Implementation of the Maryland All Payer Model Care Coordination, Integration, and Alignment May 2015 1
HSCRC Strategic Roadmap State-Level Infrastructure (leverages many other large investments) Alignment (hospitals, Medicare, and others asking for payment strategies) Create and Use, Meaningful, Actionable Data Care coordination & integration (locally led) Medicare Chronic Care Management Codes Develop Shared Tools (Patient Consumer Engagement Profiles, Enhanced Gain Sharing & Pay for Implement Provider Driven Notifications, Others) Performance Regional & Local Organizations And Resources (Requires Integrated Care Networks State And Local Outreach Large Investments And Connect Providers Efforts Dual Eligible ACO Ongoing Costs) Develop Shared Tools For Accelerating Medicare Engaging Consumers Opportunities Moving Support Provider-driven Away from Volume Regional/Local Planning Technical Assistance 2
Care Coordination & Integration Efforts State level infrastructure 90 day intense planning effort and short term implementation Regional and local planning and implementation FY 14 and FY 15 expenditure and intervention reports due with hospital annual filings Regional planning “grants” under BRFA—reports due December 1 Short term and longer term care coordination, care integration, and alignment plans due from each hospital December 1 Competitive proposals for funds of .25% due December 1, with approval by January 31 or earlier. 3
Significant Regional and Local Efforts Needed to Scale All Payer Model Delivery system changes, including: Chronic disease supports Long term and post acute care integration & coordination Physical and behavioral health integration & coordination Primary care supports, including support of Medicare Chronic Care Management fee requirements Case management and other supports for high needs and complex patients Episode improvements, including quality and efficiency improvements Clinical consolidation and modernization to improve quality and efficiency 4
Significant Regional and Local Efforts Needed to Scale All Payer Model(cont.) Increased focus on integration with community needs and supports Increased focus on community needs assessments Focus on transportation and patient supports Focus on population health Patient and family engagement Technical assistance Provided with BRFA funds through CRISP Budget and scope provided at June Commission meeting 5
CRISP Care Coordination & Integration-- DRAFT Tools Implementation Timeframes 5 6 7 5 6 6 7 5 5 6 6 5 5 5 6 6 6 6 6 7 7 7 1 6 1 7 1 1 1 1 1 5 1 1 1 1 6 1 1 1 1 1 1 1 1 1 1 1 1 1 - - - - - 1 - - - 1 - - - y - - - - y - - - - y - v - r - v - r - g p c b r g p c b r n - t n - t n a n a a n a a l u c o e p l u c o e p e e e e u u u u u M a M M a M M A O N D A A O N D A S F S F J J J J J J J 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 State-Level IT Infrastructure Care Management Tools Planning Procuring Implementation/Pilots Care management tool rollout Leverage Existing Data and Enhance Tools Data Sharing Policy Policy Develop. Enhance Tools/Procedures Sharing data on high risk patients Development Pilot Users Broader Roll Out Risk Stratification Tools Analysis and Tool Selection Pilot Broader Roll Out Health Risk Assessment and Care Pro Analysis and Development Pilot Broader Roll Out Secure New Data Sources (w/MHA) Plan Request Implentation Share Data Provider Connectivity Ambulatory Connectivity Pilots/Get Resources 100 1500 2500 5000 6
Alignment Activities Meeting with CMMI Timeline for June Commission meeting Conversations with providers regarding additional demonstrations and models 7
Monitoring Maryland Performance Financial Data Year to Date thru March 2015 1
Gross All Payer Revenue Growth Year to Date (thru March 2015) Compared to Same Period in Prior Year All-Payer Year-to-Date Gross Revenue Growth 4.00% 1.80% 2.00% 1.19% In State All 0.50% All Revenue Revenue In State 0.00% -0.04% FY 2015 CY 2015 Out of State Out of State -2.00% -4.00% -4.82% -6.00% -5.78% -8.00% 2
Gross All-Payer In-State Hospital Revenue % Change from Same Month in Prior Year 8.0% 6.2% 6.0% 5.2% 4.9% 4.4% 4.0% 3.4% 3.1% 2.4% 2.1% 1.5% 2.0% 1.0% 0.7% 0.5% 0.0% Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 -0.2% -2.0% -2.6% -4.0% -5.3% -6.0% 3
Gross Medicare Fee-for-Service Revenue Growth Year to Date (thru March 2015) Compared to Same Period in Prior Year Medicare Year-to-Date Gross Revenue Growth 4.00% 2.93% 2.80% 1.87% 1.72% 2.00% In State All All In State Revenue Revenue 0.00% FY 2015 CY 2015 -2.00% Out of State Out of State -4.00% -6.00% -8.00% -7.92% -10.00% -12.00% -11.70% -14.00% 4
Per Capita Growth Rates Fiscal Year 2015 and Calendar Year 2015 6.00% 4.00% 2.00% 1.15% -0.49% -0.44% -0.06% 0.00% All-Payer In-State Fiscal Year Medicare FFS In-State FY YTD All-Payer In-State Calendar Medicare FFS In-State CY YTD YTD Year YTD Fiscal Year Calendar Year -2.00% FFS = Fee-for-Service Population Data from Estimates Prepared by Maryland Department of Planning -4.00% Calendar and Fiscal Year trends to date are below All-Payer Model Guardrail for per capita growth. 5
Per Capita Growth – Actual and Underlying Growth CY 2015 Year to Date Compared to Same Period in Base Year (2013) 3.00% 2.55% 2.00% 1.47% 1.00% 0.00% Per Capita - All Payer Per Capita - Medicare -1.00% -1.51% -2.00% -2.53% -3.00% Net Growth Growth Before FY 15 UCC/MHIP Adjustments Per capita growth rates distorted by the availability of only two months of CY 2015 data. Underlying growth reflects adjustment for FY 15 revenue decreases that were budget neutral for hospitals. 1.09% revenue decrease offset by reduction in MHIP assessment and hospital bad debts. 6
Operating Profits: Fiscal 2015 Year to Date (July-March) Compared to Same Period in FY 2014 8.00% 7.04% 7.00% 5.92% 6.00% 5.44% 5.00% 3.77% 4.00% 3.66% 2.93% 3.00% 2.53% 1.78% 1.77% 2.00% 1.00% -0.04% 0.00% All Operating 25th Percentile Median 75th Percentile Rate Regulated Only -1.00% FY 2014 YTD FY 2015 YTD Year-to-Date FY 2015 hospital operating profits improved compared to the same period in FY 2014. 7
Operating Profits by Hospital Fiscal Year to Date (July – March) 20.00% 15.00% 10.00% 5.00% 0.00% -5.00% -10.00% -15.00% -20.00% -25.00% 8
Purpose of Monitoring Maryland Performance Evaluate Maryland’s performance against All-Payer Model requirements: All-Payer total hospital per capita revenue growth ceiling for Maryland residents tied to long term state economic growth (GSP) per capita 3.58% annual growth rate Medicare payment savings for Maryland beneficiaries compared to dynamic national trend. Minimum of $330 million in savings over 5 years Patient and population centered-measures and targets to promote population health improvement Medicare readmission reductions to national average 30% reduction in preventable conditions under Maryland’s Hospital Acquired Condition program (MHAC) over a 5 year period Many other quality improvement targets 9
Data Caveats Data revisions are expected. For financial data if residency is unknown, hospitals report this as a Maryland resident. As more data becomes available, there may be shifts from Maryland to out-of-state. Many hospitals are converting revenue systems along with implementation of Electronic Health Records. This may cause some instability in the accuracy of reported data. As a result, HSCRC staff will monitor total revenue as well as the split of in state and out of state revenues. All-payer per capita calculations for Calendar Year 2015 and Fiscal 2015 rely on Maryland Department of Planning projections of population growth of .64% for FY 15 and .56% for CY 15. Medicare per capita calculations use actual trends in Maryland Medicare beneficiary counts as reported monthly to the HSCRC by CMMI. 10
Monitoring Maryland Performance Quality Data May 2015 Commission Meeting Update 11
Monthly Risk-Adjusted Readmission Rates 17% 2013 2014 All-Payer Medicare FFS 16% Linear (All-Payer) 15% 14% 13% Risk Adjusted 12% All-Payer Medicare Readmission Rate Jan. 13 YTD 13.49% 14.20% Jan. 14 YTD 13.67% 14.96% 11% Jan. 15 YTD 12.51% 13.52% Percent Change 13-15 -7.27% -4.80% 10% Note: Based on final data for January 2012 - December 2014, and preliminary data through February 2015. 12
Change in All-Payer Risk-Adjusted Readmission Rates by Hospital Cumulative Change: CY 2013 compared 20% to Jan. 2014 – Jan. 2015 15% 10% 5% 0% -5% Goal of 9.3% Cumulative Reduction -10% -15% Risk Adjusted -20% All-Payer Medicare Readmission Rate -25% CY2013 13.86% 14.64% Jan. 2014-Jan. 2015 13.28% 14.29% -30% Percent Change -4.22% -2.38% Note: Based on final data for January 2012 - December 2014, and preliminary data through February 2015. 13
Draft Recommendations for Balanced Update May 13, 2015
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