Partners in Innovation: W What St States and the CMS Innovation C Center A Accomplish T Together Rivka Friedman Director, Division of All-Payer Models
CMMI W Waiver A Authority E Enables M Medicar are “ “Par articipat ation” i in Most I Innovat ative S Stat ate M Models Multi-payer model Novel test Medicare flexibility Hospital global budgets + TCOC Waive IPPS/OPPS to enable Maryland accountability to decouple hospital global budgets; build a revenues from volume and custom version of CPC+ to incentivize prevention engage small practices ACOs at scale statewide, with a Provide a custom Vermont common incentive structure to Medicare ACO model, make transformation a rational based on CMMI’s business strategy NextGen ACO model Hospital global budgets for Allow global budget Pennsylvania rural hospitals and a payments to deliberate plan to improve participating rural quality and efficiency hospitals across service lines
Maryland All-Payer Model and State Innovation Model (SIM) Evaluation Findings Heather Beil, PhD RTI International www.rti.org RTI International is a registered trademark and a trade name of Research Triangle Institute.
Maryland All-Payer Model Model Overview Global Budgets Goals of the Model Tests whether an all-payer system Generate $330 million in Medicare State sets total revenue target for hospital payment is an effective savings (budget) for each hospital model Limit annual all-payer per capita State uses rate-setting authority to Shifts hospital revenue into global total hospital cost growth to 3.58% determine individual hospital budgets chargeable rates Reduce Medicare 30-day Retains Maryland’s unique all-payer unadjusted readmission rate Hospitals adjust charges up and rate-setting system down to meet target budget Reduce the potentially preventable hospital complications 4
Findings for the Maryland All-Payer Model after 3 years of implementation Relative to an out-of-state comparison group, the Maryland All-Payer Model $125 million savings in non- resulted in a total of $679 million hospital savings savings to Medicare Unlikely that cost shifting to sectors of the Maryland health care system outside of the global budgets is driving $554 million savings in the reduction in hospital spending hospital spending Although the design of global budgets guarantees hospital savings, we also found reductions in inpatient admissions No adverse impacts on hospital finances or beneficiary satisfaction 5
Vermont Medicaid Shared Savings Program (SSP) Vermont had 2 Medicaid ACOs from 2014 – 2016 – 1 was hospital-based and 1 was mostly FQHCs Medicaid designed its ACO model in coordination with commercial payers and Medicare One-sided risk model calculated based on retrospective use, cost and quality Included 20 quality metrics – 8 to 10 were used for shared savings calculations Many PCPs participated in Blueprint for Health (PCMH model) prior to entering ACO arrangement Minimum Quality savings score on Shared achieved in set of savings total costs metrics of care 6
Findings for the Vermont Medicaid SSP after 2 years of implementation • Relative to an in-state comparison group, the Vermont Medicaid SSP resulted in: • $31 million savings to Medicaid • 3% relative decline in outpatient ED visits • 29% relative increase in developmental screenings (the only quality metric that was unique to Medicaid SSP) Quality • No change in: • Inpatient admissions • Follow-up visits after a mental health-related admission 7
The Vermont All-Payer Accountable Care Organization Model Agreement: A Partnership with the Center for Medicare and Medicaid Innovation Ena Backus Director of Health Care Reform Vermont Agency of Human Services Academy Health National Health Policy Conference February 4, 2019
Ve Vermont A All-Payer A Accountable C Care O Organization M Model A Agreement: Moves f from v m volume me-driven f fee-fo for-ser ervice p e payment, t to a a v value-based, p pre-paid m model f for ACO COs Medicare Medicaid Commercial VT modified VT Medicaid Next Risk-Based ACO Gen Next Gen ACO Contract ACO through 1115 /Vermont ACO waiver Initiative Vermont All-Payer ACO Model (aligned ACO standards) OneCare VT ACO Provider Care Continuum 9
Increased investment and incentives for primary care and prevention Increased investment and incentives for care coordination How is care Provider payment tied to quality and outcomes delivery changing? In 2016, the legislature required the All-Payer ACO Model and ACO to strengthen and support primary care and community-based care through local community collaboration. (Act 113 of 2016) There is consensus that a strong primary care foundation with an enhanced focus on preventive services can improve health care quality, improve the health of the population, and help reduce growth in health care costs.
All-Payer ACO Model Agreement What is Vermont responsible for? Population-level Financial Trends and Scale Targets Health Outcomes Measures and Targets All-Payer Growth Target: Compounded annualized growth rate <3.5% Improve access to primary care Medicare Growth Target: 0.1- Reduce deaths due to suicide and 0.2% below national projections drug overdose All-Payer Scale Target – Year 5: Reduce prevalence and morbidity 70% of Vermonters of chronic disease Medicare Scale Target – Year 5: 90% of Vermont Medicare Beneficiaries
Improving the e Heal alth of V Ver ermonters How w will w we m measure s e succes ess? Vermont is responsible for meeting targets on 20 measures under the Model Process Milestones and Health Care Delivery System Quality Targets support achievement of ambitious Population Health Goals Process Milestones Health Care Delivery System Quality Targets Population Goals selected based on Vermont’s priorities: Health 1. Improve access to primary care Outcomes 2. Reduce deaths due to suicide and drug overdose 3. Reduce prevalence and morbidity of chronic disease
How Did We Get Here? 2 Years Negotiating with State Innovation Model Center for Medicare and Grant Funding Medicaid Innovation (CMMI) Healthy Long-Distance Parallel Stakeholder Relationship with CMMI: Involvement: Provider-led Regular and Frequent Reform Communication
Maryland Total Cost of Care Model Katie Wunderlich, Executive Director Health Services Cost Review Commission National Health Policy Conference 2019
All-Payer Model, 2014-2018 Successes, Challenges, and Lessons Learned
All-Payer Hospital Rate Setting and Maryland’s All-Payer Model • Since 1977, Maryland operated an all-payer, hospital rate setting system • In 2014, Maryland updated its rate setting approach through the All-Payer Model: • Patient-centered approach that focuses on improving care and outcomes • Per capita, value-based payment framework for hospitals • Stable and predictable revenues for hospitals, especially those providing rural healthcare • Provider-led efforts to reduce avoidable use and improve quality and coordination • Contractual agreement with CMMI
Move from Volume to Value Transforms Hospital Incentives • No longer chasing volumes on pressured prices • Incentivized • Reduced readmissions • Reduced hospital-acquired conditions • Reduced ambulatory-sensitive conditions, or Prevention Quality Indicators (PQIs) • Better managed internal costs • Results • Improved health care quality, lower costs, better consumer experience But more to be done …
Lessons Learned • Early successes create momentum • Stakeholder engagement and management is a must • Transparency and communications • Provider-led innovations • Comprehensive data analytics • Build widespread, bipartisan political support • Proactive partnership with federal partners
Maryland Model Negotiations
Progression Plan Developed in 2016 1 2 3 4 5 Foster Align measures Encourage and Ensure Devote accountability and incentives develop availability of resources to payment and tools to support increasing delivery system all provider types consumer transformation in achieving engagement transformation goals
Guiding Principles and Critical Success Factors 1. Ensure person-centered care and consumer engagement 2. Maintain focus 3. Retain the All-Payer System that is benefitting all parties in Maryland; allowing private sector to lead 4. Set targets, allow considerable flexibility in how they are met 5. Data driven 6. Ensure accountability, predictability and transparency 7. Foster alignment 8. Modernize responsibility and regulatory oversight of the delivery system 9. Balance current and future responsibilities effectively
Negotiations Timeline May 2017 June – December 2017 Basic Term August 2017 – June 2018 Sheet Detailed May 2018 Completed Term Sheet TCOC July 2018 Negotiated Model TCOC Agreement Model TCOC Drafting Approved Model by CMMI Agreement Signed and Executed
TCOC Model Vision and Implementation
Recommend
More recommend
