Federal Initiatives to Support State/Community-Based Approaches

to Coordinated Care

ASA-N3C-NYAM SymposiumApril 27, 2011

Julianne R. Howell, Ph.D.Senior Advisor

State HIE Programs

Overview Alignment through implementation of the Affordable Care Act

– Strategic Framework on Multiple Chronic Conditions – National Quality Strategy– Federal HIT Strategic Plan– Partnership for Patients

Themes recurring across multiple initiatives:– Importance of care coordination– Focus on care transitions– Role of community-based services– Focus on the patient and family caregivers

Triple Aim: Better care, better health, lower cost

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Multiple Chronic Conditions: A Strategic Framework December 2010Source

HHS Interagency Workgroup with input from public and stakeholders

Overarching Goals: #1 Foster health care and public health system changes to improve

the health of individuals with multiple chronic conditions. #2 Maximize the use of proven self-care management and other

services by individuals with multiple chronic conditions. #3 Provide better tools and information to health care, public health,

and social services workers who deliver care to individuals with multiple chronic conditions.

#4 Facilitate research to fill knowledge gaps about, and interventions

and systems to benefit, individuals with multiple chronic conditions.

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Multiple Chronic Conditions: A Strategic Frameworkhttp://www.hhs.gov/ash/initiatives/mcc/mcc_framework.pdf

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National Quality Strategy March 2011Aims

Better Care: Improve quality, by making health care more patient-centered, reliable, accessible, and safe

Healthy People and Communities: Improve health of population Affordable Care: Reduce cost of quality health care

Six Priorities and Goals to help focus public and private efforts: Safer Care: eliminate preventable health care-acquired conditions Effective Care Coordination Person- and Family-Centered Care Prevention and Treatment of Leading Causes of Mortality: prevent

and reduce harm caused by cardiovascular disease Support Better Health in Communities Make Care More Affordable

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National Quality Strategy http://www.healthcare.gov/center/reports/quality03212011a.html#append

Partnership for Patients April 2011

Public-Private Partnership to make care safer, potentially save up to $50 billion

Two Goals of the Partnership: Keep hospital patients from getting injured or sicker: decrease

preventable hospital-acquired conditions 40% by 2013 cf. 2010– Up to $500M from CMS Innovation Center

Help patients heal without complication: decrease preventable complications during transition from one care setting to another so that hospital readmissions will be reduced 20% by 2013 cf. 2010

– Up to $500M available through Community-Based Care Transitions Program authorized by Section 3026 of ACA

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Illustrative Federal Programs to Support State/Community Initiatives Multi-Payer Advanced Primary Care Practice (MAPCP)

Demonstration HITECH

– Beacon Communities– State HIE Challenge Grants

Partnership for Patients– Community-Based Care Transitions Program ACA Section 3026

State Demonstrations to Integrate Care for Dual Eligible Individuals

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MAPCP Demonstration Overview

3-year demonstration open to states Medicare will join Medicaid and private insurers in state

health reform initiatives aimed at improving delivery of primary care

A multi-payer effort– Aligns economic incentives– Reduces administrative burdens– Provides resources that can be shared across practices

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MAPCP Goals

Goals include…– Improve safety, timeliness, effectiveness, and efficiency– Reduce unjustified variation in utilization and expenditure– Increase patient participation in decision making– Increase access to evidence-based care in underserved areas– Contribute to ‘bending the curve’ in health expenditures

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Application Requirements

Applicant had to be a State agency Program operational prior to Medicare participation Multi-payer participation

– Medicaid FFS & managed care– Medicare Advantage– “Significant” private payer participation

Specifications to be an Advanced Primary Care Practice (APCP) Evidence of physician support & participation Community-based support Coordination with state wellness/disease prevention efforts

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Program Attributes

8 States: ME, VT, RI, NY, PA, NC, MI, MN– Some projects state-wide; others limited in geographic scope or #

of practices– APCP requirements vary by state– Monthly payment to the practice for beneficiaries “assigned”

using a state-specific algorithm– Some projects involve community health teams– Some projects include additional payment to state for

administrative/evaluation services

Some states will launch July 2011; some October 2011

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Eligible Practices

Geographic range/size of project determined by state– Regional vs. state-wide– Planned expansion

Definition of APCP– Determined by state– NCQA-PCMH commonly used (often supplemented by additional

requirements)

FQHCs participating in some states

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Eligible Beneficiaries

Reside in the state – Some states have county restrictions– Excludes beneficiaries who cross state lines (operational

limitations/impacts) Have Medicare A & B Covered under traditional FFS Medicare

– Not enrolled in MA or other Medicare health plan– No restrictions on other categories such as disabled, ESRD,

hospice, etc. Medicare must be primary payer

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Payment Rates and Policy

Monthly payments to APCP generally < $10 per beneficiary per month (pbpm)– Exception: Minnesota, which uses clinically risk-adjusted tiers

(range: $0 - $60.81 pbpm; average: $14.43 pbpm estimated based on historic ACGs)

Variables determining APCP payment rate:– Age of beneficiary– NCQA-PCMH certification status of practice– Use of independent community teams vs. expecting practice to

provide/contract for community-based care coordination services

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HITECH Act (Health Information Technology for Economic and Clinical Health) Section of the American Recovery & Reinvestment Act

(ARRA) signed into law in February 2009 Key components of the legislation

– Codifies the Office of the National Coordinator for HIT– Creates Federal Advisory Committees on HIT Policy & Standards– Creates Medicare & Medicaid “Meaningful Use” (MU) incentives for

physicians and hospitals to adopt EHRs– Creates new HIT and HIE (Health Information Exchange) Programs

State HIE Planning and Implementation grants Regional Extension Center (RECs) grants Workforce Training grants New technology research & development grants

– Increases privacy protections

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HITECH Programs Address Barriers to Adoption, Meaningful Use, Exchange

Barriers Intervention Funds Allocated

Cost of EHR AdoptionCost of EHR Adoption MU IncentivesMU Incentives

Meaningful Use difficult to achieve for small providersMeaningful Use difficult to achieve for small providers REC and HITRCREC and HITRC

Lack of trained workforce Lack of trained workforce WorkforceWorkforce

$27.3 B* $27.3 B*

$643M$50M

$643M$50M

$118M$118M

Need for “real world” examples of HIT contribution to Health Care Transformation

Need for “real world” examples of HIT contribution to Health Care Transformation

Beacon CommunitiesSHARPBeacon CommunitiesSHARP

$250M$250M

$60M$60M

Lack of trust, policy frameworkLack of trust, policy framework Privacy and SecurityPrivacy and Security Addressed across all ProgramsAddressed across all Programs

Barriers to health information exchange Barriers to health information exchange

HIE ProgramStandards & InteroperabilityHIE ProgramStandards & Interoperability $64.3M$64.3M

$548M$548M

*$27.3 B is high scenario16

HITECH Programs and Goals: Where Are We Today?

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58,810 Enrolled ProvidersRegional Extension Centers

84 Community College PartnersCurriculum Available Summer 2011

Workforce Training

Adoption of EHRs

Medicare & Medicaid incentives

21,000 Total providers

State HIE Grants

46 Approved States 10 Challenge Grants

Beacon Communities

Meaningful Use of EHRs

Exchange of health information

• Improved individual and population health outcomes

• Increased transparency and efficiency

• Improved ability to study and improve care delivery

17 Communities

Research to enhance HIT4 Awardees

Standards & Interoperability framework

Security & Privacy framework

Key Objectives

Align HITECH programs and initiatives to accomplish – Adoption of EHRs– Meaningful Use of EHRs– Exchange of information

Leverage HITECH programs to have a measurable impact on health care, health, cost– Improve transitions– Reduce readmissions– Reduce medication errors– Achieve better chronic care outcomes

Support health care transformation in each state

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Beacon Communities Program

17 communities selected to demonstrate feasibility and health care delivery benefits of widespread HIT adoption and exchange of health information.

Core Aims:– Build and strengthen community/regional health IT foundation to

achieve long-term improvements in care quality, health outcomes, and cost efficiencies;

– Demonstrate that health IT-enabled interventions and community collaborations can achieve concrete cost/quality performance improvements;

– Test innovations to improve health and health care

14 of 17 include a care transitions component

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Beacon Communities

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Beacon Communities’ Transitions Aims To reduce hospital utilization, especially that arising from

errors in transitions To use HIT to improve care for individuals with high cost /

high risk chronic conditions (e.g., DM, CVD, etc.) To connect local hospital associations with primary and

chronic care settings To engineer electronic continuity and care plans, and to

incorporate them into EHRs and HIEs To build on initial successes by ongoing learning with other

Beacon Communities and by seeking Community-Based Care Transitions funding

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Beacon Communities Transitions Interventions Three tiers of IT focus

– Many Communities are using HIT systems to notify PCPs of hospital and/or ER use

– Some are using HIT to provide hospital discharge information (e.g., medications, lab values) to next providers (e.g., nursing homes, FQHCs, PCPs)

– A few are using HIT to facilitate making appointments for quick follow-up (e.g., PCPs to specialists)

IT tools are coupled with case management (e.g., self-management coaching, medication reconciliation, care coordination)

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State HIE Challenge Grants

Program Goal: provide additional funding to recipients of State HIE Cooperative Agreements to spearhead development of technology and approaches focused on 5 “Challenge Themes”:– Achieving health goals through health information exchange– Improving long-term and post-acute care transitions– Encouraging consumer-mediated information exchange– Enabling enhanced query for patient care– Fostering distributed population-level analytics

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Challenge Theme 2: Improving Long-Term and Post-Acute Care Transitions Requirements

– Identify types of long-term and post-acute care providers to be included

– Describe technology and policy to achieve timely electronic exchange of clinical summaries, medication lists, advance directives and other information most relevant to transitions

– Develop and monitor relevant quality measures– Identify barriers to timely electronic exchange and how they will

be addressed

Grantees: Colorado, Maryland, Massachusetts, Oklahoma

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Partnership for Patients: Community-Based Care Transitions Program

5 years beginning April 12, 2011; rolling application process

Program Goals:– Improve the quality of care transitions– Reduce readmissions for high-risk Medicare beneficiaries– Document measureable savings to the Medicare program by

reducing unnecessary readmissions Creates source of funding for effectively managing

transitions from acute to community-based settings Eligible entities paid on per-discharge basis for

Medicare benes at high risk of readmission, including those with multiple chronic conditions, depression, or cognitive impairment.

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Community-Based Care Transitions Program: Selection Criteria Preference given to Administration on Aging grantees that

– Provide care transition interventions in conjunction with multiple hospitals and practitioners

– Provide services to medically-underserved populations, small communities, and rural areas

Applicants must – Identify root causes of readmissions and define target population

and strategies for identifying high-risk patients – Specify transition interventions, including improving provider

communications and patient activation– Indicate how community and social supports and resources will be

incorporated to enhance beneficiary post-hospitalization management outcomes

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State Demonstrations to Integrate Care for Dual Eligible Individuals

Partnership between Federal Office of Integrated Care and the Innovation Center – Testing delivery system and payment reform that improves the

quality, coordination, and cost-effectiveness of care for dual eligible individuals.

On April 14, 2011, 15 states awarded contracts for up to $1million to design new models for serving dual eligibles:– West: California, Colorado, Oregon, Washington – Midwest: Oklahoma, Michigan, Minnesota, Wisconsin – South: North Carolina, South Carolina, Tennessee– East : Connecticut, New York, Massachusetts, Vermont

Models will be person-centered and fully coordinate primary, acute, behavioral and long-term supports and services.

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Further Information

Websites:– General http://www.healthcare.gov/ – Innovation Center http://innovations.cms.gov/– Office of the National Coordinator for HIT

http://healthit.hhs.gov/

For Questions:

julie.howell@hhs.gov

202-205-8124

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