1. NASHP Learning the ABCs of APCs and Medical Homes October 5, 2010 Foster Gesten, MD New York State Department of Health fcg01@health.state.ny.us 1

2. Outline NY Background What are we trying to fix? – Why didn’t managed care fix it? Medical Home Standards and Payments – Wide vs Deep – Going it alone and/or playing in the sandbox Trust and anti-trust Challenges and Opportunities 2

3. Background: Medicaid 5 million members - $47 billion Most in managed care plans (1115 waiver since 1997) but complex and expensive populations remain in FFS – 20 health plans – Carve outs (pharmacy, SA, MH for some) SCHIP (Child Health Plus) separate program but delivered through health plans Medicaid and public and private plans regulated through same organization in state health department 3

4. Enrollment Enrollment as of December 31 st of each year Source: DOH/OHIP Recipient Summary Fact, Child Health Plus and EPIC 4

5. What are we trying to fix? Rightsizing balance of inpatient and outpatient care expenditures Excess of preventable admissions (and readmissions) Years of quality reporting…good, getting better, but good enough? Institutional care settings Primary care standards and the chronic care model – time to raise the bar Disparities 5

6. Inpatient Spending Per Enrollee Significantly Exceeds National Averages; Spending on Ambulatory Care Has Lagged Source: CMS, 2008 Statistical Supplement Table 13.26 6

7. Despite High Spending, NY Performs Average (or Poorly) on Some Key Quality Indicators 2009 Commonwealth State Scorecard on Health System Performance Care MeasureNational Ranking Overall21 Equity11 Prevention and Treatment22 Avoidable Hospital Use50 2009 AHRQ State Snapshots Clinical AreaState Rating Trend DiabetesWeakSame Heart DiseaseAverageSlightly Better Maternal and Child HealthAverageGetting Worse Respiratory Disease WeakGetting Worse 7 7

8. New York Focus on Payer How Does the Quality of Care for Medicaid Compare to the US? 8

9. New York Medicaid Managed Care vs National Effectiveness of Care MeasuresNYS Medicaid 2008National Medicaid 2008Result Monitoring Persistent Medications86.682.6 Appropriate Testing - Pharyngitis80.561.4 Breast Cancer Screening66.850.8 Cervical Cancer Screening73.466.0 Childhood Immunization Status77.473.7 Cholesterol Management – LDL-C <10046.840.1 Comprehensive Diabetes Care – Eye Exams 62.058.8 Comprehensive Diabetes Care – Good HbA1c Testing 37.932.9 Controlling High Blood Pressure65.055.8 Follow-Up After Hospitalization for Mental Illness – 30 days 78.461.7 Care for Children w/ ADHD Med. – Continuation 60.739.5 Lead Screening86.466.7 9

10. The Executive Budget of 2009-10: Medicaid Enabling legislation: Authorized the Department to implement a Statewide initiative to incentivize the development of PCMHs to improve health outcomes through better coordination and integration of patient care – No savings assumed – primary care ‘investments’ from savings achieved in (overdue) inpatient payment reductions – ~ $66 million growing to $140 million in year 3 Medical home standards are the National Committee for Quality Assurance’s (NCQA) Physician Practice Connections® -Patient Centered Medical Home™ (PPC®- PCMH™) Recognition Program Program implementation- July 1, 2010; Hospital OPD participation still pending CMS approval 10

11. Medicaid Reimbursement For PPC®-PCMH™ Medicaid providers receive a payment commensurate with their level of NCQA PCMH designation (Level I- $2 pmpm, II - $4pmpm, or III- $6pmpm) – ‘Enhanced’ payment of qualifying claims (primary care E&M code) for FFS – PMPM from health plans for MMC State adds to premium and directs payments to recognized providers for common amounts Level I incentive ends 2013 Evaluation P4P? 11

12. Regional Multi-payer Demonstration Enabling 2009 legislation (including anti-trust) and budget (Medicaid) – $3-4 million Rural upstate NY 35 practices (including multi-site FQHC), 5 hospitals, over 130 providers – Around 100k patients 8 payers, including Medicaid and State Employee Plan NCQA level 2 or 3 in first year….‘plus’ $7pmpm Medicare application/invitation (MAPCP) 12

13. Challenges/Opportunities Multi-payer most promising, and most difficult Alignment with HITEC ACA – More business, more imperative – ‘health homes’? Beyond the home to the ‘hood’ Journey, not destination Sustainability – Interest – Resources – Primary care pipeline 13