in the state. Within the Medicaid population, the state projects a 30 percent increase in Medicaid enrollees in year 1 of the model test period and an additional 15 percent in year 3. The goal is to have 50% of Medicaid non-dual enrollees covered under ACO arrangements one to two years after the test period. During Phase Two, ACOs will also have the opportunity to receive resources to address barriers to providing patient-centered health care that is integrated with behavioral health, social services, long-term supports and services, and community prevention/public health services. These infrastructure supports will enhance their ability to collect, analyze and exchange clinical data securely; address legal and operational barriers to accessing and exchanging health care and social services data; leverage electronic health records for quality measurement and improvement; effectively use interprofessional teams in a coordinated care environment (which may include emerging roles such as community health workers, community paramedics, dental therapists and other professionals); participate in quality improvement initiatives and learning collaboratives to support practice transformation; and become certified as a Health Care Home. Effective, ongoing partnerships between ACOs and other organizations providing care or support to their populations are critical to achieving the Model s transformation goals and potential savings to the system. The foundation for these partnerships already exists in the Community Care Teams (CCTs) underway in Minnesota. Community Care Teams are 7

8 multidisciplinary, locally based teams that partner with primary care practices, hospitals, behavioral health, public health, social services and community organizations to ensure strong, coordinated support for the whole patient. The current Community Care Teams (Essentia, Mayo Clinic and Hennepin County), along with Hennepin Health, have been successfully building models for integrated services between health care, public health, community partners, behavioral health and social services. These CCT s have developed new community partnerships that focus on prioritized community health needs, and begun the hard work to integrate services to address gaps in care for complex patients through referral and transitions management and implementation of new practice guidelines. The enhanced relationships they have developed will become the foundation for Accountable Communities for Health. During Phase Two, Minnesota will work with these initial sites to develop and evaluate ACH integration into ACO payment models, document best practices for care integration, and develop guidelines for governance to allow this effective model to expand to a broader set of Accountable Communities for Health (ACHs) in Phase Three. Phase Three (July 2014 June 2016): Continue testing of current ACOs, continue infrastructure support for integrated services in ACOs, and expand Accountable Communities for Health. In Phase Three, the state will continue the ACOs and infrastructure support described Phase Two. In July 2014, the Minnesota Department of Health (MDH) will expand from three existing Community Care Teams to up to fifteen Accountable Communities for Health (ACHs) through a request for proposals from community/provider partnerships. Proposals may be initiated by a provider, a tribe, a community or consumer organization, a county, or other nonprofit entity, such as a health plan, but must include providers with ACO contracts in place, and 8

9 have strong representation from organizations representing the full diversity of the community s population and service needs. ACHs will implement population- based prevention strategies and integrate care across the spectrum of health care and social services through development of multi-disciplinary teams which will ensure secure exchange of patient information and coordination among providers and explore models for shared financial gain and risk. By the end of Phase Three, up to fifteen communities will have formed an ACH, with a priority on communities in areas with a lower level of ACO penetration, greater disparities and higher health care needs. 3. Delivery system and payment models that will be tested Medicaid ACO Models Health Care Delivery Systems demonstration (HCDS) The Medicaid ACO model or HCDS creates financial accountability through shared savings and shared risk payment arrangements for services provided to patients regardless of where they are delivered, equipping participating providers with patient-level data feedback that allows better care management and the ability to impact patient care earlier in the care cycle, and ensuring that quality is maintained or improved by linking payment to a standard set of quality and patient experience measures. The purpose of this model is to give flexibility to providers to adapt and improve care models to the specific local conditions and the needs of their populations, in a way that is aligned with other payers. Provider organizations selected through a competitive RFP will participate as ACOs in the Medicaid program (and with other payers in the market), deliver the full scope of primary care services, and directly deliver or coordinate with specialty providers and hospitals. These organizations may also partner with local organization such as counties. By participating, they 9

10 have shown a commitment to practice transformation as early innovators in care delivery transformation, and a commitment to accountability for the total cost of care of their patients, regardless of whether particular services are delivered by the ACO. The model includes two payment methodologies for sharing savings and risk with providers that reflect the diversity in Minnesota s provider community and allow for inclusion of providers that have varying ability to bear financial risk. These two models include: Model 1: Virtual ACO Health Care Delivery System (HCDS) Provider organizations eligible for the Virtual ACO HCDS include primary care providers and/or multi-specialty provider groups that are not formally integrated with a hospital or integrated system via aligned financial arrangements and common clinical and information systems. Provider organizations with a population between 1,000-2,000 attributed participants in Minnesota Health Care Programs (includes Medicaid/CHIP and MinnesotaCare, the state s subsidized coverage for low-income Minnesotans) are eligible only for the Virtual ACO HCDS, regardless of their level of formal integration. Providers participating in the Virtual ACO HCDS will share in savings based on the difference between annual expected and actual realized total cost of care if savings are achieved, contingent on quality and patient experience outcomes. Model 2: Integrated ACO HCDS Provider organizations eligible for the Integrated ACO HCDS include integrated delivery systems that provide a broad spectrum of outpatient and inpatient care as a common financial and organizational entity. The organization must serve an MHCP population of 2,000 or more attributed participants. The Integrated ACO HCDS payment model incorporates shared risk over time and builds toward a two-way risk sharing model that distributes the difference between the annual expected and actual realized total cost of care, holding providers accountable 10

11 for both shared savings and shared losses, contingent on quality and patient experience measures. All patients will be attributed to an ACO (Virtual and Integrated) using retrospective evaluation and management claims at the treating provider level, but aggregate visits for the purposes of attribution at the ACO entity level. The HCDS attribution process supports a robust primary care model for Medicaid enrollees by placing a priority on Health Care Homes and primary care providers for patient attribution. The hierarchy of the HCDS attribution is described in detail in the State Health Innovation Plan. Hennepin Health (Safety-net ACO) Hennepin County, Minnesota s most populous county and home to one of its largest hospitals, Hennepin County Medical Center, has committed to transform its payment and care delivery model and embrace ACO payment models and integrated care delivery through an integrated health delivery network financed by a prospective payment for all services provided under the Medicaid program. Hennepin Health includes the largest safety-net hospital, clinics, a Federally Qualified Health Center (FQHC) as well as the county human services and public health departments and a non-profit HMO, all operated by the county. The model focuses on integration of physical and behavioral health and social services in a patient-centered care model for up to 10,000 individuals per month (currently serving 6,000), with a focus on Medicaid adults without children with incomes at or below 75 percent of the federal poverty level. The project will measure not only direct Medicaid covered service costs, but also costs beyond medical assistance benefits, including uncompensated care, human services, and public health costs. Community Care Teams and Accountable Communities for Health (ACH) Many individuals, particularly those with multiple medical or behavioral health issues, face challenges getting the care they need. Patients with complex conditions often require health 11

12 care and supportive services (such as mental health or chemical dependency counseling, housing, home care, or rehabilitation services) from multiple entities; for these patients, it is easy to get lost in the cracks between systems, resulting in poor health outcomes and higher costs. Barriers on the provider side prevent most health care providers from partnering effectively with available community organizations, either because of lack of understanding of available services or lack of resources to coordinate with services beyond health care. In many communities, there are gaps in community services or community partners are unaware of other service agencies. While electronic health record adoption has advanced in Minnesota, many providers of supportive services such as behavioral health, long term supports and services or social services do not have electronic health records, or the means to transmit patient data securely to other partners in the care continuum. Community organizations and behavioral health, long term care have different funding streams and operational structures and often work in silos in the community. There is a lack of integrated case management or coordination in the community that leads to fragmented care and the risk of duplication of care coordination in the community. At the heart of the Community Care Team is a Health Care Home: a primary care clinic that provides coordinated, patient-centered care and links patients to needed services. There are currently 190 certified Health Care Homes in Minnesota (roughly 25% of all primary care clinics). Health Care Homes receive supplemental care coordination payments through the Medicare and Medicaid programs, as well as from commercial payers. As we move into Phase Two of the model, we will expand this work into new communities and test its impact on the effectiveness of the ACO model. In Phase Two, Minnesota will test of aspects of the Model by: 12

13 Working with three existing Community Care Team sites (Essentia Ely, Hennepin County Medical Center Brooklyn Park/Brooklyn Center, and Mayo Community/Employee Health Team) along with Hennepin Health to document best practices for care integration, payment methods, governance, and practice models for the expanded set of Accountable Communities for Health or ACHs; Convening a statewide ACH advisory committee to guide prioritization of ACH selection and criteria; and Facilitating statewide discussions about the framework for ACH s, following the successful model of community engagement and community-led design used by the MDH State Health Improvement Plan (SHIP) planning process that was created in 2009 to support locally-driven community prevention efforts. In Phase Three of the model test (beginning July 2014), the State will release a competitive RFP to implement 12 additional ACH s across the state, for a total of up to fifteen. Priority will be given to ACH proposals that include a local funding match from other sources. The RFP will require that each ACH: Include at least one ACO that provides primary care services to a threshold percentage of the community s population Be guided by a community-led oversight body with a membership majority that includes providers that represent services beyond acute and primary care Shares responsibility for the performance of the ACO within its community and share a level of financial accountability achieved by the ACO providers under their ACH agreement; and Collaborate with local public health agencies to develop a health improvement plan 13

14 The State will provide significant technical support and financial assistance to start up teams that choose to become an ACH, including to conduct community needs assessments, recruit participants, hold community meetings, implement best practices from pilot sites, as well as develop governance structures, community care teams and sustainability plans. The State will also provide financial support to community and citizen members participating in ACH s. The fifteen ACHs will continue to receive support throughout the testing period, but at a steppeddown level in the final year, reflecting their greater level of maturity as a community collaborative, and the likelihood that the realization of shared financial accountability will provide additional financial support. Rapid cycle evaluation throughout the implementation will guide modification of these components. The Medicaid ACO demonstrations and the existing Community Care Team/Accountable Communities for Health work, provide the foundation to move toward greater provider accountability for care delivery and cost as the state accelerates this transformation to address gaps and barriers in the system related to data sharing, care coordination, fragmentation of the care delivery system, quality measurement, and knowledge of best practices for improvement, the state will use Model Testing funds to invest in a variety of tools and levers to: Improve coordination and/or integration of health care services with community services, social services, long term care, public health and other support services; Expand adoption of electronic health records and other HIT, and support secure exchange of clinical data within and among different settings of care, including exchange of public health information to create population-based registries; Advance adoption of best practices for care improvement through statewide collaborative learning opportunities and quality improvement initiatives; 14

15 Develop new cost and quality measures for ACOs, including risk adjustment methodologies, and align measures across payers and provider settings; Develop common provider data feedback and reports to enable rapid-cycle quality improvement at the provider level; Engage consumers in their health and the health of their community; Incentivize providers to engage become certified as a Health Care Home and engage in other practice transformation activities; and Develop care teams that explicitly support coordinated care, including use of new roles such as community health workers, community paramedics, dental therapists and others. 4. Value proposition and performance and improvement objectives The Minnesota Accountable Health model being tested will bring significant value to the Minnesota health care delivery system and to participating communities. Specifically, the value proposition of the Model is to improve health care delivery and outcomes and reduce cost growth by incentivizing providers to manage the total health of a person through shared savings and risk payment arrangements. The value will be further enhanced through expansion of both providers and services in ACO models. Ultimately, as the model matures, it can achieve its full potential under shared provider and community accountability models, such as ACH, which encourage communities working in partnership with ACOs to promote population health in the community and integrate care for the whole patient. One aspect of value is cost: aggregate cost savings from the Minnesota model are estimated at $111.1 million over the three-year testing period, with $90.3 million in savings 15

16 accruing to the Medicaid program. Aggregate net cost savings, after provider reimbursement, are estimated at $61.4 million for Medicaid over the same period. But cost savings alone are not enough; bending the cost curve while maintaining and improving health will be the equation on which the value determination is based. Overall measurement of quality will be based on current state measures under the Statewide Quality Measurement and Reporting System and will incorporate NCQA ACO Core Performance Measures, and CMS hospital value-based purchasing measures as appropriate for the purpose of alignment. We will focus on measures related to reduction of unnecessary care, preventable emergency department visits and hospitalizations, improving access to primary and preventive care services, patient satisfaction, and functional status. Measures will also be developed to capture changes based on integration activities adopted by Accountable Communities for Health. While these measures will be developed based on the specific models communities develop, common measures will be used when possible to support model evaluation and replication. 5. Evidence basis for testing the models While the concept of accountable care is new, it builds on the Health Care Home (medical home) model as a foundation and seeks to further total cost of care (global budget) payment models which have demonstrated success at improving quality and reducing costs. Across the country, Health Care Homes have demonstrated results in improving outcomes while controlling costs across commercial populations and dual eligible populations in Medicaid managed care. 1 A recent review of the results of patient-centered health care home programs nationwide found consistent improvements in patient satisfaction, number and duration of 1 Raskas, R.S., Latts, L.M., Humme., J.R., et. al. (2012). Early Results Show WellPoint s Patient-Centered Medical Home Pilots Have Met Some Goals for Costs, Utilization, and Quality. Health Affairs. 31, No. 9.. doi: /hlthaff ; Bielaszka-DuVernay, C. (2011). Vermont s Blueprint for Medical Homes, Community Health Teams and Better Care at Lower Cost. Health Affairs. 30, No. 3: doi: /hlthaff

17 hospital stays, number of emergency department visits, and costs. 2 The Health Care Home model builds a health care delivery system that provides patient and family centered care and considers patients physical, psychosocial, and environmental factors. On the payment side, pay-for-performance approaches have evolved toward more comprehensive global payment models; both approaches have been tested in a number of settings and demonstrated positive results. 3 A study published in the August 2012 edition of Health Affairs details the impact of Blue Cross Blue Shield of Massachusetts global budgets on 11 provider organizations in Massachusetts. The study found that contract participation over two years led to a savings of 2.8% (1.9% in the first year and 3.3% in the second) compared to a control group. Additionally, the quality of care improved relative to a comparison group. 4 A second study published in Health Affairs in September 2012 reviewed a partnership between Blue Shield of California and health care providers using an annual global budget for total expected spending and shared risk and savings among partners for providing health care to certain members of the California Public Employees Retirement System in Sacramento. The study found that the ACO model showed early success based on the ease of implementation and effectiveness in controlling costs. Cost growth was held to approximately three percent, based in part on declines in inpatient lengths-of-stay and thirty-day readmission rates. The study suggests that payment approaches such as total cost of care have the potential to engage providers and 2 Patient-Centered Primary Care Collaborative. (2012). Benefits of Implementing the Primary Care Centered Medical Home: a Review of Cost and Quality Results. 3 Colla, C.H., Wennberg, D.E., Meara, E., et. al. (2012) Spending Differences Associated with the Medicare Physician Group Practice Demonstration. New England Journal of Medicine. Vol. 308, No. 10, pp ; Claffey, T.F., Agostini, J.V., Collet, E.N., et. al. (2012). Payer-Provider Collaboration in Accountable Care Reduced Use and Improved Quality in Maine Medicare Advantage Plan. Health Affairs. 31, No.9. doi: /hlthaff Song, Z., Safran, D.G., Landon, B. E., et. al. (2012). The Alternative Quality Contract Based on a Global Budget, Lowered Medical Spending and Improved Quality. Health Affairs. 31, No. 8. doi: /hlthaff

18 achieve cost savings in a short time period Theory of action for models; expected impact on cost, quality, & population health. The Minnesota Accountable Health Model supports the transitioning of providers away from the current fee-for-service model, which rewards volume over value, and towards a more rational system that rewards high quality, better health outcomes and efficiency. The fee-forservice payment system provides perverse incentives that reward physicians when their patients are sick, pays them more if they order duplicative and costly tests and does not consider the quality of the care provided the exact opposite of how we want physicians to behave. Instead, total cost of care or shared savings/risk payment arrangements reward physicians who offer high quality, efficient care and keep their patients healthier and out of the system. By paying providers who are organized and integrated together for performance against total cost of care targets for services delivered to their patient regardless of where care is delivered, providers are incentivized to use the most efficient means of keeping the patient healthy and out of the healthcare system. In order to ensure ACO provider entities are only reducing inappropriate utilization of services, while providing needed primary and preventive care, shared savings and shared risk payment arrangements also include quality and patient experience targets designed to ensure that the care offered meets or exceeds the expectations of patients and that ACOs are maintaining or improving the quality of care. While this payment model will support the transformation of primary care practices into organizations that are accountable for the total cost of care their patients, its impact can be 5 Markovich, P. (2012). A Global Budget Pilot Project Among Provider Partners and Blue Shield of California Led to Savings in First Two Years. Health Affairs. 31, No. 9 doi: /hlthaff

19 accelerated when combined with a vision of moving towards integration of mental health, chemical health, community health, public health, social services, schools and long term supports and services in a total cost of health approach that includes intensive community engagement. Coordination of care across these areas and the leveraging of infrastructure investments will reduce costs associated with duplicate testing, improve the quality of care by ensuring that all providers are aware of the treatment plan and do not provide conflicting treatment advice, and improve the experience of care for patients. Providing more coordinated, better care management for high-cost, high-risk patients can also facilitate reduced costs through reduction in preventable emergency department visits and other costly acute exacerbations of illness while improving the health and quality of life for patients. Together, these evidence-based models will transform the health care delivery system in the state, thereby improving outcomes and reducing costs. The expansion of a payment model that pays rewards based on quality of performance rather than number of patient visits, enhanced by improved care integration, robust and secure exchange of health information, and community partnerships, provides a powerful impetus for the provision of accountable care that is both of higher quality and more efficiently provided. 7. Coordination with other federal initiatives operating in Minnesota State government and local providers are actively participating in several key CMMI initiatives, described in more detail in the Innovation Plan. These include the six CMMI Innovation Awardees, which we will consult with regularly in order to inform development of ACOs in the Minnesota Model. 19

20 Specifically, Minnesota is participating in the Medicare Advanced Primary Care Program, which means that Medicare participates along with Medicaid as a payer in the Minnesota Health Care Home program. Many Health Care Homes in the state will participate in the Minnesota Accountable Health model either as the entity receiving an ACO contract under the HCDS demonstration, through ACO contracts with other payers, or as part of an Accountable Community for Health. Three entities in Minnesota participate in the Medicare Pioneer ACO program: Allina Health, Fairview Health Systems and Park Nicollet Health Services. Each will also participate as an ACO in the HCDS demonstration. Fairview is also participating in the federal Physician Group Practice Transition Demonstration program. Essentia Health, located in Duluth, Minnesota is comprised of a combination of ACO group practices, critical access hospitals, and a rural health clinic and is participating in the Medicare Shared Savings program and as an ACO in the HCDS demonstration. Specific to behavioral health, Minnesota is also planning implementation of Section 2703 of the Affordable Care Act that supports health homes for Medicaid enrollees with chronic conditions. The health home will build on the Minnesota experience with Health Care Homes and focus on enrollees with chronic disease and mental health and substance abuse issues. Health home developments will align with the Minnesota s State Prevention Enhancement planning grant, received from the Substance Abuse and Mental Health Services Administration (SAMHSA) in September 2011 to build the state s community-based approach to substance abuse prevention by aligning substance abuse, mental health, primary care and public health, including the Integrated Dual Disorders Treatment model. 6 The state will build on these efforts 6 Minnesota Department of Human Services. (2012). Minnesota Prevention Systems Alignment Plan. Retrieved from 20

21 to support ACO providers to integrate behavioral health fully into their ACOs, consistent with best practices and leveraging local public health resources. 8. Sustainability plan for models A significant portion of model testing funds will be used to develop and expand the infrastructure necessary to implement the Minnesota Accountable Health Model statewide. Infrastructure needs have been identified in the areas of health information technology and health information exchange, data analytics, practice redesign, risk adjustment methodologies, integration of new community-based professionals into care delivery and creation of a sustainable pipeline for these new providers, and support necessary to establish accountable communities for health that share financial accountability to support their activities. These are foundational activities that lay the groundwork for sustainability by providing structures and supports to move providers along the continuum of delivery system transformation within the Minnesota Accountable Health Model framework. A significant portion of testing funds will be used for upfront investments in electronic health records and other HIT, to build capacity for exchange of health information necessary for care integration - and accelerate participation in the Model. The State will continue to support providers practice transformation through incenting participation in the state Health Care Home program. The testing period also allows the State to further develop the payment methodology to move providers to a prospective risk-based payment (similar to Pioneer ACOs) which will provide the upfront funding providers need to make iterative changes to their model with flexibility to move resources to better meet the performance outcomes in their contracts. 21

22 The Accountable Communities for Health will lay the groundwork for additional communities to pursue the model beyond the testing period by participation in learning collaboratives that foster the potential to replicate the model in other areas of the state. Each selected ACH will be required to put together a sustainability plan at the point of application, and to focus a portion of the resources that they receive from the State to strengthen and implement that plan, including a shared financial accountability approach to support sustainability of ACH activities. 9. The Minnesota Accountable Health Model is replicable The core of this model an ACO under a shared savings and shared risk payment arrangement is already underway and has been adopted by other states and the Federal government via initiatives such as the Medicare Pioneer ACO program. This process has already begun in Minnesota through the state s participation in both the CMS-led Value-Based Purchasing Learning Collaborative and Minnesota s selection into the Medicaid ACO Learning Collaborative sponsored by Center for Health Care Strategies and the Commonwealth Fund. The learning collaborative provides Minnesota with the opportunity to dive deep into various models and methodologies and strategize how to adapt Minnesota s model for other states. For example, Minnesota has worked closely with Maine in the development of the HCDS demonstration as they as pursue a similar shared savings model. While Minnesota s model is flexible to local conditions and designed to work in a variety of health care market structures that allow providers and communities to organize to best serve their population, the payment, quality, and attribution methodologies and provider requirements are based on work already underway by CMS, other states, and Minnesota s provider 22

23 organizations. The experiences of early innovators in implementing these models, provides a sound foundation for other states to adapt and improve upon. 10. Geographic focus of model testing The state will begin implementation of the Minnesota Accountable Health Model with nine ACOs that are participating in the Medicaid HCDS (and Hennepin Health) demonstration and the three current Community Care Teams. The current ACOs cover many geographic regions of the state; five (Fairview, Northwest Metro Alliance (Allina/HealthPartners), Children s, FUHN, Park Nicollet) are located in the Minneapolis/St. Paul metro area, which includes about half of the state s and Medicaid s population. The other three ACOs are located outside of the metro area, covering significant rural parts of state, including the southeast (Mayo), central Minnesota (CentraCare) and most of the northern part of the state including the areas around Duluth and Fargo/Moorhead (Essentia). The three Community Care Teams are located in northern Minnesota (Ely), Minneapolis, and southern Minnesota (Rochester). Following implementation of the initial ACO sites in the HCDS demonstration, the state will expand ACOs by providing incentives for other provider organizations, particularly in the south, southwest, and west central parts of the state, as well as other provider systems in the Minneapolis/St. Paul metro area to form ACOs and participate in the Medicaid HCDS demonstration. The next RFP to select ACOs for the HCDS demonstration will be open to any provider organization in the state and will not target a specific geographic region, in order to be as inclusive as possible, but will focus on being inclusive of other providers including behavioral health and long-term supports and services and supports for complex patients. In Phase Three of the Model, the state will select Accountable Communities for Health (ACH) with some priority 23

24 given to areas of the state where community needs and health disparities are most severe. 11. Likelihood of success and risk factors Through this Model, Minnesota is building on a foundation that is already in place. Based on a survey conducted in August 2012 under the auspices of the Governor s Health Reform Task Force, health plans in the commercial market reported between 1/3 and 2/3 of covered lives or spending associated with total cost of care contracts, with higher percentages in the Twin Cities region than elsewhere in the state. With that foundation in place, and the significant number of providers that are already participating in the HCDS demonstration as ACOs, in the Health Care Homes program, in the Statewide Health Improvement Plan (SHIP), and as participants in Community Care Teams, the likelihood of success is high. Additionally, the Minnesota health care delivery system is predominantly comprised of large and mature multi-specialty provider organizations that have the interest and sophistication to undergo the transformations required by the Minnesota Accountable Health model. Minnesota s large vertically integrated provider systems across the state, which include hospitals, primary care, specialty care, mental health, and other ancillary services, will provide much of the foundation and infrastructure as the early ACO entities. However, many of these provider entities are not formally connected to or coordinating with community mental health clinics, providers of intensive mental health services, long-term supports and services, counties, local public health or social service agencies. Without investments to facilitate better coordination between these providers, take-up of the ACH model will be at risk. The state will invest a significant part of its efforts during Phase Two and Phase Three providing resources to build the infrastructure necessary for integrated care, and building 24

25 stakeholder support to move providers towards these models of integration and greater accountability for all services. Significant community outreach and stakeholder buy-in will be needed to ensure providers and organizations are committed to improved integration and coordination and understand the opportunities available to them under the Model. A. Clinical quality & beneficiary experience outcomes and specific improvement targets Minnesota has a long tradition of quality measurement and partnership with community resources in the development and reporting of quality data. The Minnesota-based Institute for Clinical Systems Improvement (ICSI) and Minnesota Community Measurement both specialize in developing and reporting on evidence-based clinical guidelines and quality measures that are widely used throughout provider and payer communities. Building off the strong collaborative relationship between the MDH, DHS, and Minnesota Community Measurement, Minnesota will establish clinical improvement targets for the Model. Specifically, the Minnesota Department of Health s Statewide Quality Reporting and Measurement System (SQRMS) collects and reports on more than 100 measures of hospital and clinic performance covering a wide range of clinical areas across all types of payers. Market wide, SQRMS data shows that hospital and clinic performance on many measures is high as high as 97 percent for optimal care for heart attack patients. However, on measures related to diabetes and vascular disease, rates were well below 50%. For many measures, performance ranged broadly, suggesting that many providers could benefit from assistance in replicating the successes of their colleagues and meeting the quality targets that are part of their ACO contracts. 25

26 Table Two: Statewide rates for key quality measures, 2010 Measure 2010 rate Range (statewide) Optimal care for heart attack patients 97% % Optimal care for heart failure patients 83% 26-98% Optimal care for adults with high blood pressure 70% 34-85% Optimal care for pneumonia patients 85% % Optimal care for adults with diabetes 28% 0-57% Optimal care for adults with vascular disease 34% 0-63% Optimal care for children with strep throat 86% 27-99% Central Line infection prevention bundle 87% 0-100% Mammogram in past two years for women ages % 55-91% Pap smear in the past three years for women ages Adults ages who received colorectal cancer screening 80% 50-89% 72% 43-94% On many measures, rates for Medicaid enrollees lagged behind those for enrollees in commercial plans. For example, rates of optimal diabetes care for Medicaid enrollees were twelve points lower than for other purchasers, and rates for optimal vascular care were thirteen points lower for Medicaid enrollees. The gap was just as wide for many preventive screening measures such as breast cancer screening (13%), and colorectal cancer screening (19%). One of the largest barriers to integration and coordination of care is the inability of many providers to electronically exchange patient information securely with other partners on the patient s care team. MDH tracks adoption of electronic health records, and exchange of health information, through annual surveys of providers. Survey results show that few providers 26

27 currently exchange information outside of their system/network, and even fewer have the ability to exchange information with providers beyond hospitals or clinics: Table Three: Minnesota E-Health Adoption Measures, 2011 Baseline Measure (2011) Clinics with an electronic health record 72% Hospitals with an electronic health record 93% Nursing homes with an electronic health record 69% Clinics exchanging health information outside system/network 41% Clinics exchanging health information with non-hospital/clinic providers 13% Hospitals exchanging health information outside system/network 43% Hospitals exchanging health information with non-hospital/clinic providers 16% Local health departments exchanging health information with MDH 44% Nursing homes with capability to exchange health information 38% The Minnesota Model is designed to address the drivers of low quality or variable quality care by tying payment to quality improvement. One of the current barriers to improved service integration and patient outcomes is the lack of data analytic capacity among some providers. The Minnesota Model will address these barriers through better data reporting and feedback to providers, support via statewide and regional quality improvement initiatives and learning collaboratives, and resources to develop the capacity for real-time data analytics and quality improvement through HIT-enabled quality reporting at the provider level. Making progress in identifying new areas for quality measurement, particularly for high-cost complex populations, including the exploration of outcome measures based on patient reported data, is a key strategy to this approach. A substantial portion of Model Testing funds will also go towards investments in electronic health records and building capacity for exchange of information across settings. If the Model is effective in improving quality of care and breaking down barriers to the secure exchange of patient information across settings, we should see improvement on a number of these measures. During and after the testing period, we will monitor and report performance 27