1. Maryland Total Cost of Care Model: Statewide Alignment and Success
January 22, 2019
Maryland Total Cost of Care Model: Statewide Alignment and Success
Maryland Department of Health, Health Services Cost Review Commission, and Maryland Hospital Association

2. Agenda Introductions Maryland’s Unique Healthcare Delivery System
All-Payer Hospital Rate-Setting
All-Payer Model,
Goals of the Total Cost of Care Model,
Hospital payment program
Care Redesign Program (CRP)
Population health
Maryland Primary Care Program (MDPCP)
State Alignment and Collaboration Across Providers
Introductions – Bobby or Katie
Maryland’s Unique Healthcare Delivery System – Katie, 2 mins
All-Payer Hospital Rate-Setting
All-Payer Model
Total Cost of Care Model Goals – Katie, 10 mins
Hospital payment program
CRP
Population Health
MDPCP – Howard, 5 mins
State Alignment and Collaboration Across Providers – Bob, 10 mins

3. Healthcare System Challenges
High costs
Aging & sicker population
Consumer demands
Health care disparities
Fragmentation & variation
Coverage & Access
More Challenges Ahead. . .
Over the next decade, Maryland’s population >65 years old will increase by nearly 40%
Recent consumer polls and bipartisan focus on affordability and costs
Fragmentation and variation: Different providers in the system have different incentives, and connectivity to one another
Health care disparities: exacerbate the fragmentation and variation, and keep people sick
Aging and sicker population: from the healthcare disparities and population’s aging, the 65 and over population will increase 40% over the next decade
Coverage and Access: even with the ACA underinsurance problems and high deductibles contribute to people not accessing the preventative care they need
Consumer demands: concentrate care to expensive and low value settings
High costs: where the system responds to all of these factors, which in turn ends up further contributing to the cycle

4. Maryland’s Unique Healthcare Delivery System

5. All-Payer Hospital Rate Setting and Maryland’s All-Payer Model
Since 1977, Maryland operated an all-payer, hospital rate setting system
In 2014, Maryland updated its rate setting approach through the All-Payer Model:
Patient-centered approach that focuses on improving care and outcomes
Per capita, value-based payment framework for hospitals
Stable and predictable revenues for hospitals, especially those providing rural healthcare
Provider-led efforts to reduce avoidable use and improve quality and coordination
Contractual agreement between Maryland and federal government
Bullet 1 – Through a federal waiver
Bullet 2 – Greater focus on patients (etc.) – because we are rewarding hospitals for things like decreased readmissions and preventing complications, rather than providing unnecessary tests etc.
Old System = Volume Driven  New System = Population and Value Driven
Uses updates for trend, population, and value

6. Value of the All-Payer System for Healthcare Consumers
Links quality and payment
Cost containment for the public
Funding for Graduate Medical Education
Transparency in hospital costs
Local access to regulators
Leverages increased federal payments
Supports state-designated health information exchange, the Chesapeake Regional Information System for our Patients (CRISP)

7. Public-Private Health Information Infrastructure through CRISP Supports Model
The TCOC Model will further leverage the statewide health information exchange (HIE) infrastructure through CRISP, to optimize processes, achieve the goals of the TCOC Model and improve care
CRISP reporting services to better inform patient care and population management at the point of care
Data sharing available to providers engaged in Model Programs
Available Analytic and Care Coordination Tools:
Medicare data analytics
Clinical query portal
Emergency notification services (ENS) for providers
Prescription Drug Monitoring Program (PDMP)
Ambulatory integration
Meaningful Use resources
CQM Aligned Population Health Reporting (CAliPHR)

8. Maryland All-Payer System Distributes Costs Equitably
Nationally, cost-shifting occurs between public and private payers
With the all-payer system, hospitals are:
Paid using a common rate structure for all payers, so costs are distributed equitably
Less susceptible to margin deterioration with payer mix changes
Not dependent on volume growth
Total costs are tackled using value-based approaches and care redesign on an all-payer basis
Uncompensated care is funded equitably
Nationally, Medicare underpays 12% of its costs and these are shifted onto private insurers and if you assume 50% of a hospital’s business is Medicare, there is a 6% secret tax for Medicare
The All-Payer system forces public payers to be honest participants in the system and pay their fair share
Source: American Hospital Association. (1) and (2) Includes Disproportionate Share Hospital payments

9. All-Payer Model Performance from 2014 through 2017
Performance Measures
APM Requirements from CMS
Results
On Target
All-Payer Hospital Revenue Growth
≤ 3.58%
per capita annually
2.03%
average growth per capita 
Medicare Savings in Hospital Expenditures
≥$330M cumulative over 5 years
(Lower than national average growth rate from 2013 base year to 2018)
$916M cumulative
(5.63% below national average growth)
Medicare Savings in Total Cost of Care
Lower than the national average growth rate for total cost of care from 2013 base year
$599M cumulative
(1.36% below national average growth)
All-Payer Reductions in Hospital Acquired Conditions
30% reduction over 5 years
53% reduction since 2013
Readmissions Reductions for Medicare
≤ National average
after 5 years
< National average
after 4 years
Hospital Revenue to Global or Population-Based
≥ 80% by year 5
100%

10. Maryland Total Cost of Care Model (2019-2028)

11. TCOC Model Agreement Signed on July 9, 2018!

12. Maryland Total Cost of Care (TCOC) Model
TCOC Model is designed to coordinate care for patients across hospital and non-hospital settings, improve health outcomes, and constrain the growth of costs
TCOC Model contract is a 10-year agreement ( ) between Maryland and the Centers for Medicare and Medicaid Services (CMS):
5 years ( ) to build up to required Medicare TCOC savings of $300 million annually, including
Medicare Part A and Part B fee-for-service expenditures, and
Non-claims based payments
5 years ( ) to maintain Medicare TCOC savings and quality improvements
Continue to limit growth in all-payer hospital revenue per capita at 3.58% annually
10-year Model — Ambitious, large-scale transformation for more than 800k Medicare FFS beneficiaries. Initial five-year performance period leading to an additional five years; no turning back on transformation, focus to support the scope of transformation and continuing large investments to reduce avoidable utilization.
Person-Centered Primary Care Transformation — Goal is to bring 500k Medicare beneficiaries into comprehensive primary care, increasing person-centeredness while improving chronic, mental health and preventive care. CMS will invest in care management fees.
Care Redesign Programs — Bring physicians, nursing homes, and other providers into aligned programs, with State flexibility in design and implementation.
Population health — The State of Maryland and providers will jointly focus on health improvement initiatives. Improved population health may offset the cost of primary care investments.
Total Cost of Care (TCOC) Medicare Savings — Progressive, but aggressive savings targets. Success in reaching targets rests on driving down avoidable hospital utilization and costs. Aggressive target rests primarily on hospitals, which need timely tools, care partner engagement, and CMS/State support to succeed.

13. Total Cost of Care Model Components
Purpose
Status
Hospital Population-Based Revenue
Expand hospital responsibility to control total costs through limited revenue-at-risk under the Medicare Performance Adjustment
Expands
Care Redesign &
“New Model” Programs
Enable private-sector led programs supported by State flexibility, “MACRA-tize” the Model, incentives for hospitals to work with others, and addt’l opportunity to develop “New Model Programs”
Population Health
Improvement programs for chronic conditions such as diabetes, behavioral health integration, etc.
New
Maryland Primary Care Program
Enable advanced primary care with behavioral health integration, and care management in medical home model
Patient-Centered Care
Care Redesign & New Model Programs
Hospital Population- Based Revenue
Maryland Primary Care Program
Population Health

14. Care Redesign Programs (CRP): Aligning hospitals and non-hospital providers
Alignment with Non-Hospital Providers
Multiple “Tracks” available to enable hospitals to redesign care and achieve quality and TCOC goals
Increase accountability for high needs populations, across the spectrum of care.
Opportunity for hospitals to collaborate with Care Partners and make incentive payments.
Pathway for a hospital’s Care Partners to participate in an advanced alternative payment model
Improve Quality & Control Cost
Increase Accountability
Pathway to MACRA-tization

15. Potential Credits for Population Health Improvement
The State of Maryland and providers will jointly focus on health improvement initiatives
Improved population health may offset the cost of primary care investments
Improve Chronic Condition Prevention
Diabetes initiatives
Hypertension, obesity, hepatitis C, smoking, and asthma
Improve Behavioral Health
Improve healthcare outcomes related to substance use disorders and opioids
Senior Health and Quality of Life
E.g., Fall-related death prevention

16. Maryland Primary Care Program (MDPCP)
As of January 1, 2019, Maryland voluntarily enrolled 380 primary care practices serving Medicare Fee For Service (FFS) beneficiaries in order to provide advanced primary care to:
Provide comprehensive care to all patients with a focus on managing the health of high- and rising-risk individuals
Provide preventive care and state-of-the-art health information technology
Address behavioral health and social needs
MDPCP strengthens and transforms primary care delivery by introducing care management and coordination supports such as:
Telemedicine, behavioral health and substance abuse counseling, care managers, and others
Care Transformation Organizations, unique to Maryland, that support small and independent practices as well as practice transformation coaches
Care Management Fees will provide resources for chronic care improvement
Aligns primary care providers with TCOC Model goals
Access and Continuity
24/7 patient access
Assigned care teams
Care Management
Risk-stratify all empaneled patients
Provide targeted, proactive, relationship-based (longitudinal) care management to all patients identified as at increased risk, based on a defined risk stratification process and who are likely to benefit from intensive care management
Provide episodic care management along with medication reconciliation to a high and increasing percentage of empanelled patients who have an ED visit or hospital admission/discharge/transfer and who are likely to benefit from care management
Ensure patients with ED visits receive a follow up interaction within one week of discharge.
Contact at least 75% of patients who were hospitalized in target hospital(s), within 2 business days
Comprehensiveness and Coordination
Systematically identify high-volume and/or high-cost specialists serving the patient population using CMS/other payer’s data
Identify hospitals and EDs responsible for the majority of patients’ hospitalizations and ED visits, and assess and improve timeliness of notification and information transfer using CMS/other payer’s data
Beneficiary and Caregiver Experience
Convene Patient Family Advisory Council (PFAC) at least annually and incorporate recommendations into care, as appropriate
Assess practice capability + plan for patients’ self-management
Planned Care for Health Outcomes
Use quarterly feedback reports to assess utilization and quality performance, identify practice strategies to address, and identify individual candidates to receive outreach, care management

17. MDPCP Benefits Patients
Freedom of choice
Team care led by my Doctor
Care Managers help smooth transitions of care
No cost sharing on enhanced services like care management
Expanded office hours
Records are available to all of my providers
Alternative, flexible care options (e.g., telemedicine, group visits, home visits)
Medication management support
Community and social support linkages (e.g., transportation, safe housing)
Behavioral health care led by my practice
Access and Continuity
24/7 patient access
Assigned care teams
Care Management
Risk-stratify all empaneled patients
Provide targeted, proactive, relationship-based (longitudinal) care management to all patients identified as at increased risk, based on a defined risk stratification process and who are likely to benefit from intensive care management
Provide episodic care management along with medication reconciliation to a high and increasing percentage of empanelled patients who have an ED visit or hospital admission/discharge/transfer and who are likely to benefit from care management
Ensure patients with ED visits receive a follow up interaction within one week of discharge.
Contact at least 75% of patients who were hospitalized in target hospital(s), within 2 business days
Comprehensiveness and Coordination
Systematically identify high-volume and/or high-cost specialists serving the patient population using CMS/other payer’s data
Identify hospitals and EDs responsible for the majority of patients’ hospitalizations and ED visits, and assess and improve timeliness of notification and information transfer using CMS/other payer’s data
Beneficiary and Caregiver Experience
Convene Patient Family Advisory Council (PFAC) at least annually and incorporate recommendations into care, as appropriate
Assess practice capability + plan for patients’ self-management
Planned Care for Health Outcomes
Use quarterly feedback reports to assess utilization and quality performance, identify practice strategies to address, and identify individual candidates to receive outreach, care management

18. Advanced Primary Care Functions
Care Delivery Redesign
Advanced Primary Care Functions
Access & Continuity
Planned Care for Health Outcomes
Beneficiary & Caregiver Experience
Care Management
Access and Continuity
24/7 patient access
Assigned care teams
Care Management
Risk-stratify all empaneled patients
Provide targeted, proactive, relationship-based (longitudinal) care management to all patients identified as at increased risk, based on a defined risk stratification process and who are likely to benefit from intensive care management
Provide episodic care management along with medication reconciliation to a high and increasing percentage of empanelled patients who have an ED visit or hospital admission/discharge/transfer and who are likely to benefit from care management
Ensure patients with ED visits receive a follow up interaction within one week of discharge.
Contact at least 75% of patients who were hospitalized in target hospital(s), within 2 business days
Comprehensiveness and Coordination
Systematically identify high-volume and/or high-cost specialists serving the patient population using CMS/other payer’s data
Identify hospitals and EDs responsible for the majority of patients’ hospitalizations and ED visits, and assess and improve timeliness of notification and information transfer using CMS/other payer’s data
Beneficiary and Caregiver Experience
Convene Patient Family Advisory Council (PFAC) at least annually and incorporate recommendations into care, as appropriate
Assess practice capability + plan for patients’ self-management
Planned Care for Health Outcomes
Use quarterly feedback reports to assess utilization and quality performance, identify practice strategies to address, and identify individual candidates to receive outreach, care management
Comprehensiveness & Coordination

19. Hospital Perspective and Opportunities for Alignment across the Healthcare Continuum

20. MODEL BRINGS AMBITIOUS TARGETS
Yearly Total Cost of Care Savings Targets
State’s hospitals at risk for total cost of care for 950,000 Medicare fee-for- service beneficiaries
Plus, aggressive goals:
quality improvement
health gains
$162m additional savings

21. BIG GOALS: BETTER CARE, BETTER HEALTH
WHOLE PERSON CARE
Individual Health Improvement
Accessibility & Convenience
Healthy Communities
Efficiency & Affordability

22. SIX KEYS TO UNLOCK VALUE1
Global Hospital Budgets
No incentive to deliver more than needed care
All-Payer Hospital Rates 2
Cost burdens shared equitably by all payers
Total Cost of Care Accountability 3
Hospitals each responsible for attributed lives
Shared Provider Incentives 4
Programs designed to align all care partners
Population Health Goals 5
Care for communities, not just individuals 6
Quality of Care Incentives
Hospitals rewarded for hitting quality targets

23. A SYSTEMS APPROACH IS NEEDED
STATE & COMMUNITIES
Better job opportunities
Stronger education
HEALTH SYSTEM
Partnerships across care continuum
Adequate & affordable housing
Food security
Robust, inclusive workforce
Resources for modernization
Integrated behavioral and physical care
Family & social supports
Safer communities
Aligned incentives
Actionable healthcare management information
Social connections
Improved transportation

24. Katie Wunderlich, Executive Director, HSCRC Howard Haft, Executive Director, MDPCP Bob Atlas, President & CEO, MHA
Thank you!