alternative payment methods & cost savings analysis: emerging results from sbhc innovation study

Alternative Payment Methods & Cost Savings Analysis: Emerging Results from SBHC Innovation Study

The project described is supported by Grant Number 1C1CMS331028 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies." The project described is supported by Grant Number 1C1CMS331028 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies."

Presenter Disclosures The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: University of Miami Miller School of Medicine No relationships to disclose

Our Vision The Dr. John T. Macdonald Foundation School Health Initiative, founded in July 2000, shares in the vision of serving school-aged children and their families while striving to become a center of excellence for school health care.

Our Mission Deliver high quality medical, dental, social and mental health services to children and adolescents in their schools; Participate as a community partner to ensure that the health care needs of youth and their families are met; Serve as a national and local advocate for school health and; Educate and train our health professions students through service-learning to ensure the future of health care delivery for our youth; Increase school performance of the students in the target schools by improving their health status, attendance, and ability to focus on academics.

Our Schools

North Miami Beach Sr.John F Kennedy MiddleFulford Elementary G.E. / Sabal Palm Elem.Greynolds Park Elem.Booker T. Washington Sr. Arch Creek ElementaryNorth Miami MiddleNorth Miami Sr.

Staffing Primary sites: NMB Sr JFK Middle North Miami Sr. BTW Sr. Satellite sites: Elementary schools North Miami Middle Arch Creek ARNP / MDRN / MA/LPN MSW MA / LPNCHW --

Indicators of poor health status: HPSA Minority status 85% of students on free school lunch program. Federal poverty level 20% of families in NMB 24% North Miami 30% Overtown A high prevalence of obesity or overweight (32%) exists among students in these areas Of 638 second grade students seen for sealant placement, 225 (35%) had existing caries. 33% of parents with children enrolled within the SBHCs report having Medicaid. 4% reported having private insurance. The remainder reported being uninsured. Asthma surveillance conducted by the DOH revealed that our schools are in zip code areas ranked 3rd highest for child ER visits due to asthma. Estimated 25% have serious mental health issues.

Current Services: Physical examinations Telehealth specialty consultations Immunizations Mental health services (social workers) Dental sealant and varnish program Chronic disease management Acute care Episodic care Laboratory services Pulmonary function testing EKG testing

Service Learners Nursing Medical students Residents Psychiatry Social work Dental

Outcomes and Individual Success Stories Reduction in 911 calls Improved absenteeism rates 87% return to class rates High detection and treatment of STDs Tracking The case of eczema herpeticum Chest pain in a teen Homeless teen

Immunization status: Student Populatio n # Children out of compliance % students in compliance NMB Sr High 2119 36 99.9 JFK Middle13043 99.8 Fulford5313 99.5 G. E. / Sabal Palm 6930 100 Greynolds Park7950 100 N Miami Sr258512 99.6 N Miami Middle96849 99.9 Arch Creek5664 99.9 BTW Sr High94940 99.9 TOTAL1051014799.8

The Dr. John T. Macdonald Foundation School Health Initiative Challenge Improve Quality Provide Better Care Lower Costs

1.Build upon our current school-based health center network for 12,000 school-aged children for primary care, nursing and social work services to include preventive dental and mental health services. 2.To address the health needs of the parents of these children and through a partnership with a grassroots primary care clinic at the Center for Haitian Studies. 3.To utilize community health workers as peer educators and coordinators of care to improve access and adherence to care plans. 4.To work with all partners, including two HMOs and CMS to develop new patient payment mechanisms that reward quality, innovation, and cost-effectiveness. The Dr. John T. Macdonald Foundation School Health Initiative Challenge Objectives

Preventive Dental Services (Nova): -Telehealth Oral Exams (pilot project) -Sealants for 2 nd and 6 th graders -Varnishes (trainings given to medical and nursing staff for application of varnishes) -Restorative care -Referrals (to community)

Off 555 students seen for services, 35.2% had dental caries in permanent teeth. 6.1% had existing caries in primary teeth. 19.7% of students had fillings of permanent teeth. 3.4% had fillings of primary teeth. Oral Health - NSU

Expansion of Mental Health: - Guidance, Supervision of SWs - Guidance, Supervision of CHWs for Mental Health -Telehealth Encounters -On-call system -Psychology Services

Telehealth: -School-to-school consultations -Dermatology, nutrition, psychiatry -Reimbursement? HB 499 2013 F L O R I D A H O U S E O F R E P R E S E N T A T I V E S A bill to be entitled An act relating to health care coverage; requiring health insurers, corporations, and health maintenance organizations issuing certain health policies to provide coverage for telemedicine services; providing definitions; prohibiting the exclusion of telemedicine cost coverage solely because the services were not provided face to face; specifying conditions under which an insurer, corporation, or health maintenance organization must reimburse a telemedicine provider for certain fees and costs; authorizing provisions requiring a deductible, copayment, or coinsurance requirement for telemedicine services under certain circumstances

UM Telehealth Services

Community Health Workers (CHWs): Peer Educators Peer Facilitators Peer Encounters

Medicaid Enrollment Goals: Cumulative Percentage: Number Students: Year One15%1650 Year Two35%3850 Year Three65%7150

Clinic Enrollment: Student PopulationClinic Enrollment% Enrolled NMB Sr High 2119 JFK Middle1304 Fulford531 Sabal Palm693 Greynolds Park795 N Miami Sr2585 N Miami Middle968 Arch Creek566 BTW Sr High949 TOTAL10510

Medicaid Enrollment:

Current JTMF Medicaid Enrollment

HMO Partners: -Medicaid Enrollment Assistance -Achievement of HEDIS (Healthcare Effectiveness Data & Information Set) Parameters -Data Capture & Analysis -New Payment Methods

Alternative payment methods -Fee-for-service -Capitation -Shared savings -Pay for performance

Pay for Performance Immunization compliance Asthma control

Medical home incentives Value based incentives related to improved care coordination and case management Practices with PCMH recognition most likely to be offered Incentives may include funding to hire care coordinator, per month stipend for care coordination activities, shared savings from decrease ER utilization

Initiative Overview Amerigroup has embarked on an initiative to ensure that all members with access to school based health centers could easily obtain quality healthcare services at these locations by contracted providers (MDs, PAs or ARNPs. As part of this initiative, Amerigroup is working closely with SBHCs to identify and engage non-compliant members in need off required care (e.g. Annual Well Child Visit) who attend these schools. 2

How Amerigroup Works with SBHCs to Provide Care to Non-Compliant Members Step 1: Amerigroup conducts location-analysis identifying non-compliant school-aged members Step 2: Amerigroup securely transfers non-compliant member file to SBHC-Provider - for matching with school or health center database Step 3: SBHC-Provider engages families of matched members and schedules an appt at school health center Step 4: SBHC-Provider communications with members PCP to inform them of care provided at school Step 5: SBHC submits encounter/billing report and receives reimbursement from Amerigroup 8

Top Clinic Visit Reasons Top ICD-9 Encounters (ensuring HEDIS measures) Well child care, annual physical examinations and sport exams Immunizations Asthma

Cost Savings & Effectiveness

Outcomes: Holistic, team approach for care of school-age children and their parents with SBHCs serving as medical, dental and mental health homes. New payment methods that save Medicaid money while rewarding cost-effectiveness, quality and innovation. Return on investment direct costs (healthcare: ER visits, ambulance transport, diagnostic tests, nonhealthcare: transportation to clinic), indirect costs (time lost from school)

Data Needs: -Enrollment -Disease Management -Impact of On-site Services -Impact of CHWs -Impact of Telehealth -Impact of Team Approach -HEDIS -Documentation of Cost-Savings

CHEER CHEER (Childrens Health, Education and Economic Resource) is a web based student encounter record used by health care professionals in schools Instantaneously access data at point of service View of the child across systems of care Updated with school district data every night, enabling accurate registration, look-up of encounter history, and data capture.

CHEER Encounter Screen

CMMS Innovations Project School Health Clinic Clients CHW 39

Kathryn McCollister, Ph.D. Associate Professor and Health Economist Department of Public Health Sciences University of Miami Miller School of Medicine Economic Analysis of the Enhanced School-Based Health Center

Overview of Presentation Importance of examining financial impact and economic viability of school-based health centers Present results of the cost analysis of University of Miamis school-based health centers with enhancements through CMS Health Care Innovation Challenge Award Describe range of outcome domains and specific measures that will factor into benefit-cost analyses Present preliminary results of cost-savings during first year of CMS HCIA project

Introduction School-based health centers effectively reduce barriers to accessing primary health care services and promote better management of chronic conditions among school-age children Have important role in reducing health disparities among minority and low-SES groups Reduce unnecessary and costly health services utilization such as emergency department visits Provide potential important indirect benefits to families of children attending schools with a SBHC

Introduction (continued) In addition to evaluating effectiveness of SBHCs, sustainability of these programs depends on showing that they are cost-saving Need to critically evaluate both costs of operating SBHC and outcomes to demonstrate that the benefits of these programs outweigh the costs (i.e., generate a positive return-on-investment) This presentation describes results of an economic evaluation of Miamis SBHC plus enhancements operating in nine middle and high schools around Miami-Dade County, Florida

Cost Analysis Cost data were collected for the academic year August 20, 2012 June 6, 2014 Data come from detailed staffing records and financial reports provided by UMMSM Department of Family Medicine Implementation costs including enhancements provided by the HCIA were comprised of: Personnel costs including volunteer labor Contracted services (dental, mental health) Telemedicine services Staff travel Indirect costs (administrative overhead)

Cost Analysis (continued) Results presented in Table 1 Total annual cost: $1.7 million Opportunity cost of volunteer labor amounted to $409,712 Average cost per student visit: $400 Average cost per contact including family visits: $376

Student/Patient Information Number of Students Seen During the Year 5,572 Total Number of Visits During the Year17,223 Average Number of Students Seen Per Week 521.4 Average Number of Indirect Contacts Per Week 33.5 Cost Information$ Personnel including volunteer labor701,403 Contracted Services63,363 Center for Haitian Studies657,699 Larkin Hospital55,170 Nova (dental)92,579 Staff travel1,254 Indirect Costs138,540 Total Annual Cost1,710,008 Annual Cost Per Student/Patient16,398 Average Cost Per Visit400 Average Cost Per Contact (health suite + indirect contacts) 376

Cost Savings Several outcomes of interest to examine cost-savings of the SBHCs Some more directly related to presence of SBHC, others indirectly related Sexually transmitted infections and pregnancies Chlamydia HIV Chronic conditions Asthma (controlled/uncontrolled cases, total cases treated) Obesity/overweight Diabetes

Cost Saviongs Mental Health Disorders ADHD Depression Anxiety Substance use disorders Dental Health Sealants (total cases treated) Varnishes (total cases treated) High risk for caries Plaque White spots Obvious decay Bleeding gums Restorations

Cost Savings & Effectiveness (Contd) Immunizations Influenza Tdap Hib Varicella MMR HPV Hep B Health Care Services Emergency department visit Hospital inpatient day Educational Attainment Graduation from high school Day missed from school

Cost Savings (continued) Total annual savings calculated by valuing improvements in these outcomes For instance, the avoided costs by diagnosing and treatment chlamydia is $329 per case The avoided costs of tooth decay from sealants is $XXXXX The avoided costs from Tdap (reduced incidence of pertussis) is $XXX Table 2 presents a cost-savings template that will allow us to estimate benefits accruing across many outcomes The monetary conversion factors describe the economic value per unit of outcome and come from published scientific studies

Table 2 - Cost savings template Outcome Estimates - Incidence During Past Year (Apr 2013 - Mar 2014) Monetary Conversion Factors (cost per outcome in 2013 dollars) Total Savings Over the Year in 2013 dollars Sexually Transmitted Infections a Chlamydia - number of positive screens38329$12,502 HIV2233174$466,348 Gonorrhea 169 Pregnancies 7670 Chronic Conditions Asthma - cases treated b 1755300 Asthma - uncontrolled cases66 Asthma - controlled cases106 Obesity/Overweight - cases diagnosed c 3262 Diabetes - cases diagnosed or monitored as borderline d 7979 Mental Health Disorders ADHD - cases diagnosed Depression diagnoses Anxiety diagnoses Other Mental Health Substance Use Disorders - diagnoses Dental Health e Sealants517 Varnishes316 High Caries risk (%) Plaque (%) White spots (%) Obvious decay (%) Bleeding gums (%) Restorations - number 411443.4$178,548 Immunizations Influenza h 35 HPV 1657.8 Tdap i 512.1 Hib -- Hep B -- Varicella -- MMR -- % in compliance with immuniz. status98.3% Health Services Emergency department visit 6240 Hospital (inpatient) day 2122 Educational Attainment Graduation from high school Day missed from school Total Annual Savings $ DRAFT

Cost savings and effectiveness preliminary results Reflecting on past year, main areas of impact are seen in sexually transmitted infections and pregnancies, dental health, and immunizations Also improving management of asthma and mental health disorders results still being evaluated over a longer timeframe Preliminary results presented in Table 3

Discussion Preliminary findings show notable savings being generated across multiple areas The most immediate impacts are occurring in diagnosing and treating STIs, improving dental health, and promoting immunizations Benefits also accruing to health care system from reduced ED visits, getting families enrolled in Medicaid and connected with health care services through the SBHCs Even more distal outcomes such as fewer days missed from school and higher graduation rates could be associated with SBHC

Discussion (continued) Limitations include limited baseline data to analyze changes pre- and post-SBHC and no control group Also reliance on estimates from the literature that are in some cases outdated or generated from a different population Next steps are to examine changes in outcomes between Year 1 and Year 2 Also conducting multivariate analyses to estimate key predictors of uncontrolled asthma cases and associated costs in this population (mainly African American and Hispanics)

The project described is supported by Grant Number 1C1CMS331028 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies." The project described is supported by Grant Number 1C1CMS331028 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies."

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alternative payment methods & cost savings analysis: emerging results from sbhc innovation study

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