Adirondack Medical Home Summit 2013: NYS Reform

Foster Gesten, MD, FACP

Office of Quality and Patient Safety

2

Overview

• Medicaid Reform

• Health Exchanges

• Primary Care: PCMH and beyond

• State Innovation Model (SIM)

• Quality and Patient Safety

• Prevention Agenda

3

Overriding Themes

• Integration

• Care Management

• Care and Payment Reform

• Alignment

• Data (to information to action)

• Transparency

• Triple Aim

4

Medicaid Reform

5

Medicaid Reform

• Managed Care for All

– SPMI

– LTC

– Duals

– Foster care

• Care Management for All (that need it)

– Health homes

• Global Cap

• Value Based Benefit Design

– PCI

– Preterm births

– Evidence based review of benefits

6

Health Insurance Exchange

New York State of Health

7

What is NY State of Health?

• Organized marketplace

– One-stop shopping for subsidized and unsubsidized coverage

– Easily compare health plan options

– The only place to check eligibility and apply for financial assistance

– Enroll in qualified health plans

• Two programs

– Individual Marketplace

– Small Business Marketplace

8

Individual Marketplace (58%)

Small Business Marketplace (42%)

Who Will Enroll In NY State Of Health?

Health Plan Marketplace enrollment is estimated to be

1.1 million New Yorkers

9

http://www.nystateofhealth.ny.gov/PlansMap

10

Health Plan Highlights

• Choice of plans in all areas of the State

• Increased competition gives consumers new health plan options

• Premiums for people who buy coverage for themselves and their families decreases by an average of 53%

compared to today’s premiums

• You will not be denied health insurance on the basis of a pre-existing condition

• All plans are required to have adequate networks

11

Required Ten Essential Health BenefitsPreventive services will be offered at no cost to you

1. Ambulatory patient services

2. Emergency room services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance abuse disorders

6. Prescription drugs

7. Rehabilitation and habilitation services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision

12

Financial Assistance

• Many individuals and families will be eligible for financial assistance to reduce the cost of coverage

• Financial assistance is available in 2 forms:

– Tax credits will reduce the cost of premiums for most single adults earning less than $45,960 and for families of 4

earning less than $94,200

– Cost-sharing reductions will lower co-payments and deductibles for single adults earning less than $28,725 and for

families of 4 earning less than $58,875

• Tax credits and cost sharing reductions are estimated at the time of application and applied immediately

13

Primary Care

14

Primary Care

• Medicaid Incentive

– Impact

– Future direction

• Hospital Medical Home Demonstration

• Multi-payer Demonstrations

– ADK

– CPCI

– SIM

15

State Health Care Innovation Plan

• CMMI challenge to states: beyond ‘demo’ and pilot

• Value based model of care/payment covering 80% of population within 5 years

– Multipayer

– ‘transformative’ care delivery and payment innovation

• Disseminate and ‘connect’ demonstrations and innovations

– ACO

– Waivers

– HIT/HIE

– PCMH

• Basis for Testing Grant application (up to ~$60 million)

16

Proximate Goals

• Refine coherent, more detailed plan with internal and external stakeholder

engagement

– Interagency alignment (DFS, DOH, Civil Service, OMH, etc.)

– Payers, providers, associations

• Review with wider set of stakeholders

• Finalize and submit SHIP

• Convert SHIP into application (early 2014)

17

Core Elements

• Care model

• HIT/HIE

• Metrics/reporting

• Payment model

• Transformation support

• Benefit design

• Workforce strategy

18

Quality and Patient Safety

• ‘New’ Office of Quality and Patient Safety

– Hub for department on Q/S initiatives

– Advance use of data for improvement, evaluation, prioritization, transparency,

accountability

• LTC

• Physician practices

– APD

– Sepsis

– Cardiac services, Stroke, Office Based Surgery

19

Make New York the Healthiest State

New York State Prevention Agenda

20

Prevention Agenda 2013-2017

• Goal is improved health status of New Yorkers and reduction in health disparities

through increased emphasis on prevention.

• Call to action to broad range of stakeholders to collaborate at the community level

to assess health status and needs, identify local health priorities and plan,

implement and evaluate strategies for local health improvement.

21

CHAs & CSPs

• Local Health Department Community Health Assessment & Community Health

Improvement Plan

– Due November 15, 2013; covers years 2014-2017

• Hospital Community Service Plans

– Due November 15, 2013, covers years 2013-15

• LHDs and Hospitals asked by Comm. Shah to work together to assess health status, select

common priorities including one to address a health disparity, and develop and implement

a plan to address priorities.

22

Prevention Agenda 2013-2017:

Ad Hoc Leadership Group• Six members of Public Health Committee and other leaders from Healthcare, Business,

Academia, Community-based & Local Health Departments.

23

Background

Ad Hoc Committee considered:

• Urgent Health Issues and Disparities in NYS

• Experience with first Prevention Agenda

• Factors that contribute to health

24

Leading Causes of Death, New York State, 2000 - 2009

Heart Disease, 207/100,000

Cancer, 160/100,000

CLRD, 31/100,000Stroke, 26/100,000

Pneumonia/flu 20/100,000

Unintentional Injury, 20/100,0000

50

100

150

200

250

300

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Rate

per

100,

000

Heart Disease Cancer CLRD

Stroke Pneumonia/Influenza Unintentional Injury

25

Estimated Number of Deaths Due to Modifiable Behaviors, New York State, 2009

0

5,000

10,000

15,000

20,000

25,000

30,000

26,222

22,021

5,071 4,5213,315 2,592 1,748 1,206

Estimates were extrapolated using the results published in:“Actual Causes of Death in the United States, 2000", JAMA, March 2004, 291 (10) and NYS 2009 death data

26

2000 2001 2002 2003 2004 2005 2006 2007 2008 20090

50

100

150

200

250

300

350

400

Age-Adjusted* Heart Disease Death Rate per 100,000 by Race/Ethnicity, New York State, 2000-2009

White/NH Black/NH AsianPI/NH Hispanic

* Age-adjusted to U.S. Census 2000 population

27Frieden T., A Framework for Public Health Action: The Health Impact Pyramid.

American Journal of Public Health. 2010; 100(4): 590-595

Framework for Improving Health

28

Five Prevention Agenda Priorities

1. Prevent chronic diseases

2. Promote a healthy and safe environment

3. Promote healthy women, infants and children

4. Promote mental health and prevent substance abuse

5. Prevent HIV, sexually transmitted diseases, vaccine-preventable diseases and

healthcare associated infections

29

For each priority area:

• Focus Areas

• Goals

• Measurable Objectives

• Interventions

• By Sector

• By Health Impact Pyramid

30

http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/indicator_map.htm

31

Statewide Update

• Communities completing community health assessments and community health

improvement plans due November 15th

• Technical assistance being provided by statewide and regional organizations

• Communication tools being distributed to local partnerships for use in engaging

stakeholders

• Meeting with foundations to seek funding to support local partnerships.

32

Priorities identified by Region - September 2013

P2P S2AY Network CNYHSA AHI HCDI HVRHON Nassau-Suffolk0

2

4

6

8

10

12

14

16

2 2

13

2

1

7

15

13

9

4

7

4

2

1 1

2

6

22

1

2 2

4 4

1

2

0

2 2

NA

Prevent Chronic Diseases

Promote a Healthy and Safe Envi-ronment

Promote Healthy Women, Infants and Children

Promote Mental Health and Prevent Substance Abuse

Prevent HIV, STDs, Vaccine Preventable Diseases and Healthcare Associated In-fections

Other

Questions?Contact Information

fcg01@health.state.ny.us518-486-6865