Vermont Blueprint for Health Building an Integrated System of Health Innovations in Medicaid: Payment and Delivery Reform Health Action 2014 Beth Tanzman, MSW Assistant Director, Blueprint for Health www.hcr.vermont.gov Beth.Tanzman@state.vt.us 1

Global Commitment to Health 1115 Demonstration Waiver Blueprint for Health Payment and Service Delivery Reforms Medication Assisted Treatment “Hub & Spoke” Reforms Vermont Chronic Care Initiative Q & A

Global Commitment to Health 2005 - Present Caps total federal funds Establishes the state XIX Authority as Managed Care Entity Allows use of XIX funds for state fiscal relief and non-Medicaid health programs Flexibility to reduce benefits, increase cost sharing, limit enrollment for optional and expansion populations with some limits

Managed Care Entity (MCE) Savings Reduce the rate of uninsured/ underinsured Increase access to quality health care to uninsured, underinsured and Medicaid beneficiaries Provide public health approaches to improve the heath outcomes and quality of life Medicaid-eligible individuals Encourage the formation and maintenance of public-private partnerships in health care

Patient Centered Medical Homes: Joint Principles American Academies of Family & Pediatric Physicians, College of Physicians, Osteopathic Association Personal Physician ongoing relationship for continuous & comprehensive care Physician Directed team who collectively take responsibility for ongoing care Whole Person provide or arrange for all a patient’s health care needs Care is Coordinated & Integrated across all elements of health care system and community. Care is facilitated by registries and health information exchange. Quality & Safety care planning process based on partnership with patients, evidence-based medicine, accountability for CQI, voluntary recognition process Enhanced Access open scheduling, expanded hours, electronic communication Payment recognizes the added value to patients including for coordination of care 5

Requires 6 of 6 Must Pass Elements All insurers pay enhanced payment based on a practices score as a patient centered medical home NCQA PCMH standards and scoring methods are used to score practices as a medical home Payment changes with each 5 point change in the NCQA PCMH score (score ranges from 0 – 100 points) Designed to incent ongoing iterative improvement, and to provide a disincentive for moving backwards Requires 6 of 6 Must Pass Elements 6

Department of Vermont Health Access Extended Community Health Team Hospitals Advanced Primary Care Specialty Care & Disease Management Programs Community Health Team Nurse Coordinator Social Workers Nutrition Specialists Community Health Workers Public Health Specialist Extended Community Health Team Medicaid Care Coordinators SASH Teams Spoke (MAT) Staff Advanced Primary Care Social, Economic, & Community Services Mental Health & Substance Abuse Programs Advanced Primary Care Advanced Primary Care Self Management Programs Public Health Programs & Services Health IT Framework Evaluation Framework Multi-Insurer Payment Reform Framework 11/27/2018 11/27/2018 7 7

+ + Multi-insurer Payment Reforms Insurers Medicaid Commercial Insurers Medicare Insurers Fee for Service Unchanged Allows competition Promotes volume Patient Centered Medical Home Payment to practices Consistent across insurers Promotes quality Community Health Teams Shared costs as core resource Consistent across insurers Minimizes barriers + + Based on NCQA PPC-PCMH Score $1.20 - $2.49 PPPM Based on active case load 5 FTE / 20,000 people $ 350,000 per 5 FTE Scaled based on population 8

Patient Centered Medical Homes and Community Health Team Staffing in Vermont # of Patients # of CHT FTEs and Practices Patient Numbers – Used the total unique patient numbers for ACTIVE practices as reported by practices (Patients and Payments) Recognized practices – Used start date of practices (subtract out closed or termed or combined practices), also input from dashboard report from UVM with NCQA score. Number of recognized practices is at end of quarter. CHT FTE – use CHT staffing reports from HSAs – Please note, the Blueprint has not received fully updated Q4-2014 CHT staffing reports from all HSAs as of 11/19/13. The number currently displayed (120) was calculated using the updated reports we do have compiled with last quarters reports. This number is expected to increase as the new reports come in. Updated 11/19/13 NFL *Since joining the Blueprint, three practices have combined to form a new practice, one practice has joined an existing practice, and one practice has closed.

Self-management Workshops Healthier Living Workshops (Stanford University Self-management) Chronic Disease Pain Diabetes Tobacco Cessation Wellness Recovery & Action Planning (WRAP) Diabetes Prevention (National YMCA) 11/27/2018

PCPs (unique providers) 613 11/27/2018 Patient Centered Medical Homes and Community Health Team Staffing in Vermont Key Components December 2013 PCMHs (scored by UVM) 122 PCPs (unique providers) 613 Patients (per PCMHs) 505,373 CHT FTEs (core staff) 120 SASH provider FTEs (extenders) 46.5 Spoke Staff FTEs (extenders) 30 *Spoke Staff FTE as of September 2013 SASH FTE and number of teams updated on 11/19, projection through end of december 13 Updated 8/21 NFL 11/27/2018

A “Perfect” Storm Increasing Rates of Opioid Dependence Inadequate Network Capacity High Health Care Expenditures Poor Patient (Client) Outcomes Program & Funding Silos

Advanced Primary Care Practices and Community Health Teams “ Hub & Spoke” Health Home for Opioid Addiction 5 Regional Centers Addictions Treatment Methadone OTP 125 Physicians Prescribing Buprenorphine OBOT Care As Usual Health Home ~ 6 FTE RN, MA / 400 Pts - OTP & OBOT - Methadone & Buprenorphine 2 FTE RN, MA / 100 Pts OBOT Buprenorphine Comprehensive Care Management - Care Coordination - Health Promotion - Transitions of Care - Individual and Family Support - Referral to Community & Social Supports Advanced Primary Care Practices and Community Health Teams HUB SPOKES

Section 2703 Affordable Care Act Health Homes Section 2703 Affordable Care Act 6 Core Services Comprehensive Care Management Care Coordination Health Promotion Comprehensive Transitions of Care Individual and Family Support Services Referral to Community and Social Support Services

Vermont Chronic Care Initiative KEY STATISTICS Total Number of Medicaid Enrolled (as of October 2013) 187,019 VCCI Eligible Candidates 103,058 Total Number in the top 5% 10,102   Total Engaged via face-to-face and/or telephonic case management (SFY 2012) 3,015 Average Episode of Care Duration 77 days Target Caseload Field – 25 Embedded – 50 Phone –50 11/27/2018

Fee for Service (Volume) 11/27/2018 Financing Payment Reform Delivery System Reform Fee for Service (Volume) Patient-Centered Medical Homes Medicaid Medicare BlueCross MVP Cigna Self Insured $ PPPM - NCQA Score Pay for Performance Community Health Teams Shared Capacity Specialized Services Vermont Chronic Care Initiative Medication Assisted Treatment (Hub & Spoke) $ PPM Capacity $ Quality (in design) $ Shared Interest (proposed) Medicaid 11/27/2018 16 16 16