Innovation in Health Service Delivery and Financing: Payer Perspectives United Hospital Fund March 1, 2012 Foster Gesten, MD, FACP NYSDOH-Office of Health Insurance Programs

Office of Health Insurance Programs  Medicaid o FFS (~1.2 million) o MMC (~3.6 million) o Almost $60 Billion/year expended o Heterogeneous population Women and children Minorities Disabled Behavioral health Multi-morbid Dually eligible Long term care  Child Health Plus  Commercial Managed Care

 More ‘efficient’, more ‘managed’ program o Cost and quality concerns  Integrated benefit package  Managed care and ‘care management’  Risk adjusted payments  Global budget/cap  Extensive stakeholder process o Open meetings o Transparency  Changing the experience of care o ACCESS! o Coordination o Health promotion Medicaid Redesign…Direction

Focus on: Care Delivery  Medical Home 1.0 (Single Payer Incentives) o Pay to play o Enlarge the tent o Build ‘critical mass’  Medical Home 2.0 o Multiple payers (CHPlus, Commercial, Medicare) o Training and care management/coordination support o Health information exchange  Medical Home 3.0 o Level 3 Recognition is ‘entry ticket’ o Neighborhood (specialists, hospitals, home care) ‘Health Home’/Behavioral Health Integration o Pays for itself

Transforming Primary Care  Investments o Medical home incentives o Health home program o Payments to Medicare level ACA o ARRA/HITEC/MU o HEAL  Expectations o Medical home standards  Collaboration o Multi-payer medical home  The Future Workforce o Hospital PCMH Demonstration

Summary  Challenges o Sufficient practice support PCMH HIT/HIE Care Management o Collaboration Self insured/employers o Meaningful inclusion of patient/family  Results o Early results on standardized quality and patient experience measures positive Utilization….mixed (but early for most demo’s)