Alternative Payment Models The Arkansas Medicaid Approach Laurence - PowerPoint PPT Presentation

Alternative Payment Models The Arkansas Medicaid Approach Laurence Miller, M.D. Senior Psychiatrist, Division of Medical Services Arkansas Department of Human Services Clinical Professor, Psychiatry University of Arkansas for Medical Science 1

Arkansas Health Care Payment Improvement Initiative Initial Questions towards Alternative Payment Solutions What are the key Which of these issues issues in the medical can be addressed and behavioral system? through payment? Which can be What is the addressed through prioritization of the practice or policy payment initiatives? changes? 2

Arkansas Health Care Payment Improvement Initiative Program Objectives Improve the health of the population Enhance the patient experience of care Enable patients to take an active role in their care Reward providers for high quality and efficient care Reduce or control the cost of care 3

Arkansas Health Care Payment Improvement Initiative Arkansas Medicaid HCI Organizational Structure Health Care Innovation (HCI) Patient Health Homes Episodes of Care Centered Medical Home (EOC) (Under discussion) (PCMH) Long-term Behavioral Developmental Services & Behavioral Health Disabilities Medical Support Health (BH) (DD) (LTSS) 4

Arkansas Health Care Payment Improvement Initiative A Multi-payer Initiative Arkansas Medicaid (EOC/PCMH) Commercial Carriers • Arkansas BlueCross BlueShield and affiliated companies (EOC/PCMH) • QualChoice (EOC/PCMH) Self-Insured Organizations • Walmart (PCMH) • Arkansas BlueCross BlueShield Employee Plan (PCMH) • Arkansas Baptist Health Employee Plan (PCMH) State Employees and Teachers (PCMH) Qualified Health Plans for “Private Option” / “Arkansas Works” - Medicaid Expansion (PCMH) Various Dual Special Needs Populations (PCMH) 5

Arkansas Health Care Payment Improvement Initiative Motivation for ADHD Episodes of Care Approximately 25,000 Beneficiaries 2011 AR Medicaid BH Spend by 2011 AR Medicaid BH Spend by Provider Type Care Category Behavioral Health Provider $76 Million Medication $29 Million Primary Care Physicians $14 Million Non-medication $49 Million Other $2 Million Office Visits $13 Million Other $1 Total $92 Million $92 Million 6

Arkansas Health Care Payment Improvement Initiative The Initial Arkansas Medicaid Approach Medical Home Episode-based Care and Delivery Health Home Providers proactively work as Patient Experience: all Patient Experience: all The Goal a team to manage a patient’s healthcare and support services related to a specific overall health. services by a patient over condition, procedure or time. disability. One provider is designated The PAP is the provider in The PAP is in the best How it Works as a Principal Accountable the best position to position to influence cost Provider (PAP) for all patient influence prevention and and quality of services for needs for a period of time. management chronic the episode. disease. Providers are rewarded for The outcomes measured The outcome measured is The Incentive providing high-quality care at includes the overall health of the average cost and quality an appropriate cost. the provider’s patient of care for all patients in a population (across all particular episode. conditions and episodes). 7

Arkansas Health Care Payment Improvement Initiative The Principal Accountable Provider Role in BH Episodes PAP Role Core provider of services This could be a physician, psychiatrist, psychologist, or other behavioral health organizations. • Episode “Quarterback” Leads and coordinates the team of care providers. • Helps drive improvement across the system through care coordination, early intervention and patient education. • Performance Management PAPs are rewarded for high-quality and cost-effective care. • PAPs receives performance reports and data to support decision making. 8

Arkansas Health Care Payment Improvement Initiative Episode of Care Process EOC algorithms are At the end of a Providers submit executed quarterly performance period Arkansas Medicaid claims for services (based on paid (12-months), Providers provide reimburses provides Patients seek care. and provide quality claims) and reports incentive services. based on standard data via Provider are made available payments/recoveries fee-for-service rates. portal. to providers via a are calculated and provider portal. transmitted. 9

Arkansas Health Care Payment Improvement Initiative Episode of Care Design Elements Global and Episode Trigger Scope of Services PAP Attribution Adjustments Thresholds Exclusions An episode is • Episode time • Often • The computer • In the ADHD • Acceptable and triggered from frames are beneficiaries see algorithm, based episode, Commendable multiple established and all multiple on a set of codes, medication costs Cost Thresholds professional paid claims for a providers. Rules flags each relevant are adjusted are determined. claims with a beneficiary are are set to claim for inclusion (leveled) to relevant diagnosis. brought into determine who or exclusion in the compensate for consideration. the Principal episode. wide variance in Pharmacy claims Accountable medication costs. are also • Some entire Provider (PAP). considered if the episodes are therapy is excluded for consistent with business or clinical the episode. reasons. 10

Arkansas Health Care Payment Improvement Initiative Episode of Care Data Source Episodes of Care Some Quality Measures are derived by are based on the provider’s response to questions paid claims. through a provider portal for information not attainable from claims. All costs are derived from paid claims. 11

Arkansas Health Care Payment Improvement Initiative Sample Portal Entry Screens 12

Arkansas Health Care Payment Improvement Initiative Sample Portal Severity Certifications Participating providers submit on Provider Portal PAP to submit on Level I episode Level II episode Provider Portal Partial or full 365 days 365 days Episode recurrence Patients included Patients included New patients ▪ ADHD-only; no BH ▪ ADHD-only; no comorbid conditions comorbid conditions ▪ Positive response to ▪ Inadequate response ‘Quality Rx treatment to Rx treatment; other Client ‘Severity’ complications assessment diagnosed ’ Treatment certification as ADHD ▪ 4-6 physician visits/ Treatment certification ▪ 6 physician visits/year year ▪ Rx stimulants and ▪ Rx stimulants and other first line non-stimulants ▪ Parent/Teacher medication ▪ Parent/Teacher Behavior support ▪ Psychosocial therapy Behavior support Price for Level 1 Price for Level 2 ‘Continuing care’ ‘Continuing care’ certification certification 13

Arkansas Health Care Payment Improvement Initiative Episode of Care Treatment Guidelines Treatment recommended in Not indicated by evidence- AAP/AACAP guidelines 2 based guidelines ▪ ▪ 4 - 6 physician visits / year Psychosocial therapy ADHD with no BH ▪ – Rx medication In-office comorbid I ▪ Parent / Teacher administered behavioral psychotherapy conditions, positive – support 3 Group response to psychotherapy medication ▪ 6 physician visits / year ADHD with no BH ▪ Rx medication comorbid II ▪ Parent / Teacher administered behavioral conditions, sub- support 3 optimal response ▪ Psychosocial therapy if needed Note: All services currently billable to medication are still billable Recommended treatment is only used to set benchmark prices 14

Arkansas Health Care Payment Improvement Initiative Episode of Care Provider Cost Curve Average Cost per Provider Costs and Quality Care are primarily derived by: High The bundling of claims related to a diagnosis by Acceptable beneficiary to determine an Episode average cost. Average cost per episode Commendable A provider’s average cost is compared to his or her peers for each provider Gain to determine commendable, acceptable or non- sharing limit acceptable total cost. Low Individual providers , in order from highest to lowest average cost 15

Arkansas Health Care Payment Improvement Initiative Episode of Care Data Reporting Episode Cost Summary Comparisons with All Other Providers Quality Measures Performance Utilization Measures Performance 16

Arkansas Health Care Payment Improvement Initiative Performance Summary Episode of Care Performance Report ADHD Level I As of April 2016 Financial Summary Baseline Year Payment Year 1 Payment Year 2 Payment Year 3 Total Number of Valid Episodes 14,044 3,046 3,768 4,392 Total Cost Unadjusted $61,863,917.47 $5,507,472.07 $5,737,171.89 $6,427,343.33 Total Cost Adjusted $61,863,917.47 $5,507,472.07 $5,737,171.89 $6,427,343.33 Average Adjusted Episode Cost $4,405.01 $1,808.10 $1,522.60 $1,463.42 Quality Measures % with completed certification N/A 46.42% 43.50% 47.45% % of episodes with medication 92.09% 97.14% 98.94% 99.45% Average number of physician visits per 1.78 3.54 3.33 3.47 episode Average number of behavioral visits per 24.02 3.25 1.15 0.54 episode Average medication fill rate per episode NA 0.90 0.86 0.90 17