Meeting New Challenges in Health Center Board Governance Tess - - PowerPoint PPT Presentation

Meeting New Challenges in Health Center Board Governance

Tess Kuenning, CSN, MS, RN President and Chief Executive Officer Bi-State Primary Care Association David Reynolds, DrPH Health Policy Analyst and Founder of Vermont’s First Federally Qualified Health Center

Session Description and Learning Objectives



Community boards need to be well informed in order to oversee and make key decisions as state and national health care reform efforts continue to unfold



It is imperative boards have knowledge of these emerging changes



Session learning objectives

–

Understand key state and national reform efforts that affect your role as a board member

–

Understand where to find resources that will support your understanding of the legal, administrative, financial and clinical requirements of the Community Health Center program

–

Understand the emerging trends in board responsibilities within the context

• f health care reform

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Agenda



Session description and learning objectives



Overview of the Bureau of Primary Health Care (BPHC) and National Association of Community Health Center (NACHC) resources and updates as it relates to Health Center boards



Overview of national health care reform



Overview of VT and NH state health care reform and its relationship to primary care and the board’s role



Putting the pieces together and meeting the challenges for both states



Conversation about what you have heard: Q&A



Wrap up and session evaluation

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Primary Care Delivery: Vehicle for Services

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

BPHC: Board Governance Expectations

 PIN 2014-01: Health Center Program Governance  Governance requirements (PIN 2014-01)

– Governance requirements for Health Centers have been set

forth in statute, regulations and through various HRSA policies

– PIN 2014-01 clarifies HRSA’s policies in implementing the

statutory and regulatory governance requirements of the Health Center program

– Must demonstrate the establishment of an independent

governing board that assumes full authority and oversight responsibility for the Health Center

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

BPHC: Board Governance Expectations

 Statutory governance (PIN 2014-01)

– Governing board size – Board composition – Organization/corporate bylaws – Board authority, functions and responsibilities

 General board oversight

– Duty of care – Duty of loyalty (conflict of interest) – Duty of obedience

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

BPHC: Board Governance Expectations

 Additional considerations for Health Center governance

–

All Health Centers with existing affiliation agreements or considering new affiliation agreements should examine their arrangements to assure their governing board remains in compliance with all governance requirements described in the PIN  Examples include:

–

Mergers

–

Acquisitions

–

Parent-subsidiary arrangements

–

Subrecipient arrangements

–

Contracts for a substantial portion of the project

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

BPHC: 19 Program Requirements



Services:

–

Required and additional services

–

Staffing requirements

–

Accessible hours of

• peration/locations

–

After hours coverage

–

Hospital admitting privileges and continuum of care

–

Sliding fee discounts

–

Quality improvement/assurance plan 

Governance:

–

Board authority

–

Board composition

–

Conflict of interest policy 

Need:

–

Needs assessment 

Management and Finance:

–

Key management staff

–

Contractual/affiliation agreements

–

Collaborative relationships

–

Financial management and control policies

–

Billing and collections

–

Budget

–

Program data reporting systems

–

Scope of project

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

BPHC: Operational Site Visit (OSV)

 Objective assessment and verification of Health Center

compliance with statutory and regulatory requirements

 Review of administration, governance, fiscal and clinical

programs

 Review of progress on clinical and financial performance  Assistance with areas of non-compliance  Assistance with identification and implementation of best

practices

 At least once per project period or at least once every 3

years

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Board Resource Guide



National Association of Community Health Centers Resources

–

Health Center Program Governance Requirements: Governing Board Responsibilities and How to Do Them

–

Health Center Board Education Video Series: Discussion and Resource Guide

–

Health Center Advocacy: Legal Do’s and Don’ts

–

Health Center Program Governance Series: Information Bulletins #1-19

–

Managed Care Handbook: A Practical Guide for Health Centers

–

Collaborative Arrangements: A Guide for Health Centers and Their Partners 

US DHHS/HRSA/BPHC/Resources

–

Health Center Program Board Governance (PIN 2014-01)

–

19 Program Requirements

–

Operational Site Visit Guide

–

Governing Board Handbook 

Other Resources

–

Supercircular (OMB condensed Circulars)

–

Federally Qualified Health Center (FQHC) Frequently Asked Questions

–

Community Health Centers: A Movement and the People Who Made It Happen

–

Community Health Forum: Moving Behavioral Health into the Mainstream of Primary Care

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

It’s not THE HEALTH CARE SYSTEM It’s M A N Y SYSTEMS MANY MANY HEALTH CARE

We Know the Health Care “System” Is Not Monolithic

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

It’s MANY MANY SYSTEMS MANY MANY HEALTH CARE M A N Y

Actually, It’s Worse: It’s Many Overlapping Systems

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

The Health Care Conundrum

 Abundant need for change:

– National uninsured rates ranging 45-55 million – Exploding health care costs – US GDP 17% vs. 8-10% major industrialized nations – Insurance premiums too expensive/rising faster than earnings – Employer sponsored insurance: Most insurance is from

employer; loss of job=loss of insurance

– Lack of affordability of premiums, deductibles, co-pays, co-

insurance, out-of-pocket expenses

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

The Health Care Conundrum: What Needs to Change?



Invest in primary and preventive health care



Assure affordability to see a provider



Coordinate care (primary care, dental, nutrition, transportation, translation; one-stop shopping; get the right care at the right prices at the right time)



Avoid unnecessary treatment or hospitalization; avoid unnecessary emergency room use



Pay for value/outcomes instead of volume/visits



Use technologies (Electronic Health Record (EHR); analytics to evaluate claims and EHR)



Affordable, low-cost prescription drugs



Assure carriers increase resources for patient care vs. high profits

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Affordable Care Act (ACA): Timeline Overview



2011: Patient Bill of Rights and Medicare free preventive services and receive 50% discount on brand name drugs in the Medicare “donut hole”



2011: New Center for Medicare and Medicaid Innovation to improve health care quality and efficiency



2012: Accountable Care Organization (ACO) providers work together in integrated health care systems



2012: Standardize billing and use of EHR and Meaningful Use



2013: Pay Medicaid at parity with Medicare (2 years; primary care only)



2013: Expand Medicaid to 138% FPL



2013: Open enrollment in Health Insurance Marketplace began October 1; offer tax credits 100-400% FPL and small business tax credit



2014: Access to affordable health insurance options on Marketplace; individual mandate/shared responsibility or pay penalty



2015: Pay physicians based on value, not volume; pay for quality

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

ACA: Investments in the National Health Service Corps

National Health Service Corps Funding, 2011-2015

Fiscal Year Trust Fund Discretionary Funding ANTICIPATED Total Annual Funding (est.) ACTUAL Received LOSS from Anticipated to Actual (+/-) LOSS/GAIN from FY to FY (+/-) FY2010 NA $142 million NA $142 million NA NA FY2011 $290 million $142 million $25 million $432 million $315 million ($117 million) $173 million FY2012 $295 million $142 million $5 million $437 million $300 million ($137 million) ($15 million) FY2013 $300 million $142 million $0 $442 million $300 million $284 million

1

($158 million) ($16 million) FY2014 $305 million $142 million $0 $447 million $289 million

2

($158 million) $5 million FY2015 $310 million $142 million $452 million Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

ACA: Investments in the Community Health Centers

Community Health Center Operations Funding, 2011-2015

Fiscal Year Trust Fund Discretionary Funding ANTICIPATED Total Annual Funding (est.) ACTUAL Received LOSS from Anticipated and Actual (+/-) LOSS/GAIN from FY to FY (+/-) FY2010 NA $2.19 billion NA $2.19 billion NA NA FY2011 $1 billion $2.19 billion $1.6 billion $3.19 billion $2.6 billion ($600 million) $400 million FY2012 $1.2 billion $2.19 billion $1.6 billion $3.39 billion $2.8 billion ($600 million) $200 million FY2013 $1.5 billion $2.19 billion $1.6 billion $3.69 billion $3.1 billion ($600 million) $300 million FY2014 $2.2 billion $2.19 billion $1.49 billion $4.39 billion $3.6 billion 3 (requested $3.7 billion) ($600 million) $700 million (increase requested from Trust Fund) 4 FY2015 $3.6 billion $2.19 billion $1 billion (requested/ask $1.49 billion) $5.79 billion ANTICIPATED: President’s budget:

• $4.6 billion

Requested/Ask:

• $5.1 billion

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

ACA: Supreme Court Decision

 On June 28, 2012, the Supreme Court (SC) upheld the

constitutionality of the ACA

 Four discrete issues the Justices viewed:

–

If the SC should hear the case at all, as there is no “standing” since SC does not usually hear theoretical cases) [heard the case]

–

Whether the individual mandate is constitutional [upheld]

–

What will happen if they strike down the mandate [no longer an issue]

–

Whether Congress exceeded its Constitutional authority in expanding the eligibility and coverage thresholds that states must adopt to remain eligible for Medicaid [upheld the ability of the states to expand Medicaid but gave states the ability to choose or not choose expansion without losing their existing Medicaid funding; ultimately creating an option versus a mandate]

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Questions and Answers Period

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Pre-ACA History: Environment (VT)

 20+ year history of health reform

–

1115 Waivers

–

Insurance market reforms

–

Expansion of Medicaid  Governor’s initiative: Blueprint for Health (2003)

–

Transform health care services

–

Collaborative community effort; seamless Patient-Centered Medical Home care  VT Coalition 21 (2004)

–

28 organizations: forge consensus to transform health care system

–

Adopted 6 principles to implement state health care reform; springboard for reform

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Pre-ACA History: Environment (VT)

 Legislative Reform

– Act 128 (2010): health care financing and universal access bill – Act 48 (2011): 3 primary areas (universal and unified health

systems):

 1) Creation of the Green Mountain Care Board (GMCB)  2) VT Health Connect the VT Exchange  3) GMCB universal system to cover all VT residents in 2017

– Act 171 (2012): health care reform implementation

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Why is VT Pursing Health Reform?

 More than 200,000 Vermonters are uninsured or underinsured  Health care costs are rising at an unsustainable rate

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014 Uninsured = deductibles exceed 5%

• f family’s income AND/OR total

health care expenses exceed 10% of family income (5% if income below 200% of FPL)

VT’s Health Care Reform Goals

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

2014 Today Expanded Medicaid and Insurance Reforms VT Health Connect Green Mountain Care (single payer system) After ACA waiver

VT’s Progress and Next Steps:

Green Mountain Care Board’s Broad Powers



Payment and delivery system reform oversight



Rate-setting authority



Health Information Technology (HIT) plan approval



Workforce plan approval



Health resource allocation plan approval



Approval of hospital budgets, Certificates of Need (CON) and insurance rates



Quality measurement and evaluation



Benefit package approval of VT Health Connect and single payer

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

VT’s Progress and Next Steps:

Unique features: VT Health Connect (VHC)



Knowledge and tools to compare and choose a quality, affordable and comprehensive plan



Participation in VHC is mandatory for individuals and small businesses (with 50 or fewer employees); no separate SHOP market



For these individuals and businesses, plans will not be sold outside VHC



Standard plans across individuals and employers for portability



VHC is located within VT’s Medicaid office; facilitating both Medicaid and VHC enrollment



Wrap-around funding to increase federal tax credits and cost-sharing subsidies

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

VT’s Progress and Next Steps:

Green Mountain Care: Why Single Payer?

 Single payer will save the most and will be simplest for

patients, providers and employers

 Single payer will allow us to maximize:

–

Administrative savings

–

Efficiency in the health care system: clear incentives and one standard of rules for providers

–

Simplicity

–

Security: change of circumstances does not equal change of coverage

–

Population health: much easier to make decisions about investments in health

–

Reinvestment of savings in things we value: better coverage, other public investments, reduced cost to taxpayers

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Post-ACA VT Environment: Responses to Health Care Reform

 Navigator funding

–

Bi-State and its members received funding for VT outreach and enrollment

–

All FQHCs received some BPHC funding for outreach and enrollment

 3 ACOs

–

OneCare Vermont: Medicare, Medicaid and Commercial Shared Savings

–

Community Health Accountable Care, LLC: Medicare, Medicaid and Commercial Shared Savings

–

Accountable Care Coalition of the Green Mountains: Medicare and Commercial Shared Savings

 CMS State Innovation Model funding: $45 Million

–

In February 2013, State of VT awarded $45 million over 4-year project period (Bi-State received $400,000 to develop LLC)

 State infrastructure (next slide)

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Post-ACA VT Environment: Responses to Health Care Reform

 State infrastructure

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Pre-ACA History: Environment (NH)

 Pillar Project incentive (2002)

–

Health promotion/disease prevention

–

Medical home

 NH Citizens Health Initiative (2004)

–

10-year plan

–

Framework for systems and finance reform

–

Public dialogue

 Medicaid Care Management (MCM; current Medicaid 91,000)

–

Mandatory MCM; 3 Carriers (Meridian/Centene/BMC-Health Plan)

–

Delay regarding hospital lawsuit/Medicaid rates

–

Resolved: First stage began December 1, 2013

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Post-ACA NH Environment: Responses to Health Care Reform



NH General Court

–

Medicaid Expansion compromise; Medicaid Study Commission (October 2013)

–

Special session; Expansion defeated (November 2013)

–

General session (March 2014); signed into law March 27, 2014



SB 413: Coverage and income security; 50,000 lives



Navigator funding ($67 million awarded August 2013; 105 awards)

–

2 NH organizations received $580,000 for NH outreach and enrollment

–

All FQHCs received BPHC outreach and enrollment funding



Federal/State Exchange (NH Marketplace)

–

1 Qualified Health Plan (Anthem)



Contracting with reduced rates



Anthem’s Pathway Network: Narrow network in exchange for volume



Market shift: 11 of 26 hospitals have no contract

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Post-ACA NH Environment: Responses to Health Care Reform



Emerging ACO Initiatives: Granite Healthcare Network

–

5 NH hospitals form ACO



Concord Hospital/Elliot/LRG/Southern/Wentworth-Douglass



Lead transformation of health care delivery in communities served by the organizations



Comprehensive HMO: ElevateHealth

–

Partnership of Dartmouth-Hitchcock/Cheshire/New London/Southern, Elliot and Harvard Pilgrim

–

Comprehensive HMO coverage including 400 primary care physicians and 2,600 Specialists



Emerging Management Services Organization (MSO) opportunity

–

FQHCs

–

Bi-State (NH’s Primary Care Association)

–

Community Health Access Network (NH’s Health Center Controlled Network)

–

Build out over time to add vertical community partnerships

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Questions and Answers Period

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Organizational Diagnostic: Assessing the Health Care Systems and Market Reform

 Organizational diagnostic: Board leadership internal and external

assessments

–

National reform

–

State reform

–

State and local health care market

–

Local health care provider community

–

Local health care provider relationships: vertical and horizontal

–

Health care operations/services

–

Health care staffing

–

Health care facilities

–

http://www.chcf.org/projects/2011/strategic-restructuring-community- clinics

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Organizational Challenges



Increase primary care footprint/ increase your presence:

• perations/economies of scale



Responding to changes: complexity of health reform/demanding efforts



Positioning in the new health care marketplace/requires added time



Future expectations: financial and/or clinical risk



Policy and political engagement/requires added time



Responsive to expanded state and federal Corporate Compliance/grants management



Stresses on improving financial stability/state and federal financial fragility



Patient population is highly complex

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Meeting the Challenge

 Strategic efforts to get your patients covered: Navigators  Assessing horizontal and vertical partnerships  Pursuing integrated network options: Alignment of Health

Centers as horizontal partnerships

– MSO in NH and Accountable Care Organization (ACO) in VT

 Demonstrate financial and/or clinical integration  Greater protections for expanded risk corridor  Anti-trust protections in contracting  Reducing variations; streamline efforts  Share best practice; performance improvement

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Meeting the Challenges

 Pursuing alignment: Health Centers as horizontal

partners

– Mission alignment – Increases expertise; builds on your strengths – Increases your contract leverage – Greater opportunity for growth – Economies of scale – Collaborative approach to programming – Larger advocacy/public policy voice – Broader range of services/breadth and scope increase – Share back office functions

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Responding to Change in VT



Community Health Accountable Care, LLC (CHAC) organized in VT in June 2012 by founding membership comprised of 9 VT FQHCs and Bi-State



CHAC’s purpose based on Patient-Centered Medical Home model of primary care delivery



CHAC is an extension of the ongoing mission of member FQHCs



CHAC has entered into ACO health reform programs made available

• n behalf of Medicaid, Medicare and Commercial insured populations



This reinvestment will allow CHAC to continue to evolve our Patient- Centered Medical Home model of care delivery



CHAC has a Management Services Agreement with Bi-State

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Responding to Change in NH

 Emerging NH MSO (Primary Health Care Partners LLC)

– NH FQHCs, Bi-State and CHAN – Build on Patient-Centered Medical Home model of primary care

delivery

– An extension of the FQHC mission – Work will include efforts with the 3 Managed Care plans and

Qualified Health Plans

– Multiple advantages; antitrust protections – Work to include operating agreement, management services

agreement and build out to incorporate other providers

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Payment Reform Evolution: Alternative Payment Methods

 Supporting better performance

–

Pay for reporting (specific measures of care = data are claims based)

–

Pay for coordination (case management fee based on practice capabilities to support prevention and disease management; PCMH)

 Payment for better performance

–

Pay for performance (fees are tied to objective measures of performance)

–

Episode-based payments (case payment for procedure or condition(s) based

• n quality and cost)

 Paying for higher value management

–

Shared savings with quality improvement (share in savings from care coordination and disease management)

–

Partial or full capitation with quality improvement (systems of care; assume responsibility for patients across providers and settings over time (ACO-MSO, etc.)

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

This is NOT Business as Usual: Building on Your Expertise

 Engagement with state, federal and commercial payers  Attention to attributed lives  You must set goals for avoidable hospital admissions and

readmissions

 You need a care management model that works across the

continuum of care

 You must work with your community hospital; goals for follow up

after admissions

 Use patient daily home tele-health monitoring  Home visits; risk assessments

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

This is NOT Business as Usual: Building on Your Expertise

 EMR templates for social detriments of health and pharmacy

reconciliation

 Guidelines to reduce care gaps between primary care and

specialists

 Link percent of primary care compensation to bundle of best

practices; better outcomes for chronic disease

 Integrate ACO Shared Savings Program information, training and

compliance into your FQHC

 Optimize coding

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Lessons Learned and Advice: Health Care Reform is Hard!

 It takes years  It takes money  It takes leadership and a clear vision  Without leadership and vision, you can take years

and lots of money and accomplish nothing

 Even with leadership and vision, constant and

consistent public education and communication is essential

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Lessons Learned and Advice: Health Care Reform is Hard!

 Keep your eye on the prize

– Flexibility is crucial, as long as it doesn’t subvert attaining

the ultimate goal

 Take time to promote achievements and progress

– It reminds people why we are doing this

 Data are critical for measuring success and for

evaluation

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Lessons Learned and Advice: Health Care Reform is Hard!

 Ultimately, health care is not a system, it is a

human enterprise

– Change is best achieved and sustained when those

affected by it are included in the making of it

– All stakeholders must be partners in the enterprise

 There will be winners and losers  So, follow the Reynolds corollary to the Golden

Rule:

– “Do with others, or others will do unto you.”

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Questions and Answers Period

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014

Contact

Tess Stack Kuenning, CNS, MS, RN

President and Chief Executive Officer Bi-State Primary Care Association 525 Clinton Street, Bow, NH 03304 (603) 228-2830, extension 112 tkuenning@bistatepca.org www.bistatepca.org

David Reynolds, DrPH

Health Policy Analyst and Founder of Vermont’s First Federally Qualified Health Center (802) 743-3443 davidreynolds2013@yahoo.com

Bi-State Primary Care Association’s 2014 Primary Care Conference ~ May 13, 2014