Presentation on theme: "Understanding ACOs in Minnesota"— Presentation transcript:
1 Understanding ACOs in Minnesota Marie ZimmermanMinnesota Department of Human ServicesCHW 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 careKey roles need to be played by all — consumers, employers, providers, health plans, government and other — to effect this transformationPayment 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 ACOsDesired OutcomesValue = Better Quality + Lower Cost/“The Triple Aim”Integrated prevention, wellness, and community servicesCoordinate care across care cycleData to monitor utilization, compare and share locally and across statesNew reimbursement structures, including incentives that encourage integrated care modelsDevelop payment approaches to create incentives for value not volumeShift risk and rewards closer to point of care to foster local accountabilityRealize return on federal and state investmentsImprove access to care, outcomes and information for the enrolleeSlide 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 SolutionsSlide provided by Center for Health Care Strategies (CHCS)
6 Key Issues for ACOs Identifying a feasible payment model Shared savings/riskPer member per month paymentsGlobal budgetBundled payments for episodes of careBuilding atop existing delivery system reform effortsPatient-centered medical homesHealth homes (Medicaid, Section 2703 of ACA)Dual eligibles integrationSlide provided by Center for Health Care Strategies (CHCS)
7 Key Issues for ACOs, Cont’d Requiring core provider capabilitiesPatient stratificationPatient-centered care management and coordinationPopulation health managementData infrastructure and analyticsEngaging providers, communities, and patientsProgram planning processesGovernance structureProvider criteriaOngoing mechanisms for inputSlide provided by Center for Health Care Strategies (CHCS)
8 Key Issues for ACOs, cont’d Including unique high-cost populationsDual eligiblesGeneral assistance and expansion populationsDefining the scope of servicesMedical servicesBehavioral healthLong term supports and servicesSocial servicesSelecting appropriate quality metricsAlign with existing programsMeasure targeted outcomesTailor metrics to sub-populations patientsTie payment to qualitySlide provided by Center for Health Care Strategies (CHCS)
9 Key Issues for ACOs, cont’d Supporting provider capabilitiesLearning collaborativesACO coachesTraining sessionsIT/data supportsAligning with other payersMedicare Shared Savings and Pioneer ACOsCommercial TCOC/ACO arrangementsState Innovations ModelPartnering with CMSCMS Concept papers for key componentsIdentifying appropriate regulatory approachSlide 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 ACOsDesigned 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 ACOsIntegrated Health Partnerships (IHP)Hennepin HealthIntegrated Care System Partnerships (ICSP)Commercial ACO/TCOC AgreementsHealth care providers and systems participate in a range of different delivery and payment arrangements aimed at improving the Triple AimMay include performance based on outcomes/quality and cost; varying levels of financial risk from shared savings to sub-capitationMany use MN Community Measurement TCOC metric and quality measuresArrangements 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 modelsAllow for local flexibility and innovation under a common framework of accountabilityFramework of accountability includes:Models based on, and with accountability for, total cost of care TCOC)Robust and consistent quality measurementModels 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 ExamplesMinnesota Medicaid ACO model: Integrated Health Partnerships (IHP)Previously the Health Care Delivery System (HCDS) demonstrationHennepin Health: a Safety Net ACOIntegrated 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 inputDeveloped and issued initial RFP in summer 2011Responses received were broadly representative of geographic and organizational structure6 provider systems, serving ~100,000 Medicaid enrollees, started in our IHP model in January 20133 additional provider systems began in 2014, for a total of ~145,000 Medicaid enrollees currently being servedReleased 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 areaSize(# Attributed)CentraCareCentral MN, north of Minneapolis/St. Paul11,037Children’s HospitalMinneapolis/St. Paul16,066Essentia HealthDuluth/NE MN30,485FQHC Urban HealthNetwork (10 FQs)23,757Hennepin Healthcare System/HCMC24,558Mayo ClinicRochester/SE MN5,985North Memorial3,824Northwest Health Alliance (Allina/HealthPartners)12,194Southern Prairie Community CareMarshall/SW MN17,947
17 Provider Characteristics/Requirements IHP providers mustDeliver 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 attributedTCOC 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 servicesGenerally excludes dental, supplies, transportation, long term services and supportsExisting 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 settingsIHPs have flexibility to propose alternative measures and methodsPerformance 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 ~ 8,600Integrated county model; health care, behavioral health, social servicesOpportunity for savings outside the Medicaid program to county servicesHennepin 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 initiativesExpands and builds on Medicare/Medicaid MCOs and provider contracting arrangements and experience; Leverages Medicare involvement in State payment reformsEncourages improved health outcomes and choice of care settingEncourages long-term care provider involvementEncourages increased coordination of physical and behavioral health30 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 savingsQuality measures/health outcomesPatient/Consumer ExperienceHow can CHWs help ACOs achieve their goals?Better understanding of communities/populations they serveAct as a member of the care team to provide the connection between clinical and community servicesTrust of the client to facilitate consumer/patient-provider communication and educationSavings achieved can help finance CHWs in ACOs
25 Next StepsMinnesota’s SIM grant builds on IHP and other ACOs in the marketSIM funding for CHWs and other emerging professionsExpansion to additional populations (duals, complex)Increasing importance placed on partnership with non- traditional health care providers and services and community involvementStrong 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 yearsBUT:Reconciliation payments at least annually and contract terms re-visited annuallyAount of risk will be proposed by the delivery system and negotiated with DHS
26 ContactMarie Zimmerman Health Care Policy Director Minnesota Department of Human Services Phone: (651)