1. State Innovation Models (SIM) Update November 14, 2013

2. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 1 Agenda for today Summary of Feedback Plan Updates, Next Steps and Timeline Potential Organizational Structure

3. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 2 Summary of Feedback ▪ Feedback received (Delaware) – Significant amount of feedback on second draft – Stakeholders eager to continue momentum – Specific focus on level playing field throughout – fairness and transparency – Importance of selecting/tracking the right metrics – Expanded definition of “health care team” – Interest in receiving plan before submission to CMMI ▪ Feedback received (CMMI and NGA Technical Assistance) – Plan is well developed – Level of stakeholder participation sets Delaware apart – Deliberately flexible approach is articulated and supported well

4. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 3 Summary of respondents (Qs 1-3) 15% Patient/consumer 15% Other 19% Community organization 26% 4% 11% Payer State 11% Health system Nurses, behavioral specialists and other providers Physician 11% 15% Sussex Kent 74% New Castle Yes No 56% 44% Stakeholder groupCounty Involved with SIM to date? SOURCE: Delaware’s State Health Care Innovation Plan – Survey Responses Note: N = 27

5. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 4 The case for change (Qs 4 & 5) Q: There is a compelling case for change to improve the health of Delawareans, improve health care quality and patient experience, and reduce health care costs." To what extent do you agree or disagree with this statement? Strongly disagree0 Disagree0 Neutral0 Agree19 Strongly agree81 Aggregate responses, percent SOURCE: Delaware’s State Health Care Innovation Plan – Survey Responses Note: N = 27

6. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 5 Importance of collaboration (Q6) Q: “We should work together as much as possible across health care professionals, providers, payers and individuals for a solution in the best interests of Delawareans." To what extent do you agree or disagree with this statement? Aggregate responses, percent 11 Strongly agree85 Strongly disagree4 Disagree0 Neutral0 Agree SOURCE: Delaware’s State Health Care Innovation Plan – Survey Responses Note: N = 27

7. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 6 Aggregate responses,percent Plan focus areas (Qs 7-8) 26Policy changes Holistic approach to workforce 15 Continuing to build System-wide shift307 Shared services and resources 7 Simple, common scorecard 154 More effective diagnosis4 Care coordination Technology-enabled patient engagement 4 "Healthy Neighborhoods" model 44 Q: To what extent do you support or oppose the focus areas of the plan? Strongly oppose Oppose Neutral Strongly support support SOURCE: Delaware’s State Health Care Innovation Plan – Survey Responses Note: N = 27

8. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 7 Proposed governance structure (Q9) Q: "The proposed governance structure, the Delaware Health Innovation Center, will be effective in bringing people together to sustain Delaware's health care transformation." To what extent do you agree or disagree with this statement? Aggregate responses, percent SOURCE: Delaware’s State Health Care Innovation Plan – Survey Responses 30 Agree 30 33 Strongly agree 0 Disagree7 Strongly disagree Neutral Note: N = 27

9. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 8 Remaining work to finalize plan More detail related to: Organizational structure Potential impact Workforce

10. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 9 Organizational Structure: Delaware Health Innovation Center Purpose Principles Roles and responsibilities Accountability Staffing ▪ Continue to drive transformation of Delaware’s health system and to implement the Health Care Innovation Plan ▪ Offer a continuing forum to bring stakeholders together ▪ Provides structure necessary for long-term success and ensuring ongoing inclusive and participatory nature of transformation ▪ Deliver services only where needed ▪ Connect with the Health Care Commission and DHIN ▪ Continue the multi-stakeholder approach ▪ Board large enough to be representative and small enough to move quickly ▪ Outside government with public and private participation (non-profit?) ▪ Reports to – Health Care Commission and DHIN – General Assembly – Governor ▪ Track and monitor overall progress against state health scorecard and cost impact ▪ Develop shared services and resources, including protocols and guidelines, and promote a common provider scorecard ▪ Manage the patient activation and engagement strategy ▪ Operationalize Delaware’s vision as Learning State and develop integrated workforce ▪ Implement Healthy Neighborhoods strategy ▪ Board with 9-13 members with demonstrated executive leadership, with sub- committees including patient representatives, providers, payers, the State, and employers (unpaid) ▪ Full-time staff of Executive Director and two full-time administrators, in addition to consulting support DRAFT

11. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 10 Innovation Center roles and responsibilities Clinical committee Patient advisory committee Workforce education and training committee Healthy neighborhoods committee DRAFT Innovation Center Board ▪ Tracks progress on state scorecard of metrics ▪ Establishes and monitors transparency and progress for overall implementation ▪ Approves membership and reviews work of committees ▪ Establishes shared services, including care coordination and transformation support shared services, and learning collaboratives ▪ Identifies, distributes, and regularly updates guidelines to focus on more effective diagnosis and treatment ▪ Represents patient perspective on all services and/or activities provided by Innovation Center ▪ Responsible for patient activation and engagement program ▪ Coordinates efforts to improve population health and leads Healthy Neighborhoods program – Facilitates establishment of the neighborhoods – Sets statewide goals – Ensures integration of population health efforts with delivery – Creates transparency on progress ▪ Coordinates workforce and educational training and retraining statewide to fill gaps and build capacity to support the new delivery system, population health, and technology requirements. ▪ Leads efforts to position Delaware as a “Learning State”

12. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 11 Open questions on organizational structure ▪ How will the Innovation Center be established (near-term/long-term)? ▪ Who will appoint the Board and committee members? ▪ How will the public/private structure work?

13. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 12 Plan Update: Delaware’s Aims and Drivers Delaware will… ▪ Be one of the 5 healthiest states in the nation by 2019 (chronic disease prevalence, healthy and preventive behavior indicators) ▪ Be in the top 10 percent in health care quality and patient experience by 2019 (outcome measures TBD) ▪ Reduce health care costs by 6.0 percent by 2019 Primary DriversSecondary DriversExample metricsAims DRAFT ▪ Engage patients in their health ▪ Data tools and resources ▪ Awareness campaign ▪ Adoption of HIT by providers to achieve meaningful use 2 ▪ Percent use of new tools ▪ Percent MU2 ▪ Every Delawarean in a Healthy Neighborhood to improve integration among community organizations and create local plans to enhance wellness, prevention, and primary care ▪ Total cost of care payment model to incentivize and fund change ▪ Common scorecard to track progress and ensure consistency of focus ▪ Data/analytic infrastructure inform strategy ▪ Proportion of population in Healthy Neighborhoods ▪ Prev services/ screening rates ▪ Provide care coordination for all high- risk adults/elderly and children that is person centered and team-based ▪ Shared resources for care coordination, practice transformation, and learning collaboratives ▪ Aligned incentives ▪ Delawarean at center of framework ▪ Workforce strategy that focuses on team- based training and retraining, expands access to providers (e.g., by simplifying credentialing) ▪ Patient satisfaction ▪ ED visits or admits per 1000 ▪ Promote more effective diagnosis and treatment ▪ Shared resources for clinical guidelines and protocols ▪ Common provider scorecard with aligned quality metrics, linked to population health scorecard ▪ Scorecard measures TBD ▪ More than 80% of population in total cost of care models that pay for outcomes with consistency across payers on non-price terms, with flexibility to maximize participation ▪ Data and analytics infrastructure (e.g., provider portal) and performance reports ▪ Medicaid MCO RFP ▪ IT workforce to support ▪ Percent in new payment models ▪ Total system costs ▪ Design for scale and assure transparency to ensure momentum ▪ Participatory organizational structure ▪ Public-private leadership ▪ Overall participation

14. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 13 Sample Scenario: Potential for Gross Savings 20142015201620172018201920202021202220232024Baseline Spend per capita ($)646866006825711774517872834488279358992110518 Total spend ($M)550457666169653869557481803085759183982410511 Insured population (000s) 851 874 904 919 933 950 962 971 981 990 999 20142015201620172018201920202021202220232024Provider participation TCC–40%55%70%80%85%90%95% P4V–30%20%10%5%0% Neither–30%25%20%15% 10%5% Total–100% Year 0Year 1Year 2Year 3Year 4Year 5Year 6Year 7Year 8Year 9Year 10 Impact by Year of Participation –0.5%2.5%4.5%7.0%9.0% TCC –0.6%1.2%1.8%2.4%3.0% P4V –0.0% Neither 20142015201620172018201920202021202220232024Gross impact Savings ($M)–1976157284440586692771825883 Impact as % of Spend for participants 0%1%3%4%6%7%8%9% –

15. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 14 Key Dates Original project dates: Project period end date: September 30 Plan due October 31 Extended project dates: Project period end date: November 30 Plan due December 31 Next round of CMMI funding FOA anticipated by January 31, 2014 CMMI seeking input re: specifics of FOA

16. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 15 Proposed Next Steps and Tentative Timeline November 27 - Complete revisions based on feedback December 6 - Distribute final version of plan to stakeholders December 15 - Submit plan to CMMI

17. PRELIMINARY PREDECISIONAL WORKING DOCUMENT: SUBJECT TO CHANGE 16 Project Support McKinsey contract end date September 30 RFP issued for ongoing support Bid review/vendor selection underway Interim funding possibilities