healthcare reform & school-based health centers

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Transforming Healthcare Through

Clinical Innovations, Technology Solutions, and

Business Efficiencies

Trivantage Solutions

HEALTHCARE REFORM

& SCHOOL-BASEDHEALTH CENTERS

Maryland Assembly on School-Based Health Care

May 17, 2012

Cindy Friend, RN, BSN, MSN, MBA/HCAManaging Director

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Continuous Improvement is a Quality Movement

AGENDAOverview of the Patient Protection and Affordable Care Act (ACA)

ACA Impact on SBHCs

Emerging Health Care Delivery ModelsAccountable Care Organizations (ACO)

Patient-Centered Medical Home (PCMH)

Opportunities for SBHCs to become involved in the Healthcare Reform movement

Strategies to assist SBHCs in quality improvement efforts

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PATIENT PROTECTION & AFFORDABLE CARE ACT

On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act (ACA), into law

The ACA includes provisions to expand coverage, control health care costs, and improve the health care delivery system

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OVERVIEW OF THE ACA

Create state-based American Health Benefit Exchanges through which individuals can purchase coverage

Premium and cost sharing credits available to individuals/families with income between 133-400% of the federal poverty level (the poverty level is $18,310 for a family of three in 2009)

Create separate Exchanges through which small businesses can purchase coverage

Require employers to pay penalties for employees who receive tax credits for health insurance through an Exchange, with exceptions for small employers

Impose new regulations on health plans in the Exchanges and in the individual and small group markets

Expand Medicaid to 133% of the federal poverty level

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ACA PROVISIONSIndividual Mandate

Requirement to have coverageEmployer Requirements

Requirement to offer coverageOther Requirements

Expansion of Public Programs

Treatment of MedicaidTreatment of CHIP

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ACA PROVISIONS (CONT)

Premium and Cost-Sharing Subsidies to Individuals

Eligibility

Premium credits

Cost-sharing subsidies

Verification

Subsidies and abortion coverage

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Premium Subsidies to EmployersSmall business tax creditsReinsurance program

Tax Changes Related to Health Insurance or Financing Health Reform

Tax changes related to health insuranceTax changes related to financing health reform

Benefit DesignEssential benefits packageAbortion coverage

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Health Insurance ExchangesCreation and structure of health insurance exchangesEligibility to purchase in the exchangesPublic plan optionConsumer Operated and Oriented Plan (CO-OP)Benefit tiersInsurance market and rating rulesQualifications of participating health plansRequirements of the exchangesBasic health planAbortion coverageEffective dates

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Changes to Private insuranceTemporary high-risk poolMedical loss ratio and premium rate reviewsAdministrative simplificationDependent coverageInsurance market rulesConsumer protectionsHealth care choice compacts and national plansHealth insurance administration

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State RoleRegulator mandates

Cost ContainmentAdministrative simplificationMedicareMedicaidPrescription drugsWaste, fraud, and abuse

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Improving Quality/Health System Performance

Comparative effectiveness researchMedical malpracticeMedicareDual eligibleMedicaidPrimary careNational quality strategyFinancial disclosureDisparities

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Prevention/WellnessNational strategyCoverage of preventive servicesWellness programsNutritional information

Long-Term CareCLASS ActMedicaidSkilled nursing facility requirements

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Other InvestmentsMedicareWorkforceCommunity health centers & school-based health centersTrauma carePublic health and disaster preparednessRequirements for non-profit hospitalsAmerican Indians

FinancingCoverage and financing

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ACA IMPACT ON SBHCS

The ACA requires HHS to establish new programs to support School-Based Health Centers (Title IV, Section 4101(a))

Authorizes the Health Resources and Services Administration (HRSA) to administer the School-Based Health Centers Capital (SBHCC) Program

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SBHCC PROGRAMGrants are intended to address capital funding that is needed to improve delivery and support expansion of services at SBHCs

Applicants must demonstrate how their proposal will lead to improvements in access to health services for children at a SBHC

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SBHCC PROGRAM (CONT)

A cap of $500,000 has been established as the maximum amount of Federal funding that can be requested in a SBHCC application

An eligible applicant may submit one application proposing a maximum of 10 projects

This may include any combination of site-specific, stand-alone facility projects, and one project to purchase moveable equipment, for example

HRSA received approximately $100 million to fund grants to an estimated 200 SBHCC grants in FY 2011

For more information visit: http://www.hrsa.gov/grants/apply/assistance/sbhcc/

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FUNDING OPPORTUNITY ANNOUNCEMENT

HRSA issued a Funding Opportunity Announcement (FOA) in October 2010

In June 2011, HRSA awarded 278 grants under the SBHCC Program FOA totaling $95M

$934,435 was awarded to 4 Maryland SBHCs

May 9, 2012, HHS announced $75M available through the SBHCC program for the renovation and construction of SBHCs

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HEALTHCARE REFORM DELIVERY MODELS

Accountable Care Organizations (ACOs)

Patient-Centered Medical Homes (PCMHs)

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ACO OVERVIEWA group of providers that come together for the purpose of rendering coordinated, high quality care

Providers includes hospitals, primary care, specialists, and other health care providers

Establish patient population management and innovative care delivery model

Model based on shared accountability and funded through shared savings arrangements

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ACA AND ACOSACO mentioned in all draft reform bills

Included in Section 3022 of the ACA, entitled Shared Savings Programs

Authorized CMS to create an ACO program by no later than January 1, 2012

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CMS ACO PROGRAMSCMS has launched a couple of programs to incentivize providers to link together and exchange data in order to lower costs and share savings

Medicare Shared Savings ProgramA program that helps a Medicare fee-for-service program providers become an ACO

Advance Payment InitiativeA supplementary incentive program for selected participants in the Shared Savings Program

Pioneer ACO ModelA program designed for early adopters of coordinated care (no longer accepting applications)

For more information visit: http://innovations.cms.gov/initiatives/ACO/index.html

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ACO ACCREDITATION OPTIONS

National Committee for Quality Assurance (NCQA)

Program launched in November 2011

Six organizations had applied for ACO accreditation in January 2012

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ACO STANDARDS (PER NCQA)

ACO Structure and Operations

Access to Needed Providers

Patient-Centered Primary Care

Care Management

Care Coordination and Transitions

Patient Rights and Responsibilities

Performance Reporting and Quality Measures

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PCMH OVERVIEW1967: The American Academy of Pediatricians (AAP) introduced the term “medical home” and it was AAP policy within a decade

1978: The World Health Organization (WHO) outlined some of the basic tenets of the medical home and the importance of primary care

1990’s: Medical Home concept embraced by Institute of Medicine (IOM)

2002: Study by Family Medicine resulting in The Future of Family Medicine: A Collaborative Project of the Family Medicine Community

2004: American Academy of Family Physicians (AAFP) PCMH Demonstration

2006: Patient-Centered Primary Care Collaborative (PCPCC) was established

2008: First release of NCQA Recognition standards

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JOINT PRINCIPLES

Whole person orientation

Safety and quality

Care coordination and integration

Personal Provider

Enhanced Access

Continuity of Care

Capacity and AccountabilityFor more information visit:

http://www.pcpcc.net/

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PCMH FRAMEWORK

Well-organized and on-time visits

Enhanced access with a self-selected provider for continuity (same day appointments, 24/7 clinical support, alternatives to the 1:1 visit)

Proactive care management (evidence based clinical care, panel management, reminder systems, registries)

Care coordination across settings (assistance with referrals, tracking for tests and referrals, care during transitions)

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PCMH FRAMEWORK (CONT.)

Patient engagement, and participation in care decisions (provider-patient relationship, patient-centered, and consumer driven)

Connections to community resources to extend support for self-care management

Health outcomes focused and plan for continuous improvement

Data driven use of health IT as a tool to support the advancement of primary care

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A FORMULA FOR SUCCESS

Well-trained workforce organized as a multi-disciplinary care teams

Mutual accountability among the team and between team and patients

System designed to support care management and coordination through enhanced access, continuity, and information availability

Cross boundary cooperation and partnership among all provider types

Technology infrastructure for information management and exchange

Payment reform to support the work

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PCMH ACTIVITY IN MARYLAND

On April 13, 2010, Governor O’Malley signed House Bill 929: Patient Centered Medical Home Program into lawStatute authorizes the Maryland Health Care Commission (MHCC) to establish a multi-payer PCMH programMHCC is also permitted to authorize a single carrier PCMH programEffective from July 1, 2011 through December 31, 2015

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PCMH ACTIVITY IN MARYLAND

• Large payers• PMPM• 3 year Pilot• 53 practices• Quality Measures• NCQA Recognition required

Maryland’s Multi-Payer

PCMH Program (MMPP)

• Single Payer• Multiple Incentives• Live Program• Over 3K PCPs• Pt Care Account/Quality Measures• NCQA Recognition Not Required

CareFirst Primary Care Medical Home

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PCMH CERTIFICATION OPTIONS

National Committee for Quality Assurance (NCQA)

The Joint Commission (TJC)

URAC (formerly the Utilization Review Accreditation Commission)

Accreditation Association for Ambulatory Health Care (AAAHC)

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CERTIFICATION OPTIONS COMPARISON

Program Details NCQA TJC URACProgram Name Patient-Centered Medical Home

(PCMH) Primary Care Medical Home (PCMH) Patient Centered Health Care Home (PCHCH)

Award Label Recognition Certification Certificate of AchievementAccreditation Required No Yes NoLevel of Assessment Practice Site Organization Practice SiteLevels of Achievement Yes, Levels 1, 2, 3 Pass/Fail Pass (65%)/FailSubmit documentation Yes No YesOn-site survey required No Yes YesOn-site survey administered by: N/A TJC Surveyor Independent Certified URAC

PCHCH Auditor# of Categories 6 (Standards) 5 (Op. Characteristics) 7 (Modules)# of Standards 28 (Elements) 12 (Focus Areas) 28 (Standards)# of Requirements 152 (Factors) 47 (Requirements) 162 (Elements)Must pass standards 6 (Elements) All 7 (Standards)Length of award 3 years 3 years 2 years

Scoring

Level 1: 35-59; Level 2: 60-84; Level 3: 85-100Including the 6 Must-Pass Elements with at least 50% for each and identified Critical Factors

In addition to achieving accreditation, the practice must meet the additional requirements consisting of five operational characteristics and 12 focus areas.

Overall score of 65%. The 7 mandatory standards that must be at least partially implemented + additional selected essential standards

CostApplication fee of $500 per clinician, plus $80 for the survey tool

PCMH certification included w/accreditation. Accreditation fees includes a fee for the initial survey and an annual fee. Fees based upon annual visits. Range for initial survey: $3,445 for <10,000 up to $13,540 w/ >120,000Range for annual fee: $1,950 for <10,000 up to $4,640 for >120,000Cost range for additional sites: $1,190 for 1-2 to $5,905 for 9-10.

Fees are per clinician:1-3 = $720 (additional standards are $1,155 each); 4-7 = $1,440 (additional standards $1,875 each); 8-20 = $2,400 (additional standards $2,835). The PCHCH Toolkit is available for $59. Onsite survey costs ~$1,500/day plus travel & lodging.


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PCMH STANDARDS & REQUIREMENTS (BASED ON NCQA)

Points Standard and Element No. Factors Critical Factors Meaningful Use Must Pass (50% score)20 1 Enhance Access and Continuity 34 3 4 A Access During Office Hours 4 Factor 1 X4 B After-Hours Access 5 Factor 3 2 C Electronic Access 6 - 1 C, 2 M, 3 C 2 D Continuity 3 - 2 E Medical Home Responsibilities 4 - 2 F Culturally and Linguistically Appropriate Services (CLAS) 4 - 4 G The Practice Team 8 Factor 2 16 2 Identify and Manage Patient Populations 34 0 3 A Patient Information 12 - 1, 2, 3, 4, & 5 C 4 B Clinical Data 9 - 1-9 C 4 C Comprehensive Health Assessment 9 - 5 D Use Data for Population Management 4 - 1 & 2 M X17 3 Plan and Manage Care 24 3 4 A Implement Evidence-Based Guidelines 3 Factor 3 1 C 3 B Identify High-Risk Patients 2 - 4 C Care Management 7 - X3 D Medication Management 6 Factor 1 1 M 3 E Use Electronic Prescribing 6 Factor 2 1-3 C and 6 M 9 4 Provide Self-Care Support and Community Resources 10 1 6 A Support Self-Care Process 6 Factor 3 2 M X3 B Provide Referrals to Community Resources 4 - 18 5 Track and Coordinate Care 25 2 6 A Test Tracking and Follow-Up 10 Factors 1 and 2 9 M 6 B Referral Tracking and Follow-Up 7 - 6 C and 7 M X6 C Coordinate with Facilities/Care Transitions 8 - 8 M 20 6 Measure and Improve Performance 22 0 4 A Measure Performance 4 - 4 B Measure Patient/Family Experience 4 - 4 C Implement Continuous Quality Improvement 4 - X3 D Demonstrate Continuous Quality Improvement 4 - 3 E Report Performance 3 - 2 F Report Data Externally 4 - 1 C; 3 & 4 M 0 G Use Certified EHR Technology 2 - 1 & 2 C

100 Points 28 Elements 152 Factors 9 Critical Factors 15 Core 10 Menu 6 MP = 29 pts

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OPPORTUNITIESStay current on healthcare activities

Take advantage of funding opportunities

Tap into community resources

Collaborate and coordinate among SBHCs

Adopt and utilize health IT

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STRATEGIES FOR QUALITY IMPROVEMENT

Identify a quality improvement champion

Establish a healthcare transformation team

Engage a subject matter expert to facilitate transformation

Conduct comprehensive clinical, technical, and business assessments

Identify and engage Stakeholders

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STRATEGIES FORQUALITY IMPROVEMENT (CONT)

Develop/evaluate programs and initiatives

Progressive program promotion/awareness

Coordinate efforts

Cost-sharing

Adopt technology

Participate in community and political events

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TIPS FOR TRANSFORMATION

Assess

Plan

Prepare

Leverage Resources

Execute

Study & Scrutinize

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CINDY FRIEND, RN, BSN, MSN, MBA/HCAMANAGING DIRECTOR443.413.6901CINDYFRIEND@TRIVANTAGESOLUTIONS.COMWWW.TRIVANTAGESOLUTIONS.COM


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