1. Medicare Waiver Year One A look at the changes to hospitals and Maryland’s health care environment

2. Maryland waiver in place since the 1970s Modernized in January 2014 Formalized shift from volume to value and is in line with health care’s Triple Aim Background 2 The Maryland Health Services Cost Review Commission

3. Limit hospital per capita spending in Maryland to annual growth of 3.58 percent Reduce total Medicare hospital spending in Maryland by $330 million over five years Limit growth in total Medicare spending in Maryland to no more than national growth Reduce the readmissions rate in Maryland to the national average within five years Reduce hospital-acquired conditions by 30 percent within five years Five key metrics 3

4. Many statewide policies had to be created (e.g.: transfers, market share, uniform coding, readmissions reduction, etc.) 95 percent of hospital revenue under global budgets in six months Implementation 4

5. $100 million savings to Medicare Inpatient use rates and admissions down 4% Potentially avoidable utilization down 6% 5 Where we stand (financial)

6. Readmissions rate declining faster than nation 5,000 fewer readmissions than previous year Statewide, uniform HAC diagnosis codes developed; sharing of best practices Where we stand (quality) 6

7. How things have changed 7 OLD NEW Fee-for-service Global budgets Episodic care Population health Fragmentation Care coordination

8. Examples of change What does it mean? 8 PatientsPartnershipsPopulation health Bedside prescription delivery Close collaboration with SNFs Wellness initiatives Health “coaches”Transport to primary care appointments Predictive data analytics In-home post-discharge visits Physician education/partnerships Mental health/substance abuse clinics Nurse hotlinesSharing of dataMobile health clinics

9. Global budgets are a powerful incentive Experiment, experiment, experiment This is the right thing to do for patients How are we doing it? 9

10. Never tested before on statewide scale No one-size-fits-all solution Innovation abounds, but jury’s out on best practices Challenges 10

11. Expansion beyond hospitals (physicians, post- acute providers, etc.) Shared savings programs Transparency Consumer engagement Building data infrastructure What’s next? 11

12. Questions 12