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Hazel
1. Virginia Rural Health Association 2015
Conference
The Honorable William A. Hazel, Jr., M.D.
Virginia Secretary of Health and Human Resources
2. Program and Services Map
VA Health and Human
Resources Secretariat
SSA DOL AOA NIH
ACL ACF FNS CDC SAMHSA EPA CMS
DARS DBHDS DHP DMAS VDSS OCS VBPD VDBVI VDDHH VDH VFHY
• Vocational
Rehabilitation
• Disability
Determination
• Community
Rehabilitation
for Disabled
• Aging Services
• Adult Protective
Services
• Developmental
Disability
Services
• Mental Health
Services
• Substance Abuse
Treatment
Services
• Behavioral
Health
Emergency
Response
Services
• Provider
Licensing
• Licensing and
Health
Profession
Regulation
• Prescription
Monitoring
Program (PMP)
• Health
Practitioners
Data Center
• Medicaid
• Family Access
to Medical
Insurance
Security
(FAMIS)
• Medicaid
Analytics and
Reform
• Supplemental
Nutrition
Assistance
Program
• Temporary
Assistance for
Needy Families
• Child Care
• Energy and
Cooling
Assistance
• Eligibility
Determination
• Foster Care and
Adoption
Services
• Child Support
Enforcement
• Child and Adult
Protective
Services
• Licensure
• Community
Policy and
Management
Teams (CPMT)
• Family
Assessment
and Planning
Teams (FAPT)
• At-Risk
Youth and
Families
• Policy
Setting
• Grants for
Innovation
• Leadership and
Advocacy
Training
Programs
• Disability
Services
Assessment
• Vocational
Rehabilitation
• Randolph-
Sheppard
Vending
Program
(RSVP)
• Virginia
Industries for
the Blind
• General Library
Services and
Education
Services
• Technology
Assistance
Program (TAP)
• Virginia Relay
• Outreach and
Community
Services
• Interpreter
Services
• Family Health
Services
• Emergency
Preparedness
and Response
• Environmental
Health Services
• Licensure and
Certification
• Epidemiology
• Virginia
Certificate of
Public Need
(COPN)
• Minority Health
and Equity
• Drinking Water
• Youth Programs
• Youth Tobacco
Use Prevention
• Youth Obesity
Prevention
IRS
A Focus on Value
What do we do? How well do we do it? How much does it cost?
4. The Virginia Health and Human Resources Secretariat is focused on six strategic issues.
Virginia Health and Human Resources
Virginia Health and Human Resources Secretariat
Healthy and Productive Virginians
Eliminating Intergenerational Poverty
Thriving Children and Families An Aging and Diverse Population
Integrating Individuals with
Disabilities in the Community
Supporting and Valuing Our
Veterans and Volunteers
Financial Sustainability Performance Management
Customer- Centric
Data Aware
Promoting Pathways to the 21st Century Economy for All Virginians While Maximizing the Value of Commonwealth Resources
Cultural Competence Trauma Informed Systems of Care
5. An interaction in one domain may only be measured by impact in another domain.
Coalition Partners
Fiscal Impact Data
Outcome Measures Data
Citizen Census Data
Population Health
Data
Specific At-Risk
Population Data
Social
Program Data
Health
Care
Data
DMAS
DSS,
OCS
DBHDS, DHCD,
DOC, DJJ
VDH
DMV, Elections
Education,
DOC, DJJ,
State Police
Tax, DPB,
Trade & Commerce
6. Virginia is shifting from a ‘program-focused’ model to a more ‘Customer-Centric Coordinated Care’ model.
‘Customer-Centric Coordinated Care’ Model
Agency
Traditional Program-Focused
Model
‘Customer-Centric Coordinated
Care’ Model
Agency
Agency
Agency
Agency
Service
Delivery
Partner
Service Delivery
Partner
Agency
Agency
Agency
Services driven by individual, family, or community needs
Agencies recognize and consider the full range of services provided by other agencies, partners and
organizations
Services are considered more broadly factoring in role of social determinants
7.
8.
9.
10. System Transformation, Excellence and Performance (STEP Virginia) – The Path
to a Healthy Virginia
• Establishes Certified Community Behavioral Health Clinics (CCBHCs)
• There are two phases:
• Phase 1: Virginia granted $982,000 for 1-year planning grant for CCBHC
• Phase 2: Up to 8 CCBHC Planning Grant states will be selected to
participate in the demonstration program.
• This grant opportunity from SAMHSA arose from the Excellence in Mental
Health Act.
CCBHCs
11. Other recent grants
• With help from the Center for Health Care
Innovation, VHQC recently received a $5.7
million grant from CMS as a Practice
Transformation Network. Only such grant
awarded in Virginia.
• In May, VCU received a $10 million grant
to establish a statewide consortium to help
small-to-medium-sized primary care practices
in Virginia.
12. METRICS ALONE ARE INSUFFICIENT
• We also require:
• Vision – Where we want to be
• Process – How to get there
• Accountability – Who does what and by
when
• Will – A commitment to move forward
• Much of the above will be addressed as we
collectively create Virginia’s Plan for Well-
Being
13. What is DSRIP?
• Medicaid waiver to access federal dollars to
invest in transformation of the Medicaid
delivery system
• CMS has approved seven DSRIP programs to
date (CA, NM, TX, KS, NJ, MA, NY)
• Helping states move from Fee-for-Service to
Value-Based Reimbursement
14. DSRIP program is an opportunity
for transformation
• The future is a Medicaid delivery system that
reimburses based on high-value care
• Ensure that even the most medically complex
enrollees with significantly behavioral,
physical, and developmental disabilities can
live safely and thrive in the community
• To accomplish either of these, significant
investment in data infrastructure at the
provider and state level is imperative
15. DSRIP program is an opportunity for
Virginia to transform
The future is a Medicaid delivery system that reimburses based
on high-value care
Ensure that even the most medically complex enrollees with
significantly behavioral, physical, and developmental disabilities
can live safely and thrive in the community
To accomplish either of these, significant investment in data
infrastructure at the provider and state level is imperative
16. Certificate of Public Need
• Study group required by 2015 legislation
• Evaluating whether Virginia’s COPN process,
needs, and relationship with charity care
• Has met 3 times, has 2 more meetings; next is
Oct. 27
• Final report due Dec. 1, 2015
• http://www.vdh.state.va.us/Administration/COPN.
htm
17. Provider Assessment
• Workgroup mandated by 2015 legislation
• Will analyze options for creating a provider
assessment program
• Prompted in part because of struggles of rural
hospitals, about half of which are operating in the
red
• Group has met twice – next meeting Oct. 28
• http://www.dmas.virginia.gov/Content_pgs/paw
g.aspx
18. Intersection of SIM and DSRIP
27 SIM projects from 8
workgroups and three
subgroups
1) Population Health,
Quality, Payment, HIT
2) Care Transitions
3) Workforce
4) Medicaid Innovation
5) VBID/Choosing, Wisely
6) Telehealth
7) Integrated Care
(Behavioral Health, Oral
Health, Complex Care)
Possible SIM project
funding via DSRIP
19. Rates of Opioid Overdose Deaths, Sales, and
Treatment Admissions, United States, 1999–2010
0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Rate
Year
Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000
CDC. MMWR 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e1101a1.htm?s_cid=mm60e1101a1_w.
Updated with 2009 mortality and 2010 treatment admission data.
Rates of Opioid Overdose Deaths, Sales,
and Treatment Admissions, United States, 1999–2010
20. 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Motor Vehicles 1037 1035 1052 1070 1124 928 841 823 878 877 831
Guns 799 824 884 812 838 818 843 868 863 830 848
Drug/Poisons 595 498 545 669 721 735 713 690 819 799 912
0
200
400
600
800
1000
1200
NumberofFatalities
OCME's Top 3 Methods of Death by Number
and Year of Death, 2003-2013
21. Deaths from Heroin and Rx Opiates in Virginia
0 4
19
100
89
107
48
100
135
213 210
0
50
100
150
200
250
NumberofDeaths
Year
Number of Fatal Heroin Overdoses by Year,
2004-2014*
1 Fatal heroin overdoses may have one or more drug or poisons contributing to
death.
2 The number of fatal heroin overdoses in 2014 is estimated based upon data for
January 1, 2014 to June 30, 2014.
389
422
398
415
487
414
468
508
0
100
200
300
400
500
600
2007 2008 2009 2010 2011 2012 2013 2014
NumberofDeaths
Year
Number of Fatal Prescription Opioid
Overdoses by Year, 2007-2014*
1 Heroin and prescription drug deaths are tallied separately. Where heroin and
prescription opioids caused or contributed to death, decedents will be counted twice.
2 Prescription opioid deaths are drug/poison deaths where one or more prescription
opioids caused or contributed to death.
3 The number of fatal heroin overdoses in 2014 is estimated based upon data for
January 1, 2014 to June 30, 2014.
22. The systems of care are constantly evolving due to some key challenges in Virginia.
Key Challenges in Health and Human Services Delivery
Population demographic changes
including aging and ethnicity
Key
Challenges
Keeping
pace with technological and political
shifts
Developing and retaining a skilled
health and human services
workforce
Balancing the requirement for specialization
with need for integration
Addressing the role of social
determinants of health
Coordinating with complex federal, state
and private structures and requirements
Managing funding instability
and inflexibility
23. An interaction in one domain may only be measured by impact in another domain.
Coalition Partners
Fiscal Impact Data
Outcome Measures Data
Citizen Census Data
Population Health
Data
Specific At-Risk
Population Data
Social
Program Data
Health
Care
Data
DMAS
DSS,
OCS
DBHDS, DHCD,
DOC, DJJ
VDH
DMV, Elections
Education,
DOC, DJJ,
State Police
Tax, DPB,
Trade & Commerce
24. The illustration below provides spending overlaps of individuals served by Medicaid, SNAP, and TANF in Virginia.
Program Overlaps – Spending
NOTE: Costs for each program have been derived by using population overlap data from SFY 2014 and program spending from SFY 2013
SOURCES: SFY 2014 VDSS Clients Served Annually , SFY 2013 VDSS Annual Statistical Reports
• Majority of the state and federal HHR
spending focuses on individuals receiving
Medicaid only followed by individuals
receiving both Medicaid and SNAP benefits
• Spending on individuals receiving TANF is
accompanied by Medicaid and SNAP
spending as well
Program
Annual Program
Spending
(in Millions)
Annual
Per-
Capita
Spending
Medicai
d
$7,600 $6,138
SNAP $1,625 $1,251
TANF $105 $655
Medicaid
Only
$5,100 M
Medicaid &
SNAP
$2,100 M
Medicaid,
SNAP &
TANF
$997 M
SNAP
Only
$572 M
TANF Only
$0.88 M
Medicaid &
TANF
$36 M
SNAP &
TANF
$30 M
Editor's Notes
DSRIP proposals in Virginia are currently just that – proposals, not done deals.
DMAS is in the stakeholder public comment process, DMAS has put together a framework/ strawman and is on the road describing the proposal and gathering feedback from stakeholders.
Virginia Health Information database of fiscal 2013 financial results for the hospitals. It lists 36 rural hospitals, 17 of which had a negative operating margin. That comes to 47 percent. In this database, the hospitals were allowed to determine for themselves whether they should be classified as rural or urban.
In a second batch of data, hospitals were sorted as rural or urban based on definitions from the federal Centers for Medicare & Medicaid Services. This grouping listed 25 rural hospitals in 2013, 16 of which ran in the red. That comes to 64 percent.
By comparison, of the 60 urban hospitals in Virginia under the federal definition, 13 had operating losses. That means nearly 22 percent of urban hospitals in the commonwealth had an operating loss in 2013.
A clear genesis of the abuse and overdose epidemics. Important to note that often these addictions begin with legitimate prescriptions.
A primary contributor to the increase in opioid overdose deaths is an abundance of supply of these very powerful drugs.
A recent analysis by CDC looked at the relationship between the sales of opioids and the number of deaths from them. What the study found was alarming:
As the amount of opioids sold increased, so did the number of deaths.
In fact, the supply of opioid pain relievers is larger than ever. The quantity sold in 2010 was four times that sold in 1999.
Enough opioids were sold in 2010 to give every American adult a 5mg Vicodin tablet every 4 hours for a month.
When you look at substance abuse treatment admissions for opioids and emergency department visits related to their misuse or abuse, you also see increases consistent with the increases in sales of these drugs.
Of the 912 poisoning deaths in 2013, 468 of those involved prescriptions opioids and 213 involved heroin. The street value of oxycontin is about $1/milligram (5-120mg available). Heroin is about $10 a dose (1/10 gram). An active heroin user may spend about $100 daily, much cheaper than the same amount of pills it would take to get high.
New 2014 numbers, not out as graphics yet, separate out opioid and heroin deaths, and show that in 2014, 728 Virginians died from heroin and prescription drug overdoses, up from 661 in 2013. In the last five years, fatal overdoses have increased by 57% and nearly 3,000 Virginians have lost their lives.
There is no reason to assume that these numbers will reverse course without significant, coordinated efforts.
Funding Stability and Flexibility
Flat federal funding and limited state funds for ongoing programs
High dependency of certain programs and agencies on federal grants/one-time grants and silo-ed funding approach
Workforce Development and Retention
Specialization vs Integration
Focusing on specialized issues sometimes results in siloes
Gaps in services due to inconsistent eligibility requirements
Complex Federal Structure and Interaction
Significant and wide-ranging federal oversight
Complicated regulations and requirements
Requirements not always current with modern service delivery
Addressing Social Determinants in Health
Limited usage of social determinants in designing, measuring and implementing policies and programs
Limited infrastructure to support social determinants in health
Legislative and Political Direction Changes