Payment Reform - The National Academy For State Health Policy

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Value-Based Alternative PaymentMethodologies for Federally QualifiedHealth Centers: Lessons from Coloradoand MinnesotaFOR AUDIO, PLEASE DIAL:888-504-7949ACCESS CODE: 241739AUGUST 24, 20172:00-3:15PM ETThis work is supported through NASHP’s Cooperative Agreement with the Health Resourcesand Services Administration (HRSA), grant #UD3OA22891

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Today’s PresentationsThe State of FQHC Value-Based Payment Reform: Lessonsfrom NASHP’s Value-Based Payment Reform AcademyHealth First Colorado FQHC Payment Reform, ShaneMofford, Director of Rates and Payment Reform, ColoradoDepartment of Health Care Policy and FinancingFUHN’s Journey: Minnesota DHS’s Integrated HealthPartnership, Deanna Mills, Director, Federally QualifiedHealth Center Urban Health Network

Value-Based Payment Reform Academy Goal: Support states todevelop and/or implementvalue-based alternativepayment models (APMs) forFQHCs within Medicaid Six states competitivelyselected to participate Received 15 months oftechnical assistance Supported throughcooperative agreement withHRSA

Payment Incentivizes Delivery System andPractice Transformation First, identify the vision and goals for how you want toimprove the delivery of care As we change how care is delivered, providers and their careteams are being asked to: provide additional services (such as care coordination) which aretraditionally not billable under volume-based payment modelsEmploy a larger staff with wider range of competencies (e.g., dataanalysts)In summary: we need to implement value-basedpayment models that will compliment how wewant care to be delivered!

A Time of OpportunityWhy include FQHCs in VBP?Why would FQHCs want toparticipate in VBP? FQHCs have experience working with and Opportunity for increased flexibilityengaging vulnerable populations Primary care focusedto support care team model: FQHCs are sometimes the only provideror only Medicaid provider in communities Many FQHCs are recognized patient-centered medical homes and alreadyprovide a wide range of services (e.g.,physical health; behavioral health) andsupports (e.g., WIC, care coordination,patient education)WorkforcePractice transformationAncillary support services and staff (e.g.,care coordination, community healthworkers) to address upstream socialdeterminants Increase capacity to catalogue anduse clinical data improved quality Experience with VBP can help withMCO contracting

Unique Criteria for FQHC Payment The Medicare, Medicaid, and SCHIP BenefitsImprovement Act of 2000 requires that FQHCs bereimbursed through the prospective payment system, oran alternative payment model (APM) as long as: Individual FQHCs agree to be reimbursed by that APM; andEach clinic’s total payments are equivalent to or higher than the totalpayments they would have received through PPS.Full text of the Act can be found here: text

VBP: Payment ModelsIncreasing risk; increasing complexitySource: HealthcarePayment Learning andAction aper.pdf

Shared Savings (SS) and PopulationBased (PB) APMs Underway for LHIAs of August 2017SS or PB FQHC APM indevelopment(8 states DC)SS or PB FQHC APMActive(5 states)NASHP AcademyState (6 states)RI

Lessons Learned from Academy States Start by identifying vision and shared goals for how careshould be delivered Then what needs to change about payment to support providers to achievethat vision Critical to foster trust and transparency among stateagencies and organizations involved in modeldevelopment Consider state agency bandwidth, and opportunities toalign FQHC payment reform with broader Medicaidinitiatives

Lessons Learned, Continued State should work with primary care association to assessFQHC readiness Remember: APMs are opt-in; not all health centers need to be readyat launch Among Academy states, PPS PMPM was of mostinterest due to opportunity for greatest flexibility forproviders APM development takes time!

Forthcoming NASHP Resources Blog Series on FQHC Payment Reform Stay tuned to www.nashp.org and our weekly e-newsletter forblogs throughout the late summer and fall. Toolkit for states on key considerations and lessonslearned for FQHC payment reform Anticipated release: October 2017

Thank You!For questions or more information, pleasecontact Rachel Yalowich(ryalowich@nashp.org)

Health First ColoradoFQHC Payment ReformShane Mofford08/23/201714

Our MissionImproving health care access andoutcomes for the people we servewhile demonstrating soundstewardship of financial resources15

Context Lay of the land – the changing nationalframework of payment reform Colorado Specific Payment and DeliverySystem Reform Why FQHC Reform? What we’re doing.16

National Drive to Value-BasedPurchasing and Integrate Care Health Care Payment Learning Action NetworkFrameworkHow you pay matters, not just how much Public commitment from CMS and Colorado MACRA - Medicare primary care payment reform CPCi/CPC /TCPi – multipayer primary and specialtycare reforms State Innovation Model – large federal investmentin integrated care and public health policy at thestate level17

Colorado Payment Reform Time of change for all providersThe Accountable Care Collaborative Behavioral Health Reform Integrated Care – SIM CPCi/CPC and TCPi Managed Care Reforms Hospital Reforms – DSRIP/HospitalTransformation/Enterprise LTSS/PACE Primary Care 18

Colorado Medicaid Expenditures19

Payment Reform InitiativesCurrently Under Way20

FQHC Reforms – Why? Primary care investments can reduce downstreamcosts. (Remember the giant blue circle on the lastslide?) 40% of clients in Colorado Medicaid’s AccountableCare Collaborative Program utilize FQHCs. The PPS model is antiquated and has strongperverse financial incentives. The delivery model enforced under PPS isinefficient.21

FQHC Reforms – What We’reDoing NASHP Technical Assistance Grant Collaborative partnership between state, providers,and professional organization to change how FQHCs arepaid Goal 1: Implement primary care limited riskcapitation with tie to quality for FQHCs by7/1/2018 – On Track! Goal 2: Implement quality incentives that tie FQHCencounter rate to value/performance for those notunder monthly cap by 7/1/2018 – On Track!22

Four Key Bodies of Work andCritical Lessons Learned Stakeholder engagement Program DesignClean up of current state Building future state AuthorityFederal – State Plan Amendment State – Statute, Rules Operational Strategy – death by 1,000 cuts23

Stakeholder EngagementPartnership – Priority #1 FQHC Alternative Payment Methodologies requireFQHC consent to implement. Building and operationalizing new payment modelsthat are sustainable and drive real change requires‘boots on the ground’ insight Reform is hard and resource intensive. StateMedicaid programs are not overflowing withadministrative resources. You will need yourprofessional association and providers’ support.24

Program Design Resource constraints are real and always havebeen. When you look at your current program to preparefor reforms, you will find things you need to fixbefore progressing – maybe a lot of things. Plan forit. (Change in scope process, for example) Look to other examples – a lot of work has alreadybeen done. You don’t need to solve every problemon your own.25

Authority Navigating CMS approval. Understand BIPA APMs can be approved through a State PlanAmendment Whatever you design must still comply unless you get an1115 waiverLean on precedent (Thanks Oregon!)Engage CMS early and often26

Operational Strategy Again, reform is hard.Systems changes, rule changes, documentationchanges, communication strategies, authority, etc. If any piece fails, the program fails. Give yourself enough time! Investment in upfront, detailed planning is timewell spent. Internal engagement is as critical as externalengagement. This is fun stuff and important work –get people excited about it.27

Contact InformationShane MoffordRates and Payment Reform DirectorShane.Mofford@state.co.us28

FUHN’s Journey:MN DHS’s Integrated Health PartnershipDeanna Mills, MPHFUHN Program DirectorAugust 20178/25/201729

What is FUHN?Federally Qualified Health Center Urban Health Network Collaborative partnership of 10 Mpls./St. Paul FederallyQualified Health Centers (FQHC) Nation’s first FQHC-only Safety Net Medicaid Accountable CareOrganization.8/25/201730

What is FUHN? cont . Member clinics serve 110,000 patients in the Twin Cities areaVery Diverse 91%; 41% best served in a language other than EnglishVery Poor 95% under 200% FPL50% Medicaid, 28% uninsured, 15% commercial, 7% Medicare40 unique service sitesServices include medical, dental, mental health, substance abuse,vision and enabling; also Variety of special programming – homeless,public housing, schools, HIV/AIDS, legal, case management, mobile,community education & outreach, enrollment in public programs, exercise,community gardens and farmers markets, domestic violence, etc.8/25/201731

Topics FUHN’s participation in the MN DHS Medicaid Program IHPWhy we did what we didResults we’ve achievedResources FQHCs need to succeedDisclaimer: I don’t represent MN DHS Medicaid/IHP Staff; they are greatpeople and partners, but I can’t represent their perspectives in thispresentation8/25/201732

FUHN/DHS IHP Project Overview FUHN’s 10 member health centers are working together with MNDepartment of Human Services on Medicaid health care reform tofurther enhance the health care provided to our Medicaid patientsthrough Value Based Purchasing called the “Integrated HealthPartnership” (IHP). The overall goals of the FUHN’s IHP project is to demonstrate ourability accomplish the Triple Aim 1 Reduce Total Cost Of Care Improve Clinical Quality Improve the Patient Experience Improve PRIMARY CARE ACCESS for vulnerable populations8/25/201733

Why did the FQHCs choose to participate inthis Medicaid ACO Project? MN Health Reform Legislation in 2010 allowed for ACO MedicaidDemonstration FUHN viewed Demonstration as Opportunity: leverage resources, foster collaboration, learn togetherThreat: survival in a quickly reforming health environment ?Join larger systems to gain access to resources OR take a leap of faith totransform our clinical practices? FQHC Mission 8/25/2017Community based, governed by patients, economic engine in urban core,tailored service delivery, social justice10 independent FQHC Boards’ support (51% patients)34

Why did the FQHC's choose to participate inthis Medicaid ACO Project? cont Health Reform was taking shape– Our Clinics needed to complete a significant operationaltransformation in order to be relevant in this new environment. FQHC’s are the model for this population:– Health reform trends place importance on primary care health carehomes that focus on the health of patients and address socialdeterminants.8/25/201735

Challenge for FQHCsShifting sands of the environment where FQHCs mustPlay Checkers –Maintain mission toserving underserved8/25/2017Play 3D Chess –Participate in“reform/evolving”marketplace36

Recognizing our need to respond to thisnew VBP market, what did the FUHN Clinicsneed to do?Clinical Practice Transformation People Process Technology8/25/201737

Clinical Practice Transformation Infuse Change Management Techniques – change culture Achieve Health Care Home Certification as building block toestablish policies/protocols/process Use of e-health technologies and data analytics Predictive modeling for higher cost patient costs ID/Stratification for gaps in care leading to higher costs eHealth Exchange for more comprehensive view of care Design new and more effective clinical interventions withstandardized medical protocols, workflow and processes andassociated workforce training Example: Avoidable ED utilization8/25/201738

Clinical Practice Transformation cont Re-invigorate care coordination Motivational interviewing LEAN process improvement Utilization of population health analytics data Team-based care Pre-visit Planning Daily Team Huddles Referral management 8/25/2017Understand new payment models Responsibility for total care received outside our 4 walls Gain/risk-sharing around TCOC, quality and patientsatisfaction39

FUHN Results: Attribution 2013: approx. 24,000 2015: approx. 32,000 Medicaid expansion Move from 12 months to 24 months attribution period This represents roughly 55% of the MA patient population servedby our 10 FUHN Member Clinics (remaining did not meeteligibility of enrollment time)8/25/201740

FUHN Results: TCOC SummaryAnnually, approx. 175,000,000 TCOC - excluded Medicaid servicesresulted in approx. 140,000,000 TCOC was FUHN’s responsibility or80% /CD100%99%99%97%43%41

FUHN Results: Shared Savings Over 3 YearsSavings %201320142015-3.10%-4.60%-5.90% 17 MMN State SavingsShared Savings FUHNState retains 50% eachyear 1,823,769 2,984,751 3,853,185 8,661,705*73% of the savingsachieved by FUHNwere used reimburseour administrativepartner for theirinvestment8/25/201742

Quality and Patient Satisfaction Savings dependent on achievement̶̶2013 no withhold but required to report quality outcomes2014 25% withheld2015 50% withheld̶ 5% relative improvement̶Vascular & diabetic care, child & adult asthma, depression remission 90% on excellent/good̶̶̶8/25/2017Able to get appointment for checkupsYour provider gives you good adviceSend your family and friends to us43

FUHN Results: ED utilization reduction graph 2013-2015Emergency department visits per 1000 PatientsDecreased -27% from Base Year 2012 to Year End 20158/25/201744

FUHN Results: Inpatient admissions reduction graphInpatient admissions per 1000 PatientsDecreased -2% from 2013 to 20158/25/201745

How did FUHN achieve these results?“Fierce competitors to extreme collaborators”8/25/201746

FUHN’s Structure Fosters Collaboration &Consensus Decision Making Committees8/25/201747

How did FUHN achieve these results? cont. Implementation of a Care Coordination Program comprised oftwo essential components designed to put ACTIONABLE datain the hands of our Primary Care Providers: Robust Data Analytics infrastructure using claims utilizationand real-time clinical data. Dedicated personnel in our clinic sites using this new dataanalytics to implement patient interventions designed todrive cost and quality improvements. This capability gave our providers a sight line to patientutilization occurring OUTSIDE of the Primary Care office.8/25/201748

How did FUHN achieve these results? cont. The implementation of this Care Coordination Program requireda significant upfront investment an investment that ourFQHCs could not possibly make: FUHN relied on an administrative partner (Optum) to providethe initial upfront funding necessary to acquire the datainfrastructure and dedicated personnel required by our CareCoordination Program.8/25/201749

How did FUHN achieve these results? cont. Using ID/Stratification Tool Emergency Department Reduction (minor conditions) Asthma Management Diabetes Management Pain Management/Opioid RX Standardized clinical policy throughout the Network – Gettingto the power of 10 Work flow – Proliferation of LEAN8/25/201750

Health Information Technology Initiative FUHN, using approx. 1.5M grants received through MDH, DHSand the BPHC, is building the data analytics infrastructure andcapability needed to manage VBP arrangements – this willreplace current “expensive” administrative partner. A data warehouse that will receive real time data feeds from: FQHC’s EMR clinical data Payer claims data Available admit, discharge and transfer data provided byselected hospital care partners A robust data reporting and analytics capabilities for use byour Care Coordinators. Future gain savings are expected to partially sustain theongoing operating costs with this new infrastructure.8/25/201751

Sustainability Through Federal Grant In August 2016 FUHN was informed that it was one of 51 HRSAGrant Recipients for Health Center Controlled Networks. This three-year, 1.5M Grant award provides FUHN and itsmembers funding to continue our organizationaltransformation by securing ongoing staffing. Will help FUHN Clinics fund the automation of data reportingobligations from our annual Federal Uniform Data System,State MNCM Submissions and VBP Reporting obligations.8/25/201752

Lessons Learned Moving to VBP requires clinical practice transformation Upfront capital for technology is very expensive– Caution: Risk Partners that take most of the risk & will take most ofthe money. Investing in staff re-training is essential & takes times – LOTS OF IT FQHCs are the model for serving the Medicaid population whoexperience social inequities TCOC reduction and improved health outcomes are possibleTHANKS!8/25/201753

ResourcesDeanna MillsFQHC Urban Health Networkmill1310@umn.eduMathew SpaanMinnesota Dept. of Human Services, Integrated Health mn.usMinnesota Statutes, section 256B.0755 Health Care Delivery Systems id 256B.0755&year 20108/25/201754

Thank You!Thank you for joining this webinar!Please complete the evaluation form followingthis presentation.

The State of FQHC Value-Based Payment Reform: Lessons from NASHP's Value-Based Payment Reform Academy . Health First Colorado FQHC Payment Reform, Shane Mofford, Director of Rates and Payment Reform, Colorado Department of Health Care Policy and Financing. FUHN's Journey: Minnesota DHS's Integrated Health Partnership, Deanna Mills,

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