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

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HHSC Initiatives focused on Quality and Efficiency

Matthew Ferrara, HHSC December 4, 2015

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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

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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

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Challenge- Multiple Payers/Systems

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RHP DSRIP Hospital and Other Performing Provider Quality Measures and Initiatives Medicaid and CHIP MCO Quality Measures and Initiatives

Medicaid FFS Hospital Quality Measures and Initiatives

Commercial Carriers

Quality Measures and Initiatives

Medicare Quality Measures and Initiatives

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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

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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
r 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)

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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

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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

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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

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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

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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.

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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

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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)

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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

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