QI Collaborative: A Learning Network for Re- designing New Jersey’s Safety -net Health System The Medicaid ACO Demonstration Project
Jeff Brown Executive Director of the QI Collaborative jbrown@njhcqi.org
The QI Collaborative Vision
The QI Collaborative Process
Economies our health care system is bigger than:
For all that money, how does the United States measure up when it comes to quality?
Waste and Innefficiency
Productivity in US Health Care 1:22
Payment variation AVERAGE CONDTION EPISODE PAYMENT LOWEST $ HOSPITAL HIGHEST $ HOSPITAL RANGE Acute myocardial infarction $45,423 $31,809 $53,833 69% Congestive heart failure $27,973 $20,743 $33,549 62% Coronary artery bypass surgery $74,152 $64,785 $82,867 28% Colectomy $42,173 $36,504 $50,888 39% Total hip replacement $29,611 $27,113 $34,578 27%
Back to the Vision
The Four Underlying Concepts of Cost Containment Through Payment Reform… Tying payment to “Bundling” payments for evidence and physician and hospital outcomes rather than services by episode or per unit of service condition Reimbursement for the Accountability for results coordination of care in - patient management a medical home across care settings
Range of Models in Existence or Development Increasing assumed risk by provider Increasing coordination/integration required Bundled Bundled payments for Incremental Accountability Current State: payments for chronic care/ FFS payments for Population Payments for acute disease carve- for value Reporting Health episode outs • BPCI • MSSP • Medicaid ACOs • Pioneer • Next Generation ACO
New Jersey’s Medicaid ACOs Passaic County Comprehensive Care ACO Healthy Greater Newark ACO New Brunswick Health Partners Trenton Health Team Camden Coalition of Healthcare Providers Healthy Cumberland Initiative
Legal Requirements New Jersey MEDICAID ACO Legislation [P.L. 114 C.30:4D-8.1] (1.) The applicant has been formed as a nonprofit corporation pursuant to the “New Jersey Nonprofit Corporation Act,” P.L.1983, c.127 (C.15A:1 -1 et seq.), for the purposes described in this act; ( 2) The applicant’s governing board includes: (a) individuals representing the interests of: health care providers, including, but not limited to, general hospitals, clinics, private practice offices, physicians, behavioral health care providers, and dentists; patients; and other social service agencies or organizations located in the designated area; and (b) voting representation from at least two consumer organizations capable of advocating on behalf of patients residing within the designated area of the ACO. At least one of the organizations shall have extensive leadership involvement by individuals residing within the designated area of the ACO, and shall have a physical location within the designated area. Additionally, at least one of the individuals representing a consumer organization shall be an individual who resides within the designated area served by the ACO; (3) The applicant has support of its application by: all of the general hospitals located in the designated area served by the ACO; no fewer than 75% of the qualified primary care providers located in the designated area; and at least four qualified behavioral health care providers located in the designated area; (4) The applicant has a process for receipt of gainsharing payments from the department and any voluntarily participating Medicaid managed care organizations, and the subsequent distribution of such gainsharing payments in accordance with a quality improvement and gainsharing plan to be approved by the department, in consultation with the Department of Health and Senior Services; (5) The applicant has a process for engaging members of the community and for receiving public comments with respect to its gainsharing plan; (6) The applicant has a commitment to become accountable for the health outcomes, quality, cost, and access to care of Medicaid recipients residing in the designated area for a period of at least three years following certification;
Keys to Success for New Jersey’s Medicaid ACOs 1. Staffing/Operations/Start-Up Costs 2. Sustainability/Contracting 3. Care Coordination and development of appropriate interventions 4. HIT Infrastructure 5. Quality Metrics 6. Access to timely data via State and plans 7. Gainsharing Plans 8. Practice Improvement 9. Provider Engagement
Other Considerations 1. Integration of Behavioral Health 2. Access to Specialty Care 3. Governance and communication strategies
How Big is the Opportunity?
How Big is the Opportunity?
How Big is the Opportunity? If the 13 communities were able to achieve the performance of the community with the best cost profile on each of the measures, substantial hospital cost savings would be achieved (note, these amounts should not be summed because of overlap in visits across measures): • $284 million from reduced inpatient high user costs • $155 million in lower costs from avoidable inpatient stays and emergency department visits • $94 million from reduced readmission costs • $70 million from reduced emergency department high user costs
Extending Beyond ACOs Consumer Education Education/ Materials Engagement Consumer Education/ Engagement Quality/ Value-Driven Cost Engagement Payment Systems Reporting of Quality Benefit Purchasers Reporting Design Quality/Cost Measure Design Cost/Price Payment Alignment of Reporting System Multiple Design Payers Value-Driven Technical Delivery Assistance Systems to Providers Design & Provider Delivery of Organization/ Care Coordination
Extending Beyond ACOs Education Materials Consumer Education/ Engagement Engagement of Regional Quality Benefit Purchasers Reporting Design Health Quality/Cost Measure Improvement Design Payment Cost/Price Collaborative Alignment of System Reporting Multiple Design Payers Technical Assistance to Providers Design & Provider Delivery of Organization/C Care oordination
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