Vermonts Statewide All -Payer Accountable Care Organization Model - - PowerPoint PPT Presentation

Vermont’s Statewide All-Payer Accountable Care Organization Model and APCD: How it all fits together

Kathryn O’Neill, Director of Data Management Analysis & Data, The Green Mountain Care Board Sule Gerovich, PhD, Director of State Health, Mathematica Policy Research

NAHDO Annual Meeting, Nov 6, 2019

Acknowledgment

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The Green Mountain Care Board Sarah Lindberg, Health Services Researcher Kate O’Neill, Director of Data Management Analysis & Data Integrity Michele Degree, Health Policy Advisor Mathematica Policy Research Sule Gerovich, Senior Researcher Tom Bell, Principal Program Analyst Keri-Ann Wells, Health Research Analyst Onpoint Health Data Karl Finison, Director of Analytic Development Adam Bakopolus, Senior Health Data Analyst Carolyne Conrad, Project Manager

Vermont’s Policy Context

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Cost Growth is Unsustainable and Health Outcomes Must Improve

In 2017, health care spending in Vermont grew 1.7%.

Cost Growth Health Outcomes

• Chronic diseases are the most

common cause of death in Vermont. In 2014, 78% of Vermont deaths were caused by chronic diseases

• Vermont’s death rates from suicide

and drug overdose are higher than the national average

Sources: Vermont Department of Health, Kaiser Family Foundation

10% 11% 12% 13% 14% 15% 16% 17% 18% 19% 20% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Health care spending as % of annual growth in GSP

VT US

Source: 2017 Vermont Health Care Expenditure Analysis, available at https://gmcboard.vermont.gov/data- and-analytics/analytics-rpts.

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History of Vermont Health Reform to Value-Based Care

2003 Blueprint for Health 2007 Patient Centered Medical Home (PCMH) Pilot 2008 VHCURES established 2011 Green Mountain Care Board founded Multipayer Advanced Primary Care Practice Demo Support and Services at Home Community Health Teams 2012 Accountable Care Coalition of the Green Mountains 2013 OneCare Collaborative Physician ACOs Hub and Spoke State Innovation Model (SIM) Medicare and Blue Cross Shared Savings Programs (SSPs)

2014 Community Health Accountable Care ACO Medicaid SSP Integrated Communities Care Management Learning Collaborative VHCURES becomes All-payer

2016 Multipayer Advanced Primary Care Practice ends Blueprint for Health Pay for Performance 2017 All- Payer ACO

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All-Payer ACO Model Agreement

What is Vermont responsible for?

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Scale and Cost Growth

• State is responsible limiting cost growth

➢ All-Payer Growth Target: Compounded annualized growth rate < 3.5% ➢ Medicare Growth Target: 0.1-0.2% below national projections

• Ensuring alignment across payers, which

supports participation from providers and increases “scale” ➢ All-Payer Scale Target – Year 5: 70%

• f Vermonters

➢ Medicare Scale Target – Year 5: 90%

• f Vermont Medicare Beneficiaries

Population Health and Quality Measures

• State is responsible for performance on

20 quality measures, including three population health goals for Vermont ➢ Improve access to primary care ➢ Reduce deaths due to suicide and drug overdose ➢ Reduce prevalence and morbidity of chronic disease

• ACO/providers are responsible for

meeting quality measures embedded in contracts with payers

Vermont’s Solution: The Vermont All-Payer Accountable Care Organization (ACO) Model

Test Payment Changes Population-Based Payments Tied to Quality and Outcomes Increased Investment in Primary Care and Prevention Transform Care Delivery Invest in Care Coordination Incorporation of Social Determinants of Health Improve Quality Improve Outcomes Improved access to primary care Fewer deaths due to suicide and drug overdose Reduced prevalence and morbidity of chronic disease

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GMCB APM Regulatory Responsibilities

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Goal #2: Vermont will ensure and improve quality of and access to care Goal #1: Vermont will reduce the rate of growth in health care expenditures

ACO Oversight (Budget Review and Certification) Act 113 of 2016 Medicare ACO Program Rate Setting and Alignment Hospital Budget Review Health Insurance Rate Review Certificate of Need GMCB Regulatory Levers

All- Payer ACO Model Statewide Analytics

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VHCURES Overview

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Statutorily, the GMCB is required to maintain VHCURES (Vermont’s APCD) for:

• determining the capacity and distribution of existing state resources;
• identifying health care needs and informing health care policy;
• evaluating the effectiveness of intervention programs for improving patient outcomes;
• comparing costs between various treatment settings and approaches;
• providing information to consumers and purchasers of health care; and
• improving the quality and affordability of patient health care and health care coverage.

GMCB’s Data Governance Council oversees data stewardship in four key areas:

Risk Management Implementing and enforcing the most appropriate data privacy and security standards and practices Data Quality Establishing data stewardship to promote highest possible quality

• f data resources

Program Sustainability Evaluating opportunities to optimize sustainability and revenue for data stewardship program Data Release Supporting clear processed for the evaluation of data requests and the release

• f data

VHCURES Overview

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• Claims data have been collected in VHCURES since 2008.
• Includes commercial payers, Medicaid, Medicare, and Medicare Advantage.
• Commercial payers include both fully and self-insured plans.

− Vermont originally required all claims data from third-party administrators of self- funded company plans. − 2016 supreme court decision held that ERISA preempts state mandate that ERISA- covered self-funded plans provide health care service data to APCDs. − Today all non-ERISA covered self-insured plans report to the APCD, while only some ERISA covered self-insured employers opt-in.

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2018 ACO Membership Results

Targets Performance Difference All-Payer 36% 22%

• 14%

Medicare 60% 35%

• 25%

Attributed Individuals Population Percent Attributed Medicare A& B 39,530 113,272 35% Medicaid 42,342 135,879 31% Self-funded employers 9,874 166,996 6% Fully insured 20,838 92,978 22%

Source: https://gmcboard.vermont.gov/sites/gmcb/files/PY1%20Annual%20ACO%20Scale%20Targets%20and%20Alignment%20Report_FINAL.pdf

All-payer Total Cost of Care

• Who is included?

Residents in Vermont

13 Eligible residents

Commercial plan members Medicare beneficiaries Medicaid enrollees

What Payments Are Included?

APM total cost

• Vermont Medicaid Next Generation ACO prospective payments
• Shared savings/losses
• Blueprint payments from payers
• Other direct care coordination payments

Claims- based payments Non-claims- based payments =

+

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What Services Are Included?

aExcluded only in PY1–PY3 for Medicaid. bOnly costs for long-term care hospital are included for Medicare. cThe agreement requires a plan to include these services in the future.

Major category of service Included in all-payer TCOC Commercial Medicare Medicaid Inpatient Y Y Y Outpatient facility services Y Y Y Professional Y Y Y Home health Y Y Y Skilled nursing facilitya Y Y Na Long-term institutional carea, b N Nb Na Hospice Y Y Y Durable medical equipment Y Y Y Pharmacy (retail) N N N Dental N N N Government health care activities—AHSc Not applicable Nc Government health care activities—HCBSc Nc Government health care activities—mental healthc Nc

AHS=Vermont Agency for Human Services HCBS = home and community-based services

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2017 Total Cost by Source of Payment

All payer Commercial Medicaid Medicare Total claims costs Total nonclaims costs 3% 14% 1.5% 0.6%

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2017 Total Cost by Payer

Commercial 41% Medicaid 15% Medicare 44%

Total cost by payer

Commercial 44% Medicaid 30% Medicare 26%

Total member months

$496.51 $459.02 $255.05 $835.18

$0 $200 $400 $600 $800 $1,000 All payer Commercial Medicaid Medicare

Total cost per member per month (PMPM)

$5,958 $5,508 $3,061 $10,022 $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000

All payer Commercial Medicaid Medicare

Total cost per member per year (PMPY)

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Total Cost PMPM by Service Type

$178.42 $133.33 $130.75 $19.04 $9.93 $5.70 $0 $20 $40 $60 $80 $100 $120 $140 $160 $180 $200 Outpatient facility Professional Inpatient acute Skilled nursing facility Home health Hospice All-payer 18

All-payer PMPY trends by Payer

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• $1,000

$1,000 $3,000 $5,000 $7,000 $9,000 $11,000 2012 2013 2014 2015 2016 2017 2018 Commercial Medicaid-claim Mecaid Total Medicare-claim Medicare Total All-payer claim All payer total

Health Outcomes

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0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

Adolescent Well-Care Visits (AWC) Engagement of Alcohol and Other Drug Dependence Treatment (IET) Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA) Follow-Up After Emergency Department Visit for Mental Illness (FUM) Initiation of Alcohol and Other Drug Dependence Treatment (IET) Medication Management for People With Asthma 50% Compliance (MMA) Medication Management for People With Asthma 75% Compliance (MMA)

Medicare Medicaid Commercial - Self-Insured Commercial - Fully Insured

Next Steps in Vermont

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• Expanded reporting and analytics
• Data Quality
• Integrating Regulatory Processes
• Financial and Program Sustainability