Alternative Payment Models, Value-Based Care, and All-Payer Claims - - PowerPoint PPT Presentation

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Alternative Payment Models, Value-Based Care, and All-Payer Claims - - PowerPoint PPT Presentation

Jun 27, 2023 569 likes •768 views

A DLH Company Alternative Payment Models, Value-Based Care, and All-Payer Claims Databases Thomas J Flottemesch, PhD Social and Scientific Systems, a DLH Company SSS Proprietary Information www.s-3.com One Day on the Way to APMs and

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SSS Proprietary Information

www.s-3.com

A DLH Company

Alternative Payment Models, Value-Based Care, and All-Payer Claims Databases

Thomas J Flottemesch, PhD Social and Scientific Systems, a DLH Company

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One Day on the Way to APMs and Value-Based Care…

Provider Patient Payer Policy Makers Medicare/ Medicaid

All Payer Claims Database

Does it explain:

  • My Costs
  • My Quality
  • My Access

Is it fair regarding:

  • My Performance
  • My Patients

(Risk Adjustment)

  • Reporting Burden

Is it usable for:

  • Performance Rating
  • Contract Evaluation
  • Community Rating
  • Standardized Data

Does it compare:

  • Population/Regions
  • Across States
  • Other data sources

Will it Inform:

  • Policy Design
  • Population Health
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Health Care Payment Learning and Action Network Alternative Payment Model Framework

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Health Care Payment Learning and Action Network Alternative Payment Model Framework

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APCD Challenge: Data, Measurement, and Value

Provider Patient Payer Policy Makers Medicare/ Medicaid

All Payer Claims Database

Things we know about APCDs:

  • Multiple Stakeholders and

Perspectives

  • Different Designs and

Requirements

  • Evolving to meet changing

needs and expectations Three examples highlighting challenges and different perspectives?

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Example 1: Post-Partum Depression Screening

Background:

  • Post-partum depression is a well-known issue
  • Medicaid mothers have poor adherence to their post-partum care
  • Loss of Medicaid Coverage
  • Other Barriers to Access
  • Relatively good adherence to infant post-partum care with pediatrician

Opportunity:

  • Screen mothers during post-partum pediatric visit
  • Develop baseline measure of issue and inform resource planning
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Example 1: The Importance of Perspectives

Provider Patient Payer Policy Makers Medicare/ Medicaid

All Payer Claims Database

I am concerned because:

  • Not really my patient
  • Lack of Behavioral

Health Providers

  • My Liability

My goals are:

  • Understand issue
  • Keep mothers

engaged I need to Inform:

  • Resource Planning
  • Population Health

Does this impact:

  • My QI initiatives
  • Provider Networks
  • PMPM costs

Why are you asking about my health?

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Example 1: Post-Partum Depression Screening

Resolution:

  • Introduction of Pediatrician/Family Practice reimbursement using two

new codes

  • Positive and Negative Post-Partum Depression
  • Pay for Reporting and not Performance
  • Measure: Screens/Visits

Role of APCD and other data systems:

  • Collection and standardization of the new billing codes
  • Matching issues with available resources
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Example 2: Dental Screening for Foster Children

Background:

  • Oral health is often neglected among high-risk populations such as

children placed in foster care

  • Medicaid contracts with managed care organizations dental coverage
  • Difficult to identify and link newly place foster children dental providers.

Opportunity:

  • Dental screening and treatment within 60 days of foster placement
  • Introduce initial screening measure to existing VBP program
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Example 2: Dental Screening for Foster Children

Provider Patient Payer Policy Makers Medicare/ Medicaid

All Payer Claims Database

I am concerned because:

  • How do I know who

these patient are

  • How can I impact this

new measure My goals are:

  • Helping when I can
  • Engaging patients

My focus is on:

  • High Risk Groups
  • Population Health

Does this impact:

  • Current contract
  • Provider Networks

(Foster Families)

  • Am I accountable?
  • Where should I go
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Example 2: Dental Screening for Foster Children

Resolution:

  • Integrating data from child-welfare and Medicaid systems
  • Identifying new patient groups
  • Reimbursement for Outreach and Capacity
  • Measure: New patient and foster family contacts

Role of APCD and other data systems:

  • Expanding to include new data sources in secure way
  • Tracking patients across systems and attributing to providers
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Example 3: Statewide Medical Home Initiative

Background:

  • Assessment of Statewide Health Care Home (PCMH) Initiative
  • 180+ clinics seeking certification
  • Two key questions:
  • Is there a relationship between PCMH clinical systems (PPC scores) and

utilization?

  • What is the impact of a PCMH “pace of change” and utilization?
  • Challenges:
  • Matching clinical system measures and healthcare utilization
  • Measureing clinical system change and improvement
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Example 3: Statewide Medical Home Initiative

Provider Patient Payer Policy Makers Medicare/ Medicaid

All Payer Claims Database

I am concerned because:

  • Are the measures fair
  • Will my progress be

fairly evaluated My goals are:

  • Improving Care
  • Containing Costs

My focus is on:

  • Triple Aim
  • Population Health

How will:

  • My data be used
  • My networks be

impacted What does this say about:

  • My provider
  • The quality of my

care

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Change in clinic system scores

10 20 30 40 50 60 70 80 90 100

20 40 60 80 100

Year 3 System Score

Year 1 System Score

450

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Variation in clinic system change

10 20 30 40 50 60 70

20 29 36 49 67

Change in PPC systems Baseline PCMH Clinic System Scores (PPC)

Correlation between Starting HCH Score and System Change:

  • .62
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Understanding the Pace of Change

10 20 30 40 50 60 70 80 90 100 2 4 6 8 10 12 14

HCH System Score (PPC)

Time Average Growth in HCH Systems

Slower than Expected Change Faster than Expected Change

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Classifying by Pace of Change

10 20 30 40 50 60 70 80 90 100

2 4 6 8 10 12 14

HCH System Score (PPC) Time

Average Pace Fast Paced Slow Paced

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Example 3: Statewide Medical Home Initiative

Resolution:

  • Defining measure that reflect the data-generating process
  • Creating a metric understandable by key stakeholders

Role of APCD and integrated data systems:

  • Collecting and collating data in a standardized, consistent way
  • Developing and reporting measures and performance
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SSS Proprietary Information

www.s-3.com

A DLH Company

Questions