QI Collaborative: A Learning Network for Re- designing New Jerseys - - PowerPoint PPT Presentation

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

CONDTION AVERAGE 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 evidence and

• utcomes rather than

per unit of service “Bundling” payments for physician and hospital services by episode or condition Reimbursement for the coordination of care in a medical home Accountability for results

• patient management

across care settings

Incremental FFS payments for value Bundled payments for acute episode Bundled payments for chronic care/ disease carve-

• uts

Accountability for Population Health

Current State: Payments for Reporting

Range of Models in Existence or Development

Increasing assumed risk by provider Increasing coordination/integration required

• BPCI
• MSSP
• Medicaid ACOs
• Pioneer
• Next Generation ACO

Healthy Greater Newark ACO Healthy Cumberland Initiative Camden Coalition of Healthcare Providers Trenton Health Team Passaic County Comprehensive Care ACO New Brunswick Health Partners

New Jersey’s Medicaid ACOs

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

• rganizations 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;

Legal Requirements

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

Value-Driven Payment Systems Quality/ Cost Reporting

Quality/Cost Measure Design Quality Reporting Cost/Price Reporting

Value-Driven Delivery Systems

Technical Assistance to Providers Design & Delivery of Care

Consumer Education/ Engagement

Consumer Education/ Engagement Education Materials Engagement

• f

Purchasers Alignment of Multiple Payers Payment System Design Benefit Design Provider Organization/ Coordination

Extending Beyond ACOs

Quality/Cost Measure Design Quality Reporting Cost/Price Reporting Technical Assistance to Providers Design & Delivery of Care Consumer Education/ Engagement Education Materials Engagement

• f

Purchasers Alignment of Multiple Payers Payment System Design Benefit Design Provider Organization/C

• ordination

Regional Health Improvement Collaborative

Extending Beyond ACOs