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Webinar: Health Care Innovation Awards Round Two - Overview of Categories One and Two


The CMS Innovation Center held the second in a series of webinars for potential applicants to Health Care Innovation Awards Round Two. The webinar held Wednesday, June 12, 2013 1:30pm – 3:00pm EDT, …

The CMS Innovation Center held the second in a series of webinars for potential applicants to Health Care Innovation Awards Round Two. The webinar held Wednesday, June 12, 2013 1:30pm – 3:00pm EDT, focused specifically on the first two of the four innovation categories.

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  • 1. Health Care Innovation AwardsOverview of InnovationCategories One and TwoJune 12, 2013
  • 2. Agenda• Introduction• Innovation Category 1: Rapidly reduce Medicare,Medicaid and/or CHIP costs in outpatient and/orpost-acute settings• Innovation Category 2: Improve care for populationswith specialized needs• Upcoming Webinar Series and Next Steps2
  • 3. The CMS Innovation CenterIdentify, Test, Evaluate, Scale“The purpose of the Center is to test innovativepayment and service delivery models to reduceprogram expenditures under Medicare, Medicaidand CHIP…while preserving or enhancing the qualityof care.—The Affordable Care Act3
  • 4. Innovation Awards Round Two GoalsEngage innovators from the field to:• Identify new payment and service delivery modelsthat result in better care and lower costs forMedicare, Medicaid and CHIP beneficiaries• Test models in Four Innovation Categories• Develop a clear pathway to new Medicare, Medicaidand Children’s Health Insurance Program (CHIP)payment models4
  • 5. Measuring Success• BETTER HEALTHImproved overall health outcomes• BETTER HEALTH CARE• LOWER COSTS THROUGH IMPROVED QUALITYReduced total cost of care for Medicare, Medicaid andCHIP beneficiaries5
  • 6. Four Innovation Categories1. Rapidly reduce Medicare, Medicaid and/or CHIP costsin outpatient and/or post-acute settings2. Improve care for populations with specialized needs3. Transform the financial and clinical models ofspecific types of providers and suppliers4. Improve the health of populations through betterprevention efforts6
  • 7. Today’s WebinarFocus on Innovation Categories 1 and 2:• Category 1: Rapidly reduce Medicare, Medicaid and/or CHIP costs inoutpatient and/or post-acute settings• Category 2: Improve care for populations with specialized needsPlease keep in mind:• Examples described in today’s webinar are illustrative only, and notintended to convey a preference or preferred approach• Applicants will identify a primary innovation category in which to beconsidered• Applicants must propose a payment model to support the proposedservice delivery model7
  • 8. Agenda• Introduction• Innovation Category 1: Rapidly reduce Medicare,Medicaid and/or CHIP costs in outpatient and/orpost-acute settings• Innovation Category 2: Improve care for populationswith specialized needs• Upcoming Webinar Series and Next Steps8
  • 9. Category 1: Rapidly reduce costs inoutpatient and/or post-acute settingsPriority Areas• Diagnostic services• Outpatient radiology• High-cost physician-administered drugs• Home-based services• Therapeutic services• Post-acute servicesCMS will consider submissions in other outpatientand/or post-acute areas within this Category9
  • 10. Why these areas?Growth in spendingOutpatient spending is larger than and growing much more rapidly thaninpatient spendingGeographic variationPost-acute spending is the biggest contributor to geographic spendingvariationUntapped opportunitiesTo balance our portfolio, which is well-developed in inpatient settingsSource: CMS claims data 10
  • 11. 2011 Medicare costs by category (billions)Part A, $189Part B, $164MA: Part A, $70MA: Part B, $63Part D, $69MedicareAdvantageMedicareFFSPart DSource: CMS claims data 11
  • 12. Inpatient hospital PBPM costs growingslower compared to post-acute$0$50$100$150$200$250$300$350$400$450$5002005 2006 2007 2008 2009 2010 2011Part A: HospicePart A: Home HealthPart A: Skilled NursingPart A: Inpatient Hospital~$356 ~$360~$388 ~$405~$429 ~$432 ~$441Source: CMS claims data 12
  • 13. Part B PBPM costs continue to grow$0$50$100$150$200$250$300$350$400$4502005 2006 2007 2008 2009 2010 2011Part B: LabPart B: Other IntermediaryPart B: Home HealthPart B: Outpatient HospitalPart B: Other CarrierPart B: Durable Medical EquipmentPart B: Physician Services~$328 ~$324 ~$337~$364~$381~$286~$301Source: CMS claims data 13
  • 14. From 2008 to 2012, outpatient and post-acute services increased most rapidly14%5%15%42%17%31%8%0%5%10%15%20%25%30%35%40%45%Total Inpt Hospital SNF OutptHospitalPhysServicesHospice HomeHealthTotal TrendSource: CMS claims data14
  • 15. Medicare spending varies widely acrossthe countryGeographic Variation in Spending, MS-DRG 291 Heart Failure and Shock with MajorComplications$0$5,000$10,000$15,000$20,000$25,000$30,000Ridgewood, NJ Hudson, FL Lancaster, PA Raleigh, NC Owensboro, KYAll OtherOutpatientPhysicianReadmissionsPost-AcuteInpatient~$26,815~$20, 727 ~$17,993~$15,279 ~$12,713atio to.S. Average1.49 1.15 1.00 0.85 0.71RUSource: CMS Office of Information Products and Data Analytics, Medicare Claims Analysis - 201015
  • 16. Variation in post-acute spendingis even greaterGeographic Variation in Spending on Post-Acute Care, MS-DRG 291 Heart Failure andShock with Major Complications$0$1,000$2,000$3,000$4,000$5,000$6,000$7,000$8,000$9,000Ridgewood, NJ Hudson, FL Lancaster, PA Raleigh, NC Owensboro, KYTherapyLTC HospitalInpatient Rehab.Home HealthSkilled Nursing~$7,956~$5,379~$2,368~$4,769~$2,336Ratio toU.S. Average2.02 1.37 1.21 0.60 0.59Source: CMS Office of Information Products and Data Analytics, Medicare Claims Analysis - 2010 16
  • 17. Outpatient and post-acute settingsDefinitionsOutpatient settings• Outpatient settings may include hospital outpatient care• Most of identified priority areas are outpatientPost-acute settings• Post-acute services may be outpatient or inpatientoHome health agencieso Inpatient rehabilitation facilitieso Skilled nursing facilitiesoLong term care hospitals17
  • 18. Diagnostic Services and OutpatientRadiologyExamples• Radiology and other imaging• EKGs, cardiac monitoring, and laboratoryExamples of Settings• Hospital Outpatient• Ambulatory Surgical Centers• Physician Office and SNF Outpatients• Independent Diagnostic Testing FacilitiesSome Payment and Service Delivery Issues• Appropriate use, duplication, overlap, roles of multiple parties (orderingphysician, technical service provider, professional interpretation)• Shared decision support and Clinical Decision Support for clinicians18
  • 19. Physician Administered DrugsExamples• Injectable drugs used in the physician office setting, e.g.: Chemotherapy,Rheumatology, Ophthalmology• Vaccines: Hepatitis B; Pneumococcal and Influenza Vaccines• Erythrocyte Stimulating AgentsExamples of Settings (outpatient)• Physician offices, pharmacies, durable medical equipment suppliers• Hospital outpatient departments, ambulatory surgical centers• Outpatient SNF• Home health agencies: only certain vaccines covered under MedicareSome Payment and Service Delivery Issues• Drug pricing; administration fees19
  • 20. Agenda• Introduction• Innovation Category 1: Rapidly reduce Medicare,Medicaid and/or CHIP costs in outpatient and/or post-acute settings• Innovation Category 2: Improve care for populationswith specialized needs• Upcoming Webinar Series and Next Steps23
  • 21. Home-Based ServicesExamples• Home health care• Home and community-based servicesExamples of Settings• Patient homesSome Service delivery and payment issues• Payment tied to therapy utilization• Home Health Prospective Payment System augments payments for moretherapy visits reaching certain thresholds• Home Health Agencies may focus on therapy payment incentives20
  • 22. Post-Acute ServicesExamples• Rehabilitation services and therapy• Prolonged ventilator supportExamples of Settings• Skilled Nursing Facility, Inpatient Rehabilitation Facilities, Home HealthAgencies, Long Term Acute Care HospitalsSome Service Delivery and Payment Issues• Same patient, different paymentso By settingo By lengths of stay and therapy use• Avoidable Hospital Readmissions• Poor care coordination• Geographic variations in PAC spending drive payment variations nationally• Shared decision making and clinical decision support21
  • 23. 2: Improve care for populations with specialized needsPriority Areas• Pediatric populations requiring high-cost services• Persons with Alzheimer’s disease• Persons living with HIV/AIDS• Children at high risk for dental disease• Children in foster care• Adolescents in crisis• Persons requiring long-term services and supports• Persons with serious behavioral health needsCMS will consider submissions that improve care for otherpopulations with specialized needs24
  • 24. Therapeutic Outpatient ServicesExamples• Surgical and other procedural care• Physical Therapy, Occupational Therapy, Speech and Language PathologyExamples of Settings• Hospital outpatient• Ambulatory Surgical Centers• Physician OfficeSome Service Delivery and Payment Issues• Large relative expenditure growth outpatient compared to inpatient care• Medicare Ambulatory Payment Classifications not diagnosis based incontrast to inpatient DRGs• Payment for services, not for outcomes and efficiency• Off-campus provider based services22
  • 25. Why these areas?High Unmet NeedThere are significant opportunities to improve careGrowth in spendingCosts for populations with complex care needs are increasingDelivery System ChangeSignificant amount of policy work to integrate care models andpayment modelsPortfolio ExpansionCreate new model tests to cover these patient populations25
  • 26. Pediatric populations requiring high-cost servicesDescription of Population• Includes children with multiple medical conditions, behavioral health issues,congenital disease, chronic respiratory disease, and complex social issues• Medicaid and CHIP pay for half of all pediatric ambulatory care visits and inpatientcare for children 1Examples of Cost Drivers• Lack of integration of care across settings, social determinants of health• Inappropriate use of specialists to provide primary care services• Fragmentation of services provided by physical and occupational therapists,developmental psychologistsExamples of Opportunities• Includes improving early screening, assessment and diagnosis; increasing complianceto care plans; coordination of community settings; slowing progression of chronicillness; and reducing avoidable services including hospitalizations and readmissions261
  • 27. Persons with Alzheimer’s diseaseDescription of Population• Five million people, onset of the disease normally occurring after age 60o 13 percent of men and women aged 65 and over have Alzheimer’s disease1• Groups unequally challenged by Alzheimer’s disease: racial and ethnic minorities,people with intellectual disabilities, and people with young onset of the diseaseExamples of Cost Drivers• Care not always provided in settings best for beneficiaries, including home andcommunity based care vs. institutional care• Breadth of providers providing duplicative servicesExamples of Opportunities• Implementing new models of dementia-capable service delivery focusing onidentifying those with the disease, specialized dementia care, care coordinationand/or caregiver support27Source: 2012 Alzheimer’s Facts and Figures, Alzheimer’s Association, 2012
  • 28. Persons living with HIV/AIDSDescription of Population• Nearly half of the people with HIV/AIDS that are estimated to be in regular care arecovered under Medicaid• Many people living with HIV/AIDS historically have inadequate access to careExamples of Cost Drivers• Uncoordinated care, behavioral health integration, unmet need for other socialsupportsExamples of Opportunities• Improve early screening, diagnosis and treatment• Improve care coordination service with social support services• Improve efforts to link and retain patients in care• Improve medication adherence that addresses drug resistance issues28
  • 29. Children at high risk for dental diseaseDescription of Population• Medicaid and CHIP beneficiaries identified as high risk through risk assessmenttoolsExamples of Cost Drivers• Emergency department visits, surgery in operating room, over-utilized restorativeservicesExamples of Opportunities• Risk-based intensive prevention and chronic disease management approach tochildhood caries that leads to less oral disease, fewer surgical interventions, andlower per capita costs29
  • 30. TRAUMA HAS A DISTINCT IMPACT ON THE HEALTH ANDDEVELOPMENT OF CHILDRENSymptoms of Child Trauma that Overlap with Symptoms of Mental IllnessMental Illness Overlapping Symptoms TraumaAttention Deficit/HyperactivityDisorderRestless, hyperactive, disorganized, and/or agitatedactivity; difficulty sleeping, poor concentration, andhypervigilant motor activityChild TraumaOppositional DefiantDisorder/Conduct DisorderA predominance of angry outbursts and irritability Child TraumaAnxiety Disorder (incl. SocialAnxiety, Obsessive-CompulsiveDisorder, Generalized AnxietyDisorder, or phobia)Avoidance of feared stimuli, physiologic andpsychological hyperarousal upon exposure tofeared stimuli, sleep problems, hypervigilance, andincreased startle reactionChild TraumaMajor Depressive DisorderSelf-injurious behaviors as avoidant coping withtrauma reminders, social withdrawal, affectivenumbing, and/or sleeping difficultiesChild TraumaGriffin, McClelland, Holzberg, Stolbach, Maj, & Kisiel , 201233
  • 31. Children in Foster Care and Adolescents inCrisisBryan Samuels, MPPCommissionerAdministration on Children, Youth and Families30
  • 32. Opportunities to Innovate for ImprovedOutcomes for Vulnerable Children andYouthBRYAN SAMUELS, COMMISSIONERADMINISTRATION FOR CHILDREN, YOUTH, AND FAMILIES31
  • 33. RATES OF MALTREATMENT AMONGAT-RISK YOUTH ACROSS SYSTEMSAnyMaltreatmentMultiple TypesofMaltreatmentChild Welfare 85% 68%SubstanceAbuseTreatment86% 64%Mental Health 75% 54%Juvenile Justice 78% 57%Miller et al., 201234
  • 34. CHILDREN KNOWN TO CHILD WELFAREHAVE COMPLEX HEALTH CARE NEEDS• The behavioral and physical health of children who have been maltreatedare inextricably linked.• 22.7% of children known to child welfare have at least one chronic healthcondition (AIDS, asthma, autism, Down syndrome, developmental delay,diabetes, cystic fibrosis, cerebral palsy, or muscular dystrophy).• Among children who use any mental health service, the prevalence ofchronic health conditions is much higher:Children using mental health services who ALSO have a chronic healthcondition, by age group1.5-2 Years <2-5 Years 6-10 Years 11-15 Years 16+ Years4.1% 38.9% 53.6% 44.9% 31.6%Horwitz, et al., 201232
  • 35. PSYCHOTROPIC MEDICATION USE AMONG CHILDRENKNOWN TO CHILD WELFARE AND IN FOSTER CAREPsychotropic Use and Polypharmacy among Children Known to Child Welfare, byAge GroupAGE GROUPAny PsychotropicMedicationOne PsychotropicMedicationas % of AnyTwo or MorePsychotropicMedicationsas % of Any1.5-5 Years Old 1.5% 1.0% 0.5%6-11 Years Old 19.6% 11.6% 8.0%12-17 Years Old 16.0% 7.9% 8.1%Ringeisen, Casanueva, Smith & Dolan, 2011• Children known to child welfare are three times more likely to use psychotropicmedications than Medicaid child enrollees without apparent child welfareinvolvement (Raghavan et al., 2012).• There is significant geographic variation in rates of psychotropic medication useamong children in foster care, ranging from less than 1% to 22% in 2008, with amedian of 13% (Rubin et al., 2012).35
  • 36. FOSTER CHILDREN INCUR SIGNIFICANT COSTSTO MEDICAID• Children in foster care account for 38% of total Medicaidexpenditures (physical health and behavioral health) for children(Allen, 2013).• On average states spend three times more for this population thanfor nondisabled children in Medicaid — approximately $4,336 forchildren in child welfare versus $1,315 for the general childpopulation without disabilities (Geen, Sommers & Cohen, 2005).• It is estimated that children known to child welfare incurapproximately $1,482 in costs for psychotropic medications – 50%to 75% more than non-foster care Medicaid child enrollees(Raghavan et al, 2012).36
  • 37. IMPROVED OUTCOMES FORCHILDREN IN FOSTER CARE• Reduced trauma symptoms and improved functioning across physical, social-emotional, cognitive, and developmental domains• Reduction in use of acute services, including ER visits and inpatienthospitalization• Reduction in unnecessary physical exams, immunizations, and routine labs• Reduction in the use of residential care• Reduction in use of psychotropic medications and prescribing practices that donot conform to best practice guidelines• Increased use of evidence-based/evidence-informed, trauma-informed,screening, assessment, and psychosocial interventions as first-line treatmentsfor behavioral health needs37
  • 38. USING DATA TO DRIVE INNOVATION• Address complex clinical needs by integratingphysical and behavioral health• Leverage EPSDT to provide validated trauma-informed screening and assessment• Intervene effectively by implementingevidence-based psychosocial interventions• Improve quality by using standard measures• Share information across child-serving systems38
  • 39. Long-Term Supports and ServicesMimi ToomeyDirector, Office of Policy Analysis andDevelopmentCenter for Disability and Aging PolicyAdministration for Community Living39
  • 40. What Are Long-Term Services andSupports (LTSS)?• LTSS help older adults and people with disabilities accomplish everydaytasks• Persons requiring LTSS:o Medicaid is the largest payer of LTSS but not the only payero More states are rethinking their delivery systems under Medicaid LTSSfor services including Medicaid Managed CareLTSS are directly related to health and health outcomeso Greater volume of attendant care, homemaking services and home-delivered meals is associated with lower risk of hospital admissionso Increased spending on home-delivered meals was associated withfewer residents in nursing homes with low-care needs•40
  • 41. Who are LTSS Users?41
  • 42. Opportunities for LTSS• Better integration of the health care systems with familiesand community supports systems through:o Support infrastructure and coordination of the LTSS systemo Building a common language between the health and the LTSSsystemso Packaging services and supports for the highest impacto Health information technology (HIT) opportunitieso Promoting self direction and person-centered planningo Creating a gateway for employmento Quality/Evidence Basedo Paying more attention to individual preference for theirsettings that are home and community based45
  • 43. LTSS Systems: Networks of Partners and ServicesPartnerships• Hospitals for discharge planning• Home Care Agencies• Community Health Centers• Transportation• Public Health Departments• Assisted Living/Nursing Facilities• Social Security• Medicaid• HUD Public Housing• Alzheimer’s Associations• Senior Centers• Volunteer Groups• Home delivered meals providers• Area Agencies on AgingServices• Care Transitions• Chronic Disease Self-Management• Information & Referral• Adult Day Care• Respite Care• Home Delivered Meals• Congregate Meals• Grocery shopping/meal preparation• Personal Care/Attendants—Assistancewith ADL/IADL• Socialization/Senior Centers• Benefits Counseling• Transportation42
  • 44. Referrals to Long Term Services and Supports During Transitions(n=739 participants and 2,129 referrals)Personal care/homemaker/choremaker services19%Home DeliveredMeals15%Transportation15%Nutrition Servicesor Counseling14%Falls Managementand Prevention13%Other Servicesand Supports11%Caregiver Support5%Mental Health andSubstance Misuse3%Exercise Program2%Alzheimer’sPrograms2%CDSMP1%DSMP Home Injury/RiskScreeningsData Source: ADRC Semi-Annual Report April – September 2012 43
  • 45. Persons with serious behavioral health needsSuzanne Fields, MSW, LICSWSenior Advisor on Health Care FinancingSubstance Abuse and Mental Health ServicesAdministration46
  • 46. High-Risk Medicare Beneficiaries without Medicaid Look Like Thosewith Medicaid Except Their High Health Costs Put Them on aSlippery Slope to Medicaid Spend Down44PBPY PBPYPBPY PBPYPBPYPBPYData source: 2006 Medicare Current Beneficiary Survey Cost and Use File
  • 47. 6/19/201347ADULTS• Over 2/3 of adults with serious mental illness have comorbidphysical health conditions such as diabetes, heart disease andchronic obstructive pulmonary disease• Adults aged 18 or older with any mental illness or majordepressive episode in the past year were more likely than to havehigh blood pressure, asthma, diabetes, heart disease, and stroke• Those with mental illness were more likely to use an emergencyroom and to be hospitalized*SAMHSA NSDUH Report, “Physical Health Conditions among Adults withMental Illnesses,” 4/5/12
  • 48. ADULTS 48 6/19/2013
  • 49. ADULTS Past Year Emergency Room Use and Past YearHospitalization among Persons Aged 18 or Older with andwithout Serious Mental Illness in the Past Year: 2008 and200949 6/19/2013
  • 50. 6/19/201350ADULTS $5,000$4,500$4,000$3,500$3,000$2,500$2,000$1,500$1,000$500$-$4,717$4,032$3,233$2,739 $2,627$1,999$2,052$1,601$1,382$751 $680$212No Costly Physical One Costly Physical Two Costly Physical Three or More CostlyConditions Condition Conditions Physical ConditionsMental Health Service Users Substance Abuse Service Users All Other Medicaid BeneficiariesSAMHSA. (2010). Mental health and substance abuse services in Medicaid, 2003:Charts and state tables. HHS Publication No. (SMA) 10-4608.
  • 51. 6/19/201351CHILDREN & YOUTH• Around 1 in 5 young people have a mental, emotional, or behavioral healthdisorder, at an estimated annual cost of $247 billion• About 1 in 4 pediatric primary care office visits involve behavioral andmental health problems• About 1 in 3 Medicaid-enrolled children who use behavioral health carehave serious medical conditions (primarily asthma)• In contrast to adults with SPMI and chronic physical conditions (COPD,diabetes, etc.) Medicaid expenditures for children with co-morbidconditions are driven primarily by behavioral health• Integrated care strategies for children differ from those for adults in anumber of important ways, including duration, diagnoses, provisions forconsent, involvement of families in peer services, increased staffing ratiosfor care coordination, etc.51
  • 52. 6/19/201352OPPORTUNITIES• Implement new financing models for integrated care forindividuals with serious behavioral health needs• Support new service delivery models for coordinating andintegrating physical and behavioral health treatments andservices, with a focus on broader social and educationalsupports• Support new service delivery models that address theprimary care and behavioral health treatment needs forindividuals with substance use disorders• Create person/family-centered systems of care thatimprove outcomes, services, and value• The use of data and the inclusion of functional outcomes52
  • 53. Agenda• Introduction• Innovation Category 1: Rapidly reduce Medicare,Medicaid and/or CHIP costs in outpatient and/or post-acute settings• Innovation Category 2: Improve care for populationswith specialized needs• Upcoming Webinar Series and Next Steps53
  • 54. Upcoming WebinarsJune 18, 2013:• Webinar 3: Overview of InnovationCategory 3–4Webinar 4: Achieving Lower Costs ThroughImprovement; Cost Categories and the FinancialPlan; Submitting a Letter of Intent• Demonstrating how applicants canachieve lower costs throughimprovement• Describing the cost categories andcompleting the Financial Plan• Technical assistance for LOI submissionWebinar 5: Performance Measures/Developing anOperational Plan• Driver Diagrams/Theory of Change• Demonstrating measurable impact onBetter Health and Better Care• Rapid cycle improvementWebinar 6: Payment Models• What is a Payment Model?• What makes a Payment Model “FullyDeveloped”?• What is a sustainable Payment Model?Webinar 7: Application Narrative and Road Map• Application Narrative• Awardee Selection Process & Criteria• Helpful HintsWebinar 8: Technical Assistance for Submitting anApplicationSlides, transcripts and audio will be posted athttp://innovation.cms.gov54
  • 55. Next Steps• Letters of Intent (LOI) are due June 28, 2013o LOI is available online in a web-based form through the InnovationAwards website.• Additional information regarding the Innovation Awardswill be posted on• Register for your DUNS number … ASAP• Register in the System for Award Management (SAM) at:• More Questions? Please EmailInnovationAwards@cms.hhs.gov55
  • 56. Thank You!Please use the webinar chat feature to submitquestions56