1 1 Measuring Physical and Behavioral Health Integration in the Context of Value-Based Purchasing Gregory Allen, MSW Director Division of Program Development and Management Office of Health Insurance Programs, NYSDOH December 7, 2016
2 December 2016 Agenda 1. Recap: Medicaid Redesign Team (MRT), Delivery System Reform Incentive Payments (DSRIP), and Value-Based Payment (VBP) Initiatives 2. BH & VBP 3. Behavioral Health (BH) in New York State (NYS) 4. Moving Towards Integrated Services 5. Q&A October 2015 Allen
3 December 2016 Recap: MRT, DSRIP, and VBP Initiatives Allen
4 December 2016 Recap: The 1115 Waiver Governor Cuomo created the Medicaid Redesign Team (MRT) to develop reforms to improve health outcomes and further savings. $6.42 billion dollars of savings were reinvested and designated to Delivery System Reform Incentive Payments (DSRIP). The MRT developed a multi-year action plan. We are still implementing that plan today. 1115 Waiver MRT Better care $17.1 billion $8 billion $6.42 billion Better Lower Federal savings Savings Designated to health cost generated by reinvested in NYS DSRIP MRT reforms CMS Triple Aim
5 December 2016 Recap: DSRIP Objectives DSRIP objectives are aligned with the objectives of Behavioral Health (BH) Organizations DSRIP was built on the Center for Medicare and Medicaid Services’ (CMS) and the Enhance PC State’s goals towards achieving the Triple Develop and Integrated Aim: Community- Delivery Better care based Systems Better health Services Lower costs To transform the system, DSRIP will focus on the provision of high quality, integrated Remove Integrate BH Goal: primary, specialty and BH care in the Silos and PC Reduce avoidable community setting with hospitals used hospital use – primarily for emergent and tertiary level of Emergency services Department (ED) and Inpatient – by 25% over 5+ years Its holistic and integrated approach to of DSRIP healthcare transformation is set to have a positive effect on healthcare in NYS Source: The New York State DSRIP Program. NYSDOH Website. & New York’s Pathway to Achieving the Triple Aim. NYSDOH DSRIP Website. Published December 18, 2013.
6 December 2016 Recap: Moving Towards VBP • A Five-Year Roadmap outlining NYS’ plan for Medicaid Payment Reform was required by the MRT Waiver. • By DSRIP Year 5 (2020), all Managed Care Organizations (MCOs) must employ non fee-for-service payment systems that reward value over volume for at least 80-90% of their provider payments (outlined in the Special Terms and Conditions of the waiver). • The State and CMS are committed to the VBP Roadmap, which core stakeholders (providers, MCOs, unions, patient organizations) have actively collaborated in creating and updating. • If Roadmap goals are not met, overall DSRIP dollars from CMS to NYS will be significantly reduced.
7 December 2016 Recap: VBP Arrangements VBP arrangements are not intended primarily to save money for the State, but to allow providers to increase their margins by realizing value. Current State Future State Increasing the value of When VBP is done well, care delivered more providers’ margins go up often than not threatens when the value of care provider’s margins delivered increases VOLUME VALUE VOLUME VALUE Goal – Pay for Value not Volume
8 December 2016 Recap: VBP Contracting In addition to choosing which integrated services to focus on, Managed Care Organizations and contractors can choose different levels of VBP: Level 0 VBP Level 1 VBP* Level 2 VBP Level 3 VBP (feasible after experience with Level 2; requires mature contractors) FFS with bonus FFS with upside-only shared FFS with risk sharing (upside Prospective capitation PMPM and/or withhold savings available when available when outcome or Bundle (with outcome- based on quality outcome scores are sufficient scores are sufficient) based component) scores (For PCMH/IPC, FFS may be complemented with PMPM subsidy) FFS Payments FFS Payments FFS Payments Prospective total budget payments Upside Risk Only Upside & Downside Risk Upside & Downside Risk No Risk Sharing Acronyms: FFS – Fee-for-Service PCMH – Patient Centered Medical Home VBP = Value Based Payments PMPM – Per Member Per Month IPC – Integrated Primary Care
9 December 2016 MCO Role: NYS BH Landscape -Insurance Risk Management -Payment Reform -Hold PPS/Other Providers Accountable -Data Analysis -Member Communication -Out of PPS Network Payments -Manage Pharmacy Benefit NYS Healthcare Initiatives: -Enrollment Assistance -Set the framework for Healthcare -Utilization Management for Non-PPS Providers MCO delivery system reform -Fully Integrated Duals Advantage (FIDA)/MLTC Plans -Establish local performance network Maintain Care Coordination and specialized projects DSRIP VBP -Promote better care delivery through performance incentives PPS/ VBP Contractor Role: -Be Held Accountable for Patient Outcomes and Overall Health Care Cost at local level VBP -Accept/Distribute Performance Payments PPS* Contractors -Share Actionable Performance Data with Network HARP Role: -Provide Process Data to Plans/State -Manage care for adults with significant -Explore Ways to Improve Population Health BH needs -Facilitate the integration of physical health, mental health and substance Program Role: abuse services for individuals requiring -Provide coordinated and integrated care to specialized approaches Advanced & HARP** targeted populations - Offer access to enhanced benefit Integrated -Care management for Medicaid members packages designed to provide the BH/PC -Participation in Alternative Payment Systems HH individual with specialized services not -Support all reforms and help link systems currently covered under the State Plan through integrated care management HH Role: -Manage care for high risk populations *PPS= Performing Provider Systems **HARP= Health and Recovery Plans
10 10 December 2016 BH & VBP
11 11 December 2016 Selecting and Refining Quality Measures is an Ongoing Process Clinical During the process: Start Advisory Group (CAG) selects • Lists get refined and reduced to those measures measures that really matter (specific to VBP arrangement) End of year: evaluation o Key outcome measures OQPS reviews results measures reported back o Measures that are key to DSRIP success to CAG o Nationally standardized key process measures • Focus on outcomes will increase as outcome measures mature VBP Start of Workgroup • VBP Pilots are essential to test feasibility measurement sets measures and relevance of measures
12 12 December 2016 CAG Composition Medical Providers Each CAG is comprised of Centers leading experts and key stakeholders throughout NYS State healthcare delivery system, Universities Agencies spanning Upstate and CAG Downstate regions. Their scope includes Clinical Medical development of quality Experts Societies measures for all VBP Health arrangements. Plans
13 13 December 2016 CAG Objectives CAG members convened to meet the following objectives: Understand the State’s visions for the Roadmap to VBP Discuss and validate definitions of VBP arrangements Review and recommend quality measures for the VBP arrangements Make additional recommendations to the State on: • Data and other support required for providers to be successful • Other implementation details related to each arrangement
• 14 14 14 December 2016 • 8 HARP Definition: CAG Recommendation The CAG recommends the following definition for the HARP VBP arrangement. Population Included • Adults enrolled in Medicaid and 21 years or older with select Serious Mental Illness (SMI) and/or serious Substance Use Disorder (SUD) diagnoses having serious behavioral health issues are eligible to enroll in HARP Plans Defined Services • The BH HCBS eligibility tool will determine if an individual is eligible for Tier 1 or Tier 2 BH HCBS. Tier I services include employment, education and peer supports services. Tier 2 includes the full array of BH HCBS • The scope of care services included in this VBP arrangement is identical to the scope of services covered by the HARP plans (including the enhanced benefit package BH HCBS)
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