Vermonts Statewide All -Payer Accountable Care Organization Model - PowerPoint PPT Presentation

Vermont’s Statewide All -Payer Accountable Care Organization Model and APCD: How it all fits together NAHDO Annual Meeting, Nov 6, 2019 Kathryn O’Neill, Director of Data Management Analysis & Data, The Green Mountain Care Board Sule Gerovich, PhD, Director of State Health, Mathematica Policy Research

Acknowledgment The Green Mountain Care Board Mathematica Policy Research Onpoint Health Data Sarah Lindberg, Sule Gerovich, Senior Researcher Karl Finison, Director of Health Services Researcher Analytic Development Tom Bell, Principal Program Analyst Kate O’Neill, Adam Bakopolus, Senior Director of Data Management Keri-Ann Wells, Health Research Health Data Analyst Analysis & Data Integrity Analyst Carolyne Conrad, Project Michele Degree, Health Policy Manager Advisor 2

Vermont’s Policy Context 3

Cost Growth is Unsustainable and Health Outcomes Must Improve Cost Growth Health Outcomes • In 2017, health care spending in Vermont grew 1.7%. Chronic diseases are the most common cause of death in Vermont. In Health care spending as % of annual growth in 2014, 78% of Vermont deaths were GSP 20% caused by chronic diseases 19% 18% • Vermont’s death rates from suicide 17% 16% and drug overdose are higher than the 15% national average 14% 13% 12% VT 11% US 10% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Source: 2017 Vermont Health Care Expenditure Analysis, Sources: Vermont Department of Health, Kaiser Family available at https://gmcboard.vermont.gov/data- Foundation and-analytics/analytics-rpts. 4

History of Vermont Health Reform to Value-Based Care 2014 Community Health Accountable Care ACO Medicaid SSP Integrated 2012 Communities Care Accountable Management Learning Care Collaborative 2003 2008 2017 Coalition of Blueprint VHCURES the Green All- Payer VHCURES becomes for Health established Mountains ACO All-payer 2007 2011 2013 2016 Patient Green Mountain Care OneCare Multipayer Centered Board founded Advanced Medical Primary Care Collaborative Home Practice ends Multipayer Advanced Physician ACOs (PCMH) Pilot Primary Care Practice Demo Hub and Spoke Blueprint for Health Pay State Innovation Support and Services at for Model (SIM) Home Performance Medicare and Community Health Blue Cross Shared Teams Savings Programs (SSPs) 4

All-Payer ACO Model Agreement What is Vermont responsible for? Scale and Population Health and Cost Growth Quality Measures • State is responsible limiting cost growth • State is responsible for performance on ➢ All-Payer Growth Target: 20 quality measures , including three Compounded annualized growth rate population health goals for Vermont < 3.5% ➢ Improve access to primary care ➢ Medicare Growth Target: 0.1-0.2% below national projections ➢ Reduce deaths due to suicide and drug overdose • Ensuring alignment across payers, which supports participation from providers and ➢ Reduce prevalence and morbidity of increases “scale” chronic disease ➢ All-Payer Scale Target – Year 5: 70% • ACO/providers are responsible for of Vermonters meeting quality measures embedded in contracts with payers ➢ Medicare Scale Target – Year 5: 90% of Vermont Medicare Beneficiaries 6

Vermont’s Solution: The Vermont All -Payer Accountable Care Organization (ACO) Model Test Payment Changes Improve Outcomes Transform Care Delivery Population-Based Invest in Care Coordination Improved access to Payments Tied to Quality primary care Incorporation of Social and Outcomes Determinants of Health Fewer deaths due to Increased Investment in suicide and drug overdose Improve Quality Primary Care and Reduced prevalence and Prevention morbidity of chronic disease 6

GMCB APM Regulatory Responsibilities Goal #1: Vermont will reduce the Goal #2: Vermont will ensure rate of growth in health care and improve quality of and expenditures access to care GMCB Regulatory Levers ACO Oversight (Budget Review and Certification) Act 113 of 2016 Medicare ACO Program Rate Setting and Alignment Hospital Budget Review Health Insurance Rate Review Certificate of Need 8

All- Payer ACO Model Statewide Analytics 9

VHCURES Overview Statutorily, the GMCB is required to maintain VHCURES (Vermont’s APCD) for: determining the capacity and distribution of existing state resources; • • identifying health care needs and informing health care policy; evaluating the effectiveness of intervention programs for improving patient outcomes; • • comparing costs between various treatment settings and approaches; • providing information to consumers and purchasers of health care; and improving the quality and affordability of patient health care and health care coverage. • GMCB’s Data Governance Council oversees data stewardship in four key areas: Risk Management Data Quality Program Sustainability Data Release Implementing and Establishing data Evaluating opportunities Supporting clear enforcing the most stewardship to promote to optimize sustainability processed for the appropriate data privacy highest possible quality and revenue for data evaluation of data and security standards of data resources stewardship program requests and the release and practices of data 10

VHCURES Overview • Claims data have been collected in VHCURES since 2008. • Includes commercial payers, Medicaid, Medicare, and Medicare Advantage. • Commercial payers include both fully and self-insured plans. − Vermont originally required all claims data from third-party administrators of self- funded company plans. 2016 supreme court decision held that ERISA preempts state mandate that ERISA- − covered self-funded plans provide health care service data to APCDs. − Today all non-ERISA covered self-insured plans report to the APCD, while only some ERISA covered self-insured employers opt-in. 11

2018 ACO Membership Results Targets Performance Difference All-Payer 36% 22% -14% Medicare 60% 35% -25% Attributed Percent Individuals Population Attributed Medicare A& B 39,530 113,272 35% Medicaid 42,342 135,879 31% Self-funded employers 9,874 166,996 6% Fully insured 20,838 92,978 22% Source: https://gmcboard.vermont.gov/sites/gmcb/files/PY1%20Annual%20ACO%20Scale%20Targets%20and%20Alignment%20Report_FINAL.pdf 12

All-payer Total Cost of Care - Who is included? Medicare beneficiaries Commercial Medicaid plan Residents in Vermont enrollees members Eligible residents 13

What Payments Are Included? payments = + Claims- Non-claims- APM based based total cost payments • Vermont Medicaid Next Generation ACO prospective payments • Shared savings/losses Blueprint payments from payers • • Other direct care coordination payments 14

What Services Are Included? Included in all-payer TCOC Commercial Medicare Medicaid Major category of service Inpatient Y Y Y Outpatient facility services Y Y Y Professional Y Y Y Home health Y Y Y Skilled nursing facility a N a Y Y Long-term institutional care a, b N b N a N Hospice Y Y Y Durable medical equipment Y Y Y Pharmacy (retail) N N N Dental N N N Government health care activities — AHS c N c Government health care activities — HCBS c N c Not applicable Government health care activities — mental health c N c a Excluded only in PY1 – PY3 for Medicaid. b Only costs for long-term care hospital are included for Medicare. c The agreement requires a plan to include these services in the future. AHS=Vermont Agency for Human Services 15 HCBS = home and community-based services

2017 Total Cost by Source of Payment 3% All payer 1.5% Commercial Medicaid 14% Medicare 0.6% Total claims costs Total nonclaims costs 16

2017 Total Cost by Payer Total cost per member per year (PMPY) Total cost by payer $12,000 $10,022 $10,000 Commercial Medicare 41% $8,000 44% $5,958 $5,508 $6,000 $4,000 $3,061 Medicaid $2,000 15% $0 All payer Commercial Medicaid Medicare Total member months Total cost per member per month (PMPM) Medicare $1,000 $835.18 26% $800 Commercial 44% $600 $496.51 $459.02 $400 $255.05 Medicaid $200 30% $0 All payer Commercial Medicaid Medicare 17

Total Cost PMPM by Service Type $0 $20 $40 $60 $80 $100 $120 $140 $160 $180 $200 Outpatient facility $178.42 Professional $133.33 Inpatient acute $130.75 Skilled nursing facility $19.04 Home health $9.93 Hospice $5.70 All-payer 18

All-payer PMPY trends by Payer $11,000 $9,000 $7,000 $5,000 $3,000 $1,000 2012 2013 2014 2015 2016 2017 2018 -$1,000 Commercial Medicaid-claim Mecaid Total Medicare-claim Medicare Total All-payer claim All payer total 19

Health Outcomes Medication Management for People With Asthma 75% Compliance (MMA) Medication Management for People With Asthma 50% Compliance (MMA) Initiation of Alcohol and Other Drug Dependence Treatment (IET) Follow-Up After Emergency Department Visit for Mental Illness (FUM) Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA) Engagement of Alcohol and Other Drug Dependence Treatment (IET) Adolescent Well-Care Visits (AWC) 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% Medicare Medicaid Commercial - Self-Insured Commercial - Fully Insured 20