Integrated Health Partnerships Minnesota’s Medicaid ACOs Heather Petermann MN Department of Human Services December 2015

Continuum of Integrated Care Models and Features Measurement Success Indicators Data capturing & sharing Improved clinical processes Improved outcomes (costs down, patient experience up) Payment $15-service $5– quality Metrics/ Evaluation Some MU core set; some adult/child core sets measures Practice measurement changes and process measures that will lead to outcomes improvement Clinical processes and new benchmarks informed by data collection; benchmarks adjusted for continuous improvement Improved care outcomes, not volume; patient experience Process measures indicate improved care in future, yield data collection for policy development and baseline Care Models Possible bonus pool $5-service Made to individual PCP; fixed $ amount Made to individual providers or entity; upfront $, savings & FFS Made to entity; $ based on savings Full ICMs Population-Focused Individual Service-Focused Population health, functional status, total cost of care Little/No Accountability for Quality and Cost Outcomes Significant Accountability for PCC FFS Only PCCM Plus P4P PCMH PCMH + Health Home Network of PCMH ACOs Comprehensive ACOs Other ICMs $10-service $10– Quality/savings $15– Oklahoma PCMH Missouri PCMH HH North Carolina CCNCs Colorado RICOs Minnesota ACOs Oregon CCOs Examples Source: Centers for Medicare & Medicaid Services (CMS)

What is an Accountable Care Organization (ACO)? A group of health care providers with collective responsibility for patient care that helps coordinate services – deliver high quality care while holding down costs Creates an incentive through payment structures for providers to efficiently and effectively manage the full spectrum of care a patient receives throughout the care system There are a variety of ACO models, many with flexibility in their structure, payments and risk assumptions

Impetus for Accountable Care Organizations Impetus for ACOs Desired Outcomes Value = Better Quality + Lower Cost/“The Triple Aim” Integrated prevention, wellness, and community services Coordinate care across care cycle Data to monitor utilization, compare and share locally and across states New reimbursement structures, including incentives that encourage integrated care models Develop payment approaches to create incentives for value not volume Shift risk and rewards closer to point of care to foster local accountability Realize return on federal and state investments Improve access to care, outcomes and information for the enrollee Slide provided by Center for Health Care Strategies (CHCS)

Integrated Health Partnerships (IHP) Background and Goals IHPs authorized in 2010 by Minnesota Legislature Allow for broad flexibility and innovation under a common framework of accountability – away from incentive “to do more” IHPs voluntarily contract under two options Integrated or Virtual Framework of accountability includes: Established provider requirements (delivery primary care, coordinate with specialty providers and hospitals, demonstrate ways they partner with community organizations and social service agencies) Payment based on accountability for, total cost of care (TCOC) Robust and consistent quality measurement

How are IHPs Accountable? Total Cost of Care (TCOC) Existing provider payment persists Gain-/loss-sharing payments made annually based on risk-adjusted TCOC performance, contingent on quality performance. Medicaid recipients (MA, MN Care, SNBC) across both FFS and all managed care organizations Core set of services included in TCOC; IHP may elect to include additional services Performance compares each IHP’s base year TCOC (year prior to start of demo) to subsequent years. TCOC: Generally includes inpatient, outpatient, physician/professional, certain mental health and chemical health services Generally excludes dental, supplies, transportation, long-term services

How do we calculate TCOC shared savings? Total Cost of Care (TCOC) target (risk adjusted, trended) is measured against actual experience to determine the level of claim cost savings (excess cost) for risk share distribution LOSS: Delivery system pays back a pre-negotiated portion of spending above the minimum threshold GAIN: Savings achieved beyond the minimum threshold are shared between the payer and delivery system at pre-negotiated levels Integrated model - Begins with shared savings and phases in downside to 2-way risk sharing of both savings and losses by year 3. IHPs have flexibility to propose amount of risk they assume. Integrated model moves toward introduces symmetrical “downside” risk for the IHP (subject to the same 2% minimum threshold) Integrated model respondents have the flexibility to propose a more variable gain-/risk-sharing arrangement that doesn’t have to be 50/50 and can vary from year-to-year within the demo.

Quality Measurement Performance on quality measures impacts the amount of shared savings an IHP can receive; phased in over 3-year demo Year 1 – 25% of shared savings based on reporting only Year 2 – 25% of shared savings based on performance Year 3 – 50% of shared savings based on performance Core set of measures based on existing state reporting requirements – Minnesota’s Statewide Quality Reporting and Measurement System Core includes 7 clinical measures and 2 patient experience measures, totaling 32 individual measure components – across both clinic and hospital settings IHPs have flexibility to propose alternative measures and methods Each individual measure is scored based on either achievement or year- to-year improvement

IHP Participation Three rounds to date, 16 total IHPs. 204,119 Three rounds to date, 16 total IHPs. ~205,000 Medicaid enrollees attributed across the 16 IHPs 53% are outside of the 7-county metro area IHPs account for 33% of attribution eligible (excludes duals, Hennepin Health, non-users, >6mos enrollment) ; estimated 28% of MHCP beneficiaries now in value based arrangements

IHP Geographic area Size (# Attributed) Bluestone Physician Services (V) Minneapolis/St. Paul ~1,000 CentraCare (I) Central MN, N of Mpls/SP 19,712 Children’s Hospital (I) 18,724 Courage Kenney (Allina Health) (V) 1,699 Essentia Health (I) Duluth/NE MN 37,482 FQHC Urban Health Network (10 FQs) (V) 27,715 Hennepin Healthcare System/HCMC (I) 30,000 Lake Region Healthcare (I) West Central MN 3,833 Lakewood Health System (I) Central MN 3,953 Mankato Clinic (V) Mankato 8,564 Mayo Clinic (I) Rochester/SE MN 5,239 North Memorial (I) 4,696 Northwest Health Alliance (Allina/HealthPartners) (I) 16,053 Southern Prairie Community Care (V) Marshall/SW MN 24,385 Wilderness Health (V) NE MN 10,664 Winona Health (I) Winona/SE MN 4,410

Results to Date In 2013 the first six participating providers saved $14.8 million compared to their trended targets. All beat their targets and met quality requirements; 5 received shared savings payments $6 million in total payments, ranging from $570,000 to $2.4 million. 2014 interim TCOC savings estimated at $61.5 million. All 9 providers to receive shared savings settlements – up to $22.7 million in total. For 2014, a quarter of each IHP’s shared savings is dependent on quality measurement to be calculated with final settlement. Innovative approaches to better coordinate care Focused initiatives (asthma, expanded hours/”Call First”) contribute to decreases in hospitalizations, ED visits Use of emerging professions More intensive collaboration with mental health care providers, county agencies and community resources.

Role of Emerging Professions Use of Community Paramedics and Community Health Workers are examples of the innovative approaches that flexible payment models are intended to encourage Several IHPs have credited use of emerging professions in their care coordination efforts, improving patient engagement and reaching goals at reducing readmissions Innovative approaches to better coordinate care Focused initiatives (asthma, expanded hours/”Call First”) contribute to decreases in hospitalizations, ED visits Use of emerging professions More intensive collaboration with mental health care providers, county agencies and community resources.

What’s Next? Incorporate provider feedback to develop advanced model track Explore Medicare/Medicaid Integrated ACO model for under 65 duals Emphasis on integration of acute care and other care settings, behavioral health, and home and community based services/social services Support ACO strategies toward more community responsibility for health/accountable communities for health Work with new health financing taskforce on state purchasing reform and planning related to waiver options under the ACA to align requirements across affordability programs. Ready or not – time for the next iteration of IHP