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AUGUST 2ND 2019
Placide Hiol
Quality Of Care Models in Medicaid ACOs
AGENDA
ALTERNATIVE PAYMENT MODELS OVERVIEW
MEDICAID ACOs
§ Background
§ Value-Based Payment Structure
§ Quality Assessment
§ MassHealth Quality facts
§ Data Analytics Challenges
§ Data Analytics Examples
ALTERNATIVE PAYMENT MODELS OVERVIEW
An Alternative Payment Model (APM) is a different payment approach from typical fee-for-service and usually emphasizes high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a total population.
§ CMS Accountable Care Organizations (ACO)§ Medicaid Accountable Care Organizations (ACO)§ Bundled Payments§ Pay For Performance (P4P)§ Patient Centered Medical Homes
ACOsBackground
§ Accountable Care Organizations (ACOs) are groups of doctors, hospitals, or other health care providers, who organize to give coordinated high quality care to the patients they serve.
§ When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it may share in the savings it achieves.
Accountability is often achieved through three key activities:
§ Implementing a value-based payment structure;
§ Measuring quality improvement; and§ Collecting and analyzing data.
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MEDICAID ACO EXAMPLE: MASSACHUSETTSValue-Based Payment Structure
To establish a financial incentive for providers to deliver value instead of volume within the Medicaid ACO Program, the State of Massachusetts uses the following models:
§ Global Budget Model - Providers participating in an ACO partner with MassHealth and share in savings and losses on their enrolled population based on a total cost of care budget.
§ Capitated Model - ACOs partner with MCOs and receive a capitated per-patient payment to provide services and accept full financial risk for the health of their patient population.
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MEDICAID ACOsQuality Structure
§ Quality metrics are used to track whether ACOs improve patient outcomes and to ensure that providers are not withholding health services to retain savings.
§ States with APMs typically require ACOs to measure health outcomes, report process metrics that focus on service delivery, and record patient experience metrics to determine an ACO’s quality performance.
§ These measurements are compared to quality benchmarks, which could be based on either the ACO’s prior performance, the performance of other ACOs, or statewide averages of other health care providers’ performance.
§ Quality metrics can be tied to payment, and providers typically will not receive a portion of shared savings or other quality payments if they do not meet or exceed their quality benchmarks.
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MEDICAID ACO EXAMPLE: MASSACHUSETTSQuality Structure
• Medicaid ACOs are accountable for 39 quality measures grouped in 7 domains• Prevention & Wellness• Chronic Diseases Management• Behavioral Health / Substance use• Long-Term Services supports (LTSS)• Avoidable Utilization• Integration of services• Member care experience
• MassHealth assesses quality for both achievement and improvement• All quality measures are tied to payments• Of the 39 measures 19 are clinical quality measurements reported directly by the ACO
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CHALLENGES IN MEASURING QUALITY
• ACOs encounter three major data challenges in measuring quality:• There are too many quality metrics and ACOs do not have the adequate analytics
resources to monitor each of them on a regular basis• Measuring patient level services and utilization: An ACO should know the level of
service each patients is using and the cost to provide more accurate quality metrics• Tracking individual physician data: Facility-level data does not give ACOs actionable
information. Provider level data allows an ACO to monitor in real time provider performance
• ACOs need interactive data tools and visualization in order to keep track of quality measures at the patient and provider level.
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QUALITY DATA ANALYTICS: OVERVIEW
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Emergency Department (ED)(1)
§ Non-emergent: visits that did not require immediate medical care within a 12-hour window
§ Emergent — primary care treatable: visits that required care within a 12-hour window that could be effectively treated within a primary care setting
§ Emergent — preventable/avoidable: visits that could have been prevented through appropriate primary care management (e.g., medication adherence for diabetes)
§ Not preventable: visits that required emergency care which could not be prevented
QUALITY DATA ANALYTICS: EXAMPLES
(1) Not Required by Masshealth as a Quality Metric
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Preference Sensitive Procedures (PSP) (1)
Preference Sensitive Procedures (PSP) are inpatient or outpatient procedures that could have been managed outside of the facility
QUALITY DATA ANALYTICS: EXAMPLES
(1) Not Required by Masshealth as a Quality Metric
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Ambulatory Care Sensitive Admissions (ACSA)
§ ACSA are based on Prevention Quality Indicators (PQIs)
§ The PQIs are area-level indicators that enable tracking of potentially preventable hospitalizations, including diabetes, in a community or region. The PQIs are a key tool for community health needs assessments.
QUALITY DATA ANALYTICS: EXAMPLES
