South Carolina Healthy Outcomes Plan (HOP) SCDHHS Perspective Tripp Jennings, MD, FACEP System Vice President, Palmetto Health Medical Director, South Carolina Dept of Health and Human Services

SCDHHS Mission: To purchase the most health for our citizens in need at the least possible cost to the taxpayer.

SCDHHS Vision: Be a responsive and innovative organization that continuously improves the health of South Carolina.

Proviso 33.34 Outcome of the General Assembly passed FY 2014 budget Components of Proviso 33.34 Health system does a poor job prioritizing who is in need of services Once identified, individuals who are poor or living with disabilities generally enter a system not designed to meet their needs Proviso 33.34 addresses the root causes of these problems Healthy Outcomes Plan (HOP) Hospital Transparency and DSH Graduate Medical Education (GME) OB/GYN & Telemedicine Optional State Supplementation (OSS) Proviso 33.34 Outcome of the General Assembly passed FY 2014 budget State-based plan to improve health while increasing value and transparency

Project Scope Incentive program to participating hospitals and primary care safety net providers, designed to improve health outcomes and reduce system costs through better coordinated care of the uninsured, chronically ill, high-utilizers of emergency department services.

IDENTIFY FIND ASSESS MANAGE Prioritize people in need Outreach Healthy Outcomes Plan IDENTIFY Prioritize people in need FIND Outreach ASSESS PAM, GAIN-SS MANAGE Develop care plan

Healthy Outcomes Plan Start:August 1, 2013 After weeks of collaborating with stakeholders, SCDHHS released the Healthy Outcomes Plan guidelines and application.  Marked the first time funding may only be accessed if hospitals and primary care safety net providers serving the uninsured collaborate and adhere to health improvement initiatives outlined in the proviso.  Hospitals and their partners will propose service delivery models to improve case management / coordinated care for chronically ill, uninsured, high utilizers of emergency department (ED) services. HOP is one of the largest process improvement efforts that Medicaid has undertaken to effectively integrate the Triple Aim into our delivery systems.

Preliminary Guidelines Criteria Healthy Outcomes Plan Preliminary Guidelines Criteria Targeted Outcomes Strategic Measures (Care, Cost, & Health Metrics) Measurement Periods Target Population Targeted Conditions Patient Eligibility and Program Inclusion Patient Eligibility for Health Affordability Programs Social Determinants of Health Assessment Patient Care Plans Quality and Cost Transparency Plan Evaluation Matrix

“Model” Collaborative Partners Collaboration “Model” Collaborative Partners Hospital(s) FQHCs/FQHC look-a-likes RHCs Free Clinics Community Health Centers DHEC DMH DAODAS Welvista/Pharmacies Physicians Benefit Bank Housing Services Transportation Food Supports

IDENTIFY FIND ASSESS MANAGE Prioritize people in need Outreach Healthy Outcomes Plan IDENTIFY Prioritize people in need FIND Outreach ASSESS PAM, GAIN-SS MANAGE Develop care plan

Next Year

Rural Hospital DSH Payment (100%) $20M $25M Legislative Funding Purpose Proviso 33.34 FY 13/14 Proviso 33.26 Proposed FY 14/15 Rate Increase $35M Rural Hospital DSH Payment (100%) $20M $25M Primary Care Safety Net – FQHC $5M $8M FQHC – Capital Needs $2M $4M Primary Care Safety Net – Free Clinics Primary Care Safety Net – Innovative Care Rural Provider Capacity – Telemedicine $10M Care Coordination – Alcohol/Drug Services n/a Total $77M $91M Note: The FY 14/15 budget is not finalized, and there is a House and Senate version.

HOP Comparative Enrollment, Assessments and Care Plans Healthy Outcomes Plan HOP Comparative Enrollment, Assessments and Care Plans As of April 30, 2014 Enrollment Target HOPs

Draft Sept data

Where We Are Going

Current DSH Future DSH: DSH Waiver Inflexible Retrospective Flexible Less prescriptive More innovative Proactive Prospective Stakeholder input essential on DSH waiver CMS approval (comprehensive)

Introducing Healthy Connections Checkup Overview Introducing Healthy Connections Checkup What is Checkup? Healthy Connections Checkup is a Medicaid limited benefit program. This program was previously called “Family Planning”. Who is Eligible for Checkup? Men and Women in South Carolina with an income at or below 194% FPL who are ineligible for any other Medicaid program. Why the New Name? Beginning Aug. 1, 2014, Healthy Connections Checkup will include benefits that enable a more holistic and comprehensive provision of not only Family Planning and Family Planning-related services, but also new preventive health screenings. The new name helps communicates the enhancement in addition to the importance of preventive health care for the eligible population.

Enhanced Benefit for Healthy Connections Checkup Enhancement Enhanced Benefit for Healthy Connections Checkup Enhancement Update the benefit structure for the current Family Planning-Only benefit category to include a comprehensive biennial (once every two years) physical examination and screenings/labs recommended by the U.S. Preventive Services Task Force Goals Enable providers to make informed decisions regarding the selection of an appropriate contraceptive method Promote the utilization of preventive health care in order to improve health outcomes for families in South Carolina Expected Outcomes Regular preventive screening of members Identification of health problems that may negatively impact members in this eligibility category Strong referral network to connect members to systems of care

New Screenings Behavioral & Mental Health screenings Cholesterol abnormalities screening Diabetes screening Hepatitis C virus infection screening Obesity screening and counseling Breast cancer screening (mammography) Abdominal Aortic Aneurysm screening Colorectal cancer screening Lung cancer screening for smokers *Please refer to the U.S. Preventive Services Task Force guidelines (Grade A & B) for preventative screening standards. Screenings vary by age, gender and risk factor.

Healthy Connections Checkup Cards Important Notes on Cards: New Checkup cards will be distributed to current members on Sept. 1 After Sept. 1, all individuals who enroll in Checkup will be issued the new version of the card Providers should continue to expect that some current members may try to utilize their old card; that is fine. ID numbers will remain the same

Tripp Jennings, MD, FACEP Thank You Tripp Jennings, MD, FACEP @trippjennings

Proviso 33.34 Sec A(1), C, D – Medicaid Accountability and Quality Improvement Initiative

Proviso 33.34 33.34. (DHHS: Medicaid Accountability and Quality Improvement Initiative) From the funds appropriated and authorized to the Department of Health and Human Services, the department shall implement the following accountability and quality improvement initiatives: Healthy Outcomes Initiative - Upon approval of the Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services shall make available to participating hospitals up to a $35,000,000 aggregate rate incentive effective October 1, 2013. This incentive shall be directly linked to a hospital's participation in initiatives designed to reduce system cost and increase health outcomes. To improve community health, the department may explore various health outreach, education and patient wellness and incentive programs. Working with Kershaw Health and its LiveWell Kershaw program, the department may pilot diabetes, smoking cessation, weight management, and heart disease interventions to identify the potential to offer such interventions as models for other hospitals to pursue. These initiatives may include, but are not limited to:

Proviso 33.34 1. entering into a Memorandum of Understanding (MOU) with selected primary health care and other providers to co-manage chronically ill uninsured high-utilizers of emergency room services; and 2. participating in price and quality transparency efforts initiated by the department. In designing these initiatives the department shall receive public input, and make the final determination of the initiative design. The department shall, no later than August 1, 2013, publish the manner in which participation in these initiatives will correspond with incentives. If at the end of the state fiscal year the department determines that this program is not generating cost savings or increasing health outcomes the department may retract this incentive in part or full. (B) Disproportionate Share (DSH) Payment Accountability - Upon approval of CMS, in order to increase accountability for money reimbursed to hospitals under the DSH program and to improve outcomes for the uninsured, hospitals shall:

Proviso 33.34 1. submit claims-level data for all individuals receiving uncompensated care; and 2. obtain a patient attestation to determine whether or not the individual receiving uncompensated care has access to affordable health insurance or does not have other means to pay for services. Rural Hospital DSH Payment - Upon approval of CMS, Medicaid-designated rural hospitals in South Carolina shall receive full coverage of uncompensated care as part of the State's Medicaid Disproportionate Share (DSH) program. Funds shall be allocated from the existing DSH program and shall not exceed $20,000,000 total funds. Rural Hospitals are ineligible for this increased coverage should they not participate in reporting and quality guidelines published by the department and outlined in the Healthy Outcomes Initiative in the Fiscal Year 2013-14 Appropriations Act. These guidelines shall be published no later than August 1, 2013. In addition to the requirements placed upon them by the department, rural hospitals must actively participate with the department and any other stakeholder identified by the department, in efforts to design an alternative health care delivery system in these regions.

Proviso 33.34 (D) Primary Care Safety Net - The department shall develop a methodology to reimburse safety net providers to provide primary care, behavioral health services, and pharmacy services for chronically ill individuals that do not have access to affordable insurance. Qualifying safety net providers are approved, licensed, and duly organized Federally Qualified Health Centers (FQHCs, entities receiving funding under Section 330 of the Public Health Services Act, and FQHC Look-A-Likes), Rural Health Clinics (RHCs), Free Clinics, other clinics serving the uninsured, and Welvista. No FQHC and FQHC Look-A-Likes operating under a management agreement or operated by a Chief Executive Officer who is not an employee of the entity is eligible to receive funds allocated by this proviso. The department shall allocate at least $5,000,000 for baseline funding to FQHCs as defined in paragraph (D), at least $2,000,000 for documented capital needs for FQHCs as defined in paragraph (D), at least $2,000,000 for baseline funding for Free Clinics, and at least $5,000,000 for innovative care strategies for qualifying safety net providers.

Proviso 33.34 The department shall consult with the SC Primary Health Care Association to determine the entities with the most critical capital needs. From the aforementioned $14,000,000, Welvista shall receive at least an additional $600,000. To be eligible for funds, qualifying providers shall be required to provide the department patient and service data to assist in the overall improvement of the state's health quality and when appropriate safety net providers must enter into a MOU with hospitals to co-manage chronically ill uninsured high-utilizers of emergency room services. Participants in this program shall submit evaluations of effectiveness annually to the department. Rural Provider Capacity - The department shall incentivize the development of rural physician coverage and capacity building through the following mechanisms: 1. the department shall leverage the Graduate Medical Education program and develop a methodology to improve accountability and increased outcomes for the State's GME and Supplemental Teaching Payments investment by January 1, 2014; and

Proviso 33.34 2. the department shall develop a program to leverage the use of teaching hospitals to provide rural physician coverage, expand the use of Telemedicine, and ensure targeted placement and support of OB/GYN services in at least four (4) counties with a demonstrated lack of adequate OB/GYN resources by July 1, 2014. 3. during the current fiscal year the department shall allocate $4,000,000 to the MUSC Hospital Authority for telemedicine. (F) Community Residential Care Optional State Supplement - The department shall establish policies and procedures to include establishing a facility rate per eligible beneficiary at $1,500 per month for recipients and providers who meet the requirements for the enhanced maximum OSS payment; establish eligibility criteria; and establish a methodology for increasing the personal needs allowance.

Proviso 33.34 The department will revise the net income limit to accommodate the change in the maximum OSS facility rate. A total of at least $12,000,000 shall be made available for this rate increase. The facility rate shall increase a minimum of $100 per month per eligible beneficiary. All current recipients shall remain eligible for the supplement during the fiscal year and nothing contained herein may conflict with or limit existing regulations. In addition, the department will establish Quality of Care Standards and other requirements for facilities licensed as a Community Residential Care Facility and participating in the OSS program and Medicaid Waiver services. (G) The department shall publish quarterly reports on the agency's website regarding the department's progress in meeting the goals established by this provision.

Stakeholders: SCHA SCCEP SCORH Family Connections SCPHCA Proviso 33.34 Stakeholders: SCHA SCCEP SCORH Family Connections SCPHCA SC EMS Association SCMA SC American Case Management Association DAODAS DHEC SC Free Clinics Assoc. DMH The Duke Endowment SC Legislative representation Health Plans Governor’s Original Six Foundation AccessHealth Welvista ORS

Disproportionate Share Hospital (DSH) Payments Proviso 33.34 Disproportionate Share Hospital (DSH) Payments SCDHHS will commit to spending 100% of the October 1, 2013-September 30, 2014 DSH allotment Approximately $474.5M; an increase of $17.3M Greater accountability in use of Medicaid DSH Increased transparency in patients served, health pricing and health quality

Healthy Outcomes Initiative Proviso 33.34 Healthy Outcomes Initiative All hospitals that participate and submit a proposed plan will receive 100% of their calculated DSH payment for October 1, 2013-September 30, 2014 SC-designated non-rural DSH hospitals that choose not to participate will receive 90% of their calculated DSH payment for October 1, 2013-September 30, 2014 Per Proviso 33.34, all SC Medicaid-designated rural hospitals must participate in the Healthy Outcomes Initiative and submit a plan to receive full coverage of their uncompensated care

Rate Increase All hospitals will receive a 2.75% rate increase ($35M) Applies to both Medicaid inpatient and outpatient hospital services SCDHHS will submit appropriate State Plan Amendment for CMS approval Graduate Medical Education will not be impacted by increase