NYSACRA Outcome Based Payment & the Link to Care Coordination December 2015 Maureen M. Corcoran, President Marisa P. Weisel, Senior Advisor

Medicare-Medicaid eligible individuals are a diverse population & inc. those with IDD 3

Health or Health Care Medical care Behavioral Health Home Care HCBS Housing/ Recovery- LTC Supports

Health or Health Care Medical care Behavioral Health Home Care HCBS Housing/ Recovery- LTC Supports Prevention & Early Intervention Population health management Better Value for $

ACA established requirement for innovation: CMMI Accountable Care Episode based Payment Initiatives Primary Care Transformation Medicaid & CHIP population Medicaid-Medicare Population inc. Dual Financial Alignment (FIDA & DD-FIDA) Accelerate the Development and Testing of New Payment & Service Delivery Models; inc. State Innovation Models (SIM) Initiatives to Speed the Adoption of Best Practices

Reform & Innovation Target populations Design contracts Assemble integrated patient records Coordinate care Target interventions Measure outcomes Pay for Value People, Health/Care, Systems & Money

is to pay attention to the changes or innovations that Involve/affect the (type of) individuals you serve Involve/affect the type of care you provide Affect or intersect with your system of care And how the changing financial dynamics impact your business model The challenge for providers…

Payment Strategies to Improve Quality and Contain Costs Commonly used today DRGs APR-DRGs Per diem rates ambulatory patient groups FFS cost based reimbursement Risk adjusted …

Payment Strategies to Improve Quality and Contain Costs Realigning incentives-inside or outside of capitation rates: FFS w/ bonus or shared saving (upside only) Exclusion of Potentially Preventable Events Pay for Performance Risk sharing-upside & downside Bundled payments/Episodes of Care Global payments-total cost of care/ACO Paying for Value, not Volume

Value Based Payment– Paying for value, rather than volume

New York MRT

People, Health/Care, Systems & Money

18 THE DSRIP VISION: 5 YEARS IN THE FUTURE How the Pieces Fit Together: MCO, PPS & Health Home ROLE:  Insurance Risk Management  Payment Reform  Hold PPS/Other Providers Accountable  Data Analysis  Member Communication  Out of Network Payments  Manage Pharmacy Benefit  Enrollment Assistance  Utilization Management for Non PPS Providers  DISCO & Possibly FIDA/MLTCP Maintains Care Coordination ROLE  Be accountable for Pt Outcomes & Overall Health Care Cost  Accept/Distribute Payments  Share Data  Provider Performance Data to Plans/State  Explore Ways to Improve Public Health  Capable to Accept Bundled & Risk Based Pmts. *MLTC, FIDA, HARP, DISCO & Mainstream MCO* OTHER PROVIDERS HEALTH HOME #1 PPS Provider ROLE: Case Management for HH Eligible Participate in Alternative Pmt. System PPSs HEALTH HOME #2

ROLE:  Insurance Risk Management  Payment Reform  Hold PPS/Other Providers Accountable  Data Analysis  Member Communication  Out of Network Payments  Manage Pharmacy Benefit  Enrollment Assistance  Utilization Mgt for Non PPS Providers  DISCO&Possibly FIDA/MLTCP Maintains Care Coord ROLE  Be accountable for Pt Outcomes & Overall Cost  Accept/Distribute Payments  Share Data  Provider Performance Data to Plans/State  Explore Ways to Improve Public Health  Capable to Accept Bundled & Risk Based Pmts. *MLTC, FIDA, HARP, DISCO & Mainstrea m MCO* PPS s

Our Current Proposed Roadmap Contains a Menu of Options for Reform

Level 1 - Upside-only shared savings Level 2 – shared risk with upside savings and a percentage of downside loss Level 3 – Prospective payment (e.g., PMPM for total cost of care) Combinations of the Options and Risk Levels make up the menu of VBP approaches which MCOs and providers may use (other off-menu approaches also Allowed) All Care for Total Population Integrated Primary Care Acute and Chronic Bundles Total Care for Special Needs Populations Source: UHF Navigating the New York State Value-Based Payment Roadmap, November

Remember: it’s all the care, not just LTC/HCBS Medical care Behavioral Health Home Care HCBS Housing/ Recovery- LTC Supports Prevention & Early Intervention Population health management Better Value for $

NY criteria for VBP re: IDD VBP will be patient centric, not provider centric. Direction seems to be total cost of care Shared savings and/or shared loss will include a focus on both outcomes and cost of care delivered. Will establish guidelines for setting benchmarks and setting quality scores related to amount of shared saving/loss. A minimum level of standardization is required to allow for transparency of costs vs. outcomes.

Just a few words about METRICS Measure…need metrics What you measure & pay for will change behavior Measurable…but it has to matter Typical metrics…HEDIS Development of new metrics All the HIT/EHR work is essential (& expensive) Examples

MRT Vision Case Management for All

Medicaid Service Coordination Medicaid service coordination- 99% of our sample “Conflict Free” Case Management Start thinking about the financial impact of this

Case Management Generally Variety of terms Term is used very differently in the commercial managed care context Integration rests on the function of case management The “management” in managed care relies on case management There is a significant intersection with person centered planning Personal, face to face contact more effective than telephonic methods

Case Management-what is it? Person focused (?driven) Process Identification of needs, assessment Development of a plan of care Referrals and assistance to ensure timely access to providers Exchange of information Coordination of care actively linking the enrollee to providers, medical services, residential, social, behavioral, and other support services Integration and facilitation Knowledge of own and other’s roles, typically requires numerous participants Monitoring Continuity of care Follow-up and documentation.

Case Management CMMI – Care Coordination – Transitions of Care, – Care for High Cost Individuals Innovation including PCMH, Health Home

Case Management New federal regulations regarding managed care will have a significant impact on case management. Scheduled to take effect 1/1/17. Embeds all the HCBS regs. into the mgd care requirements, and Includes requirements/definition regarding: – Access – Coordination of Care and Continuity of care – Everyone receiving “long term services and supports” – Transitions of care – “Persons with special health care needs”

Punchline Case management, by whatever names, is the ‘secret sauce’ It’s a key link between care & outcomes There is no single definition You are experts As you go forward, think about it…all the facets, and beyond the surface.

Examples-IDD Specific NY IDD-FIDA—Dual, fiscal alignment Arkansas Health Care Payment Improvement Initiative (AHCPII); also CMMI Comprehensive Primary Care Initiative (CPC) – PCMH and Episode Based Payments – PCMH inc. Health Home, inc. IDD Ohio SIM PCMH and Episode Based Payments

Example – Ohio SIM GOAL: percent of Ohio’s population in some value-based payment model (combination of episodes- and population-based payment) within five years Patient-centered medical homes: – By 2016: Model rolled out to all major markets, 50% of patients are enrolled – By 2018: Scale achieved state-wide, 80% of patients are enrolled Episode-based payment

Example – Ohio SIM

Current Episodes: Preinatal care Asthma – acute exacerbation COPD exacerbation PCI – acute and non- acute Total joint replacement Wave 2 episodes: Upper respiratory infection Urinary tract infection Cholecystectomy Appendectomy Upper GI endoscopy Colonoscopy GI hemorrhage

Example – Ohio SIM Retrospective thresholds reward cost-efficient, high-quality care SOURCE: Arkansas Payment Improvement Initiative; each vertical bar represents the average cost for a provider, sorted from highest to lowest average cost 7 Provider cost distribution (average episode cost per provider) Acceptable Gain sharing limit Commendable ILLUSTRATIVE Ave. cost per episode $ Principal Accountable Provider Risk sharingNo changeGain sharing Eligible for gain sharing based on cost, didn’t pass quality metrics ILLUSTRATIVE - No change in payment to providers Gain sharing Eligible for incentive payment Risk sharing Pay portion of excess costs +

See more about the reports at /Providers/PaymentInnovation/R ead-Your%20Report-FFS pdf

48 About Vorys Health Care Advisors VHCA helps health care providers, decision makers and professional associations achieve their objectives in a constantly changing governmental and business health care environment and assists them in making well informed, strategic and tactical decisions tailored to their individual goals, needs and aspirations. Maureen M. Corcoran, MSN, MBA Vorys Health Care Advisors 52 E.Gay St Columbus OH Marisa P. Weisel