HHSC Initiatives focused on Quality and Efficiency Matthew Ferrara, - PowerPoint PPT Presentation

HHSC Initiatives focused on Quality and Efficiency Matthew Ferrara, HHSC December 4, 2015

Topics Covered in this Presentation  HHSC Initiatives  Overarching Goals and Considerations  Hospital Pay for Quality  MCO Pay for Quality  MCO Payment Reform with Providers  MCO Performance Improvement Projects  MCO Report Cards  Delivery System Reform Incentive Payment (DSRIP) projects  Other HHSC Activities 2

General Concepts  Quality is an ongoing process  Maintaining open communications and transparency in processes/methods is critical  Continuous engagement of stakeholders  Use of effective measures to advance quality and efficiency  Focus on highest value measures  Must also be clearly understood  Balance of properly scaled incentives and disincentives  Coordinated approach, harmonize where possible  Must be cognizant of administrative burdens and overtaxing system- maintain simplicity  Healthcare is a very complex environment  HHSC and DSHS roles 3

Challenge- Multiple Payers/Systems Medicare Quality Measures and Initiatives Commercial Carriers RHP DSRIP Hospital Medicaid FFS Quality Measures and and Other Hospital Initiatives Performing Provider Quality Quality Measures Measures and and Initiatives Initiatives Medicaid and CHIP MCO Quality Measures and Initiatives 4

Hospital Pay-for-Quality  Potentially Preventable Re-admissions (PPR)  Potentially Preventable Complications (PPC)  FFS reimbursement adjustments (reductions) to hospitals based on PPR and PPC rates in excess of established threshold  PPR: 1% to 2 % reduction of inpatient claims (based on high rates)  PPC: 2% to 2.5 % reduction of inpatient claims (based on high rates)  Re-calculated annually  Hospital adjustments are also made in each MCO’s experience data and adjustments are then made to MCO capitation rates  Introducing an incentive component this fiscal year (leveraging PPR and PPC metrics)  Technical assistance and “customer service” function at HHSC  Challenges:  Awareness and knowledge transfer  Data lags vs Real time 5

Hospital Pay-for-Quality-Incentives for Safety Net Hospitals  Metrics include Potentially Preventable Re-admissions (PPR) Potentially Preventable Complications (PPC)  Limited pool of funds ~$15,000,000/annual, limited pool of hospitals-this created the need for a process to ensure that HHSC work within funds availability, ensure fairness, and that it is appropriately scaled. Steps:  Split pool in half-50% for PPR incentives, 50% for PPC incentives  Establish criteria for eligibility for each pool  non rural, non state-owned, DSH eligible  high volume  performance better at lest 10% better than state average, and no penalty for PPR or PPC  Allocate a base incentive amount for each eligible hospital (~100K)  After base allocation, calculate a variable allocation based on relative performance and relative size (among eligible group of hospitals) 6

Safety Net Hospitals Incentive-Steps (cont.)  Relative Performance : based on hospital’s actual to excepted ratios compared to group average  Relative Size* : based on hospital’s inpatient claims paid compared to group average  Performance-Size Composite : hospital’s relative performance score X relative size score= final relative score Total Allocation for each eligible hospital for each metric: Hospital’s final relative score / total sum of relative scores for all eligible hospitals X Funds pool after distribution of base allocations for eligible group = Hospital’s Variable Allocation + Hospital’s Base allocation = Hospital’s Total Allocation * Note size is capped to ensure $ are spread more evenly among eligible hospitals 7

MCO/DMO Pay for Quality  Percentage of MCO capitation is placed at-risk, contingent on performance on targeted measures---risk/reward  Program has evolved over time:  Percentage of capitation at – risk  Selection of measures  Overarching structure of program  Ideally, MCO value-based contracting/payment models with providers and Performance Improvement Projects (PIPs) goals should align with P4Q metrics  Program challenges:  Design  Expansions of managed care  Measures selection  Sufficient N for measurement for some measures  Data sources/data collection 8

MCO Value-Based Provider Contracting  Operates under the premise (supported by literature) that FFS payment models tend to reward based on volume and not necessarily quality  Recent provision in the MCO/DMO contract has strengthened the requirements for MCO/DMO-provider payment structures to focus on quality, not volume  Requires MCOs/DMOs to submit to HHSC their plans for alternative payment structures (value-based purchasing) with providers  Describe what types they are, metrics used, volume (approximate dollar amount and enrollees impacted), and process for evaluation  Regular QI meetings with MCOs to discuss progress and barriers  Data collection tools and interaction with MCOs/DMOs will enable HHSC to better assess MCO/DMO progress in this area  Challenges:  Measurement of what is happening, and the impact  Potential impact on administrative data quality 9

MCO Performance Improvement Projects (PIPs)  Projects must be designed to achieve, through ongoing measurements and interventions, significant improvement, sustained over time, in clinical care and non-clinical care areas that have a favorable effect on health outcomes and enrollee satisfaction  Collaborative approaches by MCOs  Starting in 2016, MCOs will be required to collaborate with each other or a DSRIP initiative on one PIP in order to implement system-wide interventions 10

MCO Report Cards  Report cards are posted online and included in the enrollment packets sent to prospective enrollees to help them make better informed decisions about picking a health plan.  Because they are posted online, report cards are a form of public reporting on performance  Allows enrollees to easily compare the health plans on specific quality of care and patient satisfaction measures. 11

DSRIP  HHSC is further aligning MCO quality efforts with DSRIP projects by exploring ways that projects with a “high impact to Medicaid” can become integrated into managed care  There is also another effort aimed at “measurement streamlining”  The goal of this effort is to ensure a level of measurement harmonization  Renewal has been submitted to CMS - we are now in Demonstration Year 5 12

Other Key HHSC Activities  Better leveraging of extant data sources, for internal and external purposes (e.g. birth records sharing)  Collaborative relationships to explore opportunities for quality and efficiency improvement (e.g. researchers and academia)  Targeted projects and initiatives focused on high cost populations (super-utilizers, NICU study, behavioral health)  Dedicated quality website and increased public reporting: http://www.hhsc.state.tx.us/hhsc_projects/ECI/index.shtml  Keeping abreast of research and best practices  Embracing a quality improvement role and partnership (e.g. MCO and Hospital interfaces regarding quality)  Network Access Improvement Program (NAIP) 13

Summary  HHSC and DSHS have numerous initiatives focused on quality and efficiency within Medicaid/CHIP programs designed to:  improve health outcomes,  reduce health care costs - particularly within our Medicaid and CHIP programs, and  to improve the quality of care that is delivered to all Texans.  Many are underway, some are in development  The science is evolving  Coordination, and communication and harmonization is extremely important 14

Questions? HHSC Quality Website (includes links to DSHS sites): http://www.hhsc.state.tx.us/hhsc_projects/ECI/index.shtml 15