1. Maryland’s Changing Health Care EnvironmentB H
Maryland’s Changing Health Care Environment
June 7, 2018

2. Health Care Environment│ Overview
All-Payer Waiver
Primary Care Program for duals and link to all- payer waiver
Implications for community behavioral health providers – directly and indirectly
What we need from you
Not going into details on the programs. Both hospital and PCP have good website, with webinars, concept papers, meeting minutes and recordings. We share the links at the end of the slide deck, but want to focus on the concepts in this discussion.

3. All-Payer Waiver│ Take-Aways
Meeting and exceeding targets on restricting spending growth
Meeting and exceeding targets on hospital-based quality measures
Broadening to total-cost-of-care (TCOC) has been an area of challenge.
Behavioral health is a current pain point not explicitly addressed in future planning.

4. All-Payer Waiver│ Meeting Performance Targets
Through April 2018, Maryland’s all-payer waiver is on target to meet its performance targets. Targets: (1) reduction in all-payer hospital spending; (2) reduction in Medicare hospital spending per beneficiary; (3) reduction in Medicare all-provider spending per beneficiary; (4) reduction in Medicare readmission; and (5) reduction in hospital-acquired conditions.
So what’s this got to do with you? Reducing the readmission rate and all-provider spending may impact you, but it’s limited to Medicare, right? Let’s drill down on that.

5. All-Payer Waiver│ Problems Simmering
Hospitals reporting concern with stuck patients in their ERs. GBMC data to BHA’s Advisory Council shows that avg LOS roughly doubled since Hospitals across the state are identifying behavioral health as a critical need in their ERs.
21 of their 24 beds are occupied by behavioral health patients who are unable to be safely discharged. If GBMC can’t clear the beds, it can’t manage its ER admissions, which is critical to meeting waiver’s other goals.
Source: GBMC Presentation to
BHA Advisory Council, May 2018

6. All-Payer Waiver│ Problems Simmering
Hospitals look around, see a dearth of beds, psychiatrists. And note their concern rolls over to the commercial market.

7. Duals Primary Care Program│ Take-Aways
Creates alignment between hospital and physician practices on quality measures and financial incentives for population.
Behavioral health is a current pain point not addressed in planning.

8. Duals Primary Care Program│ Overview
May 2018: CMS approves next phase of all-payer waiver.
Creates a Primary Care Program for duals.
This will be the vehicle for achieving the Medicare TCOC goals in the waiver.
Primary Care Program qualifies as MACRA Alternative Payment Model (APM)
Exempts participating providers from MIPS
Receives lump sum payment from Medicare equivalent to 5% of last year’s FFS payments.
Tackles the waiver’s goals outside of hospital walls for goals of reducing per-beneficiary Medicare spending and Medicare readmissions by:

9. Duals Primary Care Program│ Overview
Patient-designated provider (PDP): Primary care doctors, specialty physicians (including psychiatrists), and certified, registered nurse practitioners able to practice independently.
Patient-centered home (PCH) employing PDP must:
use certified electronic health record;
provide services to a minimum of 125 Medicare beneficiaries;
At least 60% of the services provided by PDPs must be primary care
Note: Duals enrolled in health homes are currently excluded from Primary Care Program. This is a state decision.

10. Duals Primary Care Program│ Overview

11. Duals Primary Care Program│ Overview
Note expanded role for CRISP, incorporating “social needs” and “claims reports.” Legislation passed this past session authorizes CRISP to pilot expansion to claims, including Medicaid. Unifying the Medicare and Medicaid claims data is vital to true population health management for duals.

12. Duals Primary Care Program│ Timeline

13. Duals Primary Care Program│ Problem Simmering
Yet, the Department data shows that psychosis is the leading diagnostic cost driver for the duals population.
Let this sink in for a moment. The all-payer waiver’s next phase is tied to successfully reducing admissions and TCOC for Medicare beneficiaries. The state’s vehicle to achieve those doesn’t take in account the leading cost driver.

14. Change Drivers │ So What?
Medicare’s a small part of my revenue
Duals are a small part of my clinic mix.
This doesn’t impact me.

15. Change Drivers │ So What?
Medicaid MCOs have formed dedicated association
Newly receptive audiences in executive and legislative branches
Important players in Maryland’s health care ecosystem are calling for more behavioral health capacity.
State’s responses to date haven’t tackled capacity-building across continuum in sustained or scaled way.
Options to expand community BH capacity:
Piecemeal growth by state;
Growth financed and controlled by hospitals and/or MCOs;
Us.
If we don’t become part of the conversation about a solution, we’ll end up with a piecemeal system that grows crisis beds and outpatient capacity in rate-regulated space.
CBH must become a proactive part of the policy solution, just as you become a proactive part of the practice solution, with same-day access and tight PHM strategies to reduce hosp utilization.

16. Change Drivers │ CCBHC National Results
Workforce Expansion
Increased Capacity
72 new psychiatrists
212 addiction specialty staff
87% expanded treatment capacity
85% expanded opioid treatment capacity
75% expanded crisis care
72% expanded technology
72% partnered with hospitals
We can be part of the solution, bringing the CCBHC conversation back to the forefront in Maryland.

17. Change Drivers │ Roads to CCBHC
CMS pilot program
SAMHSA grants
Medicaid waiver (Texas)

18. Change Drivers │ Future
Short-term
Behavioral health will rise as cost driver and waiver problem for Maryland hospitals.
CBH members engage in bidirectional data exchange with CRISP to meet population health management approaches to care, working to put warehouse & network in place.
Mid-term
CBH works to increase buy-in of CCBHCs among key decision-makers in Maryland.
Leverage collective strengths and services amongst members and with new partners to increase bargaining power and shorten learning curves.
Long-term
Maryland accepts a model tool (CCBHC) to meet behavioral health needs aligned with waiver.
CBH members form regional CCBHCs, growing capacity and partnering with local hospitals.
How you as an organization can start taking steps to prep for CCBHC or participate in Primary Care Model.
Members need to have a hard and honest look at how they run their business, so they can stay in business. We need to be inspired to get through this and get on the path. We have to get out of crisis response and into developing the next phase.
Let’s talk about this. Do you see yourself doing this? Any part? What’s stopping you?

19. Change Drivers│ What We Need from You
Do you know the CTOs in your region (once designated)? Are you talking to CTOs or patient- centered homes in your area about the duals initiative?
Are you seeing significant changes in referrals for your duals?
Are you partnering with your hospital?
Is your hospital moving into behavioral health services – crisis beds, IOP, care management, ER diversion, etc.

20. Change Drivers│ To Learn More
All-Payer Waiver and Total-Cost-of-Care (TCOC), including webinars about PCP: tcoc.aspx
Primary Care Program for duals, included recorded webinars and slides about CTOs and PCP: