Partners in Innovation: W What St States and the CMS Innovation C - - PowerPoint PPT Presentation

Partners in Innovation: W What St States and the CMS Innovation C Center A Accomplish T Together

Rivka Friedman Director, Division of All-Payer Models

CMMI W Waiver A Authority E Enables M Medicar are “ “Par articipat ation” i in Most I Innovat ative S Stat ate M Models

Medicare flexibility

Maryland Vermont Pennsylvania Provide a custom Medicare ACO model, based on CMMI’s NextGen ACO model Waive IPPS/OPPS to enable global budgets; build a custom version of CPC+ to engage small practices Allow global budget payments to participating rural hospitals

Multi-payer model Novel test

Hospital global budgets + TCOC accountability to decouple hospital revenues from volume and incentivize prevention ACOs at scale statewide, with a common incentive structure to make transformation a rational business strategy Hospital global budgets for rural hospitals and a deliberate plan to improve quality and efficiency across service lines

www.rti.org

RTI International is a registered trademark and a trade name of Research Triangle Institute.

Maryland All-Payer Model and State Innovation Model (SIM) Evaluation Findings

Heather Beil, PhD RTI International

Maryland All-Payer Model

• State sets total revenue target

(budget) for each hospital

• State uses rate-setting authority to

determine individual hospital chargeable rates

• Hospitals adjust charges up and

down to meet target budget

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• Tests whether an all-payer system

for hospital payment is an effective model

• Shifts hospital revenue into global

budgets

• Retains Maryland’s unique all-payer

rate-setting system

• Generate $330 million in Medicare

savings

• Limit annual all-payer per capita

total hospital cost growth to 3.58%

• Reduce Medicare 30-day

unadjusted readmission rate

• Reduce the potentially preventable

hospital complications Model Overview

Global Budgets Goals of the Model

Findings for the Maryland All-Payer Model after 3 years of implementation

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$554 million savings in hospital spending $125 million savings in non- hospital savings

• Relative to an out-of-state comparison

group, the Maryland All-Payer Model resulted in a total of $679 million savings to Medicare

• Unlikely that cost shifting to sectors of

the Maryland health care system

• utside of the global budgets is driving

the reduction in hospital spending

• Although the design of global budgets

guarantees hospital savings, we also found reductions in inpatient admissions

• No adverse impacts on hospital

finances or beneficiary satisfaction

Vermont Medicaid Shared Savings Program (SSP)

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Minimum savings achieved in total costs

• f care

Quality score on set of metrics Shared savings

• Vermont had 2 Medicaid ACOs from 2014 – 2016 – 1 was hospital-based and 1 was mostly

FQHCs

• Medicaid designed its ACO model in coordination with commercial payers and Medicare
• One-sided risk model calculated based on retrospective use, cost and quality
• Included 20 quality metrics – 8 to 10 were used for shared savings calculations
• Many PCPs participated in Blueprint for Health (PCMH model) prior to entering ACO

arrangement

Findings for the Vermont Medicaid SSP after 2 years of implementation

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• Relative to an in-state comparison group, the Vermont Medicaid SSP resulted in:
• $31 million savings to Medicaid
• 3% relative decline in outpatient ED visits
• 29% relative increase in developmental screenings (the only quality metric

that was unique to Medicaid SSP)

• No change in:
• Inpatient admissions
• Follow-up visits after a mental health-related admission

Quality

The Vermont All-Payer Accountable Care Organization Model Agreement: A Partnership with the Center for Medicare and Medicaid Innovation

Ena Backus Director of Health Care Reform Vermont Agency of Human Services Academy Health National Health Policy Conference February 4, 2019

Ve Vermont A All-Payer A Accountable C Care O Organization M Model A Agreement: Moves f from v m volume me-driven f fee-fo for-ser ervice p e payment, t to a a v value-based, p pre-paid m model f for ACO COs

Medicare Medicaid Commercial OneCare VT ACO

Risk-Based ACO Contract VT modified Next Gen ACO /Vermont ACO Initiative VT Medicaid Next Gen ACO through 1115 waiver

Vermont All-Payer ACO Model (aligned ACO standards) Provider Care Continuum

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How is care delivery changing?

Increased investment and incentives for primary care and prevention Increased investment and incentives for care coordination Provider payment tied to quality and outcomes In 2016, the legislature required the All-Payer ACO Model and ACO to strengthen and support primary care and community-based care through local community collaboration. (Act 113 of 2016) There is consensus that a strong primary care foundation with an enhanced focus on preventive services can improve health care quality, improve the health of the population, and help reduce growth in health care costs.

All-Payer ACO Model Agreement

What is Vermont responsible for?

Financial Trends and Scale Targets All-Payer Growth Target: Compounded annualized growth rate <3.5% Medicare Growth Target: 0.1- 0.2% below national projections All-Payer Scale Target – Year 5: 70% of Vermonters Medicare Scale Target – Year 5: 90% of Vermont Medicare Beneficiaries

Population-level Health Outcomes Measures and Targets

 Improve access to primary care Reduce deaths due to suicide and drug overdose Reduce prevalence and morbidity

• f chronic disease

Process Milestones

Health Care Delivery System Quality Targets

Population Health Outcomes

Improving the e Heal alth of V Ver ermonters

How w will w we m measure s e succes ess?

• Vermont is responsible for meeting targets on 20 measures under the Model

Process Milestones and Health Care Delivery System Quality Targets support achievement of ambitious Population Health Goals

Goals selected based on Vermont’s priorities:

• 1. Improve access to primary care
• 2. Reduce deaths due to suicide and drug overdose
• 3. Reduce prevalence and morbidity of chronic disease

How Did We Get Here?

State Innovation Model Grant Funding 2 Years Negotiating with Center for Medicare and Medicaid Innovation (CMMI) Parallel Stakeholder Involvement: Provider-led Reform Healthy Long-Distance Relationship with CMMI: Regular and Frequent Communication

Maryland Total Cost of Care Model

Katie Wunderlich, Executive Director Health Services Cost Review Commission

National Health Policy Conference 2019

All-Payer Model, 2014-2018

Successes, Challenges, and Lessons Learned

All-Payer Hospital Rate Setting and Maryland’s All-Payer Model

• Since 1977, Maryland operated an all-payer, hospital

rate setting system

• In 2014, Maryland updated its rate setting approach

through the All-Payer Model:

• Patient-centered approach that focuses on improving care and outcomes
• Per capita, value-based payment framework for hospitals
• Stable and predictable revenues for hospitals, especially those providing rural

healthcare

• Provider-led efforts to reduce avoidable use and improve quality and

coordination

• Contractual agreement with CMMI

Move from Volume to Value Transforms Hospital Incentives

• No longer chasing volumes on pressured prices
• Incentivized
• Reduced readmissions
• Reduced hospital-acquired conditions
• Reduced ambulatory-sensitive conditions, or Prevention

Quality Indicators (PQIs)

• Better managed internal costs
• Results
• Improved health care quality, lower costs, better consumer

experience

But more to be done …

Lessons Learned

• Early successes create momentum
• Stakeholder engagement and management is a must
• Transparency and communications
• Provider-led innovations
• Comprehensive data analytics
• Build widespread, bipartisan political support
• Proactive partnership with federal partners

Maryland Model Negotiations

Progression Plan Developed in 2016

1

Foster accountability

2

Align measures and incentives

3

Encourage and develop payment and delivery system transformation

4

Ensure availability of tools to support all provider types in achieving transformation goals

5

Devote resources to increasing consumer engagement

Guiding Principles and Critical Success Factors

• 1. Ensure person-centered care and consumer engagement
• 2. Maintain focus
• 3. Retain the All-Payer System that is benefitting all parties in Maryland;

allowing private sector to lead

• 4. Set targets, allow considerable flexibility in how they are met
• 5. Data driven
• 6. Ensure accountability, predictability and transparency
• 7. Foster alignment
• 8. Modernize responsibility and regulatory oversight of the delivery system
• 9. Balance current and future responsibilities effectively

Negotiations Timeline

May 2017 Basic Term Sheet Completed June – December 2017 Detailed Term Sheet Negotiated August 2017 – June 2018 TCOC Model Agreement Drafting May 2018 TCOC Model Approved by CMMI July 2018 TCOC Model Agreement Signed and Executed

TCOC Model Vision and Implementation

Maryland Total Cost of Care (TCOC) Model

• TCOC Model is designed to improve health outcomes of individuals

and the population across hospital and non-hospital settings, and to slow the growth of per capita healthcare spending

• TCOC Model contract is a 10-year agreement (2019-2028) between

Maryland and the Centers for Medicare and Medicaid Services (CMS):

• 5 years (2019-2023) to build up to required Medicare TCOC savings of $300

million annually, including

• Medicare Part A and Part B fee-for-service expenditures, and
• Non-claims based payments
• 5 years (2024-2028) to maintain Medicare TCOC savings and quality

improvements

• Continue to limit growth in all-payer hospital revenue per capita at 3.58%

annually

Roadmap for TCOC Model

TCOC Model Contract

• Execute Contract

with CMS

• Implement

policies

• Initiate Medicaid

alignment Prepare for Model continuation

Policies and Incentives

Enhance methodologies and tools Develop incentives to further reduce avoidable and unnecessary utilization Continue refinement

• f policies,

methodologies and communication tools

Model Programs

• Launch and operate

MDPCP and Care Redesign Programs

• Develop system-wide

accountability

Further innovate with additional programs that are provider-led

Data Enhancement

• Create accessible,

timely All-Payer TCOC data

• Redesign data systems

and warehouses Use capability to analyze all payer TCOC data for performance improvement

Administrative Challenges

• Ensure adequate

resources

• Modernize

systems

• Create leadership

bench strength

• Ensure sustainable

funding for CRISP

Years 0-1 2018-19 Years 4-5+ 2022-23+ Years 2-3 2020-21