Collaborative HB-1281 Pilots An Overview of Rocky Mountain Health - - PowerPoint PPT Presentation

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Collaborative HB-1281 Pilots An Overview of Rocky Mountain Health - - PowerPoint PPT Presentation

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The Accountable Care Collaborative HB-1281 Pilots An Overview of Rocky Mountain Health Plans Prime Program Improvement Advisory Committee May 16, 2018 1 Our Mission Improving health care access and outcomes for the people we serve while

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The Accountable Care Collaborative HB-1281 Pilots

An Overview of Rocky Mountain Health Plans Prime

Program Improvement Advisory Committee May 16, 2018

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Our Mission

Improving health care access and

  • utcomes for the people we serve

while demonstrating sound stewardship of financial resources

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Objectives

  • Review the principles and history of managed care

in Colorado

  • Review the design and implementation of Rocky

Mountain Health Plans (Rocky) Prime

  • Discuss the performance and lessons learned of

Rocky Prime

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Key Questions

  • How does the Department develop and monitor

delivery system innovations through the Accountable Care Collaborative (ACC)?

  • How does the Department scale effective

innovations across the ACC?

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Objectives

  • Review the principles and history of managed care

in Colorado

  • Review the design and implementation of Rocky

Mountain Health Plans (Rocky) Prime

  • Discuss the performance and lessons learned of

Rocky Prime

5

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CO Managed Care 101

Key Principles

Managed Care (noun // CMS): “A health care delivery system organized to manage cost, utilization, and quality…through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for [contracted] services.”

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CO Managed Care 101

Key Principles

  • Key policy levers
  • Capitation: actuarial-sound monthly rate per cohort
  • Affords flexibility with service provision and coordination
  • Based on three years of cohort utilization
  • Medical Loss Ratio (MLR): determined percentage of
  • verall medical expenditures
  • CMS Standard = 85%
  • Encourage coordinated system across established

utilization patterns

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CO Managed Care 101

Authority

  • Federal authority granted through state plan

amendment (SPA) with CMS

  • State legislation (HB-1281) created two payment

innovation pilots under SPA and the ACC

  • 1915(b) waiver becomes new authority for ACC

Phase II and pilots

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CO Managed Care 101

History

  • 1990’s
  • Legislation in 1995 required managed care for 75% of

Medicaid

  • Rates 95% of FFS
  • Produced initial savings
  • 2000’s
  • Conflicts over rates and savings precipitated lawsuits

from providers and plans

  • Medicaid returned to FFS, but some managed care

remained

  • Denver Health and Rocky Administrative Services

Organization (ASO)

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CO Managed Care 101

History

  • 2010’s
  • Patient Protection and Affordable Care Act passed

(2010)

  • Uncontrolled costs precipitated ACC (2011)
  • HB-1281 created payment reform pilots (2012)
  • Colorado expanded Medicaid (2014)
  • Rocky procured HB-1281 bid, folded in ASO, and

implemented Prime (2012-Sept 2014)

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Objectives

  • Review the principles and history of managed care

in Colorado

  • Review the design and implementation of Rocky

Mountain Health Plans (Rocky) Prime

  • Discuss the performance and lessons learned of

Rocky Prime

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Rocky Prime

Design

  • Rocky submitted HB-1281 RFP Payment Reform

Initiative for Medicaid Expansion

  • Emphasized the following:
  • Achievement of the triple aim for Medicaid expansion
  • Behavioral health integration through aligned

incentives and shared savings

  • Economic basis for whole person care
  • New quality models through practice transformation
  • Broad community engagement through governance and

transparency

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Rocky Prime

Design

  • MLR is adjusted to 89% with 4% tied to four quality
  • utcomes
  • Two physical health
  • One behavioral health
  • One patient engagement
  • Prime uses an integrated governance structure

composed of behavioral and physical health providers

  • Advises and develops strategies to foster system

coordination

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Rocky Prime

Implementation

  • Enrollment covers six counties
  • 2016-2017: 34,893 members
  • Primarily (expansion) adults
  • ~300 complex children
  • Expenditures have leveled
  • 2016-2017: $174,158,426
  • 12% decrease from 2015-2016
  • Benefits are “comprehensive”
  • Full-risk program
  • Wrap-around services

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Rocky Prime

Implementation

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Rocky Prime

Enrollment

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Rocky Prime

Expenditures

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Objectives

  • Review the principles and history of managed care

in Colorado

  • Review the design and implementation of Rocky

Mountain Health Plans (Rocky) Prime

  • Discuss the performance and lessons learned of

Rocky Prime

18

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Rocky Prime

MLR Performance

  • Prime ties 4% of MLR to quality metrics
  • Metrics target triple aim and service coordination
  • Physical Health
  • A1c poor control (>9%) (HEDIS)
  • BMI assessment (HEDIS)
  • Behavioral Health
  • Anti-depressant medication management (HEDIS)
  • Patient Engagement
  • Patient Activation Measure (PAM) implementation

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Rocky Prime

MLR Performance

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SFY15 SFY16 SFY17 Metric 1 A1c Poor Control MET A1c Poor Control MET A1c Poor Control MET Metric 2 BMI Assessment MET BMI Assessment MET BMI Assessment MET Metric 3 Anti-Depressant Rx Mgmt MET Anti-Depressant Rx Mgmt MET Anti-Depressant Rx Mgmt NOT MET Metric 4 PAM Implementation MET PAM Implementation MET PAM Coaching Tool MET Final MLR 85% 85% 86%

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Rocky Prime

MLR Performance

  • Future metrics emphasize broader service

coordination and program alignment

  • Depression screening and follow-up
  • SUD ER utilization
  • Future metrics also use clinical data to drive

performance

  • A1c poor control (>9%) and depression screening and

follow-up reported as eCQM through SPLIT

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Rocky Prime

Emergency Room Utilization (PKPY)

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SFY15 SFY16 SFY17 Rocky Prime 37.7* 76.1 74.8 ACC** 61.4 57.6 58.5 ACC: RCCO 1** 53.6 51.1 49.0

*Year-long, ramped enrollment. **Includes all populations.

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Rocky Prime

Behavioral Health Penetration

23 *Includes all populations.

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Rocky Prime

Practice Support

  • Prime deploys community integration agreements

with practices

  • Agreements are fine-tuned to practice needs and

status and include:

  • Alternative payment arrangements
  • Attribution incentives
  • Transformation and quality targets
  • Tools, technology and workforce needed

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Rocky Prime

Practice Support

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Rocky Prime

Member Engagement

  • Prime ensures cultural competency through

consumer network and capacity building with diverse member groups

  • Independent living centers
  • Translation services and Deaf community
  • First generation and mono-lingual Latino community)
  • Prime creates a local leadership network to foster

greater inclusion of social factors

  • Health Alliances
  • Accountable Health Communities Model

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Rocky Prime

Member Engagement

  • Prime creates integrated care coordination to

address complex members’ needs

  • Whole Health, LLC created in partnership with

community mental health centers

  • Funded through payment reforms
  • Includes Fleet transportation
  • Accountable to primary care practices
  • Defined cohorts

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Rocky Prime

Member Engagement

Whole Health Outcomes

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Rocky Prime

Member Engagement

Whole Health Outcomes

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Rocky Prime

Lessons Learned

  • Coordination efforts need to happen at all delivery

levels and in concert with one another

  • MLR metric
  • Integrated governance structure
  • Integrated care coordination
  • Tailored practice support leads to more successful

practice transformation and capacity building efforts

  • Diverse member engagement strategies lead to

locally-driven health care

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Rocky Prime

ACC Phase II

  • 1915(b) waiver becomes new authority for ACC

Phase II and pilots

  • RAE 1 will oversee managed care contract
  • Greater alignment will occur with other programs
  • MLR metrics, BH Incentives, and RAE KPIs
  • Greater consistency in contract language

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Rocky Prime

Continued Questions

  • Are competing payment systems creating varying

delivery systems?

  • Is capitation appropriate for all populations?
  • Can managed care produce and demonstrate long-

term savings and cost-effectiveness?

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Key Questions

  • How does the Department develop and monitor

delivery system innovations through the Accountable Care Collaborative (ACC)?

  • How does the Department scale effective

innovations across the ACC?

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Contact Information

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Patrick Gordon // Vice President, RMHP patrick.gordon@rmhp.org Ben Harris // ACC Operations benjamin.harris@state.co.us