1 How Multi-Sector Collaborations Can Help Support Community Population Health Enrique Martinez-Vidal Vice President, AcademyHealth Susan Kennedy Senior Manager, AcademyHealth
Robert Wood Johnson Foundation’s Payment Reform for Population Health (P4PH) Project: Overview and Framework 2
P4PH Vision and Mission 3 • Vision Community-wide population health will be improved through a more supportive o health care payment system. • Mission (i.e., P4PH Goals): o To better understand the systems, context and structures needed to create the conditions for a health care payment system to support community-wide population improvement; and o To identify and address barriers and promote promising opportunities . • Defining population health : “Health outcomes of a group of individuals, including the distribution of such o outcomes within the group.” ( Kindig and Stoddart, 2003) For our purposes, the population is geographically-based total community, not a o patient panel or payer’s covered lives. 3
Role of Health Care Funding in Addressing SDH Services Alternative Payment Models Operations Comprehensive Performance Shared Shared Bundled Community (e.g., Employment, Population-Based Indicators (1) Risk (3) Savings (2) Payment (4) Benefits Procurement and Payment (5) Investment) Engagement Enablers – Conceptual Engagement Enablers – Operational Engagement Vehicles • • Data Collection (Environmental Scan) Leadership • Direct Payment • • Data Analysis/Measurement (Evidence Cross-Sector Consensus Building and • Partnering w/Fin Institutions (CDCs, CFDIs) Generation and ROI) Strategic Alignment • Direct Workforce (i.e. Social Workers, CHWs) • • Data Infrastructure Transparency • Community Benefit Investments • Collaborations • Contracting with CBOs • Convenings • Contracting with Non-Health Care • Communication Government Agencies • Practice Transformation • Collaborations • Trusted Convener Social Determinants of Health (Community Resources) (6) Neighborhood Healthy Food and Built Housing Education Employment Transportation Behaviors Security Environment 1. Financial Bonus for meeting quality / cost targets 4. Episodic or condition-specific billing 2. Upside risk only 5. Capitation / Global Budgets 3. Upside and downside risk 6. Components from Healthy People 2020
Health System SDH Investment: The Why and the How 5 Why How Motivating Factors (Examples) Nuts n’ Bolts (Examples) • • Mission Driven Misaligned economic motives • • External Policy Driven Rate-slide for managed care entities • • Business Case Wrong-pocket problem • • ROI/Evidence Structuring a risk-based contract • State policies and contracting levers
Collaborative Partners: Projects and Lessons 7
Jean McGuire/Northeastern University: Case Studies 8 • Paying for Population Health: Case Studies on the Role of the Health System in Addressing Social Determinants of Health : Four case studies of sites where health systems were actively involved in addressing SDH: o Burlington, VT - medically complex homeless individuals o Muskegon, MI - people with chronic diseases o Cincinnati, OH - pregnant women and their newborns o Greenville, SC - uninsured individuals with multiple chronic conditions • Identifies key contextual factors in individual communities that influence health care systems willingness to sustainably fund non-clinical interventions: o Commitment to Multi-Sector Collaborations o Commitment to Data Acquisition, Analysis and Use o Experience with Care Delivery Transformation o Participation in Alternative Funding and Financing Efforts 8
Network for Regional Health Improvement (NHRI) 9 • January 2017 – January 2018: o Convened multi-sector teams from 5 communities led by regional health improvement collaboratives and content experts to inform next steps in the teams’ specific community - based collaborative projects. Four main topic areas: • Data and Population Metrics • Alignment Across Sectors: Multi-sector Care Delivery • Alignment Across Sectors: Trusted Convener and Governance • Payment and Financing o Provided on-going TA, supporting 4 Affinity Groups focused on each of the four topics above, producing two reports: – Update on Efforts by Five Communities : Outlines their continued efforts to guide collaboration with providers and social service organizations to address the priority health needs of their communities. – How Regional Collaboratives Can Advance Funding and Financing to Improve Population Health : Details how regional collaboratives can serve a critical role in encouraging, developing, and testing the implementation of new funding and financing models for population health. 9
Nemours Children’s Health System: Medicaid Challenges 10 Worked with Maryland, Oregon, and Washington to explore current Medicaid authorities to promote and/or provide prevention services in community settings, cover upstream prevention benefits, and deliver services using nontraditional community-based providers. • Challenges to Investing in Social Determinants of Health o Making the business case to payers/MCOs for investing in upstream prevention. o Understanding what Medicaid can and cannot pay for. States, health plans, and providers often feel like they are always breaking new o ground when determining which upstream interventions to deploy. Medicaid cannot adequately address and invest in SDH on its own — it must o partner with other agencies and CBOs 10
Nemours Children’s Health System: Medicaid Opportunities 11 • Opportunities to Overcome Challenges to Upstream Investments Have the right people at the table. o Allow flexibility on how to accomplish goals. o Identify and build on proven approaches to upstream prevention investments. o Look for ripe opportunities for cross-sector alignment among specific populations, o such as children. o Employ strategies that link traditional clinical care with community-based prevention initiatives as a portfolio of investments. o Focus interventions on the family as the unit of partnership. Engage CMS as a partner, rather than viewing them as only a payer. o Think broadly about ways to use payment reform, rather than addressing a o specific issue. Harness the flexibility under current federal Medicaid regulations. o 11
Green and Health Homes Initiative 12 AcademyHealth contracted with GHHI to provide technical assistance to Talbert House, a large social-service organization in Cincinnati, OH, to explore structuring a risk-based contract with a large local Medicaid MCO to provide targeted services to a subset of plan members, based on an economic analysis. Experiences of a Social-Service Provider: Lessons Learned in Exploring Value- Based Contracts with a Managed Care Insurance Plan (forthcoming) • Outlines processes needed to build a clinical-CBO contractual arrangement (i.e., project planning, stakeholder analysis, data discovery/analysis, economic/financial analysis, contract development) • Lessons Learned: – It Takes a Village : Advancing value-based purchasing arrangements relies on the collective work of many people within and across the partnering organizations. – People are the Process : While substantial time is focused on the technical elements of the process for implementing value-based purchasing arrangements, leadership and facilitation may be the most important elements. – Data Sharing is a Key Barrier : The technical, legal, and procedural barriers to sharing data are limiting the rate of adoption for value-based purchasing arrangements. 12
Green and Health Homes Initiative 13 Value-Based Purchasing: Making Good Health Good Business (forthcoming) • Report shows how the flow of payments for health and healthcare can impact health outcomes by creating natural business and economic incentives to fund or not to fund services that address broad health risk-factors including behavioral, environmental, and social determinants of health. Value-Based Purchasing: How to Succeed by Changing the Business of Health (forthcoming) • Once a system of value-based purchasing is in place, parties within that system have different roles and ways to create value that contribute to the system. Report describes: o Roles each of the healthcare system entities have played/ can play under value-based purchasing models; o Opportunities and challenges the future may hold for those entities; o How those entities can take full advantage of their opportunities; and o What the impact of taking those opportunities (or not) can be. 13
Discern Health 14 Approaches to Cross-Sector Population Health Accountability • Explores a framework for defining two different risk relationships – parallel risk and hierarchical risk – that could be used to establish accountability for health care providers and community-based organizations (CBOs) working to improve population health. • Examines how to align value-based incentives for the health care system with incentives for CBOs working to improve social outcomes. • Proposes a common measure set relevant to both risk models to help align goals and create incentives across health care and CBOs. 14
Challenges and Lessons Learned 15
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