Connecticut Medicaid and the Future of Population Health...Connecticut Medicaid and the Future of Population Health 1 Dr. Robert Zavoski, MD, MPH Medical Director, Department of Social

Connecticut Medicaid and the Future of Population Health

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Dr. Robert Zavoski, MD, MPH

Medical Director, Department of Social Services

Lawrence Magras, MD, MBA,

SVP of Population Health and CMO

Community Health Network of CT, Inc.

Agenda

Medicaid national perspective

CT specific perspective

o Population covered

o Self insured model

o How the model is performing

o PCMH/PCMH+

o Single set of claims data

o Integrating medical/BH and dental into one model/plan of care

How the FQHCs fit into the bigger picture

o Original vision

o Participation in HUSKY Health/PCMH, etc.

Improving Care in Communities

o Providing Tools and Data

o Addressing Health Outcomes at a Community Level

o Role of Geo-mapping

o Role of Social Determinants of Health

o Strategies for Addressing SDOH’s

Getting to better outcomes - together

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Medicaid – A National Perspective

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Status of State Medicaid Expansion Decisions

WY

WI

WV

WA

VA

VT

UT ◊

TX

TN

SD

SC

RI

PA

OR

OK

OH

ND

NC

NY

NM

NJ

NH

NV NE ◊

MT

MO

MS

MN

MI

MA

MD

ME

LA

KY KS

IA

IN IL

ID ◊

HI

GA

FL

DC

DE

CT

CO

CA

AR AZ

AK

AL

Not Adopting At This Time (14 States)

Adopted (37 States including DC)

NOTES: Current status for each state is based on KFF tracking and analysis of state activity. ◊Expansion is adopted but not yet implemented in ID, NE, and UT. (See link below for additional state-specific notes). SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated August 1, 2019.

https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
























Medicaid – A National Perspective

May 2019 Medicaid & CHIP Enrollment

• 72,295,837 individuals were enrolled in Medicaid and CHIP in the 51 states that reported enrollment data for May 2019.65,663,268 individuals were enrolled in Medicaid.

• 6,632,569 individuals were enrolled in CHIP.

34,761,353 individuals were enrolled in CHIP or were children enrolled in the Medicaid program in the 48 states that reported child enrollment data for May 2019representing 50.5% of total Medicaid and CHIP program enrollment.

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https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-

data/report-highlights/index.html

https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html













Medicaid in CT -HUSKY

Key Point 1 HUSKY Health is a major payer that covers over 820,000 Connecticut citizens (22% of the population), enrolls over 43,000 providers, and provides comprehensive health benefits

Key Point 2 HUSKY Health is a self-insured, managed fee-for- service program that is administratively efficient and effective

Key Point 3 HUSKY Health has implemented significant care delivery and payment reforms under State Plan authority (not through an 1115 waiver)

Key Point 4 HUSKY Health is improving health and care experience outcomes, resulting in effectively controlled costs

Key Point 5 HUSKY Health continues to evolve to meet current and future needs

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HUSKY – Population Statistics

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HUSKY A clients (parents and children) represent 60% of enrollees but account for only 29% of program costs

HUSKY C clients (older adults and people with disabilities) make up 11% of the enrollees but represent 46% of program costs

HUSKY D clients (expansion adults) represent 29% of enrollees and 25% of program costs

HUSKY B is the Connecticut CHIP Program

HUSKY – Population Statistics

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HUSKY A – Families and children

HUSKY C – Aged and disabled

HUSKY D – ACA single adults

Significant

HUSKY D

enrollee growth

has contributed to

its increasing

share of overall

Medicaid

enrollees,

resulting in slightly

smaller shares of

both HUSKY C

and HUSKY A

enrollees

HUSKY – A Self Insured Model

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By contrast to most other states, Connecticut is not using capitated managed care arrangements for its medical, behavioral health and dental services

Like most large employers, and for the same reasons, HUSKY Health is self-insured and has entered into contracts with Administrative Services Organizations (ASOs)

A simplified, streamlined, statewide structure, rates, and policies enable a “one call does it all” approach and ensures lean administrative costs of only 3.2%

Program Performance

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HUSKY Health . . . is continuously improving health and care experience outcomes and effectively controlling costs through a range of strategies (Person-Centered Medical Homes, Intensive Care Management, behavioral health community care teams)

HUSKY Health realizes positive outcomes through a focus on primary and preventive care.

Enabling immediate access to primary care visits, preventive dental care, and behavioral health care, for both adults and children, through broad coverage and provider incentives lessens reliance on more expensive sites of care.

Person Centered Medical Homes have achieved better results than non-PCMH practices on a variety of health outcome measures.

Program Performance

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HUSKY Health measures everything it does with a mixture of national standards and targeted measures, including:

a broad array of HEDIS (Healthcare Effectiveness Data Information Set) measures

Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys

mystery shopper surveys

review of financial trends: overall expenditures and per member per month spend, spending in major service categories

Program Performance: Health Outcomes

Select Outcomes Measures by Practice Setting

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Select Health Outcomes Measures by Practice Setting

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Program Performance: Health Outcomes (cont.)


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Routine care is increasing

Utilization Changes: Physician Services

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Program Performance: Utilization Improvements

CY 2015 CY 2016 CY 2017 CY 2015 vs CY 2017

COE Description Util Util/1000 Util Util/1000 Util Util/1000 Util/1000 %

Clinic Services 189,975 232 187,696 230.3 187,728 226.1 -5.9 -2.5

FQHC – Medical 702,989 858.6 756,645 928.5 788,787 949.9 91.3 10.6

Other Practitioner 459,228 560.9 526,855 646.5 580,637 699.2 138.3 24.7

Physician Services –

All 3,948,428 4,822.50 4,403,791 5,404.00 4,655,918 5,606.90 784.4 16.3

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Program Performance: Utilization Improvements (cont.)

2015 2016 2017 CY 2015 vs CY 2017

Admissions 84,777 85,618 80,573 -4,204 -4.96%

Admissions per 1,000 103.54 105.06 97.03 -6.51 -6.29%

Re-admission Rate 11.35% 11.26% 10.95% -0.40% -3.52%

Days/1,000 479.7 472.4 428.1 -51.6 -10.76%

Average Length of Stay (ALOS) 4.63 4.50 4.41 -0.22 -4.75%

Hospital utilization is decreasing

Inpatient Metrics

Population Outcomes: Utilization Improvements (cont.)

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683.7

734.5

750.8

650 700 750 800

2017

2016

2015

Utilization / 1,000

Utilization / 1,000

567,750

598,578

614,749

540,000 560,000 580,000 600,000 620,000

2017

2016

2015

Utilization

Utilization

ED utilization is decreasing

Program Performance: Financial

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What financial trends are we seeing?

Cost trends in select service categories align with strategic objectives.

The state share of HUSKY Health costs are stable while the federal share has increased.

Total expenditures have increased due to increases in enrollment, but per member per month costs have remained remarkably steady over time.

HUSKY Health’s financial trends compare very favorably with national Medicaid trends.

Value Based Programs - PCMH

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Incorporating Value-Based Payment approaches through . . .

• Hospital payment modernization • Pay-for-performance initiatives:

Person-Centered Medical Home quality and year-over-year improvement payments and obstetrics P4P

• PCMH+ upside-only shared savings initiative with seven FQHCs and two Advanced Networks

the right care at the right time in the right setting . . .

Value Based Programs - PCMH

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People served by Medicaid who receive their care at Federally Qualified Health Centers and “advanced networks”

People served by Medicaid who need community-based Long-Term Services and Supports (LTSS)

People with behavioral health conditions health conditions who receive services from Local Mental Health Authorities (LMHA)

Person-Centered Medical Home Plus (PCMH+)

Key goal: Clinical and community integration

Who: Medicaid members other than those served by long-term services and supports; assignment based on retrospective examination of where individual has received care

What: Care coordination funded by Medicaid supplemental payments to FQHCs; shared savings model How: primary care-based care team

Home and Community-Based Waivers Key goal: Diversion of individuals from institutional care

Who: Individuals who have functional limitations that put them at risk of nursing home placement; by application

What: Care coordination and LTSS services How: Care coordination through assigned care manager or self-direction; services provided by a range of providers

Health Homes

Key goal: Integration of behavioral health care, medical care and social services Who: Individuals with Serious and Persistent Mental Illness served by LMHA, who have annual expenses in excess of $10,000; enrollment with provider from whom individual has received services, with opt-out What: Care coordination team funded by Medicaid per member per month payments How: multi-disciplinary team

Money Follows the Person

Key goal: Community integration Who: Individuals with need for LTSS who have received care in a hospital or nursing home for three or more months; by application

What: Transition assistance, funded by a federal grant for first year; state-funded housing vouchers How: Transition supports provided through assigned transition staff, services provided by a range of providers

Community First Choice

Key goal: Enabling individuals to self-direct services within individual budgets Who: Individuals who are at nursing home level of care; by application

What: Self-directed PCA and related services funded under Medicaid State Plan; support from fiscal intermediary

How: Through self-direction

ASO Intensive Care Management Key goal: Enabling individuals in development of health goals and improved outcomes Who: Individuals who risk stratify as in high need based on CareAnalyzer results, referrals, self-referrals What: Care coordination; community care teams How: Nurse care managers organized in geographic teams

People with need for support in accessing and coordinating their services

Person Centered Medical Homes

(PCMH)

Key goal: Supporting individuals in effectively using primary care

Who: Individuals who select such practices for their care

What: Limited embedded care coordination supported by enhanced Medicaid fee-for-service payments How: Practice elects the means of fulfilling this function

Medicaid strategies for supporting Medicaid Members

Value Based Programs – PCMH+

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On a foundation of

Person-Centered Medical Homes

ASO-Based Intensive Care Management (ICM)

Pay-for-Performance (PCMH, OB)

we are building in

with the desired result of creating Multi-disciplinary (medical,

behavioral health, dental services; social supports)

health neighborhoods

Supports for social determinants (ICM, transition/tenancy sustaining

services, interventions for childhood trauma)

PCMH+ Community-based

care coordination through expanded care team

(health homes, PCMH+)

Data Analytics/ Risk Stratification


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1 Protecting the interests of Medicaid members

2 Improving overall health and wellness for Medicaid members

3 Creating high performance primary care practices with integrated support for both physical and behavioral health conditions

4 Building on the platform of the Department’s PCMH Program, as well as the strengths and analytic capability of the Medicaid program’s medical ASO

5 Enhancing capacity at practices where Medicaid members are seeking care, to improve health outcomes and care experience

6 Encouraging the use of effective care coordination to address the social determinants of health

PCMH+ model design was guided by a number of important values:


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PCMH+ requires PEs to build on the limited, PCMH care coordination with enhanced care coordination activities targeting improved outcomes in:

• Behavioral health integration

• Cultural competency, including use of the national Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS) standards

• Children and youth with special health care needs

• Disability competency


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Opt-Outs

• PCMH+ opt-outs have been lower than other assignment-based care coordination programs at 1% of initially assigned members.

Member Participation

• PCMH+ assigned members steadily decreased in 2017.

• The majority of that decrease was due to member loss of HUSKY eligibility. Temporary eligibility lapses have been administratively addressed.

Mystery Shopper Survey

• 78% of PCMH+ practices responded that a doctor in the office was taking new patients, as compared to 85% of PCMH practices.

• 94% of PCMH+ primary care practices offered an appointment after identifying HUSKY insurance, as compared to 83% of PCMH practices.

Complaints

•Member complaints have decreased since the initial launch of PCMH+. •PCMH+ average member complaints in 2017 were lower than the 2016 average for the same members.


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2016 2017

Participating Entities 81.5 82.8

Comparison Group 82.0 82.5

CAHPS composite scores for Participating Entities and the Comparison Group:

The composite CAHPS score were provided by Yale and have been weighted by the number of respondents to derive the Participating Entities and Comparison Group averages.


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QUALITY MEASURES: W1

Results All PE 2016 All PE 2017 CG 2016 CG 2017 PE Change CG Change

Individual Saving Pool Quality Measures

Adolescent well-care visits 72.4% 73.7% 76.8% 76.7% 1.9% -0.2%

Avoidance of antibiotic treatment in adults with acute

bronchitis 27.6% 30.8% 27.4% 31.0% 11.6% 13.1%

Developmental screening in the first three years of life 41.7% 47.2% 42.1% 46.5% 13.1% 10.4%

Diabetes HbA1c Screening 88.5% 89.0% 91.3% 91.1% 0.6% -0.2%

Emergency Department (ED) Usage* 87.2 82.8 69.6 65.4 -5.0% -6.1%

Medication management for people with asthma 44.3% 47.7% 45.2% 49.1% 7.6% 8.7%

PCMH CAHPS 81.5% 82.8% 82.0% 82.5% 1.6% 0.6%

Prenatal Care 74.4% 73.6% 75.1% 74.0% -1.1% -1.4%

Postpartum Care 48.7% 47.8% 51.9% 46.7% -1.8% -10.1%

Well-child visits in the first 15 months of life 80.5% 81.0% 86.6% 87.2% 0.7% 0.6%

Challenge Pool Quality Measures

Behavioral health screening 1-17 19.7% 25.5% 21.1% 23.8% 29.5% 12.8%

Metabolic monitoring for children and adolescents on

antipsychotics 41.5% 40.8% 42.0% 45.0% -1.6% 7.0%

Readmissions within 30 days* 15.0% 14.1% 11.2% 10.9% -6.3% -2.2%

Post-hospital admission follow-up 40.4% 42.4% 43.4% 43.1% 5.0% -0.6%

* A lower score indicates more appropriate care.


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2017 Performance Year Results

Participating Entity

Adolescent

well- care

visits

Avoidance of

antibiotic

treatment in

adults with

acute bronchitis

Developmental

screening in the

first three years

of life

Diabetes HbA1c

Screening

Emergency

Department

(ED) Usage

Medication

management

for people with

asthma

PCMH CAHPS

Prenatal Care

Postpartum

Care

Well-child visits

in the first 15

months of life

St. Vincent's AN 77.6% 20.1% 56.4% 88.1% 62.1 52.7% 82.9% 67.2% 44.0% 87.2%

Northeast Medical

Group AN 75.3% 25.9% 26.5% 89.5% 71.8 51.2% 85.3% 65.6% 42.1% 87.3%

Charter Oak Family Health 70.5% 41.3% 3.4% 86.7% 100.9 41.2% 82.1% 82.9% 48.7% 66.0%

Community Health Center 72.9% 39.8% 74.1% 91.8% 93.5 47.9% 81.3% 69.1% 39.3% 73.6%

Cornell Scott- Hill Health 69.6% 28.6% 13.9% 83.9% 91.0 50.6% 83.7% 74.5% 47.5% 77.0%

Fair Haven Community

Health 73.9% 37.1% 32.8% 93.1% 67.5 45.4% 82.7% 84.8% 64.6% 89.3%

Generations Family Health 64.2% 46.0% 16.1% 89.3% 116.6 43.7% 83.5% 71.8% 29.6% 77.8%

Optimus Health Care 77.7% 29.3% 16.7% 86.1% 71.8 43.4% 81.3% 81.6% 63.4% 84.3%

Southwest

Community Health 70.7% 25.6% 51.2% 92.5% 80.7 49.8% 83.2% 86.7% 70.3% 92.9%


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QUALITY MEASURES: W1 Results

Significant improvement was observed for the following quality measures for PCMH+:

• Behavioral health screening 1-17 (29.5% improvement) • Developmental screening in the first three years of life (13.1%

improvement)

• Avoidance of antibiotic treatment in adults with acute bronchitis (11.6% improvement)

• Medication management for people with asthma (7.6% improvement)

Quality measures that did not improve:

• The Prenatal and Postpartum Care measure only saw improvement for four out of nine participating entities. The other five participating entities scores decreased from the prior year.

• Although eight of nine participating entities saw improvement for Emergency Department Usage, only two participating entities improved more than the comparison group average.


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Summary of Savings Distributions

Wave 1 Results

Challenge Pool

All PEs

NEMG

St. V IN

Charter

Oak

CHC

CS- HH

FH -CHC

GFHC

Optimus

HC

SW CHC

Number of Challenge

Measures Passed

20 2 4 2 3 1 3 2 2 1

Performance Year Member

Months

1,027,995 55,498 134,501 54,259 335,648 108,139 59,801 58,783 158,299 63,067

Member-weighted

Challenge Measures

2,549,235 110,996 538,004 108,518 1,006,944 108,139 179,403 117,566 316,598 63,067

Challenge Pool Distribution

Percentage

100.00% 4.35% 21.10% 4.26% 39.50% 4.24% 7.04% 4.61% 12.42% 2.47%

Challenge Pool Award $820,465 $35,724 $173,155 $34,926 $324,082 $34,804 $57,740 $37,838 $101,896 $20,298

Savings Awarded via

Individual Savings Pool

$915,033 $0 $0 $436,435 $0 $0 $0 $0 $478,598 $0

Savings Awarded via

Challenge Pool

$820,465 $35,724 $173,155 $34,926 $324,082 $34,804 $57,740 $37,83

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$101,896 $20,298

Total Shared Savings $1,735,498 $35,724 $173,155 $471,361 $324,082 $34,804 $57,740 $37,83

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$580,495 $20,298

HUSKY – A Unified Data Set

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Big Data! • Claims : 322,819,286

• Claim Lines: 717,685,420

• Enrollment Transactions: 361,392,307

• EHR Visits: 19,199,907

• PCP Transactions: 6,127,888

• Provider Transactions: 46,792,020

• CCMS (Care Management System)

• Interview Response Transactions: 2,220,551,412

• CCMS Case Records: 1,444,872

• CRM

• Contacts: 7,120,611

• Tasks: 8,275,460

• ASO data warehouse (claims, enrollment, provider, lab values, reference data, ADTs) • 1.89 terabytes.

• Our raw data storage for the data for the data we receive for the data warehouse:

• 0.9 terabytes

• CCMS

• 2.24 terabytes.

• CRM (Call tracking system used by Member Engagement) • 0.29 gigabytes.

Behavioral Health & Global Concern for Life Expectancy

The National Alliance on Mental Illness; Mental Illness Facts and Numbers; Dr. Ken Duckworth; http://www2.nami.org/factsheets/mentalillness_factsheet.pdf Milliman Report Summary: Economic Impact of Integrated Medical-Behavioral Healthcare; April, 2014; American Psychiatry Association; www.psychiatry.org

National Institute of Mental Health;

www.nimh.nih.gov/about/director/2015/mortality-and-mental-disorders.shtml

Integration of BH and Dental Care

http://www2.nami.org/factsheets/mentalillness_factsheet.pdf

http://www2.nami.org/factsheets/mentalillness_factsheet.pdf

http://www.psychiatry.org/

http://www.nimh.nih.gov/about/director/2015/mortality-and-mental-disorders.shtml







www.ctbhp.com

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http://www.ctbhp.com/

http://www.ctbhp.com/

BH Integration Models

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Integrating Behavioral Health and Primary Care: Consulting, Coordinating and Collaborating Among Professionals; Cohen, et al., doi: 10.3122/jabfm.

2015.S1.150042



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Dental Home

• Provides comprehensive dental care including prevention and emergency services by a Connecticut Medicaid enrolled licensed dentist at a fixed location;

• coordinated delivery of dental services that improves or maintains their oral health to a functional level

– adjunctive, diagnostic, endodontic, oral surgical, orthodontic, pediatric, preventive, prosthodontic, restorative and emergency services available under the program

– personalized to each patient and includes individualized oral care instruction.

• Care is coordinated to maximize effectiveness and efficiency, consistent with evidence-based and community

www.ctdhp.com

https://www.ctdhp.com/providers_info.asp?a=21&b=2


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Dental Home

• Risk assessment completed for each patient • used to design an individualized treatment plan must include

consideration of the patient's overall health and any needed coordination with other health care providers;

• Continuously accessibility ; • It has a fixed location for the continuity of services that is within a

twenty mile radius of the patient base.

» Exceptions made at the discretion of DSS in rural or underserved areas as defined by the CT Department of Public Health;

– Records of treated patients are available at that site.

– Charts and records of treated patients are accessible at that site.

– Has regularly scheduled appointment hours available weekly.


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Dental Home

Is person or family centered

Has a plan for providing emergency care after regularly scheduled office hours twenty-four hours a day, seven days per week, other than simply providing a referral to the local hospital emergency room

Has written or electronic communication with primary care and specialty medical providers when in the best interests of the patient

HUSKY – Role of FQHCs

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FQHC’s – The Original Vision

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Health Center Overview

For more than 50 years, health centers have delivered affordable, accessible, quality, and value-based primary health care to millions of people regardless of their ability to pay. Not only are health centers serving 1 in 12 people across the country, the Health Center Program is leading the nation in driving quality improvement and reducing health care costs for America’s taxpayers. Because health centers provide high quality primary care services across the country, the health center network is also called upon to support public health priorities such as the opioid crisis and the White House initiative, Ending the HIV Epidemic: A Plan for America.

Providing Value-Based Care to Millions Across the Nation

HRSA’s investments have advanced the nation’s health by ensuring more patients and communities each year have access to high quality, comprehensive primary care. Today, HRSA funds nearly 1,400 health centers operating approximately 12,000 service delivery sites in every U.S. state, U.S. territory, and the District of Columbia. In 2018, there were more than 236,000 full-time health center providers and staff serving nearly 28.4 million patients. In fact, health centers have almost tripled the number of patients served in 2000 when the program served approximately 9.6 million patients.

Driving Quality Improvement

The number of staff and patients is just one piece of the story. HRSA’s quality improvement investments advance a model of coordinated, comprehensive, and patient-centered care, integrating medical, dental, behavioral health, substance use disorder, and patient services.

These investments have positioned 1,045 health centers (77 percent) to achieve Patient- Centered Medical Home (PCMH) recognition. The PCMH model of care enables health centers to sustain strong patient outcomes at lower costs despite treating a sicker and poorer population than other health care settings.

https://bphc.hrsa.gov/sites/default/files/bphc/about/healthcenterfa

ctsheet.pdf

https://bphc.hrsa.gov/sites/default/files/bphc/about/healthcenterfactsheet.pdf

https://bphc.hrsa.gov/sites/default/files/bphc/about/healthcenterfactsheet.pdf


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What is a Community Health Center?

Affordable: Community Health Centers are open to everyone, with sliding

scale fees based on income and family size.

Appropriate: Community Health Centers offer primary health, oral and mental

health/substance abuse services, and preventive health care, as well as

supportive services such as translation, transportation, case management,

health education, and social services.

Accessible: Services that include primary and preventive care, outreach and

dental care, must be available to all residents of their service areas to help

ensure access to care and continuity of care.

Accountable: A community board, the majority of whose members are patients

of the health center, governs Community Health Centers.


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Community Health Center’s in CT

In Connecticut, Community Health Centers provide health care to anyone who

needs it, regardless of income or insurance status.

• Health centers serve as the family doctor and medical home for over

230,000 patients or 6.6% of the CT population who receive care at over

110 sites in rural and urban areas across the state.

• More than three out of four (77%) health center patients have family

incomes under 100% of the Federal Poverty Level ($19,350 per year for a

family of four).

• Forty-nine percent (49.5%) of health center patients are

Hispanic/Latino, 24% are African American, 24% are White, and 2.1% are

Asian/Pacific Islander. More than 85,698 (40%) are best served in a

language other than English.

• Nearly half (46%) of health center patients are Medicaid beneficiaries

and 28% are uninsured.

FQHC’s – Participation in HUSKY

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47.7%

42.9%

9.4% FQHC (175,752)

PCMH Practices(158,344)

Glide PathPractices(34,730)

15.0%

69.2%

15.9%

FQHC (16)

PCMH Practices(74)

Glide PathPractices (17)

CY 2017 DSS PCMH Program Practices by Practice Setting

Dual Members and Limited Benefit Excluded | Attribution as of 1/1/2018 | TPL Members Included

• FQHC membership ranged from 2,031 to 51,013 in CY 2017 with an average membership of 10,985 members per FQHC, compared to an average membership of 10,456 members in CY 2016

• CY 2017 FQHCs accounted for 15.0% of the PCMH program practices, but 47.7% of the PCMH program’s attributed membership compared to 14.8% of the PCMH program practices and 50.6% of the membership attribution in CY 2016


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Role of Big Data


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Accessing the data


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Provider Tools

• Individual Practice Profiles • Practices with greater than 50 members receive an individual

practice profile

• Each individual practice profile includes the following:

– 43 selected HEDIS® and DSS custom measures

– Comparisons to practice setting, statewide and national benchmarks (where available)

• Annual Provider Profiling Report- tool used to stratify providers (by practice setting) • Statistical Analysis done for every measure on profile, includes a

Box-Whisker plot for each measure

– Identifies practice’s performance at mean, median, and the 5th, 25th, 75th, and 95th percentile

• Used to target practices for interventions


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Accessing the data


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Provider Website

• Evidence-based guidelines

• Patient Management

Tools

• Secure portal • Gaps in Care reports

Value-Based Initiatives

• PCMH/PCMH+

• OB P4P


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Addressing Health Outcomes at a Community Level A framework from Health Leads©, the Essential Needs Roadmap, serves as a gateway to a

curated library of tools, best practices, implementation guidance, and other dynamic content.

Six key drivers that are key to successful social needs strategies in clinical settings:

• Patient Identification and Screening: Which patient population will you target and how will you assess their social needs? (PRAPARE)

• Navigation and Resource Connections: For which specific social needs will you offer support? What level and type of support?

• Social Health Team and Workflow: Who will provide resource support for patients? How will this integrate with broader clinical processes?

• Data and Evaluation: How will you know how much to invest in social supports in the long run? How will you know how to maximize the impact of this investment?

• Community Partnerships: What community-based organizations are critical to the health of your members? How will you partner with them to continually improve access to resources?

• Leadership and Change Management: Have you identified a social needs champion with the ability to allocate resources? Do you have the necessary buy-in from key stakeholders?

https://healthleadsusa.org/resource-library/roadmap/

http://www.nachc.org/research-and-data/prapare/


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Geo-Mapping SDOH’s

• Baltimore example

• Beacon MAT map

• Inequity in CT (Data Haven)

• HUSKY Data: Tableau Data

(Interactive Demo)

Health Measure TIPS (To Improve Performance Sheet): Addressing Social Determinants of Health in HUSKY Health Members to Improve Health Outcomes

http://gis.baltimorecity.gov/healthmaps/

https://public.tableau.com/views/CTBHPMedicaidMATProviderMap/TreatmentProviders?:embed=y&:display_count=yes&:showVizHome=no

https://www.ctdatahaven.org/reports/merging-500-cities-and-connecticut-data-health-equity

https://www.huskyhealthct.org/providers/provider_postings/TIPS_sheets/Social_Determinants_of_Health.pdf




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Strategies for addressing SDOH’s

• Gather better data A report from the National Academies of Sciences, Engineering and Medicine on

accounting for social risk factors has five “guiding principles” that CMS should consider when choosing sources for gathering sociodemographic data:

• First scrutinize data it has already gathered

• Look for ways to use data from other federal agencies, including other groups under the Department of Health and Human Services

• To the degree that it can, gather additional data when a patient enrolls in Medicare/Medicaid

• For those social determinants that may change over time, access data reported by providers or included in electronic health records

• For factors that are related to a patient’s home environment, employ local measures for data collection

National Academies of Science, Engineering and Medicine,

Accounting for Social Risk Factors in Medicare Payment: Data

(2016), http://nap.edu/23605

https://www.nap.edu/catalog/23605/accounting-for-social-risk-factors-in-medicare-payment-data


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Strategies for addressing SDOH’s

• Aligning Risk Adjustment and Payment To incorporate sociodemographic factors into payments in a way that achieves

balance, the researchers identified four categories CMS value-based programs should account for:

• Stratified public reporting

• Direct adjustment of payments incorporating social risk factors

• Direct payment adjustments

• Restructured payment incentive design

“Accounting for social risk factors in Medicare payments is not intended to obscure disparities that exist, but rather bring disparities to light,” Steinwachs said in a statement to press. “Payment systems should include sufficient incentives for

quality improvement for both socially at-risk populations and to patients overall.”

National Academies of Science, Engineering and Medicine,

Accounting for Social Risk Factors in Medicare Payment:

Criteria, Factors, and Methods (2016), http://nap.edu/23613


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Strategies for Addressing SDOHs: using location-based analytics along with

social and behavioral data to refine community outreach efforts and boost patient engagement through localized, disease-specific patient resources

• Children’s National Medical Center • uses environmental data tied to socioeconomics, nutrition and housing to

geographically visualize disease variations and roll out localized efforts targeting specific conditions

– reduced the number of scalding and contact burns in children ages 0-2 using geospatial analytics to highlight neighborhoods where the injuries were occurring and notifying parents to decrease the temperature on water heaters.

– Same approach to sickle cell patients, providing physicians information on each patient’s risk of readmission based on where they lived

– made surprising discoveries about the relationship between fast food restaurants and childhood obesity.

HIMMS 2017


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Strategies for Addressing SDOHs: using location-based analytics along with social and behavioral data to refine community outreach efforts and boost patient engagement through localized, disease-specific patient resources

• Loma Linda University Medical Center • Mark Zirkelbach, CIO at Loma Linda University Medical Center located

outside of San Bernardino, California, said the hospital now views location as the "seventh vital sign.“

• Over the last several years, the hospital developed personalized “wellness maps” for each patient depending on their condition.

• The map, which is integrated with the system’s EHR and patient portal, contains specific community resources such as nearby clinics, drugstores, bus transportation routes and even places to exercise or purchase nutritious food.

HIMMS 2017

Better Together

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There remain significant opportunities to address high cost, high need members and to make the program as efficient and effective as possible:

Implementation of regional health neighborhoods composed of

Person Centered Medical Home (PCMH) practices, specialties, and non-medical services and supports

Development of additional value-based payment strategies, with a focus on pharmacy purchasing

Acceleration of efforts to serve people who need long-term services and supports in the community, as opposed to in institutional settings

Summary

Questions?

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Past Present Future

Administrative/ financial model

A mix of risk-based managed care contracts and central oversight

Self-insured, managed fee-for service model; contracts with four Administrative Services Organizations (ASOs)

Self-insured, managed fee-for-service model that incorporates health neighborhoods and Value-Based Payment (VBP) approaches

Financial trends Double digit year-over-year increases were typical

Overall expenditures are increasing proportionate to enrollment; per member per month spending is trending down

Quality-premised VBP strategies will enable further progress on trends

Data Limited encounter data from managed care organizations

Fully integrated set of claims data; program employs data analytics to risk stratify and to make policy decisions

Data match across human services and corrections data sets will enable more intelligent policy making


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Past Present Future

Member experience

Members had different experiences depending on which MCO oversaw their services; MCOs relied upon traditional chronic disease management strategies

ASOs provide streamlined, statewide access points and Intensive Care Management; PCMH practices enable coordination of primary and specialty care; health homes enable integration of medical, behavioral health and social services

Health neighborhoods will address both health needs and social determinants of health (e.g. housing stability)

Provider experience

Provider experience varied across MCOs; payment was often slow or incomplete

ASOs provide uniform, statewide utilization management and ICM; providers can bill on a bi-weekly basis

Consideration of migration to health neighborhood self-management of provider relationships


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Documents

Connecticut Medicaid and the Future of Population Health...Connecticut Medicaid and the Future of Population Health 1 Dr. Robert Zavoski, MD, MPH Medical Director, Department of Social