Finding Common Ground: Vermont s Blueprint for Health and ACO Shared Savings Programs Presentation to: Rhode Island Care Transformation Collaborative February 27, 2015 Pat Jones, Health Care Project Director, Green Mountain Care Board 1
Snapshot of Vermont Today s Discussion Overview of Blueprint for Health Overview of Vermont s ACOs and Shared Savings Programs Examples of Collaboration 2
Snapshot of Vermont 625,741 population 9,615 square miles 14 Health Service Areas 3 3
VT Health Care Reform Overview Assure that all Vermonters have Access to and Coverage for High Quality Care Improve the Health of Vermonters Reduce Health Care Costs and Cost Growth Assure Greater Fairness and Equity in How We Pay for Health Care 4 4
Green Mountain Care Board (GMCB) Created by the Vermont Legislature in 2011, GMCB is an independent group of five Vermonters nominated by a broad-based committee and appointed by Governor Peter Shumlin. GMCB is charged with ensuring that changes in the health system improve quality while stabilizing costs. The Legislature assigned GMCB 3 responsibilities: Regulation (e.g., hospital budgets, payer premiums, Certificate of Need applications) Innovation (e.g., payment reform models) Evaluation (e.g., evaluate innovations) 5 5
GMCB Payment and Delivery System Reform Charge 18 V.S.A. 9375(b)(1): GMCB shall [o]versee the development and implementation, and evaluate the effectiveness, of health care payment and delivery system reforms designed to control the rate of growth in health care costs and maintain health care quality in Vermont. 6 6
Overview of Blueprint for Health 7
Department of Vermont Health Access Blueprint Structure Within Each Health Service Area Specialty Care & Disease Management Programs Social, Economic, & Community Services Mental Health & Substance Abuse Programs Self Management Programs Hospitals Community Health Team Nurse Coordinator Social Workers Nutrition Specialists Community Health Workers Public Health Specialist Extended Community Health Team Medicaid Care Coordinators Medicare SASH Teams Spoke Staff for Opioid Dependence Trtmt Public Health Programs & Services Advanced Primary Care Advanced Primary Care Advanced Primary Care Advanced Primary Care All-Insurer Payment Reforms Local leadership, Practice Facilitators, Workgroups Local, Regional, Statewide Learning Forums Health IT Infrastructure Evaluation & Comparative Reporting 8 8
Blueprint Networks Key Components 7/2014 (unless otherwise noted) PCMHs (active PCMHs) 123 PCPs (unique providers) 644 Patients (APCD attribution by Onpoint Health Data) 347,489 (12/2013) CHT Staff (core) 218 staff (133 FTEs) SASH Staff (extenders) 60 FTEs (48 panels) Spoke Staff (extenders) 58 staff (39 FTEs) Regional Program Managers 14 staff Community Health Team Leaders 14 staff Practice Facilitators 13 contracted staff Self-Management Regional Coordinators 14 staff 9 9
Department of Vermont Health Access 10 10
Department of Vermont Health Access 11 11
Overview of Vermont s ACOs and Multi-Payer Shared Savings Programs 12
Accountable Care Organizations Accountable Care Organizations (ACOs) are composed of and led by health care providers who have agreed to be accountable for the cost and quality of care for a defined population These providers work together to coordinate care for their patients and have established mechanisms for shared governance Provider participation in an ACO is voluntary 13 13
Shared Savings Programs Shared Savings Programs (SSPs) are payment reform initiatives developed by health care payers. SSPs are offered to health care providers who agree to participate with the payers to: Promote accountability for the care of a defined population Coordinate care Encourage investment in infrastructure and care processes Share a percentage of savings realized as a result of their efforts Vermont has designed and implemented Medicaid and Commercial SSPs ACO and other provider participation in SSPs is voluntary 14 14
Shared Savings Calculated Annually Projected Expenditures Actual Expenditures Shared Savings Quality Targets Payer Accountable Care Organizations 15 15
Vermont Has Three ACOs OneCare Vermont Includes hospitals, primary care and specialist practices, home health, designated mental health agencies, and other providers Participating in the Medicare SSP as of January 1, 2013 Participating in VT s Commercial and Medicaid SSPs Community Health Accountable Care (CHAC) Includes Vermont s FQHCs and partnerships with other providers Participating in the Medicare SSP as of January 1, 2014 Participating in VT s Commercial and Medicaid SSPs Accountable Care Coalition of the Green Mountains (ACCGM) Includes a number of independent primary care and specialist practices Participating in the Medicare SSP as of July 1, 2012 (not participating in 2015) Participating in VT s Commercial SSP as Vermont Collaborative Physicians 16 16
Development of SSP Standards Medicare Shared Savings Program Vermont Shared Savings Program Development Commercial SSP Standards Medicaid SSP Standards Program Agreement Medicaid RFP Contract with ACOs 17 17
SSP Standards in Vermont Designed in stakeholder work groups consisting of payers, providers and stakeholders Facilitated by State, with help from Bailit Health Purchasing Commercial standards reviewed and approved by GMCB Medicaid standards were approved by Medicaid for incorporation into SSP contracts with ACOs Standards include: Attribution of Patients (based on Blueprint PCMH attribution) Establishment of Expenditure Targets Distribution of Savings Impact of Performance Measures on Savings Distribution Governance 18 18
How are Patients Attributed to an ACO? People see their Primary Care Provider (PCP) as they usually do If their PCP belongs to an ACO, the ACO can share savings based on the cost and quality of services provided to that person ACO Providers bill as they usually do 19 19
Excerpt from Governance Standard At least 75 percent control of the ACO s governing body must be held by or represent ACO participants or provide for meaningful involvement of ACO participants on the governing body. 20 20
Department of Vermont Health Access Summary: Current State Statewide foundation of primary care (PCMHs based on NCQA standards) Statewide infrastructure of community health team services and evolving community networks Statewide infrastructure for transformation, selfmanagement, quality improvement Statewide comparative evaluation and reporting Three ACOs consisting of primary care, hospitals, specialists, home health, mental health and other providers Medicare, Medicaid, Commercial Shared Savings Programs Opportunity to unify work, build on strong primary care foundation, and strengthen community health systems 21 21
Department of Vermont Health Access Design Principles for Community Health Systems Services that improve population health through prevention Services organized at a community level Integration of medical, social, and long term support services Enhanced primary care with a central coordinating role Coordination and shared interests across providers in each area Capitated payment that drives desired outcomes 3/5/2015 22
ACO-Blueprint Collaboration Meetings ONECARE VERMONT ACCOUNTABLE CARE COALITION OF THE GREEN MOUNTAINS (ACCGM) COMMUNITY HEALTH ACCOUNTABLE CARE (CHAC) Proposed Goals: -Highly Functional State-Wide HIE System -Streamlined Clinical Performance Committees -Sharing of resources, including analytics and infrastructure -Coordinated Care Management Protocols BLUEPRINT FOR HEALTH 23 23
Examples of Collaboration Between the Blueprint and ACOs Unified Community Collaboratives/Regional Clinical Performance Committees Unified Performance Measurement Data Utility/HIT Infrastructure Enhanced Support for PCMHs and Community Health Teams 24
Unified Community Collaboratives Regional quality collaboratives blend existing Blueprint health services work groups and ACO regional clinical performance committees Local groups adopt charters and select leadership Co-chairs include leadership from ACOs (SIM funds support leadership engagement and training) Will work together to set care management and quality improvement priorities Focus on Blueprint and SSP measures 25
Year 1 & 2 SSP Payment Measures Commercial & Medicaid Medicaid Only All-Cause Readmission Adolescent Well-Care Visits Follow-Up After Hospitalization for Mental Illness (7-day) Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis Chlamydia Screening in Women Cholesterol Management for Patients with Cardiovascular Disease (LDL Screening)* Rate of Hospitalization for Ambulatory Care Sensitive Conditions: Composite+ Diabetes Care: HbA1c Poor Control (>9.0%)*+ Developmental Screening in the First Three Years of Life *Medicare Shared Savings Program measure + Year 2 only 26 26
Unified Performance Measurement Co-produce comparative profiles at practice and health service area levels Include dashboards with results for ACO SSP measures Begin to link claims and clinical data Provide Unified Community Collaboratives with objective information for planning, quality improvement and extension of best practices 27
Adding SSP Measures to Blueprint Practice Profiles Profiles generated by Onpoint Health Data from Vermont s APCD 28 28
Blueprint/ACO Patient Experience Survey In 2013, quality measures were being selected for Vermont s Medicaid and Commercial ACO Shared Savings Programs Stakeholders expressed strong interest in Patient Experience of Care as a measurement domain There was concern that multiple, similar surveys were being fielded by different organizations (e.g., the Blueprint on behalf of participating primary care practices, hospitals, Medicare SSP, home health agencies, health plans) A sub-group consisting of provider organizations, health plans and State staff formed to see if there was a way to dovetail efforts 29
Project Details After careful examination of a number of surveys, the decision was made to field the CAHPS PCMH survey to random samples of primary care practice patients Survey is funded by Blueprint and SIM State contracted with certified vendor after competitive bid process Survey provides practice-level results that can be used for NCQA recognition and quality improvement efforts ACOs will work with vendor to identify survey respondents who are their attributed beneficiaries, to generate ACO-level reports 30
Year 1 & 2 ACO SSP Reporting Measures Patient Experience Survey Data Commercial & Medicaid Access to Care Communication Shared Decision-Making Self-Management Support Comprehensiveness Office Staff Information Coordination of Care Specialist Care Provider Knowledge of DLTSS Services and Help from Case Manager/Service Coordinator (added for 2015) 31 31 31
Data Utility/HIT Infrastructure All three ACOs are collaborating with the state s health information exchange, Vermont Information Technology Leaders (VITL), to build a single common infrastructure to: Electronically report on quality measures, Notify providers of transitions in care, and Exchange relevant clinical information about patients. For the past couple of years, the Blueprint has been working intensely with VITL, PCMHs and others on data quality ACO work is being supported with SIM funds 32
Problems to be Addressed We didn t know the baseline status of provider ability to capture and electronically transmit the clinical information needed for ACO SSP quality measure data elements We need a way for electronic data to be routed to ACOs for care management and analytic processes to support patient care We don t have the ability to notify providers and care managers in real time when patients experience an important clinical event We still need to fill some basic gaps in HIE interfaces and data element exchange from hospitals and other providers Success: A health information technology and health information exchange system that works, that providers use, and that produces analytics to support the best care management possible. 33
Components of ACO/VITL Collaboration Gap Analysis Identify the gap among statewide ACO SSP data requirements and data capacity ACO Gateway Build Build the technical architecture to support movement of data from source systems to analytics destinations Event Notification ( VITLNotify ) Install a system that improves quality and timeliness of transitions of care, through real-time notification of important clinical encounters Gap Remediation Expand data capacity of State for improved population management 34
Department of Vermont Health Access Enhanced Support for PCMHs and CHTs Current PCMH and CHT payments have stimulated substantial transformation, including improved health care patterns, linkage to services, and local networks Reduced expenditures appear to offset investments Modifications are needed for further advancement Proposed modifications will support Unified Community Collaboratives and quality improvement Recommendations include increasing PCMH payments by shifting to a composite measures-based payment, and increasing CHT payments and capacity Governor supported enhancements from Medicaid in 2015 budget address; ACOs have also expressed support 3/5/2015 35
Department of Vermont Health Access Proposed PCMH Payment Modifications (working version) 6.00 $PPPM 5.00 4.00 3.00 2.00 1.00 Base Payment NCQA 2011 2.25 average Utilization 0.75 Quality 0.75 Base Payment NCQA 2014 3.50 to all Eligible practices Payment tied to service area results* Performance payment based on benchmarks Improvement payment based on change Payment tied to service area results* Performance payment based on benchmarks Improvement payment based on change Payment tied to practice activity Participation in UCC initiatives** Recognition on 2014 NCQA standards*** 0.00 Current Proposed *Incentive to work with UCC partners to improve service area results. **Organize practice and CHT activity as part of at least one UCC quality initiative per year. ***Payment tied to recognition on NCQA 2014 standards with any qualifying score. This emphasizes NCQA s priority must pass elements while de-emphasizing the documentation required for highest score. 36 36
Enhanced PCMH and CHT Payments are One Element in VT s Comprehensive Payment and Delivery System Reform Approach Enhanced Payments for PCMHs and CHTs Population Based Payments for ACOs Regulated Fee For Service All Payer System Hospital Global Budgets Blueprint-ACO Integrated Health Service Delivery Embedded in All Models 9 37
Questions/Discussion 38