Collaborations Can Help Support Community Population Health - - PowerPoint PPT Presentation

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How Multi-Sector Collaborations Can Help Support Community Population Health

Enrique Martinez-Vidal Vice President, AcademyHealth Susan Kennedy Senior Manager, AcademyHealth

Robert Wood Johnson Foundation’s Payment Reform for Population Health (P4PH) Project: Overview and Framework

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P4PH Vision and Mission

• Vision
• Community-wide population health will be improved through a more supportive

health care payment system.

• Mission (i.e., P4PH Goals):
• To better understand the systems, context and structures needed to create the

conditions for a health care payment system to support community-wide population improvement; and

• To identify and address barriers and promote promising opportunities.
• Defining population health:
• “Health outcomes of a group of individuals, including the distribution of such
• utcomes within the group.” (Kindig and Stoddart, 2003)
• For our purposes, the population is geographically-based total community, not a

patient panel or payer’s covered lives.

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Alternative Payment Models Performance Indicators (1) Shared Savings (2) Shared Risk (3) Bundled Payment (4) Comprehensive Population-Based Payment (5) Housing Food Security Education Employment Transportation Neighborhood and Built Environment

1. Financial Bonus for meeting quality / cost targets 2. Upside risk only 3. Upside and downside risk 4. Episodic or condition-specific billing 5. Capitation / Global Budgets 6. Components from Healthy People 2020

Social Determinants of Health (Community Resources) (6) Healthy Behaviors

Role of Health Care Funding in Addressing SDH Services

Community Benefits Engagement Vehicles

• Direct Payment
• Partnering w/Fin Institutions (CDCs, CFDIs)
• Direct Workforce (i.e. Social Workers, CHWs)
• Community Benefit Investments
• Contracting with CBOs
• Contracting with Non-Health Care

Government Agencies

• Collaborations

Engagement Enablers – Operational

• Data Collection (Environmental Scan)
• Data Analysis/Measurement (Evidence

Generation and ROI)

• Data Infrastructure
• Collaborations
• Convenings
• Communication
• Practice Transformation
• Trusted Convener

Engagement Enablers – Conceptual

• Leadership
• Cross-Sector Consensus Building and

Strategic Alignment

• Transparency

Operations

(e.g., Employment, Procurement and Investment)

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Health System SDH Investment: The Why and the How

Why How

Motivating Factors (Examples)

• Mission Driven
• External Policy Driven
• Business Case
• ROI/Evidence

Nuts n’ Bolts (Examples)

• Misaligned economic motives
• Rate-slide for managed care entities
• Wrong-pocket problem
• Structuring a risk-based contract
• State policies and contracting levers

Collaborative Partners: Projects and Lessons

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Jean McGuire/Northeastern University: Case Studies

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• Paying for Population Health: Case Studies on the Role of the Health System in Addressing

Social Determinants of Health: Four case studies of sites where health systems were actively involved in addressing SDH:

• Burlington, VT - medically complex homeless individuals
• Muskegon, MI - people with chronic diseases
• Cincinnati, OH - pregnant women and their newborns
• Greenville, SC - uninsured individuals with multiple chronic conditions
• Identifies key contextual factors in individual communities that influence health care systems

willingness to sustainably fund non-clinical interventions:

• Commitment to Multi-Sector Collaborations
• Commitment to Data Acquisition, Analysis and Use
• Experience with Care Delivery Transformation
• Participation in Alternative Funding and Financing Efforts

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Network for Regional Health Improvement (NHRI)

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• January 2017 – January 2018:
• Convened multi-sector teams from 5 communities led by regional health improvement

collaboratives and content experts to inform next steps in the teams’ specific community- based collaborative projects. Four main topic areas:

• Data and Population Metrics
• Alignment Across Sectors: Multi-sector Care Delivery
• Alignment Across Sectors: Trusted Convener and Governance
• Payment and Financing
• Provided on-going TA, supporting 4 Affinity Groups focused on each of the four topics

above, producing two reports:

– Update on Efforts by Five Communities: Outlines their continued efforts to guide collaboration with providers and social service organizations to address the priority health needs of their communities. – How Regional Collaboratives Can Advance Funding and Financing to Improve Population Health: Details how regional collaboratives can serve a critical role in encouraging, developing, and testing the implementation of new funding and financing models for population health.

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Nemours Children’s Health System: Medicaid Challenges

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Worked with Maryland, Oregon, and Washington to explore current Medicaid authorities to promote and/or provide prevention services in community settings, cover upstream prevention benefits, and deliver services using nontraditional community-based providers.

• Challenges to Investing in Social Determinants of Health
• Making the business case to payers/MCOs for investing in upstream prevention.
• Understanding what Medicaid can and cannot pay for.
• States, health plans, and providers often feel like they are always breaking new

ground when determining which upstream interventions to deploy.

• Medicaid cannot adequately address and invest in SDH on its own—it must

partner with other agencies and CBOs

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Nemours Children’s Health System: Medicaid Opportunities

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• Opportunities to Overcome Challenges to Upstream Investments
• Have the right people at the table.
• Allow flexibility on how to accomplish goals.
• Identify and build on proven approaches to upstream prevention investments.
• Look for ripe opportunities for cross-sector alignment among specific populations,

such as children.

• Employ strategies that link traditional clinical care with community-based

prevention initiatives as a portfolio of investments.

• Focus interventions on the family as the unit of partnership.
• Engage CMS as a partner, rather than viewing them as only a payer.
• Think broadly about ways to use payment reform, rather than addressing a

specific issue.

• Harness the flexibility under current federal Medicaid regulations.

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Green and Health Homes Initiative

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AcademyHealth contracted with GHHI to provide technical assistance to Talbert House, a large social-service organization in Cincinnati, OH, to explore structuring a risk-based contract with a large local Medicaid MCO to provide targeted services to a subset of plan members, based on an economic analysis. Experiences of a Social-Service Provider: Lessons Learned in Exploring Value- Based Contracts with a Managed Care Insurance Plan (forthcoming)

• Outlines processes needed to build a clinical-CBO contractual arrangement (i.e., project planning,

stakeholder analysis, data discovery/analysis, economic/financial analysis, contract development)

• Lessons Learned:

– It Takes a Village: Advancing value-based purchasing arrangements relies on the collective work of many people within and across the partnering organizations. – People are the Process: While substantial time is focused on the technical elements of the process for implementing value-based purchasing arrangements, leadership and facilitation may be the most important elements. – Data Sharing is a Key Barrier: The technical, legal, and procedural barriers to sharing data are limiting the rate

• f adoption for value-based purchasing arrangements.

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Green and Health Homes Initiative

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Value-Based Purchasing: Making Good Health Good Business (forthcoming)

• Report shows how the flow of payments for health and healthcare can impact health
• utcomes by creating natural business and economic incentives to fund or not to fund

services that address broad health risk-factors including behavioral, environmental, and social determinants of health.

Value-Based Purchasing: How to Succeed by Changing the Business of Health (forthcoming)

• Once a system of value-based purchasing is in place, parties within that system have different

roles and ways to create value that contribute to the system. Report describes:

• Roles each of the healthcare system entities have played/ can play under value-based purchasing

models;

• Opportunities and challenges the future may hold for those entities;
• How those entities can take full advantage of their opportunities; and
• What the impact of taking those opportunities (or not) can be.

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Discern Health

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Approaches to Cross-Sector Population Health Accountability

• Explores a framework for defining two different risk relationships –

parallel risk and hierarchical risk – that could be used to establish accountability for health care providers and community-based

• rganizations (CBOs) working to improve population health.
• Examines how to align value-based incentives for the health care system

with incentives for CBOs working to improve social outcomes.

• Proposes a common measure set relevant to both risk models to help

align goals and create incentives across health care and CBOs.

Challenges and Lessons Learned

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Lessons Learned: Trusted Environment/Convener

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• Build trust in each other and the convener
• Recognize all partners diverse viewpoints/perspectives, regardless of power
• Identify common interests
• Find and foster a community voice/ownership of the efforts
• Exhibit adaptive leadership qualities
• Demonstrate effective communication practices
• Utilize community organizing principles
• Separate form (who is convener) from function (what convener does)

Lessons Learned: Data and Population Metrics

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• Ground efforts to collect and use data within a shared understanding

across partners of mutual goals

• Use available data as an acceptable starting point
• Stay pragmatic and realistic when establishing partner expectations
• Identify the most effective data platform for collective use
• Develop standardized data definitions
• Establish a governance process for data collection, sharing, and

analysis

• Identify target population that leads to short-term results (i.e., low-

hanging fruit)

Lessons Learned: Multi-sector Care Delivery

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• Start small - Identify practical interventions and data collection activities
• Builds trust and demonstrates proof of concept
• Continued engagement ensures commitment and leadership
• Credible data collection and analysis is critical for intervention’s proof of

concept

• SDH assessments are critical to understand individual needs and link with

community services

• Involve local community partners in key decision-making
• Engage all payers can help shift care coordination to be seen as a “utility”

for total community (i.e., limit “free riders”)

Lessons Learned: Payment and Financing

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• Use existing provider payment models as a jumping off point
• Need to “increase signal strength and reduce noise”
• Leverage other funding and financing sources
• Recognize other funding sources may be collectively used/multiple investors
• Medicaid financing changes are under exploration/ development
• Evidence
• Identifying positive ROI may be possible with a few population health interventions
• Using qualitative data and storytelling to illustrate the value in reinvestment and

rebalancing of funds

• Intervention Savings
• For some interventions/ populations, initial savings may be substantial, but with fixed

costs, savings will be not be continual

• Sites, always looking to control costs, will seek to titrate interventions and move

individuals to less expensive/dependent support to diminish intervention costs

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Lessons Learned: Enabling Factors Provide Foundation for Moving Upstream Often communities that are primed to move upstream have:

• Prior investment by government and philanthropy
• Sole or dominant health care plan/provider market player
• Mechanism to transfer healthcare premium resources (savings)

to other sectors (e.g., The Vermont Green Mountain Care Board)

• Care delivery improvements presently underway
• Understanding that success begets success …and can create

challenges

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Overall Lessons Learned

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• APMs rarely directly reimburse non-clinical, SDH-related support

services.

• Other financing sources (e.g., community benefit dollars, grants,

and reserves) more commonly used to support SDHs.

• Three funding streams:
• Internal organizational level (operations);
• External-facing organizational level (community benefit); and
• Service provider level (APMs).
• Alignment is needed across the three streams.
• The “Why” (motivation) is as important to understand as the “How.”

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P4PH Questions to Pursue

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• For both Health Care and CBOs: What is “adequate” capacity to enter

into/pursue a financial contract to deliver related non-clinical services? Must an organization have a particular strength in one or more of the foundational elements? Are certain elements more important than

• thers?
• Are particular non-clinical services/SDHs more amenable to APM

arrangements?

• What are those contextual and technical factors that influence interest

and ability to enter into these financial relationships?

• What types/strength of evidence or ROI are partners willing to accept to

test or enter into financial arrangements/make upstream investments?

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P4PH Questions to Pursue

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• Since all health is local, regional collaboratives can have important

roles to play in addressing this challenge. How do you think regional collaboratives can incentivize the health care system to collaborate with the non-health care sector to connect patients to valuable social services – such as transportation, housing and food? Do you have examples?

P4PH 2.0

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P4PH 2.0 Goals and Approach

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• To develop and strengthen existing collaborations between health care plans and

community benefit organizations (within a broader community context) to support the implementation of alternative payment models, financial arrangements, and

• ther financing mechanisms that can best support effective non-clinical

interventions for plan beneficiaries and members.

• Phase I: Refining Understanding and Identifying Capacity: Focus on deepening and

refining our understanding of the community factors and technical needs required for health care plans and CBOs to consider contractual relationships with each other.

• Phase II: Identifying and Recruiting Partnerships & APM Design Development and

Testing: Using the readiness assessment tools, identify those HFMA health plan members and their collaborative CBO partners most “ready” and engage them in two inter-related strategies.

• Phase III: Synthesis and Dissemination of Findings

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Any Questions? Please contact us…

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Enrique Martinez-Vidal, Vice President enrique.martinez-vidal@academyhealth.org Susan Kennedy, Senior Manager susan.kennedy@academyhealth.org www.academyhealth.org/about/programs/payment-reform- population-health