1. Department of Vermont Health Access The Vermont Approach to Building an Integrated Health System Creating “Accountable Care Partners” Based on Shared Interests State Health Research and Policy Interest Group Meeting June 11, 2011 Richard Slusky Director, Payment Reform Department of Vermont Health Access

2. H.202: Universal and Unified Health System: “The Path to Single Payer” Delivery system reform Payment reform Integrated health information technology Multi-payer claims data base Health insurance exchange Financing Plan Green Mountain Board Department of Vermont Health Access

3. Medicaid Medicare BlueCross MVP Cigna Self Insured Advanced Primary Care NCQA Standards Patient Centered Care Access Communication Guideline Based Care Use of Health IT Advanced Community Support Community Health Teams MCAID CCs SASH Teams Fee for Service (Volume) PPPM # 1 -NCQA Score Standards Payment Reform Delivery System Reform Financing Shared Costs State Role: Designing & Promoting New Payment Methods Phase I – Blueprint for Health

4. Department of Vermont Health Access Multi-insurer Payment Reforms Phase I – Blueprint for Health Insurers Community Health Teams Shared costs as core resource Consistent across insurers Minimizes barriers Patient Centered Medical Home Payment to practices Consistent across insurers Promotes quality Fee for Service Unchanged Allows competition Promotes volume + + Based on NCQA PPC-PCMH Score $1.20 - $2.49 PPPM Based on active case load Medicaid Commercial Insurers Medicare

5. Department of Vermont Health Access Multi-insurer Payment Reforms Patients with 2+ Chronic Conditions Phase II – PCP/Specialists Insurers Community Health Teams Shared costs as core resource Consistent across insurers Minimizes barriers PCP/specialist partnership Equal payment to PCP/Specialist Includes all payers Promotes coordination /collaboration Payment based on reduction in total cost of care, avoidable services, quality performance, patient engagement ++ Medicaid Commercial Insurers Medicare?

6. Department of Vermont Health Access Medicaid Medicare BlueCross MVP Cigna Self Insured Advanced Community Support Community Health Teams MCAID CCs SASH Teams Specialized Services Hospitals Specialty Care Targeted Services Mental Health Services Substance Use Services Family Services Social Services Economic Services Long Term Care Nursing Homes Payment Reform Delivery System Reform Financing Fee for Service (Volume) PPPM # 2 -Outcome, Quality, and Patient Centered Measures Phase II Blueprint and PCP/Specialists

7. Department of Vermont Health Access Payment Based on Shared Interests: PCPs & Specialists Adjustable outcomes based payment – ongoing refinement First shared interest $PPPM payment 6 mo Baseline Continue current FFS 12 mo Decreased FFS Adjust Payment Dials Total new FFS + $PPPM > baseline FFS Measure results Second shared interest $PPPM payment Measure results

8. HEALTH CARE PROVIDERS INCLUDED EXAMPLES OF COST REDUCTION OPPORTUNITIES Improved Outcomes and Efficiency for Major Specialties Major Specialists (Cardiology, Orthopedics, Etc.) Greater Efficiency & Improved Outcomes for Inpatient Care Other Specialists Hospitals Level 2 FFS, CHT’s, PMPM Level 3 Bundled Level 4 Global (ACO) Level 5 Cost based payments grants Primary Care Practice Prevention & Early Diagnosis Appropriate Use of Testing/Referral Reduction in Preventable ER Visits & Admissions Better Management of Complex and Low-Income Patients Safety-Net Programs Public Health Phase III Integrated Medical & Social Svcs © 2010 Center for Healthcare Quality and Payment Reform, Network for Regional Healthcare Improvement FQHC’s

9. State Role: Fostering the Use of Accountability Measures Four Dimensions of Performance Measurement Reduction in growth of total cost of care Reduction in avoidable services: – ED visits – Inpatient admissions/readmissions – Imaging – Laboratory tests Improvement in adherence to quality performance standards – Process measures – Outcome measures Improved patient experience and engagement Department of Vermont Health Access

10. State Role: Designing and Promoting Data Vermont Information Technology Leaders (VITL) Medicity (Gathering/Organizing) Onpoint (Gathering/Organizing) University of Vermont (Analyzing) Docsite (Reporting) Department of Vermont Health Access

11. State Role: Supporting a Continuum of Care and the Role of Medical Homes Primary & specialty care providers share common goals & interests Encourages provider relationships as “Accountable Care Partners” Incentive to help patients be followed in a medical home Incentive for well coordinated health services (communications, transitions)

12. Incentives are balanced and payment is optimized by collectively improving quality, prevention, control of costs Patient centered not organization centered (payment follows patients) Incentive to meet needs & engage patient in ongoing care Levels out the roles of primary & specialty care (equal payment for coordinated and effective care) Department of Vermont Health Access State Role: Supporting a Continuum of Care and the Role of Medical Homes

13. Department of Vermont Health Access State Role: Supporting a Continuum of Care and the Role of Medical Homes Builds on established (and successful) payment methodologies in the Blueprint (Quality based on NCQA score, CHTs in place) Builds on established measurement capabilities Does not require new organizations or administrative entities Promotes shared interests across all providers within a practice (in addition to promoting shared interests across primary and specialty care)

14. Department of Vermont Health Access State Role: Supporting a Continuum of Care and the Role of Medical Homes Payment based on goals that are shared by most / all stakeholders (patients, families, providers, insurers, businesses) Payment streams & methods are applicable in any financing system (multiple payers, private & public, single payer)

15. State Opportunities for ACO/ACP Development ACO FFS Payment Shared Risk Retrospective Attribution of Patients Requires Organizational Structure 65 Quality Measures] Requires 50% of PCP’s to meet meaningful use criteria ACP FFS & Enhanced Payment Based on Value Initial Upside Only – Performance Risk Increases as FFS is Reduced Prospective Attribution Based on Historical Usage No New Org Structure Required Measures Four Dimensions of Performance Requires Data Submission in Several Formats Based on Provider Capabilities Department of Vermont Health Access