Designing Value-Based Payment (VBP) to Support Health ...€¦ · incent ACO, plan and employer partnerships with HECs, in a variety of areas including: •Attribution models •Short-term

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Designing Value-Based Payment (VBP) to Support Health Enhancement Communities (HECs)Population Health Council WebinarJune 21, 20181:00 pm – 2:30 pm

Value Based Payment (VBP) is a core design element in rewarding and incenting HEC prevention activities

• There is a range of existing VBP models in CT and across the country

• We will explore adjustments that may need to be made to current VBP models to align with and promote investment in prevention work being undertaken by HECs

• Aligning VBP approaches and incentives across health plans, providers, ACOs and HECs is key to overall initiative success

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HEC

PSI

PCM

Develop better community linkages

Improve access to high-quality primary care

Multi-sector investments that reward community

partners that contribute to prevention

outcomes for community members

Community Members

ACOs

Our Goal: Discuss potential adjustments to VBP models to align prevention activities and incentives across key sectors and across SIM

Payer/provider focused delivery

system and finance reforms

intended to support better

health care outcomes for

attributed patients

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An Example: VBP driving alignment in prevention activities

Employer/Plan Support of Primary Care VBP premised on prevention goals to drive employee/beneficiary health.

Primary Care providers as members of ACOs are incented to achieve aligned prevention goals.

ACOs will be incented to leverage HEC multi-sector collaboration to achieve prevention goals.

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Review of Existing VBP Models

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Transform CT’s healthcare delivery system to incentivize value and better health care outcomes rather than volume-driven treatment by 2020.

88% of insured population participate in Shared Savings Models promoted by Medicare, Medicaid or Commercial

payers

5,743 primary care professionals participating in Shared Savings

Model

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VBP Models Will Serve As an Important Tool in Enabling the State to Meet its Goal

15Medicare

SSP ACOs

14PCMH+ Shared

Savings Program

14-16Commercial Shared

Savings ACOs

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CT Plans and Providers Already Participating in VBP Initiatives

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Example 1

Value Care Alliance

Example 2

ProHealth Phsicians

Plan Market Share Model

Aetna 14.4%

Aetna has implemented shared savings arrangements with physician networks statewide, they also offer Aetna Whole Health, a statewide enhanced accountable care product. The enhanced accountable program features care coordination, care management, data and quality measurement, and tiered out-of-pocket costs for members who see preferred providers. Aetna, nationally currently has 40% of its spend tied to VBP models and a goal of reaching 75% by 2020.

Anthem 49%

Anthem operates an Enhanced Personal Health Care program for primary care providers including a shared savings model with upside risk and monthly care coordination payments. Anthem also utilizes episodic and bundled payments and offers enhanced analytics to address chronic and extended specialty episodes of care. Anthem currently has shared savings arrangements with a large number of physician networks across the State.

Cigna 17.7%Cigna’s value-based payment program, called Cigna Collaborative Care, rewards medical groups for meeting quality targets and reducing costs. Ten large physician groups participate in CT.

Commercial Payers Are Promoting VBP Models Amongst Their Provider Networks in CT

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Example 1

Value Care Alliance

Example 2

ProHealth Phsicians

Plan Market Share Model

ConnectiCare 7.5%

ConnectiCare operates a sizable number of shared savings arrangements with primary care networks; they also offer an episodic and bundled payment program, has an existing partnership with St. Francis Hospital. ConnectiCare also owns Care Management Solutions, which administers one of the largest value-based wellness programs in the country.

UHC 7.7%

UHC offers a variety of VBP models including: a shared savings model for primary care networks; care management fees for patient-centered medical homes; and ACO programs with upside risk and potential bonuses for exceeding medical cost and quality targets. ProHealth currently partners with UHC on a product serving 11,000 CT residents, including an integrated product for Medicare Advantage beneficiaries and an incentive-based program for individuals with employer-sponsored plans.

Commercial Payers Are Promoting VBP Models Amongst Their Provider Networks in CT

National Models of VBP That Promote Prevention or Community Collaboration

State Key Design Elements

Minnesota Integrated Health Partnerships

Methodology targeting health equity, health disparities, incorporating social and clinical factors in risk-adjustment, and population-level data on social health drivers.

Massachusetts Health ACO Program

State designation of organized community partnerships, requirements for contracting at ACO level, and risk-adjustment/cost targets based on social determinants of health.

Vermont All Payer ACO Recognition of Community Collaboratives inclusive of non-medical providers and designing an interface with ACO organizations.

New York State Delivery System Reform Incentive Payment (DSRIP) Program

Requirements to engage and include community based organizations in VBP arrangements and addressing social determinants of health.

Oregon Coordinated Care Organizations (CCOs)

Expectation of local organizations to manage global budgets and reinvest profits into community health.

Maryland All-Payer Model Expectation that local hospitals manage global budgets and invest in care coordination and population health

More detail on these models available in the Appendix 10

Aligning VBP and the HEC Initiative

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Existing Shared Savings Model

Based on a Risk-Adjusted Clinical

Measures Benchmark

Complementary Shared

Savings Model

Based on a To Be Determined Prevention Benchmark

Health Enhancement Communities

Prevention Service Initiative

Primary Care Modernization

Community/Prevention

Savings

Traditional Savings Based

on Claims Expenditures


• Views improvement on short-time horizon

• Rewards premised on health care utilization and management of current disease

• Limits ability to diversify care teams and provide non-visit methods for patient care support/engagement

• Does not adequately reward prevention of disease progression

Existing VBP Models Do Not Adequately Reward Prevention

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Based on a Risk-Adjusted Clinical

Measures Benchmark

Complementary Shared

Savings Model

Based on a To Be Determined Prevention Benchmark

Health Enhancement Communities

Prevention Service Initiative

Primary Care Modernization

Community/Prevention

Savings

Traditional Savings

Based on Claims

Expenditures

Complementary Shared Savings Model

• Views improvement on longer time horizon

• Rewards upstream prevention through social, environmental, and genomic interventions

• Creates need for new measures for quantifying long-term impacts of health/wellness improvement activities

• Opportunity to harness non-traditional and private investments

A Complementary VBP Model is a Way to Better Reward Prevention in the Community

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Example 3

Hartford Health

These approaches are not exclusive – we are addressing both and planning to be sure that existing and complementary approaches are

aligned.

Two Possible Approaches to VBP to Promote Investment in HEC Prevention Work

Po

ssib

le M

od

ific

atio

ns

Adapt Current VBP Models

• Modify Conditions of Participation

• Adjust Quality/Measures Scorecard

• Define New Payment Rules P

oss

ible

De

sign

Ele

me

nts

Create Complementary VBP Model

• Set Conditions of Participation

• Design Payment Requirements

• Determine Quality Measures

• Develop Benchmark for Determining Performance and Savings

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Example 3

Hartford Health

Key Characteristics of VBP

Measures

Measurement Period

Interventions

Social Determinants

Health Equity

Cost and Quality

Benchmarks

Attribution

Geographically Defined

Population Defined

Community Defined

Reimbursement and Incentives

Financing

Non-Reimbursable

Services

Spending Targets

Distribution of Incentives

Risk Adjustment

Demographic

Social

Clinical

Data and Analytics

Clinical

Administrative

Fiscal

Network/

Participation

HEC

ACO

Providers

Payers

Employers

Government

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Example 3

Hartford Health

Current VBP Model Complementary VBP Model

Current VBP participants are not required to address social determinants of health, are focused on traditional health improvement measures, and are being measured on a shorter time horizon year-to-year.

• Is it feasible to expand the list of measures to include prevention and social determinants of health measures?

• Can we modify the existing measurement period to accommodate longer window for ROI?

• Is it feasible to measure different populations separately to capture health equity?

• How should HECs define the measurement period that corresponds with potential interventions?

• When interventions are selected, how can we design measures that correspond to the impact of the intervention including potential social determinants of health measures?

• How can measures be tailored to ensure HECs are appropriately addressing health equity and health disparities?

• How do we define and measure interim activities that prevent onset of disease or improve prevention?

• How do we benchmark prevention outcomes? Do we establish overall health risk or condition specific targets?

Key Characteristics of VBP: Measures

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Example 3

Hartford Health


Current attribution models for ACOs are determined based on utilization of health care services at the provider level. This may not include community members that are not receiving health care services and is based on a model that may incent and promote greater utilization of health care services.

• When we are talking about population health, how can we accommodate population-level measurement for spending or prevention activities?

• Should HECs be responsible for the health of an entire population to be defined by a certain geography?

• Should there be exceptions or carve-outs for certain communities?

• How can populations be accurately tracked over a longer measurement period?

• How should we define the community/geography contemplated under this model?

• Should individuals be able to opt out of participation/attribution for the HEC initiative?

Key Characteristics of VBP: Attribution

• How will the HEC Financing Model be sustainable?

• How are rewards designed to encourage community engagement, health equity and prevention? (see measures)

• How should savings be distributed when multiple sectors are contributing to the outcome?

• How should the cost of health be calculated to determine cost savings?

• How will upfront costs be divided across sectors and paid for?

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Example 3

Hartford Health

Some VBP programs have minimal participation requirements to partner with communities but this is not embedded into the reimbursement model or incentives.

• Could a withhold from any shared savings be designed to encourage community engagement or prevention activities?


Key Characteristics of VBP: Reimbursement and Incentives

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Example 3

Hartford Health

• How, if at all, should the HEC financing model adjust for different community needs across HEC regions?

• How will risk be tracked and how frequently should it be updated?

Current forms of risk adjustment are structured to recognize individual health needs. This creates an incentive for “upcoding” and a disincentive to prevent disease onset.

• Could a performance incentive (or withhold) that encourages community engagement or prevention counterbalance this incentive?


Key Characteristics of VBP: Risk Adjustment

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Example 3

Hartford Health

• Is cross sector (social service/clinical) data available at the person level?

• Are there confidentiality restrictions that limit data sharing??

• Is the data collected consistent across geography; demographic and time?

Current models use clinical data to guide care, treatment and clinical interventions, and use Claims data to track performance relative to spending benchmark(s)

• Are new data sources or analytics required based on new measures or other adjustments?


Key Characteristics of VBP: Data and Analytics

• Who is required to participate in the HEC?

• ACOs? • PCMHs?• Payers?

• Should there be other conditions of participation?

• Contracting with CBOs• Use of Advance Directives• Hiring CHWs

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Example 3

Hartford Health

• Should existing models be required to include HECs or HEC-affiliated entities in their provider network?

• Which entities, and for which functions?


Key Characteristics of VBP: Network/Participation

• Modify data collection and reporting requirements to align with the goals of prevention activities contemplated in HEC initiative

• Work with stakeholders, including ACOs, employers, and health plans to adopt a common approach to VBP to promote aligned prevention activities

Implementing Adjustments to VBP

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VBP Design Elements Can Align and Incentivize HEC Prevention Work

• Adjustments to current VBP models and the creation of a complementary VBP model must overlap and be aligned; this will incent organizations to align their own models and goals around prevention activities

• The HEC plan will contemplate VBP adjustments to incent ACO, plan and employer partnerships with HECs, in a variety of areas including:• Attribution models• Short-term and long-term benefits for key sectors• Fiscal incentives

• Ultimately VBP adjustments should align prevention activities and incentives across all key sectors and across SIM

AppendixState-by-State VBP Analysis

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Program Mechanism Evaluation

Minnesota Integrated Health Partnerships

Requires commissioner of human services to develop a methodology to pay a higher payment rate for health care providers and services that take into consideration the higher cost, complexity, and resources needed to serve patients and populations who experience the greatest health disparities in order to achieve the same health and quality outcomes that are achieved for other patients and populations.

Payment is in part predicated on a “social risk factors quotient” that is determined by the Department of Health. Actuaries identify the predictive value of social and clinical factors. If a social determinant increases the expected costs, patients are moved up the risk ladder, and providers earn more PMPM for population-based quarterly payments.

Developed population-based payments that link health equity with clinical metrics (region specific – reflecting both urban and rural areas) and more traditional clinical measures.

The state supports these efforts by providing Integrated Health Partnerships (IHPs) data at the aggregate level (and in some cases on the individual level, if legal) on how many people are dealing with housing instability, food insecurity, substance use issues, or deep poverty. They are also working on prison data and county jail data.

MN Key Take Away:

Methodology targeting health equity, health disparities, incorporating both social and

clinical factors in risk-adjustment, and population-level data on social health drivers.

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OTHER STATE AND LOCAL VBP APPROACHES THAT ADDRESS SOCIAL

DETERMINANTS/COMMUNITY HEALTH


Mass Health ACO Program Includes a component to incentivize coordination for individuals with intensive needs that include social supports.

ACOs must contract with Community Partners (CPs), which are community-based organizations selected by the state, to provide care coordination and are specialized either in behavioral health or long-term services and supports.

CPs receive infrastructure and capacity-building investments from the state’s pool of DSRIP money.

Provider-level shared savings and capitated payment arrangements combined with explicit incentives to address the social determinants of health via partnerships with community-based organizations and flexible services

Measure of ACOs on social service screenings, as well as use of state certified community partners (as described above); and

Risk-adjusted ACO rate and cost targets that are based on social determinants including stability of housing status and “neighborhood stress score.”

MA Key Take Away:

State designation of organized community partnerships, requirements for contracting

at ACO level, and risk-adjustment/cost targets based on social determinants of health.

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Vermont All Payer ACO Vermont is operating an all-payer ACO model and through its SIM initiative has developed local Accountable Communities of Health (ACHs) at 10 sites across the state.

In addition, Vermont’s Primary Care Medical Home model, the Blueprint for Health, has worked with the ACOs to create Community Collaboratives within each hospital service area to provide local medical and non-medical provider leadership in providing guidance about how to improve ACO and Blueprint performance.

The state envisions a future model in which the ACHs build on the community governance structure of the Community Collaboratives. Similarly, the relationship between the ACO model and Vermont’s ACHs is not yet structured. According to a SIM sustainability report, ACHs are envisioned primarily as community governance models, which may or may not take on some financial role within the ACO model in the future.

To ensure integration of population health management with traditional health care the Vermont ACOs are obligated to work closely with the Blueprint for Health to coordinate the ACO’s population health management and care coordination activities with certain specific Blueprint functions.

Vermont is still working to clearly define the relationship between a VBP model (ACOs and Primary Care Medical Homes) with a population health-driven entity.

VT Key Take Away:

Recognition of Community Collaboratives inclusive of non-medical providers and

designing an interface with ACO organizations.

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New York State Delivery System Reform Incentive Payment (DSRIP) Program

New York has set a goal of shifting 80% Medicaid Managed Care payments to VBP by 2020. As part of this effort, there are hard requirements on Performing Provider Systems and Medicaid MCOs to incorporate Community Based Organizations in such VBP arrangements to address social determinants of health.

Each Performing Provider System and Medicaid MCO are required to engage and include CBOs in their VBP arrangements as vehicle for reducing avoidable hospitalizations.

In 2018 , NYS plans to pilot a VBP arrangement that is focused specifically on achieving Prevention Agenda targets through CBO-led community-wide efforts.

Any VBP contract that incorporates shared losses or capitation must, as a statewide standard, implement at least one social determinant of health intervention and monitor progress on NY’s Prevention Agenda targets.

NY Key Take Away:

Requirements to engage and include community based organizations in VBP

arrangements and addressing social determinants of health.

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Oregon CCOs In 2012, OR established 16 Coordinated Care Organizations (CCOs) that have local control to manage a global budget to meet the triple aim of better health, better care, and lower cost. The model is continuing through December 2021.

The CCOs have a governing board and a community advisory committee. Each is contracted with the Oregon Health Authority to provide managed care services to Medicaid clients. They work within the context of their communities at their own discretion and to meet their needs.

Waiver outlines mechanisms to promote reinvestment in social determinants through investment in health related services, a 3-year rolling average MLR, and a gain augmentation program that promotes investment.

The Oregon Health Authority is using quality health metrics to show how well Coordinated Care Organizations (CCOs) are improving care, making quality care accessible, eliminating health disparities, and curbing the rising cost of health care.

Outcome and quality measures have been developed by the Metrics and Scoring Committee. Funds from a quality pool will be awarded to CCOs based on their annual performance on these CCO Incentive Measures.

OR Key Take Away:

Expectation of local organizations to manage global budgets and reinvest profits into

community health.

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Mission Health Partners (Medicare SSP Participant)

MHP, a North Carolina based ACO adopted a social determinants model that focuses on identifying gaps in care, including those created by socioeconomic factors.

When high-risk patients are identified, they partner with agencies in the region to close gaps so that patients are empowered to better manage their care.

Mission Health relies heavily on analytics to identify highest risk patients, and to predict which individuals would be most positively impacted by specific services.

To support these efforts, they have incorporated social determinants of health data into their analytics reporting tool.

MHP Key Take Away:

Analytics to support the identification of high risk patients based on socioeconomic

factors.

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Documents

Designing Value-Based Payment (VBP) to Support Health ...€¦ · incent ACO, plan and employer partnerships with HECs, in a variety of areas including: •Attribution models •Short-term