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Presented by John Snow, Inc.October 23, 2014
OREGON SCHOOL-BASED HEALTH CENTERS
PAYMENT REFORM
INTRODUCTIONS
John Snow, Inc. (JSI)
JSI is a health care consulting and research organization dedicated to improving the health of individuals and communities, in particular underserved and vulnerable populations.
www.jsi.com
JSI RECENT PROJECTS
• RWJF – Safety-net ACOs• BSCF – Whole-person-centered care• California Primary Care Assoc/California
Association of Public Hospitals and Health Systems – FQHC payment reform
• AHRQ Medicaid Readmissions• California Association of School-based Health
Centers• Colorado Health Care, Policy and Financing• NACHC Payment Reform
OBJECTIVES
• Provide national context on payment reform• Reflect on: How should SBHCs be paid?• Provide overview of reform models
• FFS • Capitation• Supplemental PCHH• Performance-based
• Posit additional strategies for SBHCs to consider:• Braiding• Layering
• Discuss opportunities and challenges for SBHCs
Oregon is a national leader with its 1115 Waiver and CCO activityCollaboration in community needs assessments are in the vanguard nationally
WHY PAYMENT REFORM?
• Goal: Delivery system transformation to meet Triple Aim and Reduce Disparities
Better Healt
h
Improved Cost
per Capita
Reduced Health
Disparities
Better Care
Payment Reform
Delivery System
Transformation
Triple Aim
Better Health
Improved Cost per
Capita
Reduced
Health Disparities
Better Care
PAYMENT REFORM IS PROMOTING COLLABORATION
Patient-Centered Health Home
Patient-Centered Medical Home
Accountable Care Organization
Accountable Care Community
PAYMENT REFORM IS PROMOTING COLLABORATION
• But reform is not that neat….• Delivery system and payment reform are
mutually reinforcing PCHH
PCMH
ACO
ACC
Managed Care
2 KEY QUESTIONS TO ASK
1)How is a provider paid?2)How is a larger system paid?
Payment Strategies
Support More Robust Primary Care
Support Integration/Coordination across Settings
Moving toward Accountable Care
Grants • PCMH transformation grants
• Meaningful Use • Community Transformation Grants
Fee-for-service strategies • pay for traditionally
unfunded services • non-payment for
services• limit payment for
services
• New Medicare Transitional Care Management Codes
• Medicare Payment rates for PC Medicaid
• Non-payment for Medicare readmissions
• Reference Pricing
Episode-based payments
Hospital episode-based payments
Partial capitation (PMPM)
•PC Capitation•PCMH
•PCHH (care mgt and care coordination)
•Professional services capitation
Performance payments (withholds, P4P and shared savings)
•P4P based on quality •Value-based pay-for-performance
•Shared Savings in MSSP and various ACOs •Global Budgets
Global Capitation • Managed Care? • ACOs• Integrated
Delivery Systems
Blended funding streams
Duals demonstrations Accountable Care Communities
Foundation for change Increasing Coordination Transforming Care
R
isk-b
eari
ng a
rrang
em
ents
In
cen
tives
PAYMENT REFORM IN ONE PAGE
2 KEY QUESTIONS TO ASK
1)How is a school-based health provider paid?
2)How is a larger system paid?
A couple of Delivery System Transformations
to keep in mind
ACCOUNTABLE CARE ORGANIZATIONS
• Organizations that assume accountability for a defined patient population across a continuum of care with payment tied to quality and cost outcomes
• Shared savings designed as strategy to encourage cost saving and quality outcomes under global budget or global capitation
• A wide variety of entities are emerging as ACOs – Oregon’s CCOs
ACCOUNTABLE CARE COMMUNITIES
• ACOs may not be enough• Need to be better connected to the community• Need to connect to public health and prevention
• Collaboration across sectors to address social determinants
• Building on top of or incorporating ACOs, PCMH, Community Health Teams
• Political lever to engage whole community• Leadership coming from States, foundations and local
community
How should a school-based health
provider be paid?
KEY PAYMENT REFORMS
Key Payment strategies:1. FFS for traditionally non-funded services2. Capitation
• Primary Care (a provider)• Global capitation (a system)
3. PCMH and PCHH supplemental payment4. Value-based pay-for-performance (P4P)5. Braiding6. Innovative grant funding under ACA
#1: FFS STRATEGIES
• Execute contractual agreements for specific preventive services to be paid for traditionally unfunded services
• As risk-bearing entities assume responsibility for global costs of a population, SBHCs could propose being paid for: • asthma prevention/treatment• teen pregnancy prevention• diabetes prevention• behavioral health • oral health• access to care for high-risk populations
• Explore Opportunities to Expand FQHC Scope of Service to include SBHC services
#1: FFS STRATEGIES
Considerations:• Contracting FFS for previously unfunded services
requires a compelling return on investment case• Particularly relevant for non-assigned patients
(that a payer holds financial accountability for)• For Medicaid, could require policy change
(Medicaid funding for preventive services rendered by non-licensed providers)
• FQHC scope only relevant for Medicaid patients at FQHC SBHCs
#2: PRIMARY CARE CAPITATION
Financial Objective of PC Capitation in FQHC
Delivery System Transformation Objective
• Maintain comprehensive primary care in transition to new system
• Monthly payment per member
• Flexibility to deliver care in more cost-effective and patient-centered ways
• Some visits converted to new modes of care; use of care teams
#2: PRIMARY CARE CAPITATION
Considerations• Requires being PCP for assigned patient
population• Can be negotiated with multiple payers• Increasingly comes with accountability
#3: SUPPLEMENTAL PCMH/PCHH
• 29 Medicaid programs are making PCMH payments
• Based on services and/or recognition
• Payments tend to be relatively small ($2-10PMPM)
Map Source: NASHP
#3: SECTION 2703 - PCHH
• ACA Section 2703:• 90/10 Federal Match for 8
quarters• Medicaid and Dual eligibles
with chronic conditions and SMI
• PCHH services: • Comprehensive Care
Management• Care coordination and
health promotion• Comprehensive transitional
care • Individual and family
support• Referral to community and
social support services,• Use of HIT to link services
• Payments significant (avg. $50PMPM) Map Source: NASHP
#3: SUPPLEMENTAL PCHH
Considerations: • Often requires being PCP for assigned patient
population• Can be based on provider capabilities/recognition• Can be negotiated with multiple payers• Comes with accountability
#4: PAY FOR PERFORMANCE INCENTIVES
Community Outcome (reduced obesity
prevalence)
Systems- Wide
Outcome (inpatient days)
Primary Care Outcome
(reduced BMI)
Primary Care Process
(BMI assessment & plan)
• P4P is increasingly moving to Triple Aim P4P and shared savings
#4: PAY FOR PERFORMANCE INCENTIVES
Considerations: • Often requires being PCP for assigned patient
population• Can be associated with being part of an ACO• Can be negotiated with multiple payers• Requires accountability for processes and
outcomes • What could SBHCs help an ACO or RBE to
achieve? • HEDIS• Access• Avoidable admissions
#5: BRAIDING FUNDING
• Braiding funding• Use of multiple sources of funding while maintaining
individual funding stream obligations and reporting requirements
Relevant Examples:1. Braid education and health $
• Ex. Michigan used K-12 funds appropriated for SBHCs to leverage federal Medicaid matching funds to support SBHC outreach and education services
2. Braid hospital community benefit $ and health $3. Braid BH, Dental, health - CCOs
#6: GRANT FUNDING
• Hospital Community Benefit• Non-profit hospitals must invest a certain percentage of their
revenue in the community• Non-profit hospitals must conduct a community health needs
assessment and develop an implementation strategy every three years
• Accountable Communities for Health
• Considerations:• Could SBHCs collect data for needs assessements• Could SBHCs position themselves to be regular recipients of
Wellness Trust $ or CB $
NO SINGLE PAYMENT REFORM “SOLUTION”
• There is no one way• Depends on payers, state regulations, other transformations
LAYERING PAYMENT REFORMS STRATEGY
• Payment/Delivery System Models can be layered and phased as part of a Comprehensive Multi-Layer Strategy
CPCA COMPREHENSIVE PAYMENT REFORM STRATEGY
Payment Reform
OPPORTUNITIES
• SBHCs may be only access point for some patient populations (and families)
• Movement toward increased accountability of broader health system – what are leverage points?
• Regional CCOs with accountability for all Medicaid may be more interested in population health investment (teen pregnancy prevention)
• Addressing social determinants of health increasingly being recognized as part of the solution
• ACCs/grants – investment in kids is a political advantage• State Innovation Model?
KEY CHALLENGES
• SBHCs are a diverse group• Health systems are moving toward assigned
patient populations – are SBHCs the assigned PCP?
• Need access to total health system data and sophisticated analytics to make ROI case
• FQHC is an opportunity; becoming an FQHC is complex
• Policy change required for funding some preventive services
• Negotiating contracts with MCOs/RBEs may be a new skill
THINGS TO WATCH
Reimburse non-provider preventive services in Medicaid:• Medicaid agencies allowed to reimburse for preventive services
provided by professionals that may fall outside of a state's clinical licensure system
Primary Care Extension Program (authorized but not funded)• Focus on “preventive medicine, health promotion, chronic disease
management, mental and behavioral health services…in order to enable providers to incorporate such matters into their practice and to improve community health by working with community-based health connectors
Community Health Teams (authorized but not funded)• Program to establish health teams to “collaborate with local primary care
providers and existing State and community based resources”• Some states have implemented with other funds: VT, ME, MD
QUESTIONS
CONTACT
Rachel TobeyJohn Snow, Inc. (JSI)116 New Montgomery St. Suite 605San Francisco, CA [email protected]