1. Understanding ACOs in Minnesota
Marie Zimmerman
Minnesota Department of Human Services
CHW Alliance June 5, 2014

2. Why transformation is needed
State budget pressures Medicaid program and other payers of health care.
Provider financial incentives do not encourage reducing cost and improving quality of care – volume vs. value.
Provider innovation to lower cost and improve quality is often penalized, not supported.
Health outcomes for Medicaid enrollees and other populations need improvement.
Care should be centered around patients and their families.

3. Moving toward value-based incentives
Addressing these challenges will require important changes in provider payment and methods of delivering care
Key roles need to be played by all — consumers, employers, providers, health plans, government and other — to effect this transformation
Payment systems should:
Give providers the freedom and support necessary to foster innovation within the delivery system so that they can determine the most efficient and effective means of providing and improving health.
Provide the opportunity to replicate these innovative care models across the state of Minnesota.

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. Accountable Care Organization**
A group of health care providers, with collective responsibility for patient care that helps coordinate services – delivering high quality care while holding down costs*
Innovation lies in the flexibility of their structure, payments and risk assumption (i.e., how much “skin in the game” they have in terms of controlling costs and improving quality)
Likely to include PCPs, specialists, and likely a hospital, and other provider and community agreements/partnerships. May need the ability to administer payments, set benchmarks, measure performance, and distribute savings
*Robert Wood Johnson Foundation,
**Accountable Care Organizations: A new model for sustainable innovation, Deloitte Center for Health Solutions
Slide provided by Center for Health Care Strategies (CHCS)

6. Key Issues for ACOs Identifying a feasible payment model
Shared savings/risk
Per member per month payments
Global budget
Bundled payments for episodes of care
Building atop existing delivery system reform efforts
Patient-centered medical homes
Health homes (Medicaid, Section 2703 of ACA)
Dual eligibles integration
Slide provided by Center for Health Care Strategies (CHCS)

7. Key Issues for ACOs, Cont’d
Requiring core provider capabilities
Patient stratification
Patient-centered care management and coordination
Population health management
Data infrastructure and analytics
Engaging providers, communities, and patients
Program planning processes
Governance structure
Provider criteria
Ongoing mechanisms for input
Slide provided by Center for Health Care Strategies (CHCS)

8. Key Issues for ACOs, cont’d
Including unique high-cost populations
Dual eligibles
General assistance and expansion populations
Defining the scope of services
Medical services
Behavioral health
Long term supports and services
Social services
Selecting appropriate quality metrics
Align with existing programs
Measure targeted outcomes
Tailor metrics to sub-populations patients
Tie payment to quality
Slide provided by Center for Health Care Strategies (CHCS)

9. Key Issues for ACOs, cont’d
Supporting provider capabilities
Learning collaboratives
ACO coaches
Training sessions
IT/data supports
Aligning with other payers
Medicare Shared Savings and Pioneer ACOs
Commercial TCOC/ACO arrangements
State Innovations Model
Partnering with CMS
CMS Concept papers for key components
Identifying appropriate regulatory approach
Slide provided by Center for Health Care Strategies (CHCS)

10. National ACO models Medicare Shared Savings Program (CMS)
Eligible providers, hospitals, and suppliers participate in ACOs to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs.
Advance Payment ACO Model provides supplemental support from CMMI to physician-owned and rural providers for start-up resources to build the infrastructure (e.g., staff, improving information technology systems, etc.)
Pioneer ACO Model (CMMI)
For early adopters of ACOs
Designed to support organizations with experience operating as ACOs or in similar arrangements in providing more coordinated care to beneficiaries at a lower cost to Medicare. The Pioneer ACO Model will test the impact of different payment arrangements in helping these organizations achieve the goals of providing better care to patients and reducing Medicare costs.
Slide provided by Center for Health Care Strategies (CHCS)

11. Minnesota’s ACO Models
Minnesota Medicaid ACOs
Integrated Health Partnerships (IHP)
Hennepin Health
Integrated Care System Partnerships (ICSP)
Commercial ACO/TCOC Agreements
Health care providers and systems participate in a range of different delivery and payment arrangements aimed at improving the Triple Aim
May include performance based on outcomes/quality and cost; varying levels of financial risk from shared savings to sub-capitation
Many use MN Community Measurement TCOC metric and quality measures
Arrangements can be across multiple population (self-insured, commercial and government) for some health plans

12. Minnesota’s Approach to Medicaid ACO development
Define the “what” we seek, rather than the “how”
Provide multiple opportunities for innovation under a framework of several models
Allow for local flexibility and innovation under a common framework of accountability
Framework of accountability includes:
Models based on, and with accountability for, total cost of care TCOC)
Robust and consistent quality measurement
Models that drive rapidly away from the incentive “to do more”
Models that drive rapidly towards increasing levels of integration

13. Minnesota Medicaid ACO model: Integrated Health Partnerships (IHP)
Three Examples
Minnesota Medicaid ACO model: Integrated Health Partnerships (IHP)
Previously the Health Care Delivery System (HCDS) demonstration
Hennepin Health: a Safety Net ACO
Integrated Care System Partnerships (ICSPs)

14. Example 1: Minnesota’s Medicaid ACO Demonstration: IHP
“The Minnesota Department of Human Services shall develop and authorize a demonstration project to test alternative and innovative health care delivery systems, including accountable care organizations that provide services to a specified patient population for an agreed- upon total cost of care or risk/gain sharing payment arrangement.”
(Minnesota Statutes, 256B.0755)

15. IHP Process and Timeline
Started with an RFI process, to gather input
Developed and issued initial RFP in summer 2011
Responses received were broadly representative of geographic and organizational structure
6 provider systems, serving ~100,000 Medicaid enrollees, started in our IHP model in January 2013
3 additional provider systems began in 2014, for a total of ~145,000 Medicaid enrollees currently being served
Released an updated RFP in February 2014 seeking additional providers to begin in January 2015

16. Minnesota’s Medicaid ACO Demo (IHP): 145,000 enrollees total
Geographic area
Size
(# Attributed)
CentraCare
Central MN, north of Minneapolis/St. Paul
11,037
Children’s Hospital
Minneapolis/St. Paul
16,066
Essentia Health
Duluth/NE MN
30,485
FQHC Urban Health
Network (10 FQs)
23,757
Hennepin Healthcare System/HCMC
24,558
Mayo Clinic
Rochester/SE MN
5,985
North Memorial
3,824
Northwest Health Alliance (Allina/HealthPartners)
12,194
Southern Prairie Community Care
Marshall/SW MN
17,947

17. Provider Characteristics/Requirements
IHP providers must
Deliver the full scope of primary care services.
Coordinate with specialty providers and hospitals.
Demonstrate how they will partner with community organizations and social service agencies and integrate their services into care delivery.
Have flexibility in governance structure and care models to encourage innovation and local solutions.

18. Accountability Framework
Providers contract with DHS under one of two models: Virtual IHP or Integrated IHP.
The models include the same framework but have different financial arrangements.
The goal was to ensure broadest possible participation and available options.
The agreements are 1-year contracts that renew annually for the 3-year demo period.

19. Accountability for Total Cost of Care
The IHP is accountable for its attributed Medicaid enrollees’ Total Cost of Care (TCOC)
Both fee-for-service (FFS) and managed care (MCO) recipients attributed
TCOC is defined as subset of Medicaid services health care organizations can reasonably be expected to impact. IHP may elect to add excluded services.
Generally includes inpatient, outpatient, physician/professional ,pharmacy, certain mental health and chemical health services
Generally excludes dental, supplies, transportation, long term services and supports
Existing provider payment for services persists during the demo, with shared savings/loss payments made annually based on risk-adjusted TCOC performance

20. Patient’s Included IHP (Attribution)
Patient attribution is based on where the patient had the most visits using health care claims data; goal is for attribution to reflect established patient/provider relationship.
Attribution is based primarily on health care homes (HCH) and primary care provider (PCP) relationships.
Patients still maintain freedom of choice, no “opt out” required.
IHP receives monthly attribution roster of people for whom they are accountable.
All Medicaid populations are included except for people dually eligible for Medicare and Medical Assistance.

21. Accountability for Quality/Patient Experience
IHP performance on core set of measures based on existing state reporting requirements – Minnesota’s Statewide Quality Measurement and Reporting System (e.g. optimal diabetes, asthma, and vascular care; depression remission)
Core includes 7 clinical measures and 2 patient experience measures, across both clinic and hospital settings
IHPs have flexibility to propose alternative measures and methods
Performance on quality measures impacts the amount of shared savings an IHP can receive; phased in over 3-year demo

22. Example 2: Hennepin Health
“Safety-net ACO”
Population focus: adults on Medicaid with incomes below 133% FPG ~ 8,600
Integrated county model; health care, behavioral health, social services
Opportunity for savings outside the Medicaid program to county services
Hennepin county: Minnesota’s largest county (Minneapolis)
NOTE: CBP

23. Example 3: Integrated Care System Partnerships (ICSPs)
Initiative within Minnesota Senior Heath Options/Senior Care+ (MSHO/MSC+) and Special Needs Basic Care (SNBC) managed care programs for seniors and people with disabilities, designed to align with statewide HCH, SIM and Medicaid ACO provider payment reform initiatives
Expands and builds on Medicare/Medicaid MCOs and provider contracting arrangements and experience; Leverages Medicare involvement in State payment reforms
Encourages improved health outcomes and choice of care setting
Encourages long-term care provider involvement
Encourages increased coordination of physical and behavioral health
30 MCO/Provider ICSP proposals accepted for implementation for January 2014, with additional ICSPs required for 2015

24. Opportunities for CHWs in ACOs
Contribute to ACO performance on the Triple Aim:
Health care expenditure savings
Quality measures/health outcomes
Patient/Consumer Experience
How can CHWs help ACOs achieve their goals?
Better understanding of communities/populations they serve
Act as a member of the care team to provide the connection between clinical and community services
Trust of the client to facilitate consumer/patient-provider communication and education
Savings achieved can help finance CHWs in ACOs

25. Next Steps
Minnesota’s SIM grant builds on IHP and other ACOs in the market
SIM funding for CHWs and other emerging professions
Expansion to additional populations (duals, complex)
Increasing importance placed on partnership with non- traditional health care providers and services and community involvement
Strong emphasis on integration of acute care and other care settings and long-term services and supports (more global community responsibility)
Demonstration Projects will last three years
BUT:
Reconciliation payments at least annually and contract terms re-visited annually
Aount of risk will be proposed by the delivery system and negotiated with DHS

26. Contact
Marie Zimmerman Health Care Policy Director Minnesota Department of Human Services Phone: (651)