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

2. 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)

3. 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

4. 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)

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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.

12. 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.

13. 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