What’s Next for Maryland Hospitals HFMA Maryland Chapter Michael Robbins Senior Vice President Maryland Hospital Association January 27, 2017

All-Payer Model (Waiver) All-payer system All pay same price for same service at same hospital Rate setting system State commission sets hospital rates Federal Medicare payment rules had to be “waived” Brings over $2 billion per year to Maryland Entered into new demonstration with CMS in 2014; We are in year four of the five-year agreement

Maryland Waiver Requirements Three financial metrics: Annual hospital spending cap – 3.58 percent per capita Medicare savings target - $330 million over five years Growth in Maryland spending (hospital and non-hospital spending) cannot exceed the nation Two quality metrics: Reduce 30-day readmissions to national average Reduce complications by 30 percent in five years Tells us what to do; not how to do it Maryland decision: hospital global budgets

Maryland Waiver Performance Dashboard Cumulative Performance – Jan 2014 to Most Recent Data Available

Annual Medicare All-Provider Spending Growth per Beneficiary Trend Medicare All Provider Spending Growth Per Beneficiary Trends (Total Cost of Care) Annual Medicare All-Provider Spending Growth per Beneficiary Trend Spending Growth per Beneficiary Source: CMS data, see disclaimer

Triple Aim

New Incentives Changes how hospitals are paid to reward the right things Success under the new rules requires cost reduction care for patients in the community care in lower cost setting reduce unnecessary care The key: population health management

Population Health Management “Managing the health outcomes of a group of individuals” Central role of primary care Patient activation, involvement and responsibility Care coordination through wellness, disease and chronic care management 8

Population Health Management Changes how hospitals think Do more to earn more  Rewards for efficiency and quality Care for an individual patient  Care for an entire population Acute care  Ambulatory care  Community care Competition  Collaboration Hospital care  Health care

Health is About More Than Clinical Care Family History and Genetics Health is driven by multiple factors that are intricately linked – of which medical care is one component. Personal Behaviors 40% Family History and Genetics 30% Environmental and Social Factors 20% 10% Medical Care Source: Determinants of Health and Their Contribution to Premature Death, JAMA

Maryland’s Transformational Change Maryland at leading edge of innovation Demo still in its infancy; performance very positive to date Dramatic and difficult transformation Transformation underway but not complete Where from here? Provider alignment We need: Partnership and collaboration Laser-like focus Flexibility to focus on outcomes Time to prove success and sustainability Can’t jeopardize core hospital model

Expectations Chasm Insert Dashboard Here

Maryland Demonstration Next Steps “Care Redesign” amendment to current Maryland All-Payer Model Hospital Care Improvement Program Complex and Chronic Care Improvement Program Primary care model Primary Care Homes with patient-designated providers (primary care physicians and specialists) Regional care management entities (ACOs, local care improvement coalitions, regional partnerships, others) New Medicare Part B funding for care management fees, MACRA bonuses Dual eligible model Model progression plan

Care Redesign Amendment HSCRC proposed amendment to the All-Payer Model Provides access to new tools: Detailed, patient-identifiable Medicare data Fraud and abuse waivers under two initial programs: State can modify programs without CMMI approval Details to watch for: “Voluntary” program Hospital-specific total cost of care guardrail State oversight functions

Primary Care Model Led by Dr. Howard Haft, Deputy Secretary DHMH Structure: Standardized, common performance metrics Details to watch for: Impact on total cost of care guardrail Funding source(s) Interaction with existing care management models Role of commercial payers

How Does Transformation Feel?

New Developments The Affordable Care Act – Repeal and Replace

ACA – Repeal and Replace What we know: lack of clarity Our message: coverage is paramount Continue our focus on value: extend our demonstration

The Road Ahead

What’s Next for Maryland Hospitals HFMA Maryland Chapter Michael Robbins Senior Vice President Maryland Hospital Association January 27, 2017