1. Care Coordination, Provider Alignment and Infrastructure: Laying the Foundation for Health Care Transformation Nicole Stallings Vice President Maryland Hospital Association August 21, 2015

2. 1 Objectives Provide overview of key HSCRC and DHMH incentives and activities to promote care coordination and provider alignment Outline reporting requirements Describe timeline of key initiatives

3. State-Level Infrastructure (leverages many other large investments) Create and Use, Meaningful, Actionable Data Develop Shared Tools (Patient Profiles, Enhanced Notifications, Care Needs, Others) Connect Providers Alignment Medicare Chronic Care Management Codes/Medical Homes Gainsharing & Pay for Performance Integrated Care Networks & ACOs Including Dual Eligibles Accelerating All-Payer Opportunities Moving Away From Volume Care coordination & integration (locally-led) Implement Provider- Driven Regional & Local Organizations & Resources (Requires Large Investments And Ongoing Costs) Support Provider- Driven Regional/Local Planning Technical Assistance Consumer Engagement State & Local Outreach Efforts Develop Shared Tools For Engaging Consumers Maryland’s Strategic Transformation Roadmap Source: HSCRC Public Meeting. May 13, 2015 2

4. Implementation Focus Areas Year 1 Global Budgets Meeting test metrics Monitoring infrastructure Potentially avoidable utilization concepts and data Stakeholder input Year 2 Payment Alignment: Gainsharing, pay-for-performance, Medicare Chronic Care fees, Dual eligible & integrated care networks Clinical improvement: care coordination, chronic disease management Year 3 Implementation of models developed in year 2 Focus on additional alignment opportunities Patient, family and community engagement Source: Modified from HSCRC presentation. 3

5. Implementation Focus Areas Year 1 Global Budgets Meeting test metrics Monitoring infrastructure Potentially avoidable utilization concepts and data Stakeholder input 4

6. Accomplishments to Date Financial targets were exceeded and quality was improved Nearly all hospital revenues are under global budgets Hospitals are engaging with physicians, long-term care providers, and community partners to plan and implement changes to the delivery system Medical home and Accountable Care Organizations (ACOs) continue to develop Starting to see expansion in MCO efforts beyond Medicaid to address Medicare patients 5

7. Implementation Focus Areas Year 2 Payment Alignment: Gainsharing, pay-for-performance, Medicare Chronic Care fees, Dual eligible & integrated care networks Clinical improvement: care coordination, chronic disease management 6

8. Physician Alignment & Engagement Workgroup Report Focused on what State and Commission could do as regulator, facilitator and catalyst to promote alignment of strategies among hospitals and other health care providers Considered strategies that are both: –Non-Compensatory: Shared infrastructure, analytics and other resources Better health care quality and cost reporting Investment to improve ease of practice such as care management support –Compensatory: Pay for performance Gainsharing Shared Savings 7

9. Status Update MHA’s Gainsharing program methodology finalized and phase 1 recruitment complete HSCRC, on behalf of MHA, MedChi and others, seeking enhanced Medicare data and federal waivers to facilitate various alignment activities –Expected approval Q2 of 2016, if not sooner –MHA exploring alternative vehicles to accelerate gainsharing implementation HSCRC initiating discussions on additional alignment models with stakeholders; expect to establish a workgroup for additional input 8 Source: HSCRC Executive Director’s Report. August 12, 2015

10. Care Coordination Workgroup Report Consensus that improved care coordination and alignment among providers (particularly for high needs patients) is key to meeting the goals of the All-payer model and improving population health Partnerships at the regional and local levels are critical to effective care coordination Statewide infrastructure is needed to support these efforts 9

11. Who is High Risk? 10

12. Regional and Local Efforts to Focus on… Delivery system changes, including: –Chronic disease supports –Integration and coordination across care continuum –Case management and other supports for high needs and complex patients –Episode improvements, including quality and efficiency improvements –Clinical consolidation and modernization to improve quality and efficiency 11

13. Regional and Local Efforts (cont.) Increased focus on integration with community needs and supports –Increased focus on community needs assessments –Focus on transportation and other social needs –Focus on population health –Patient and family engagement Technical assistance –Provided via State Budget Reconciliation and Financing Act of 2014 (BRFA) funds through CRISP 12

14. REGIONAL PARTNERSHIPS FOR HEALTH SYSTEM TRANSFORMATION 13

15. Regional Partnership for Health System Transformation Planning Grants 2014 Budget authorized up to $15 million to fund the planning of regional partnerships and statewide infrastructure to facilitate care management and coordination in support of waiver goals Department of Health and Mental Hygiene and HSCRC released RFP in February; 11 applications received Eight grantees awarded total of $2.5 million in May Technical assistance provided to all grantees Resources and webinars available to all hospitals 14

16. Regional Partnerships Hospital-led partnerships to develop regional plans to do the following: –Collaborate on analytics –Target services based on patient/population needs, and –Plan and develop care coordination and population health improvement approaches Plans must: –Propose delivery and financing model –Identify infrastructure and staffing to support the model –Target outcomes for reducing utilization/costs and improving quality Initial target populations: high utilizers such as Medicare patients with multiple chronic conditions and high resource use, frail elders with support requirements, and dual eligibles with high resource needs 15

17. Regional Transformation Grantees 16 Regional Group NameAward AmountLead Hospital Trivergent Health Alliance$ 133,334Western Maryland Health System $ 133,333Frederick Regional Health System $ 133,333Meritus Medical Center Bay Area Transformation Partnership$ 400,000Anne Arundel Medical Center Howard County Regional Partnership for Health System Transformation$ 200,000Howard County General Hospital University of Maryland Upper Chesapeake Health and Hospital of Cecil County Partnership$ 200,000 University of Maryland Upper Chesapeake Regional Planning Community Health Partnership$ 400,000Johns Hopkins Hospital(s) Baltimore Health System Transformation Partnership$ 300,000University of Maryland Medical Center NexusMontgomery$ 200,000Holy Cross Hospital Southern Maryland Regional Coalition for Health System Transformation$ 200,000Doctors Community Hospital Total$ 2,500,000

18. HSCRC INFRASTRUCTURE FUNDING & MONITORING REQUIREMENTS 17

19. FY 2016 Balanced Update 0.4% adjustment to FY 2016 GBR budgets to provide new infrastructure funding Require all hospitals to submit multi-year plans for improving care coordination, chronic care, and provider alignment by December 1, 2015 Require specialty hospitals to begin submitting admission and discharge data to CRISP by April 1, 2016 to facilitate tracking of readmissions Up to an additional 0.25% available through competitive awards to hospitals implementing or expanding innovative care coordination, physician alignment, and population health strategies 18

20. Competitive Implementation RFP ** Based on Draft RFP released August 5 Eligible applicant: –An individual hospital –Multiple hospitals as lead applicants –A hospital applying on behalf of a regional partnership All applicants must include collaborating partners Broad and meaningful networks preferred Hospitals may participate in multiple applications 19 Source: HSCRC Webinar. August 6, 2015

21. Funding Limits A maximum of 0.25% of aggregate rates could be awarded (approximately $40M) Total dollars awarded to a hospital acting as a single entity are capped at 0.5% of the hospital’s FY 2015 net patient revenue plus markup If named in multiple applications, total combined awards to a hospital are capped at 0.75% of the individual hospital’s FY 2015 net patient revenue plus markup Awarded funds will be collected by the hospital through permanent rate increases beginning Rate Year 2016 20 Source: HSCRC Webinar. August 6, 2015

22. Selection Criteria of Note Consistency with Strategic Plans, and GBR infrastructure, and other appropriate investments Efficacy of investments to date Do investments complement state and regional resources and policies Demonstration of how care coordination efforts flow among providers for high risk patients using different hospitals and the extent to which it addresses patient and family preferences Feasibility of ROI and sustainability over time, the apportionment of ROI to payers, the potential to reduce total cost of care 21

23. Timeline of RFP Mid to late August – RFP to be released Mid-September – Webinar for Questions to be posted to the Website December 1 – Applications/Proposals Due January 2016 – Awardees Announced 22

24. HSCRC Infrastructure Monitoring 23

25. Implementation Focus Areas Year 3 Implementation of models developed in year 2 Focus on additional alignment opportunities Patient, family and community engagement 24

26. Alignment: Future Work Models that support integration beyond hospitals need to be developed –Hospitals, SNFs and post-acute care facilities –Episodes of care that include providers beyond the hospital –Other payment models that include costs beyond hospital costs Development of statewide framework to facilitate approval of models necessary to address total cost of care; includes appropriate federal waivers –Stark –Anti-Kickback –Civil Monetary Penalties –SNF 3-day Stay 25

27. Patient, Family and Community Engagement Including patients, caregivers and community organizations as partners in this work Addressing risk factors upstream Understanding and honoring care preferences Explaining how our system is changing 26

28. THANK YOU 27

29. Speaker Biography Nicole Dempsey Stallings is Vice President for Policy & Data Analytics at the Maryland Hospital Association (MHA), the trade association for Maryland’s 66 hospitals and health systems. In this role she manages advocacy for quality-related regulatory activities and is charged with the development and implementation of care coordination and physician alignment strategies to support the goals of Maryland’s unique Medicare waiver, which allows the state to set the rates hospitals can charge. Prior to joining MHA, Nicole served as Senior Policy Advisor to the Secretary of the Maryland Department of Health and Mental Hygiene and the Director of the Maryland Health Quality and Cost Council. Ms. Stallings was charged with coordinating and facilitating collaboration on health care quality improvement and cost containment initiatives for the state. Ms. Stallings also staffed the Maryland Health Benefit Exchange Board and the Health Care Reform Coordinating Council, established by Governor O’Malley to coordinate implementation of the Affordable Care Act. Ms. Stallings held previous roles as Chief of Government Relations and Special Projects at the Maryland Health Care Commission and was a registered lobbyist and the Director of Policy for the New Jersey Hospital Association. Nicole holds degrees from Virginia Tech and Rutgers University. 28