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innovative care and innovative payment in value-based payments to providers
- 1. Innovative Care and Innovative Payment in Value-Based Payments to Providers NC PROVIDERS COUNCIL 2018 CONFERENCE GREENSBORO, NC JANUARY 15, 2019
- 2. Environmental Scan Quality issues Waiting list DSP turnover DSP open positions Growing cost for states and federal government Minimal quality comparative data Administratively burdensome with questionable value added
- 3. Value Movement Movement to pay for value over volume Shift from inputs to outcomes Shift from service focus to focus on impact of services Typically shifts from fee for service to value-based payments systems Pay for Performance/Quality Incentives/Shared Savings/Capitated Payments May include FFS payments to some or all providers
- 4. LAN Alternative Payment Model Framework 4 HCP-LAN Alternative Payment Model Framework Fact Sheet, http://hcp-lan.org/workproducts/apm-factsheet.pdf
- 5. Value Movement Drivers Triple aim Path to quality, better lives and improved health outcomes Better care coordination Governmental budget predictability Administrative simplification for government Less government employees Flexibility in services offered Lower cost (bend the cost curve) Increased market share for MCO’s Political will
- 6. Medicaid Long-Term Services & Supports
- 7. 201 8 2018 Texas MCO RFP includes potential enrollment of people with ID/DD 2018 Michigan begins implementation of managed care pilots for people with ID/DD 201 7 201 5 200 7 1998 2014 Kansas becomes first state to implement mandatory comprehensive managed care including LTSS for people with ID/DD through for-profit MCO contracts 2016 Iowa implements mandatory comprehensive managed care through for-profit MCO contracts 2016 Tennessee begins ECFC managed care waiver for new ID/DD enrollees through for-profit MCO contracts Incremental Yet Steady Growth 1988 2003 2014 201 6 201 8 2018 Arkansas begins implementation of PASSE program, provider-led managed care for people with ID/DD 2018 New York begins implementation of provider-led Health Home/Care Coordination model 1988 Arizona implements first ID-DD LTSS managed care program (state agency as mgmt. entity) 2003 North Carolina implements PIHP model (LMEs) for ID/DD and BH 1998 Michigan implements PIHP shared risk model through local community health boards 1998 Wisconsin pilots FamilyCare model 2007 Wisconsin significantly expands FamilyCare: 56 counties by 2010 2015 New York implements FIDA-IDD, provider-led duals integration model 2015 Texas implements CFC through StarPlus Managed Care as an option for 2017 Texas awards MCOs “pilot” programs for people with ID/DD in January; announces cancellation in September 2017 North Carolina announces plans for 2019 implementation including concept Source: HMA Presentation to ANCOR Board of Directors, April 2018
- 8. CMS Medicaid Innovation Accelerator Program VBP for HCBS 8 Advancing MLTSS in VPP, HCBS Conference, August 2018, https://s3.amazonaws.com/eshow001/FD032DF7-9A97-E611-B084-0025B3A62EEE/7E331C0E-DCC3-E711-80C6- 001B21D7CC11/handouts/2782018143748_Advancing-MLTSSInVBP-HCBSconf2018-August28115pm- Final.pdf?AWSAccessKeyId=AKIAJJGNJEP5JIXCBLJA&Expires=1536276212&Signature=reyOPzEXqFbukAIkW7lAB1ezIyY%3D
- 9. CMS Medicaid Innovation Accelerator Program VBP for HCBS – State Areas of Interest Target Populations Older adults Adults with physical disabilities Adults with intellectual disabilities Children with physical and/or intellectual disabilities Individuals with specific diagnoses
- 10. CMS Medicaid IAP- VBP for HCBS State Areas of Interest 10 Advancing MLTSS in VPP, HCBS Conference, August 2018, https://s3.amazonaws.com/eshow001/FD032DF7-9A97-E611-B084-0025B3A62EEE/7E331C0E-DCC3-E711-80C6- 001B21D7CC11/handouts/2782018143748_Advancing-MLTSSInVBP-HCBSconf2018-August28115pm- Final.pdf?AWSAccessKeyId=AKIAJJGNJEP5JIXCBLJA&Expires=1536276212&Signature=reyOPzEXqFbukAIkW7lAB1ezIyY%3D
- 11. CMS Medicaid IAP- VBP for HCBS Key Challenges for States 11 Advancing MLTSS in VPP, HCBS Conference, August 2018, https://s3.amazonaws.com/eshow001/FD032DF7-9A97-E611-B084-0025B3A62EEE/7E331C0E-DCC3-E711-80C6- 001B21D7CC11/handouts/2782018143748_Advancing-MLTSSInVBP-HCBSconf2018-August28115pm- Final.pdf?AWSAccessKeyId=AKIAJJGNJEP5JIXCBLJA&Expires=1536276212&Signature=reyOPzEXqFbukAIkW7lAB1ezIyY%3D
- 12. State Goals for Alternative Payment Models 12 State goal: address waitlist, offer more integrated services, increase employment, expenditure predictability. Two year engagement and design process; specific stakeholder requirements in contract and through ongoing state groups. 1700 new enrollees in first 15 months of program; 17% of ID-DD waitlist members self-referred for enrollment. TENNESSEE State goals: improve choice, access, cost- effectiveness. MCOs governance requirements include stakeholders. Contracts include specific personal experience outcome measurements, strong enrollment/disenrollment requirements. Less than 500 people on waitlist expected to be served by 2021. WISCONSI N State goal: primarily cost reduction, with high immediate annual savings targets set. No ID-DD specific goals identified. Little to no stakeholder engagement. Very limited ID-DD specific contract requirements. ID-DD waitlist has grown from 2400 to 2900. IOWA State goal: integrated care, cost savings. Little to no stakeholder engagement. .Some ID-DD specific contract requirements, eg staff qualifications, incentives for employment. ID-DD waitlist growth from 3070 to 3775. KANSAS
- 13. Value Movement Challenges Lack of appreciable and sustainable savings Minimal and immeasurable impact on waiting lists Service reductions Medical model (acute/chronic vs life cycle) Strong grassroots Growing body of evidence Single payer to multiple payers complexities
- 14. Value Movement Challenges Lack of epidemiological and actuarial data for population heath management Social determinants of health Data informed best practices Small “n” and a large degree of variability Financial strength of providers – risk readiness Economies of scale vs reality Stakeholder input vs impact Lack of transparency and data Provider IT capacity
- 15. ANCOR APM Workgroup Advancing Value and Quality in Medicaid Service Delivery for Individuals with Intellectual and Developmental Disabilities: ANCOR Alternative Payment Model Workgroup Report – January 16, 2019 General release on January 17, 2019
- 16. ANCOR APM Workgroup 16 Convened to identify and assess current and potential financing models that move beyond the current fee for service system. Workgroup Goals: gather information to better educate members and encourage them to participate in the process of pursuing alternate payment and service innovation models continue developing relationships with key external groups and convince them of the value of engaging provider in the process
- 17. ANCOR APM Workgroup 17 Key Activities: Monthly Calls Gather Member Input Engage with External Partners Develop Work Products, including: Principles Document Value Proposition Key Outcome: Final Report providing an overview and summary analysis of current APM Models – highlighting promising characteristics – with recommendations and suggested strategies moving forward
- 18. ANCOR APM Workgroup Process Key stakeholders discussions CMS NASDDDS NAMD NASUAD ANCOR member surveys Provider value Existing APM’s Workgroup discussions and feedback
- 19. ANCOR APM Workgroup Report Provider value proposition Key principles to guide new payment models Profile of 10 APM initiatives in 8 states and analysis (Arizona, Arkansas, Kansas, Michigan, New York (3), Pennsylvania, Tennessee and Wisconsin) Key themes and attributes of 10 APM’s ANCOR’s APM recommendations Next steps for APM work at ANCOR Government Relations Committee feedback ANCOR Board
- 20. Questions and Discussion Mark Davis President and CEO Pennsylvania Advocacy and Resources for Autism and Intellectual Disabilities mark@par.net **Special Thanks to Kim Opsahl, formerly ANCOR’s State Partnerships & Special Projects Director for her work on this presentation** For information on ANCOR: www.ancor.org
Editor's Notes
- The Framework was established to: [read bullets] The framework builds on the CMS proposed framework, which includes a trajectory of categories, with Category 1, fee for service without a link to quality, being the predominant model today – and a progression to Category 4, which includes population-based payment models. It is important when we discuss the framework to understand what the framework “is” and what it “is not.” The framework is a MODEL for categorizing payment models The framework is not a tool for establishing categories of delivery systems It is also not the Work Group’s intention to determine which model is the best model to follow. The framework is meant to allow for evolution and innovation in the field while driving toward value-based payments. Category 1: Payment models classified as Category 1 use traditional FFS payments (i.e., payments that are made for units of service) that are not adjusted to account for infrastructure investments, provider reporting of quality data, or provider performance on cost and quality metrics. Category 2: Payment models classified as Category 2 use traditional FFS payments (i.e., payments that are made for units of service), but these payments are subsequently adjusted based on infrastructure investments to improve clinical services, providers reporting quality data, and/or providers performance on cost and quality metrics. Category 2 includes four subcategories: Payments placed in Category 2A involve payments for infrastructure investments that can improve the quality of patient care. Payments placed in Category 2B provide positive or negative incentives to report quality data to the health plan and (preferably) to the public. Payments are placed in Category 2C if they provide rewards for high performance on clinical quality measures. Payments placed in Category 2D reward providers who perform well on quality metrics and penalize providers who do not perform well, thus providing a significant linkage between payment and quality. APMs Built on Fee-for-Service Architecture (Category 3): Payment models classified as Category 3 are based on a FFS architecture, while providing mechanisms for the effective management of a set of procedures, an episode of care, or all health services provided for individuals. Episode-based and other types of bundled payments encourage care coordination because they cover a complete set of related services for a procedure that may be delivered by multiple providers. Clinical episode payments fall into Category 3 if they are tied to specific procedures, such as hip replacement or back surgery. Category 3 includes two subcategories: Category 3A gives providers an “upside” opportunity to share in the savings they generate. Payments in Category 3B involve both upside gainsharing and downside risk based on performance on cost measures. Population-Based Payment (Category 4): Payment models classified as Category 4 involve population-based payments, structured in a manner that encourages providers to deliver well-coordinated, high-quality, person-level care within a defined (4A) or overall (4B) budget. Payments within Category 4 are intended to cover a wide range of preventive health, health maintenance, and health improvement services. Category 4 includes two subcategories: Category 4A payments are population-based, but they are limited to certain sets of condition-specific services (e.g., asthma, diabetes, or cancer), but they remain person-focused in the sense that they hold providers accountable for the total cost and quality of care related to that condition. Payments in Category 4B are capitated or population-based for all of the individual’s health care needs.
- The Framework was established to: [read bullets] The framework builds on the CMS proposed framework, which includes a trajectory of categories, with Category 1, fee for service without a link to quality, being the predominant model today – and a progression to Category 4, which includes population-based payment models. It is important when we discuss the framework to understand what the framework “is” and what it “is not.” The framework is a MODEL for categorizing payment models The framework is not a tool for establishing categories of delivery systems It is also not the Work Group’s intention to determine which model is the best model to follow. The framework is meant to allow for evolution and innovation in the field while driving toward value-based payments. Category 1: Payment models classified as Category 1 use traditional FFS payments (i.e., payments that are made for units of service) that are not adjusted to account for infrastructure investments, provider reporting of quality data, or provider performance on cost and quality metrics. Category 2: Payment models classified as Category 2 use traditional FFS payments (i.e., payments that are made for units of service), but these payments are subsequently adjusted based on infrastructure investments to improve clinical services, providers reporting quality data, and/or providers performance on cost and quality metrics. Category 2 includes four subcategories: Payments placed in Category 2A involve payments for infrastructure investments that can improve the quality of patient care. Payments placed in Category 2B provide positive or negative incentives to report quality data to the health plan and (preferably) to the public. Payments are placed in Category 2C if they provide rewards for high performance on clinical quality measures. Payments placed in Category 2D reward providers who perform well on quality metrics and penalize providers who do not perform well, thus providing a significant linkage between payment and quality. APMs Built on Fee-for-Service Architecture (Category 3): Payment models classified as Category 3 are based on a FFS architecture, while providing mechanisms for the effective management of a set of procedures, an episode of care, or all health services provided for individuals. Episode-based and other types of bundled payments encourage care coordination because they cover a complete set of related services for a procedure that may be delivered by multiple providers. Clinical episode payments fall into Category 3 if they are tied to specific procedures, such as hip replacement or back surgery. Category 3 includes two subcategories: Category 3A gives providers an “upside” opportunity to share in the savings they generate. Payments in Category 3B involve both upside gainsharing and downside risk based on performance on cost measures. Population-Based Payment (Category 4): Payment models classified as Category 4 involve population-based payments, structured in a manner that encourages providers to deliver well-coordinated, high-quality, person-level care within a defined (4A) or overall (4B) budget. Payments within Category 4 are intended to cover a wide range of preventive health, health maintenance, and health improvement services. Category 4 includes two subcategories: Category 4A payments are population-based, but they are limited to certain sets of condition-specific services (e.g., asthma, diabetes, or cancer), but they remain person-focused in the sense that they hold providers accountable for the total cost and quality of care related to that condition. Payments in Category 4B are capitated or population-based for all of the individual’s health care needs.
- The Framework was established to: [read bullets] The framework builds on the CMS proposed framework, which includes a trajectory of categories, with Category 1, fee for service without a link to quality, being the predominant model today – and a progression to Category 4, which includes population-based payment models. It is important when we discuss the framework to understand what the framework “is” and what it “is not.” The framework is a MODEL for categorizing payment models The framework is not a tool for establishing categories of delivery systems It is also not the Work Group’s intention to determine which model is the best model to follow. The framework is meant to allow for evolution and innovation in the field while driving toward value-based payments. Category 1: Payment models classified as Category 1 use traditional FFS payments (i.e., payments that are made for units of service) that are not adjusted to account for infrastructure investments, provider reporting of quality data, or provider performance on cost and quality metrics. Category 2: Payment models classified as Category 2 use traditional FFS payments (i.e., payments that are made for units of service), but these payments are subsequently adjusted based on infrastructure investments to improve clinical services, providers reporting quality data, and/or providers performance on cost and quality metrics. Category 2 includes four subcategories: Payments placed in Category 2A involve payments for infrastructure investments that can improve the quality of patient care. Payments placed in Category 2B provide positive or negative incentives to report quality data to the health plan and (preferably) to the public. Payments are placed in Category 2C if they provide rewards for high performance on clinical quality measures. Payments placed in Category 2D reward providers who perform well on quality metrics and penalize providers who do not perform well, thus providing a significant linkage between payment and quality. APMs Built on Fee-for-Service Architecture (Category 3): Payment models classified as Category 3 are based on a FFS architecture, while providing mechanisms for the effective management of a set of procedures, an episode of care, or all health services provided for individuals. Episode-based and other types of bundled payments encourage care coordination because they cover a complete set of related services for a procedure that may be delivered by multiple providers. Clinical episode payments fall into Category 3 if they are tied to specific procedures, such as hip replacement or back surgery. Category 3 includes two subcategories: Category 3A gives providers an “upside” opportunity to share in the savings they generate. Payments in Category 3B involve both upside gainsharing and downside risk based on performance on cost measures. Population-Based Payment (Category 4): Payment models classified as Category 4 involve population-based payments, structured in a manner that encourages providers to deliver well-coordinated, high-quality, person-level care within a defined (4A) or overall (4B) budget. Payments within Category 4 are intended to cover a wide range of preventive health, health maintenance, and health improvement services. Category 4 includes two subcategories: Category 4A payments are population-based, but they are limited to certain sets of condition-specific services (e.g., asthma, diabetes, or cancer), but they remain person-focused in the sense that they hold providers accountable for the total cost and quality of care related to that condition. Payments in Category 4B are capitated or population-based for all of the individual’s health care needs.
- The Framework was established to: [read bullets] The framework builds on the CMS proposed framework, which includes a trajectory of categories, with Category 1, fee for service without a link to quality, being the predominant model today – and a progression to Category 4, which includes population-based payment models. It is important when we discuss the framework to understand what the framework “is” and what it “is not.” The framework is a MODEL for categorizing payment models The framework is not a tool for establishing categories of delivery systems It is also not the Work Group’s intention to determine which model is the best model to follow. The framework is meant to allow for evolution and innovation in the field while driving toward value-based payments. Category 1: Payment models classified as Category 1 use traditional FFS payments (i.e., payments that are made for units of service) that are not adjusted to account for infrastructure investments, provider reporting of quality data, or provider performance on cost and quality metrics. Category 2: Payment models classified as Category 2 use traditional FFS payments (i.e., payments that are made for units of service), but these payments are subsequently adjusted based on infrastructure investments to improve clinical services, providers reporting quality data, and/or providers performance on cost and quality metrics. Category 2 includes four subcategories: Payments placed in Category 2A involve payments for infrastructure investments that can improve the quality of patient care. Payments placed in Category 2B provide positive or negative incentives to report quality data to the health plan and (preferably) to the public. Payments are placed in Category 2C if they provide rewards for high performance on clinical quality measures. Payments placed in Category 2D reward providers who perform well on quality metrics and penalize providers who do not perform well, thus providing a significant linkage between payment and quality. APMs Built on Fee-for-Service Architecture (Category 3): Payment models classified as Category 3 are based on a FFS architecture, while providing mechanisms for the effective management of a set of procedures, an episode of care, or all health services provided for individuals. Episode-based and other types of bundled payments encourage care coordination because they cover a complete set of related services for a procedure that may be delivered by multiple providers. Clinical episode payments fall into Category 3 if they are tied to specific procedures, such as hip replacement or back surgery. Category 3 includes two subcategories: Category 3A gives providers an “upside” opportunity to share in the savings they generate. Payments in Category 3B involve both upside gainsharing and downside risk based on performance on cost measures. Population-Based Payment (Category 4): Payment models classified as Category 4 involve population-based payments, structured in a manner that encourages providers to deliver well-coordinated, high-quality, person-level care within a defined (4A) or overall (4B) budget. Payments within Category 4 are intended to cover a wide range of preventive health, health maintenance, and health improvement services. Category 4 includes two subcategories: Category 4A payments are population-based, but they are limited to certain sets of condition-specific services (e.g., asthma, diabetes, or cancer), but they remain person-focused in the sense that they hold providers accountable for the total cost and quality of care related to that condition. Payments in Category 4B are capitated or population-based for all of the individual’s health care needs.
- The Framework was established to: [read bullets] The framework builds on the CMS proposed framework, which includes a trajectory of categories, with Category 1, fee for service without a link to quality, being the predominant model today – and a progression to Category 4, which includes population-based payment models. It is important when we discuss the framework to understand what the framework “is” and what it “is not.” The framework is a MODEL for categorizing payment models The framework is not a tool for establishing categories of delivery systems It is also not the Work Group’s intention to determine which model is the best model to follow. The framework is meant to allow for evolution and innovation in the field while driving toward value-based payments. Category 1: Payment models classified as Category 1 use traditional FFS payments (i.e., payments that are made for units of service) that are not adjusted to account for infrastructure investments, provider reporting of quality data, or provider performance on cost and quality metrics. Category 2: Payment models classified as Category 2 use traditional FFS payments (i.e., payments that are made for units of service), but these payments are subsequently adjusted based on infrastructure investments to improve clinical services, providers reporting quality data, and/or providers performance on cost and quality metrics. Category 2 includes four subcategories: Payments placed in Category 2A involve payments for infrastructure investments that can improve the quality of patient care. Payments placed in Category 2B provide positive or negative incentives to report quality data to the health plan and (preferably) to the public. Payments are placed in Category 2C if they provide rewards for high performance on clinical quality measures. Payments placed in Category 2D reward providers who perform well on quality metrics and penalize providers who do not perform well, thus providing a significant linkage between payment and quality. APMs Built on Fee-for-Service Architecture (Category 3): Payment models classified as Category 3 are based on a FFS architecture, while providing mechanisms for the effective management of a set of procedures, an episode of care, or all health services provided for individuals. Episode-based and other types of bundled payments encourage care coordination because they cover a complete set of related services for a procedure that may be delivered by multiple providers. Clinical episode payments fall into Category 3 if they are tied to specific procedures, such as hip replacement or back surgery. Category 3 includes two subcategories: Category 3A gives providers an “upside” opportunity to share in the savings they generate. Payments in Category 3B involve both upside gainsharing and downside risk based on performance on cost measures. Population-Based Payment (Category 4): Payment models classified as Category 4 involve population-based payments, structured in a manner that encourages providers to deliver well-coordinated, high-quality, person-level care within a defined (4A) or overall (4B) budget. Payments within Category 4 are intended to cover a wide range of preventive health, health maintenance, and health improvement services. Category 4 includes two subcategories: Category 4A payments are population-based, but they are limited to certain sets of condition-specific services (e.g., asthma, diabetes, or cancer), but they remain person-focused in the sense that they hold providers accountable for the total cost and quality of care related to that condition. Payments in Category 4B are capitated or population-based for all of the individual’s health care needs.
- The Framework was established to: [read bullets] The framework builds on the CMS proposed framework, which includes a trajectory of categories, with Category 1, fee for service without a link to quality, being the predominant model today – and a progression to Category 4, which includes population-based payment models. It is important when we discuss the framework to understand what the framework “is” and what it “is not.” The framework is a MODEL for categorizing payment models The framework is not a tool for establishing categories of delivery systems It is also not the Work Group’s intention to determine which model is the best model to follow. The framework is meant to allow for evolution and innovation in the field while driving toward value-based payments. Category 1: Payment models classified as Category 1 use traditional FFS payments (i.e., payments that are made for units of service) that are not adjusted to account for infrastructure investments, provider reporting of quality data, or provider performance on cost and quality metrics. Category 2: Payment models classified as Category 2 use traditional FFS payments (i.e., payments that are made for units of service), but these payments are subsequently adjusted based on infrastructure investments to improve clinical services, providers reporting quality data, and/or providers performance on cost and quality metrics. Category 2 includes four subcategories: Payments placed in Category 2A involve payments for infrastructure investments that can improve the quality of patient care. Payments placed in Category 2B provide positive or negative incentives to report quality data to the health plan and (preferably) to the public. Payments are placed in Category 2C if they provide rewards for high performance on clinical quality measures. Payments placed in Category 2D reward providers who perform well on quality metrics and penalize providers who do not perform well, thus providing a significant linkage between payment and quality. APMs Built on Fee-for-Service Architecture (Category 3): Payment models classified as Category 3 are based on a FFS architecture, while providing mechanisms for the effective management of a set of procedures, an episode of care, or all health services provided for individuals. Episode-based and other types of bundled payments encourage care coordination because they cover a complete set of related services for a procedure that may be delivered by multiple providers. Clinical episode payments fall into Category 3 if they are tied to specific procedures, such as hip replacement or back surgery. Category 3 includes two subcategories: Category 3A gives providers an “upside” opportunity to share in the savings they generate. Payments in Category 3B involve both upside gainsharing and downside risk based on performance on cost measures. Population-Based Payment (Category 4): Payment models classified as Category 4 involve population-based payments, structured in a manner that encourages providers to deliver well-coordinated, high-quality, person-level care within a defined (4A) or overall (4B) budget. Payments within Category 4 are intended to cover a wide range of preventive health, health maintenance, and health improvement services. Category 4 includes two subcategories: Category 4A payments are population-based, but they are limited to certain sets of condition-specific services (e.g., asthma, diabetes, or cancer), but they remain person-focused in the sense that they hold providers accountable for the total cost and quality of care related to that condition. Payments in Category 4B are capitated or population-based for all of the individual’s health care needs.