Health Enhancement Community Initiative Population Health Council: Finance Design Team July 30, 2018 2:00 – 3:30 p.m. WEBINAR 1
Today’s Objectives Confirm HEC model elements for inclusion in concept paper: I. Geography II. Attribution III. Payment Model IV. Funds Flow 2
HEC Geog ographi hies Design Principles 1. Statewide coverage (all areas would be part of an HEC) 2. No overlapping boundaries (an area may be in only one HEC) 3. Minimum population required: Necessary to be able to measure changes and minimize risk 4. “Rational” boundaries to avoid “cherry picking;” boundaries need to be functional Proposed Process • Iterative formation process between the State and prospective HECs 3
Potential Variation in HECs’ Geographic Configurations E XAMPLE 1 E XAMPLE 2 E XAMPLE 3 Existing Community Multiple Existing Community Existing Community Collaborative + Collaboratives + Additional Collaborative Additional Communities Communities Central Structure Existing Community Additional Additional Collaborative Communities Communities Existing Community Existing Community Existing Community Collaborative Collaborative Collaborative Additional Communities 4
HEC Attrib ibut utio ion • Attribution is a key element of HEC accountability. Attribution determines: o Population whose health the HEC is accountable; and for whom the HEC may be eligible for shared savings o Denominator for performance measurement • During last meeting, we reviewed three options : (See Appendix for examples) o Retrospective o Prospective o Snap-shot in time (beginning/end) 5
ACO Attrib ibut utio ion: n: Sna napshot ot Exa xample le Snapshot Attribution - Example In any given performance snapshot, include all persons who resided within a HEC geographic boundary. Example: 10-Year Medicare Demo Waiver Demonstration Attribution 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Baseline Year First Baseline X opportunity for 1 Attributed Population 2021 shared savings 2 Attributed Population 2022 3 Attributed Population 2023 4 Attributed Population 2024 Second 5 Attributed Population 2025 X opportunity for 6 Attributed Population 2026 shared savings 7 Attributed Population 2027 8 Attributed Population 2028 9 Attributed Population 2029 10 Attributed Population 2030 X 6
HEC Attrib ibut utio ion: n: Sna naps pshot ot appr pproa oach Confirm Snapshot Approach: Uses a methodology to capture a defined population group at a point in time, which can be repeated at a subsequent point in time • Key advantage: Does not require longitudinal person-level data to establish a record of ongoing residency within a HEC geography • Payer Preference: Payers and other HEC funders may have specific preferences about attribution due to the availability of data and/or their own goals and interests. 7
HEC Attrib ibut utio ion: n: Sna naps pshot ot appr pproa oach Confirm Snapshot Approach: Uses a methodology to capture a defined population group at a point in time, which can be repeated at a subsequent point in time • Potential disadvantage: There will be some environmental, economic, or health factors that occur which influence HECs’ ability to “move the needle.” Examples include: in/out - migration of higher or lower socioeconomic groups; broader changes in cultural attitudes toward diet and exercise; funding for other government programs (e.g., food security, access to pre-K, etc.) • Question: What, if anything, should be “controlled for”— meaning, changes in prevention indicators over time that HECs should not be held accountable for? 8
How ow will ll HECs be funde unded? Debt and Equity • Grants New • Funds Tax Credits • Capture and • HECs Reinvest (e.g., shared savings Braided • arrangements) Funds Outcomes- Outcomes Rate • Blended Flexible • Based Cards Funds Funds Financing Wellness • Trust Source: Nonprofit Finance Fund (NFF) 9
HEC Social Finance Options: Considerations for Priority Health Areas How will HECs be fund unded? HEC Social Fina nanc nce Opti tion ons for Prior ority ty Health th Areas Flexible Outcomes- Debt & Grants Tax Credits (Hybrid) Based Equity Models Financing Foundation Hospital Pay for New Markets Blended Program- Community Success/Social Related Tax Credits Funding Benefit Impact Bonds Investments Foundation Low Income Braided Outcomes Rate Mission-Related Philanthropy Housing Tax Funding Cards Investments Credits Community Development Capture & Wellness Trust Financial Reinvest Institutions Commercial Banks / CRA Likely option Possible option High Net Worth Individuals / Wealth Advisor Unlikely option Source: Nonprofit Finance Fund (NFF)
Payment Mode odel: l: Likely ly Sour urces of Fund nds Confirm Years 0 to 4 Year 5 Years 6 to 9 Year 10 Capture & Capture & Reinvest: • • Philanthropy Philanthropy Reinvest: Shared • • Braided Funding Braided Funding Shared Savings • • Wellness Trust Wellness Trust Savings tied to • • Other options rated Other options rated tied to Prevention “possible” “possible” Prevention Benchmark Benchmark 11
Fund nds Flow ow Example: Medicare Funds Flow Confirm Medicare Agreement Medicare State of Connecticut $ Shared savings tied to HEALTH ENHANCEMENT COMMUNITY achievement on prevention HEC Fiscal HEC Governing Entity benchmarks Intermediary $ HEC Partner HEC Partner HEC Partner Organization A Organization C Organization B Attributed HEC Population 12
Fund nds Flow ow Example: Medicare Funds Flow Payer • Assuming shared savings are achieved, HECs will receive distribution of savings (e.g., every 5 years) HEC Fiscal Intermediary • Distribution of funds within HEC pursuant to its governance HEC structure. Governing • The parameters for HEC funds distribution may be subject to Entity State approval. • Reporting on the distribution of funds will be required HEC Partner (Example: hospital community benefits reporting) Organization 13
Fund nds Flow ow Example: Philanthropic funding Confirm Funder $ Philanthropic funding could HEALTH ENHANCEMENT COMMUNITY be distributed to one or more HEC Fiscal HEC Governing Entity levels within Intermediary $ an HEC HEC Partner HEC Partner HEC Partner Organization A Organization C Organization B Attributed HEC Population 14
Appe pendix dix 15
HEC Attrib ibut utio ion: n: Opt ptio ions ns Retrospective Prospective Snapshot • • • Description Retrospective (also referred to Uses historical claims to Uses a methodology to capture a as “concurrent” or identify the persons included defined population group at a in a providers’ patient roster “performance year”) attribution point in time , which can be assigns patients to providers prior to the start of a defined repeated at a subsequent point in based on historical claims at the performance period time end of the performance period measured • • • Considerations Ensures the patient actually Roster of patients is known May be more consistent with a received care from the before the performance year population health approach • attributed provider during the begins. (Patients can “fall out” “Open group” approach does not performance year of the attribution methodology account for in-or out-migration • • Proponents of retrospective during the performance year, Could adjust methodology to attribution argue that providers but new people cannot be account for significant changes in should treat all patients in the added.) makeup of a community over time • most effective and efficient Quality and cost data can be manner; therefore, advance shared with provider on a notification is unnecessary timely basis during performance year 16
ACO Attrib ibut utio ion: n: Rollin olling Retrospe pectiv ive Exa xample ple Rolling Retrospective attribution - Example In any given performance year, include all persons who reside within a HEC geographic boundary, except the following: - Persons who did not live in the HEC geography for 12 or more of the previous 60 months (5 years) - Persons who did not live in the HEC geography during any part of the of the most recent 12 months - Newborns of mothers who fall into the previous exclusions (#1 and #2) Example: 10-Year Medicare Demo Waiver Demonstration Attribution 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Year 1 Attributed Population 2021 X X X X X X 2 Attributed Population 2022 X X X X X X 3 Attributed Population 2023 X X X X X X 4 Attributed Population 2024 X X X X X X 5 Attributed Population 2025 X X X X X X 6 Attributed Population 2026 X X X X X X 7 Attributed Population 2027 X X X X X X 8 Attributed Population 2028 X X X X X X 9 Attributed Population 2029 X X X X X X 10 Attributed Population 2030 X X X X X X 17
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