A Presentation to the Committee on Health Coverage

Value-Based Purchasing Discussion

A Presentation to the

Committee on Health Coverage, Insurance and Financial Services

Michelle Probert

Director, Office of MaineCare Services

Maine Department of Health and Human Services 1

Goals for Session

1. Understand basic elements of Value-Based Purchasing

(VBP)

2. Review continuum of alternative payment models

3. Review MaineCare VBP initiatives and efforts toward multi-

payer alignment

3Maine Department of Health and Human Services

What is Value-Based Purchasing?

VALUE =COST

QUALITY

Alternative payment models are the means to

get to Value-Based Purchasing

r-=== Population-Based Accountability

Category 1 Category 2 Category 3 Category4 •••• •••• •••• ••••

Fee for Service - Fee for Service - APMs Built on Population-Based

No Link to Quality Link to Quality Fee-for-Service Payment & Value & Value Architecture

Source: Alternative Payment Model (APM) Framework and Progress Tracking Work Group

But I thought Value-Based Purchasing meant…


• Accountable Care Organizations

• Patient Centered Medical Homes

• Centers of Excellence

?

Exam

ples o

f Initiativ

es Usin

g A

lternativ

e

Pay

men

t Models

6M

aine D

epartm

ent o

f Health

and H

um

an S

ervices

Med

ica

re Sh

ared

Savin

gs P

rogra

m

Carru

m C

enter o

f Excellen

ce, in u

se by S

tate of M

aine

Blu

e Cro

ss Blu

e Sh

ield: H

osp

ital P

4P

BC

BS

of M

ichig

an p

rov

ides b

onu

s pay

men

ts to h

osp

itals wh

o ach

ieve

success in

qu

ality, cost efficien

cy, and

po

pu

lation

health

man

agem

ent, as

lon

g as th

ey h

ave receiv

ed eith

er a CM

S S

tar Ratin

g o

f 2 o

r a Leap

frog

Safety

Grad

e of “C

”

Carru

m co

ntracts w

ith C

enters o

f Excellen

ce to receiv

e pro

spectiv

e bu

nd

led

pay

men

ts for p

roced

ures lik

e join

t replacem

ents an

d b

ariatric surg

ery.

Pro

vid

ers mu

st abso

rb th

e cost o

f any read

missio

ns.

Gro

up

s of p

rov

iders co

mm

it to b

eing

accou

ntab

le for th

e costs

of th

eir Med

icare mem

bers. T

hey

can receiv

e a shared

savin

gs

pay

men

t if they

spen

d lo

wer th

an p

rojected

costs an

d m

eet

qu

ality b

ench

mark

s

It f\

~

VBP Success Depends on Multiple Factors

7Maine Department of Health and Human ServicesFigure citation: Chee, Tingyin T et al. “Current State of Value-Based Purchasing Programs.” Circulation vol. 133,22 (2016): 2197-205. doi:10.1161/CIRCULATIONAHA.115.010268

External Environment Regulations, policies, pa ien

preferenc s, patien popul tion, o her programs

System s rue ure, organizational cu ure, resource capability,

in orma ion echnology


How is quality measured?

StructureMeasures of a provider’s capacity, systems, & processes

e.g. Provider use of Electronic Health Records, Ratio of providers to patients

ProcessMeasures of actions taken in the course of medical care; often based on widely

accepted clinical recommendationse.g. Percentage of individuals with diabetes receiving blood glucose screening,

Percentage of adolescents with well-care visits

OutcomeMeasures of a group or individual’s health status

e.g. Readmission rate, percent of patients with controlled asthma, functional

outcomes

Patient ExperienceMeasures of an individual’s satisfaction with care

e.g. Consumer Assessment of Healthcare Providers and Systems (CAHPS)

9

Maine Department of Health and Human Services

New York: 15% of

managed LTC

expenditures in

Level 2 or above

by April 2020.Arizona: 70% of

payments for acute

physical claims

linked to VBP by

2021.

State Goals for APMs

Washington:

90% of publicly

funded health

payments linked

to VBP by 2021

2A: Health Homes 3N: Opioid Health Homes

2C: Behavioral Health Homes 3A:

Accountable Communities

CY2018 MaineCare Alternative Payment Model

Results

78% 4% 18% 0%

Population-Based Accountability I

Category 1 Category 2 Category 3 Category 4 •••• •••• •••• ••••

Fee for Service - Fee for Service - APMs Built on Population-Based

No Link to Quality Link to Quality Fee-for-Service Payment & Value & Value Architecture

Source: Alternative Payment Model (APM) Framework and Progress Tracking Work Group

Polling Instructions


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tool called Poll Everywhere. Your

answers will populate on our computer

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see everyone’s answers in the visual

display. Responses are anonymous.

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5:37 PM

22333

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1) Open your cell phone SMS/text

application.

2) Log into Poll Everywhere by entering

the contact number as 22333 and

sending the message erinripley445.

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your first time using this tool.

4) Type your response to the question

into the message field and press send.

Polling Instructions

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Forum Poll: Provider Opinions

By the end of 2022, where do you think MaineCare should be in

terms of the percent of payments in alternative payment models?

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

30% 40% 50% 60% 70% 80%-

National Goal for Percentage Payment in Shared

Savings and Population-Based APMs

23% 30% 54% 41%2018Maine: 18%

Medicare Traditional Medicaid Commercial Advantage Medicare

2020 .

2022

2025

15


MaineCare Value-Based Purchasing Programs

and Alternative Payment Models

Prim

ary C

are Health

Ho

mes, B

ehav

ioral H

ealth

Hom

es, and

Acco

untab

le Com

munities E

nro

llmen

t

16

Main

e Dep

artmen

t of H

ealth an

d H

um

an Services

0

10,0

00

20,0

00

30,0

00

40,0

00

50,0

00

60,0

00

70,0

00

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

2017

2018

2019

Acco

untab

le

Com

munities

Beh

avio

ral

Health

Ho

mes

Health

Ho

mes

There are 9

2,1

20

un

du

plicated

mem

bers acro

ss all three p

rog

rams

+ I +I +


Primary Care

Primary Care Case Management

(PCCM)

• Providers receive a Per Member Per

Month (PMPM) payment for

providing 24/7 coverage and

coordinating care.

• About 60% of MaineCare members

are part of PCCM.

Primary Care Provider Incentive Program

(PCPIP):

• Bonus payment made to independent

primary care providers, based on their

comparative performance on certain

measures related to member access,

utilization, and quality.

• Payments total $2.6M annually.

C.ATEGORY2 FEE FOR SERVICE -LINKTO QUALITY

&VALUE

A Foundational Payments

for Infrastructure & Operations

(e.g. , care coordination

fees and paymen s for HIT inves ·men· s}

C Pay-for-Performance

(e.g., bonuses for uality per ormance)


Primary Care Health Homes

CATEGORY2 FEE FOR SERVICE -LINK TO QUALITY

& VALUE

A Foundational Payments

for Infrastructure & Operations

(e.g., care coordina ·on fees a d paymen s or

HIT inves men s)

!i!

-oiact1ce e, \. ~ ~

:$" A Health Home ~ P1:actice delivers

~ enhanced pri.J.uary care services to MaineCare members.

PJ.\O>l\l: 12 I I

A Community Care TeaDl is a cominuni.ty-1based care managen1ent tea1n .. CCTs address housing food

I insecurity. transpm1atioo, \ literacy de.

\

I I I

I , .----,._ ' Pl\lP_ I: $129.50 ~


Primary Care: MaineCare’s Next Steps

1. Grow enrollment in PCCM and Health Homes

2. Explore alignment with Center for Medicare &

Medicaid Innovation (CMMI) Primary Care First

Initiative

3. Simplify MaineCare’s primary care initiatives into one

4. Tie payment to quality for all foundational payments

5. Explore further movement along the APM continuum

and Beyond!

C.ATEGORY2 FEE FOR SERVICE -LINK TO QUALITY

&VALUE

A Foundational Payments -+

for Infrastructure & 01Perations

(e.g., care coordination

fees and pay en s or IT inves men s}


(e.g., bonuses for uaility p-er ormance) ..


Behavioral Health Homes (BHH)


&VALUE


(e.g., bonuses for uality performance)

. or amzatj0.J]

Behavioral Health Home


Behavioral Health Homes (BHH) Next Steps

1. Evaluate BHH Model alongside comparable services

(Community Integration, Targeted Case Management)

2. Move toward a more unified model of care coordination

for adults with Serious Mental Illness and kids with

Serious Emotional Disturbance

3. Re-visit current Pay for Performance model and metric

4. Explore potential for integration of services such as

medication management into the model, or for the

introduction of a higher level of service to act as a step-

down for individuals reeving Assertive Community

Treatment (ACT)


& VALUE


(e.g., bonuses for uality performance)

22

Opioid Health Homes (OHH)

Does not get counted in APM %

CATEGORY3 APMS BUILT ON

FEE-FOR-SERVICE ARCHITECTURE

3N Risk I ents

NOT Unk:ed to Quality

• an1zatj01J

A Opioid Health Home is an organization that provides a team-based approach to care for individuals receiving office-based Medication Assisted treatment.

PMPM is based on servicelevel and team composition

C Dor.'<}· · IIJation

otb.et Service88 .

----- ii-Oct . ," ,,~~ , ~ 4, , ,~

I \ I • Behavioral health \ I • HIV ca1·e I I • Primary care I \ • Social service agencies I \ I ' , ', ,, , _____ ,

OHH Enrollment


0 0 0 0 10 39 39 35 41 31

254 292364 373 425 410 403 447 496 519

594733

837966

1144

135814611491

1 2 3 2 1 4 2 3 10 7

2520

21 2142 86 124

150190 215

182

187

216

214

222

221

225 243

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

2017 2018 2019

Opioid Health Homes Member and Uninsured Monthly Attestations Opioid Health Home Member Attestations Opioid Health Home Uninsured Client Attestations■ ■

_ ______ 11 I

24

Opioid Health Homes (OHH) Next Steps

1. Continue to grow enrollment in

program

2. Introduce pay for performance

model and metrics

3. Propose additional changes to:

• Improve access to Opioid Use

Disorder treatment

• Better integrate with primary

care

• Meet the needs of individual

members in treatment

C.ATEGORV3 APMS BUILT ON


3N Risk Based Payments

NOT Linked to Quality

CATEGORY4 POPULATION -

BASED PAYMENT

A Con diti o n-S peoific Population-Based

Payment

(e.g., per member per month paymen s, payments for

specialty serv ices, such as oncology or mental health)


Accountable Communities (AC)

CATEGORV3 APMS BUILT ON


A APMswith

Shared .Savings

(e.g., shared sav ings wi h upside risk only)

B APMswith

Shared .Savings and Downside Risk

(e.g., e iso e-based payme s or proce ures

and co prehensive payme ts with upside

an downsi e risk)

.~munit Gc\i~

~~ ~ ~

:::J An Accountable Community is a group 8 of providers who take responsibility for U the cost and quality of care for attributed

"'< 1nembers through a shared savings model.

(D Meet cost benchmarks

+ Q) Quality achievement

$ Shared Savings Payment


Accountable Communities (AC) Performance

First 3 Years of AC Initiative

Shared Savings payments to 4 AC’s Over $4M

Savings to MaineCare from 4 AC’s Over $24M

Minimum # of ACs who have received shared savings each year

2

Largest shared savings payment to an AC $1.1M

Range of quality scores for ACs receiving shared savings payments

72% – 95%


Accountable Communities (AC) Next Steps

1. Move ACs toward assumption of downside risk

2. Promote partnership with community-based

organizations to move ACs beyond accountability for

“traditional” healthcare services to better serve high

need members

3. Incent screening and referral for social health needs

CATEGORV3 APMS BUILT ON


A APMswith

Shared .Savings

(e.g., shared sav ings w i h upside risk only)

Shared .Savings aind Downside Risk

(e.g., episo e-based paymen s or procedures

and comprehensive payments with upside

nd downside ris

28


What Else?

• MaineCare assessing opportunity for APMs as a part

of its evaluation of its current rate setting system

• CMMI’s multi-payer Rural Health Model

• Episodes of care/ bundled payments for maternity,

other services

• Provide greater flexibility through bundled payment

models with links to quality for:

• Assertive Community Treatment

• Care Coordination Services for individuals with

Long Term Services and Supports needs

Michelle Probert

Director

Office of MaineCare Services

[email protected]


Questions

Documents

A Presentation to the Committee on Health Coverage