payment reform quarterly update

Payment Reform Quarterly Update

August 23, 2016

Agenda

I. Payment Reform

I. P4PII. HHP / Section 2703 III.APM PilotIV.CP3

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CPCA Payment Reform Strategy

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CPCA Payment Reform

Strategy

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Medi-Cal P4P Core Measure Set

© 2016 Integrated Healthcare Association. All rights reserved. 6

Health care measurement important to assess health system performance and improve care delivered

Number and scope of measures providers held accountable for steadily increasing

Lack of alignment across incentive programs creates unnecessary burdens on providers and confusion among consumers

As Medi-Cal enrollment increases and Medi-Cal shifts to managed care, imperative emerging for consistent performance measurement

Performance Measurement Landscape


Medi-Cal P4P Inventory: Program Prevalence

P4P Programs

Of the 20 Medi-Cal managed care plans interviewed, 16 have pay-for-performance programs in place

The P4P programs vary in extent and approach

Overview of Current P4P Activities

Number of Plans

P4P Programs in Place 16

Just Starting 1

Started 2009 - 2013 5

Started 2004 - 2008 3

Started 2003 and before 7

No P4P Program in Place 4

Total 20


Why do we need greater standardization?

Only 1 measure aligns across all programs:

Diabetes HbA1c Testing

California Health & Wellness

Cal Optima

CenCal

Central California Alliance

Health Net

Health Plan of San

JoaquinHealth

Plan of San Mateo

Inland Empire Health

Plan

Kern Health

Systems

LA Care

Partnership

San Francisco

Health Plan

Anthem

Medi-Cal

Only 2 measures align across all programs:

1. Controlling Blood Pressure for People with Hypertension

2. Diabetes: Medical Attention for Nephropathy

Federal Quality Rating

System for Covered

California

CMS & AHIP Core Quality

Measures Collaborative

Medicare Advantage

Stars

IHA Value Based P4P

DHCS External

Accountability Set

Cross Product

Only one measure out of 86 distinct measures align across all programs (based on IHA’s 2014 inventory)

Only two measures align across all measure sets


Reduce unnecessary burdens associated with the lack of

alignment across incentive programs

Enhance provider effectiveness by “strengthening the signal”

–focus improvement efforts and resources

Facilitate the comparability of performance results and

benchmarking statewide

Benefits of a Core Measure Set


Convene an Advisory Committee to provide expertise and guidance across project activities

Identify a core measure set that all plans could adopt as a part of their P4P programs

Develop a menu of additional measures that plans can use to supplement the core measure set at the local level as well as a set of incentive design principles and best practices

Funding – Blue Shield of CA Foundation

Timeline: April 2015 – March 2016

Medi-Cal P4P Core Measure Set


Health Plans Alameda Alliance for Health Anthem Blue Cross California Health & Wellness CalOptima CenCal Health Central California Alliance for Health Health Net Health Plan of San Joaquin Health Plan of San Mateo Inland Empire Health Plan Kern Health Systems LA Care Health Plan Partnership Health Plan San Francisco Health Plan UnitedHealthcare

Standardizing Medi-Cal Advisory Committee

Collaborators American Institutes of Research

Blue Shield of California Foundation

California HealthCare Foundation

California Quality Collaborative

Center for Care Innovations

Center for Health Care Strategies

Health Services Advisory Group

John Snow, Inc.

Provider Representatives

Alameda Health Consortium

AltaMed

CHOC Health Alliance

Community Clinic Association of Los Angeles County

Community Medical Centers

County of San Mateo

Family Care Specialists Medical Group

Hill Physicians

Integrated Health Partners

Omnicare Medical Group IPA

Palo Alto Medical Foundation

San Mateo Medical Center

Santa Clara Valley Health & Hospital System

Santa Rosa Community Health Centers

Shasta Community Health Center

SynerMed

West County Health Center

Associations California Association of Health Plans

California Primary Care Association

CAPG

Local Health Plans of California

Safety Net Institute

California Department of Health Care Services


Medi-Cal P4P Continuum

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Voluntary Core

Measure Set; shared

specifications and

benchmarks

Voluntary Core & Supplemental

menu of measures;

shared specifications

and benchmarks

Quality based P4P in Medi-Cal; Core and Supplemental measure set

and incentive design

required; payment

amount not required

Quality based P4P in

Medi-Cal; payment amount required

Value based P4P in

Medi-Cal; payment based on

quality and resource use

Voluntary Core and

Supplemental menu of

measures and incentive

design options

IHA’s Standardizing Medi-Cal P4P Project

Current Status Medi-Cal P4P –Uniform/Broad Adoption

COORDINATION / COLLABORATIONLESS MORE

No formal coordination/collaboration;

Variation in performance measurement

& incentive design


Key features of the Core Measure Set:

• No more than 10 measures

• Included in DHCS’s External Accountability Set

• Feasible for a wide array of providers to report using administrative only data

Core Measure Set Overview

CORE MEASURE SET

Domain Measures Steward NQF #

CardiovascularAnnual Monitoring for Patients on Persistent Medications: ACE or ARB NCQA 0021

Annual Monitoring for Patients on Persistent Medications: Diuretics NCQA 0021

Diabetes Care

HbA1c Testing NCQA 0057

HbA1c Control (<8.0%) NCQA 0575

Eye Exam NCQA 0055

Maternity Timeliness of Prenatal Care NCQA 1517

Prevention

Childhood Immunizations, Combo 3 NCQA 0038

Well-Child Visits in 3rd, 4th, 5th, and 6th Years of Life NCQA 1516

Cervical Cancer Screening NCQA 0032

Respiratory Medication Management for People with Asthma – Medication Compliance 75% NCQA 1799


A menu or library of additional measures that plans can use to supplement the core measure set at the local level

Selection Criteria:

1. EAS measures that were not included in the core measure set

2. Additional measures currently included in Medi-Cal P4P programs

3. Measures included in more than one of the other existing performance measurement requirements for Medi-Cal plans and providers, including:

o DHCS EAS

o Covered California’s Quality Rating System

o NCQA Medicaid Managed Care Health Plan Accreditation Standards

o CMS Medicaid Core Measures for Adults and Children

Supplemental Measure Set Overview


Supplemental Measure Set

Access Children and Adolescents’ Access to PCPs NCQA 1390

Behavioral Health /

Substance Abuse

Antidepressant Medication Management NCQA 0105

Follow-Up for Children Prescribed ADHD Medication NCQA 0108

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment NCQA 0004

Cardiovascular Controlling blood pressure for people with hypertension NCQA 0018

Diabetes Care

Blood Pressure Control <140/90 mm Hg NCQA 0061

HbA1c Poor Control >9% NCQA 0059

Medical Attention for Nephropathy NCQA 0062

Maternity Timeliness of Postpartum Care NCQA 1517

Musculoskeletal Overuse of Imaging Studies for Low Back Pain NQCA 0052

Prevention

Adolescent Well-Care Visits NCQA n/a

Adult BMI Assessment NCQA n/a

Breast Cancer Screening NCQA 2372

Childhood Immunizations, Combo 10 NCQA 0038

Chlamydia Screening NCQA 0033

Colorectal Cancer Screening NCQA 0034

Flu Vaccinations for Adults Ages 18-64 NCQA 0039

Human Papillomavirus Vaccine for Female Adolescents NCQA 1959

Immunizations for Adolescents NCQA 1407

Medical Assistance with Smoking & Tobacco Cessation NCQA 0027

Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents: NCQA 0024

Well-Child Visits in the First 15 Months of Life (6 or more visits) NCQA 1392

Respiratory

Asthma Medication Ratio NCQA 1800

Appropriate Testing for Children with Pharyngitis NCQA 0002

Appropriate Treatment for Children with URI NCQA 0069

Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis NCQA 0058

Resource UseAll-Cause Readmissions NCQA 1768

Emergency Department Visits NCQA n/a


• Creation of consensus core, supplemental measure sets

• Active and engaged Advisory Committee, including both plans and providers

• Strong interest from plans not initially involved

• DHCS engagement, including seeking guidance from AC on measure set update

Results to Date


• Core measure set adoption underway – intent to adopt by 6 plans for MY 2017, partial adoption by 7 more

Adoption Efforts to Date

Intent to adopt for MY 2017 Partial adoption for MY 2017

1. Alameda Alliance 1. CalOptima

2. Anthem Blue Cross 2. CalViva

3. California Health & Wellness 3. Health Net

4. CenCal 4. Health Plan of San Joaquin

5. Central California Alliance for Health 5. Health Plan of San Mateo

6. LA Care 6. Partnership Health Plan

7. San Francisco Health Plan


Next Phase of Standardizing Medi-Cal P4P

Create greater measure set alignment across the policy landscape

Support the implementation of the core measure set across all Medi-Cal P4P programs

Spread the adoption of the core measure set to plans not participating on the Advisory Committee

Funding – CMMI (included in Transforming Clinical Practices Initiative grant awarded to PBGH/CQC)

March 2016 – February 2018


Objective: • Identify opportunities for greater measure set alignment across the

policy environment

Planned Activities:• Identify initiatives underway or planned in Medi-Cal & the safety net

• Develop crosswalk of key initiatives to use as a resource toward creating a shared performance measurement strategy

• Summarize findings in an issue brief

• Support DHCS’ EAS update efforts

Timeline: • March 2016 – September 2016

Policy Initiatives -- Measure Set Status


Objective:• To support implementation efforts and create opportunities for

collaboration and learning

Planned Activities:• Convene quarterly Advisory Committee meetings

• Develop timeline and process for adopting new measures to core measure set and complete one update of core measure set

• Explore feasibility of developing benchmarks at provider level

• Explore providing access to IHA’s web-based portal

• Re-survey plans to identify issues and unintended consequences

Timeline:• March 2016 – February 2018

Implementation of the Core Measure Set


Spread Core Measure Set

Objective:• To spread the core measure set to Medi-Cal plans not currently

participating on the Advisory Committee

Planned Activities:• Schedule 1:1 meetings with plan representatives to share information

about project and the core measure set

• Develop resources to support plans with adoption

• Provide technical support to plans interested in developing P4P programs

Timeline:• March 2016 – December 2016

For more information:

Sarah Lally, [email protected]

Web: www.iha.org

mailto:[email protected]

http://www.iha.org/

California’s Health Home Program (HHP)

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Section 2703

State Option to Provide Health Homes for Enrollees with Chronic Conditions as defined by each state

• Funding for 2 years and requirement to demonstrate savings

• 90% Federal/ 10% State funding

• The California Endowment contributing California’s 10%

HHP

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State Process

• State submitted a State Plan Amendment (SPA) in March 2016.

• Based on California Concept Paper Final -Health Homes for Patients with Complex Needs final concept paper (3/29/16)

http://www.dhcs.ca.gov/services/Documents/HealthHomesForPatients_Final.pdf

HHP

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What does the HHP fund?

• Comprehensive care management

• Care coordination

• Health promotion

• Comprehensive transitional care & follow-up

• Patient and family support

• Referral to community and social support services

…services not already funded by Medicaid

* No funding for direct medical or social services.

HHP

• Target Population • The Health Homes Program (HHP) is intended to be an

intensive set of services for a small subset of members who require coordination at the highest levels.

- Individuals with two or more chronic conditions

- Individuals with one chronic condition and at risk for another;

- Individuals with serious and persistent mental illness

• The highest-risk top three to five percent of the Medi-Cal population will be eligible.

HHP• Eligibility Criteria:

1. At least two of the following: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Traumatic Brian Injury, Chronic or Congestive Heart Failure, Coronary Artery Disease, Chronic Liver Disease, Dementia, Substance Use Disorder OR

2. Hypertension and one of the following: COPD, Diabetes, Coronary Artery Disease, Chronic or Congestive Heart Failure OR

3. One of the following: Major Depression Disorders, Bipolar Disorder, Psychotic Disorders (including Schizophrenia)

And the member must also have one of the following:

1) Risk Score of at least three,

2) at least one inpatient visit in the last year, or

3) at least three ED visits in the last year.

HHP• Rollout Schedule:

Counties Physical Conditions and SUD

SMI

Del Norte, Humboldt, Lake, Marin, Mendocino, Napa, Shasta, Solano, Sonoma, Yolo, San Francisco

January 1, 2017 July 1, 2017

Imperial, Lassen, Merced, Monterey, Orange, Riverside, San Bernardino, San Mateo, Santa Clara, Santa Cruz, Siskiyou

July 1, 2017 January 1, 2018

Alameda, Fresno, Kern, Los Angeles, Sacramento, San Diego, Tulare

January 1, 2018 July 1, 2018

*HPP implementation in the following counties is not currently scheduled: Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, El Dorado, Glenn, Inyo, Kings, Madera, Mariposa, Modoc, Mono, Nevada, Placer, Plumas, San Benito, San Joaquin, San Luis Obispo, Santa Barbara, Sierra, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Ventura and Yuba

HHP

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HHP

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Logistics• Health Home Program will run through the managed care plans• They will certify and select organizations to be CB-CMEs

(community based care management entities)• CB-CME’s can be:

• Community health center • Community mental health center• Hospital or hospital-based physician group or clinic • Local health department • Primary care or specialist physician or physician group • Substance use disorder treatment provider • Providers serving those that experience homelessness • Providers serving individuals/persons diagnosed with HIV/AIDS • Other entities who meet certification and qualifications of a CB-CME may

serve in this capacity if selected and certified by the MCP

HHP

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Timeline

• February 2016: Provider Self-Assessment to help MCPs identify potential CB-CMEs

• March 2016: SPA submission to CMS

• Ongoing: Technical Assistance to prepare for program implementation

• October 2016: Rate development

• January 1, 2017: Begin HPP services in first implementation counties

APM Pilot

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California’s APM

Most Basic

• PPS rate converted to a monthly capitation payment

• Same amount you are receiving today, just paid up front on a monthly basis rather than per visit

• EXAMPLE: $175 PPS x 3 Avg Adult Visits = $525• $525/ 12 member months = $43.75 PMPM

• PPS Rules Gone- billable provider/same day visit restriction/4 walls/etc

Today- PPS

DHCS

Traditional Rate Setting

FQHC

Primary care

capitation

Health Plan Wrap around payment

FFS for mental health

• DHCS sets rates for health plans

• Plans pay primary care capitation to health centers

• Health centers bill state a wrap-around payment

• Annual reconciliation

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APM Demonstration

DHCS

Traditional Rate Setting

FQHC

APM

Health Plan

Wrap Cap-ChildAdultSPD

Expansion

• DHCS sets rates for health plans• Monthly, plan would tell State

how many medi-cal members are assigned to FQHC in demonstration.

• State would pay the plan an additional “Wrap Cap” for that site(s)• Wrap around payment

becomes a capitation payment that is AID Category specific

• Health center would receive 4 per member per month payments (Child, Adult, SPD, Expansion)

• Rate Adjustment between FQHC and plan.

• Health center receives strictly capitation for all services in their PPS rates for the four aid categories

APM Demonstration

• Plans will have risk corridor (.75%/.75%)• At risk for max of .75% of wrap cap amount. State responsible

for rest.

• Can benefit up to .75% of wrap cap if FQHC had to pay back. State would get rest.

• Possible rate adjustment at end of year• Year 1 – Rate adjustments would be occur if traditional visits

increase by more than 5% or decrease by more than 30%

• Yr 2 –more than 7.5% or decrease of more than 30%

• Yr 3 –more than 10% or decrease of more than 30%

APM Demonstration

• 3 year demonstration with volunteer health centers• Roll out will be staggered

• 3 years starts when the county starts

• Abide by Federal APM– PPS is Floor

• Health centers will continue to:• Have site-specific rates

• Have ability to do scope change (with State)

• Receive annual MEI increases (State to pass to plans)

APM Pilot Timeline

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2016

• Implementation Detail WGs – Spring • Rate Development• Contracting• Alternative Encounters

• Concept paper – Summer • Will initiate the SPA process

• Invitation/Application to all FQHCs in CA- Fall

• State will select FQHCs- Winter

2017

• Rate setting- Spring

• Launch- October

Current Work

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APM WG

• Meets monthly

• Non Traditional Services Sub WG currently reviewing list of CPT codes• State wants only non traditional services with an

associated CPT code

• Must be submitted on the 837 file

Goal of CP3

To demonstrate through statewide aggregated data

that under the APM pilot, FQHCs can help bend the

total cost of care curve, improve patient outcomes,

and enhance patient experience while remaining

financially robust.

CP3 Objectives

• Define what it means to be a successful FQHC within a value-based, managed care payment system

• Provide technical assistance and support to demonstration sites within the Alternative Payment Methodology (APM) demonstration

• Utilize the lessons learned within the pilot environment to inform future payment reform transition efforts of all California FQHCs

CP3 Measures of Success

CP3 Measures of Success

APM Demonstration External Evaluation

Measures

Clinical 1. IP Utilization: Admissions2. IP Utilization: All cause

readmissions 3. ED Visits per 1000 members4. Controlling HTN high blood

pressure5. Diabetes Control6. Childhood Immunization Status7. Cervical Cancer Screening8. Colorectal Cancer Screening9. Frequency of Ongoing Prenatal

Care10. BMI Screening & counseling11. TBD – Behavioral Health

Integration metric

Operational 12. Provider/Patient Productivity13. Staff ratio: total non-clinical/total

staff14. Member/care team ratio15. % of patients with at least 1 “touch”

in measurement year16. Total Member touches17. Continuity of Care: % of PC visits

with assigned PCP org18. Clinic staff satisfaction19. Patient Experience/Satisfaction20. Care ratings from assigned Medi-

Cal members21. TBD – Data goal around the ability

to capture social determinants of health

Submitted CP3 Measure Set

CHCC Required Capacities

Population Health Management

Data Management

Financial Management

Population Health Management

• Shifting from patients to assigned members

• Understanding who your patients are and what needs they have

• Using care teams more effectively

• Using the appropriate visit type to manage patients’ needs

• Engaging patients effectively and meaningfully

Data Management

• Foundational Elements• Data leadership & strategy

• HIT (integrated EHR, registry, PMS, accounting software)

• Data analytic expertise

• New Elements• Monitoring eligibility data & payments

• Monitoring encounter data

• Monitoring resource use

• Capturing risk stratification data

• Integrating utilization data from other sources

• Generating meaningful reports

Financial Management

• Ability/tools to plan for and manage capitated payments

• Understanding costs and revenue per site, per member, per service line, per care team/panel, etc.

• Identifying high cost/high utilizing patients

• Modeling for PMPM/budget planning for PMPM

• Ability to operate dual payment systems

Payment Reform Readiness Checklist

Designed to assess gaps and strengths in seven domain areas including: • Population health management• Leadership• Learning organization• Technology• Financial infrastructure• Patient centered care• Access innovations (non-traditional touches)

Payment Reform Readiness Preparation

• Checklist completed by 63 sites; data used to develop implementation plans

• Series of three change management webinars

• Regional Training on Finance and Operational Preparedness• August 18 & 19• September 15 & 16• September 22 & 23

• Data/Rate technical assistance

• Population Health Management Technical Assistance provided through our partner, CCI

• Additional Managed Care (data and finance) TA being developed for roll out later this year.

TA Priorities

• Population Health Management• Empanelment• Panel Management• Access• Stratifying Population• Data Collection & Management (SDOH)

• Managed Care• Monitoring eligibility data• Managing capitation payments• Understanding cost/revenue per site• Data collection & Management (SDOH and non traditional

touches)

How can you stay informed?

• CPCA Weekly Update listserv

• CPCA/CP3 Monthly Steering Committee and Wrap Cap workgroups

• CP3 Monthly Bulletin

• CPCA Website: http://www.cpca.org/index.cfm/health-center-resources/capitation-payment-preparedness-program-cp3/

http://www.cpca.org/index.cfm/health-center-resources/capitation-payment-preparedness-program-cp3/

CPCA Staff Roles

Cindy KeltnerDeputy Director Health Center

[email protected]

Lucy MorenoData Informaticist

[email protected]

Nenick VuAssociate Director of Managed Care

[email protected]

Tina CanuppAssociate Director of Health Center

[email protected]

Allie BundenzAssociate Director of Quality

[email protected]

Charlotte ReischeSenior Administrative Assistant

[email protected]







Contact

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Sara LallyProject Manager, IHA

[email protected]: P4P

Meaghan McCammanAssistant Director of Policy

[email protected]: PCHH

Andie Patterson Director of Government Affairs

[email protected]: APM

Cindy KeltnerDeputy Director [email protected]

Re: CP3



