Health Care Home Payment Methodology Critical Access Hospitals, Chief Financial Officers Roundtable April 28, 2011.

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Presentation transcript:

Health Care Home Payment Methodology Critical Access Hospitals, Chief Financial Officers Roundtable April 28, 2011

Legislative Requirements for HCH Care Coordination Payment [256B.073] -DHS and MDH develop a system of per-person care coordination payments to certified HCHs by January 1, Fees vary by thresholds of patient complexity -Agencies consider feasibility of including non-medical complexity information -Implemented for all public program enrollees by July 1, 2010

Legislative Requirements for HCH Care Coordination Payment [62U.03] -Health plans include HCHs in their provider networks by January 1, 2010 and make care coordination payments by July 1, Payment conditions and terms shall be developed “in a manner that is consistent with” the system under 256B.0753

Minnesota’s Insurance Market: The “Critical Mass” Challenge

Payment Methodology: Health Care Home Payment Methodology Steering Committee Work Group: Clinic and Payer Communication Processes for Care Coordination Payments Work Group: Patient Risk Stratification Models and Methods for MHCP Rate Development Work Group: Consumer / Patient Payment Considerations

Patient Complexity: Why? The law requires that payments be higher for more complex patients Complexity represents the amount of time and work needed to coordinate care Complexity includes both medical and psycho-social issues.

Complexity Tiers Based on the number of condition groups (e.g. endocrine, cardiovascular) that providers identify as: –Chronic –Severe –Requiring a Care Team for Optimal Management

DHS Rates: MHCP Fee-for-Service - DHS will increase the rate by 15% for each of the two supplemental complexity factors. - The adjusted average PMPM rate across Tiers 1-4 (incl. the supplemental factors) is $31.39.

HCH’s Population TIER 0 HCH Participants No chronic conditions or less complex conditions. TIERS 1-4 HCH Patients Need: More intensive care coordination by a care team. HCH CERTIFICATION AND OUTCOMES MEASUREMENT 50% HCH Patients Need Routine Panel Management & Preventive Care TIERS 1-4 HCH Participants: More Complex Severe Conditions We starting here with HCH Care Coordination Payments for Certified HCH’s

Patient Complexity Across Populations: Example 2 HCH CERTIFICATION AND OUTCOMES MEASUREMENT TIER 0 HCH Participants (Less Complex) TIERS 1-4 HCH Participants Receiving Intensive Care Coordination (More Complex) 27% 73%

Multipayer Advance Primary Care Demo MAPCP Sites Awarded in November MichiganMinnesota New York North Carolina Maine Pennsylvania Rhode Island Vermont

MN MAPCP Demo: Quick Facts All certified HCHs will be eligible to participate by billing for their eligible Medicare patients The demo will last 3 years Over 200,000 MN beneficiaries are projected to participate Dollars will go from Medicare directly to the practices using a similar rate structure to FFS Medicaid

MAPCP Work to Date OMB approval of budget neutrality (mixed track record of Medicare demos) Equipping regional carriers to pay care coordination claims (first payments expected 10/11) Planning for externally-contracted CMS evaluation 2-way transmission of health care claims data

Questions: Rachel Tschida: