A DLH Company Alternative Payment Models, Value-Based Care, and All-Payer Claims Databases Thomas J Flottemesch, PhD Social and Scientific Systems, a DLH Company SSS Proprietary Information www.s-3.com
One Day on the Way to APMs and Value-Based Care… Does it explain : Is it fair regarding: • My Costs • My Performance • My Quality Patient • My Patients • My Access (Risk Adjustment) • Reporting Burden Provider Will it Inform : Is it usable for: All Payer Claims Does it compare : • Policy Design • Performance Rating • Population/Regions • Population Health • Contract Evaluation Database • Across States • Community Rating • Other data sources • Standardized Data Policy Makers Payer Medicare/ Medicaid SSS Proprietary Information
Health Care Payment Learning and Action Network Alternative Payment Model Framework SSS Proprietary Information
Health Care Payment Learning and Action Network Alternative Payment Model Framework SSS Proprietary Information
APCD Challenge: Data, Measurement, and Value Things we know about APCDs: Patient Multiple Stakeholders and Provider Perspectives Different Designs and All Payer Claims Requirements Database Evolving to meet changing needs and expectations Policy Payer Makers Three examples highlighting Medicare/ Medicaid challenges and different perspectives? SSS Proprietary Information
Example 1: Post-Partum Depression Screening Background: • Post-partum depression is a well-known issue • Medicaid mothers have poor adherence to their post-partum care Loss of Medicaid Coverage Other Barriers to Access • Relatively good adherence to infant post-partum care with pediatrician Opportunity: • Screen mothers during post-partum pediatric visit • Develop baseline measure of issue and inform resource planning SSS Proprietary Information
Example 1: The Importance of Perspectives Why are you I am concerned because: asking about • Not really my patient my health? Patient • Lack of Behavioral Health Providers • My Liability Provider My goals are: I need to Inform : Understand issue • All Payer Claims • Resource Planning • Keep mothers Does this impact : • Population Health engaged Database My QI initiatives • Provider Networks • Policy PMPM costs • Makers Payer Medicare/ Medicaid SSS Proprietary Information
Example 1: Post-Partum Depression Screening Resolution: • Introduction of Pediatrician/Family Practice reimbursement using two new codes Positive and Negative Post-Partum Depression • Pay for Reporting and not Performance Measure: Screens/Visits Role of APCD and other data systems: • Collection and standardization of the new billing codes • Matching issues with available resources SSS Proprietary Information
Example 2: Dental Screening for Foster Children Background: • Oral health is often neglected among high-risk populations such as children placed in foster care • Medicaid contracts with managed care organizations dental coverage • Difficult to identify and link newly place foster children dental providers. Opportunity: • Dental screening and treatment within 60 days of foster placement • Introduce initial screening measure to existing VBP program SSS Proprietary Information
Example 2: Dental Screening for Foster Children (Foster Families) I am concerned because: • Am I accountable? • How do I know who Where should I go • Patient these patient are • How can I impact this new measure Provider My focus is on: My goals are: All Payer Claims • High Risk Groups • Helping when I can • Population Health Engaging patients • Database Does this impact : • Current contract Policy • Provider Networks Makers Payer Medicare/ Medicaid SSS Proprietary Information
Example 2: Dental Screening for Foster Children Resolution: • Integrating data from child-welfare and Medicaid systems Identifying new patient groups • Reimbursement for Outreach and Capacity Measure: New patient and foster family contacts Role of APCD and other data systems: • Expanding to include new data sources in secure way • Tracking patients across systems and attributing to providers SSS Proprietary Information
Example 3: Statewide Medical Home Initiative Background: • Assessment of Statewide Health Care Home (PCMH) Initiative 180+ clinics seeking certification • Two key questions: Is there a relationship between PCMH clinical systems (PPC scores) and utilization? What is the impact of a PCMH “pace of change” and utilization? • Challenges: Matching clinical system measures and healthcare utilization Measureing clinical system change and improvement SSS Proprietary Information
Example 3: Statewide Medical Home Initiative What does this say I am concerned because: about : • Are the measures fair My provider • Patient • Will my progress be The quality of my • fairly evaluated care Provider My focus is on: My goals are: All Payer Claims • Triple Aim • Improving Care • Population Health How will: Containing Costs • Database My data be used • • My networks be Policy impacted Makers Payer Medicare/ Medicaid SSS Proprietary Information
Change in clinic system scores 100 90 80 Year 3 System Score 70 60 50 40 30 20 10 45 0 0 0 20 40 60 80 100 Year 1 System Score SSS Proprietary Information
Variation in clinic system change Baseline PCMH Clinic System Correlation between Starting HCH Score 67 and System Change: -.62 Scores (PPC) 49 36 29 20 0 10 20 30 40 50 60 70 Change in PPC systems SSS Proprietary Information
Understanding the Pace of Change 100 Average Growth in HCH 90 Systems HCH System Score (PPC) 80 70 60 Faster than 50 Expected Change 40 30 Slower than 20 Expected Change 10 0 0 2 4 6 8 10 12 14 Time SSS Proprietary Information
Classifying by Pace of Change 100 90 HCH System Score (PPC) 80 70 60 50 40 30 Average Pace 20 Fast Paced 10 Slow Paced 0 0 2 4 6 8 10 12 14 Time SSS Proprietary Information
Example 3: Statewide Medical Home Initiative Resolution: • Defining measure that reflect the data-generating process • Creating a metric understandable by key stakeholders Role of APCD and integrated data systems: • Collecting and collating data in a standardized, consistent way • Developing and reporting measures and performance SSS Proprietary Information
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