Medicaid ACO Programs: Promising Results from Leading-Edge States

Medicaid ACO Programs: Promising Results from Leading-Edge States

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Description: Accountable care organization (ACOs) are designated entities held accountable for the financial and quality outcomes of a defined population. ACOs were developed to move the U.S. health care system toward the goals of the Triple Aim.

ACOs were first adopted in Medicare under the Affordable Care Act of 2010. First Medicaid ACO Program launched in 2011. ACOs have since become a leading payment and delivery reform model across all payers.

 
Author: Tricia McGinnis, Pamela Riley, Matthew Spaan, Chris DeMars, Alicia Cooper  | Visits: 232 | Page Views: 407
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Contents:
Advancing innovations in health care delivery for low-income Americans

Medicaid ACO Programs: Promising
Results from Leading-Edge States
January 17, 2017, 1:00 – 2:30 pm ET
For Audio Dial: 888-576-4390

Passcode: 187417
Made possible by The Commonwealth Fund

www.chcs.org | @CHCShealth

Questions?
To submit a question, please click the question mark icon
located in the toolbar at the top of your screen.
Answers to questions that cannot be addressed due to time constraints will be
shared after the webinar.

2

Agenda
I. Welcome and Introductions
II. Medicaid ACO Landscape
III. Medicaid ACOs: Results from Leading-Edge States


Minnesota’s Integrated Health Partnerships



Oregon’s Coordinated Care Organizations



Vermont’s Medicaid Shared Savings Program

IV. Question & Answer Session

3

Today’s Speakers
Tricia McGinnis,
Vice President, Programs,
Center for Health Care
Strategies

Chris DeMars, Director of
Systems Innovation,
Transformation Center,
Oregon Health Authority

Pamela Riley,
Assistant Vice President,
Delivery System Reform,
The Commonwealth Fund

Alicia Cooper, Health Care
Project Director,
Department of Vermont
Health Access

Matthew Spaan,
Manager, Care Delivery
and Payment Reform,
Minnesota Department of
Human Services

4

About the Center for Health Care
Strategies
A non-profit
policy center
dedicated to
improving
the health of
low-income
Americans

5

Advancing innovations in health care delivery for low-income Americans

Pamela Riley
Assistant Vice President
Delivery System Reform
commonwealthfund.org

6

www.chcs.org | @CHCShealth

Advancing innovations in health care delivery for low-income Americans

Medicaid ACO Landscape
Tricia McGinnis, Vice President, Programs
Center for Health Care Strategies

7

www.chcs.org | @CHCShealth

What is an Accountable Care Organization?
 Accountable care organization (ACOs) are
designated entities held accountable for the
financial and quality outcomes of a defined
population
 ACOs were developed to move the U.S. health
care system toward the goals of the Triple Aim
 ACOs were first adopted in Medicare under
the Affordable Care Act of 2010
 First Medicaid ACO Program launched in 2011
 ACOs have since become a leading payment
and delivery reform model across all payers
8

Improve
patient care
experience

Reduce per
capita costs

Improve
health of
populations

What is the Current ACO Market?
Rapid expansion
across payers
Over 25 million
covered lives

 Commercial: 17.2 million
 Medicare: 8.3 million
 Medicaid: 2.9 million

Widespread
penetration
9

 Over 800 ACOs in the
United States

 ACO service areas in all
50 states and the District
of Columbia

Federal Policies and Promising Results
Support Building Momentum for ACOs
 ACOs are a key vehicle in the industrywide shift from fee-for-service to valuebased purchasing

HHS Value-Based
Payment Goals

 Providers are increasingly likely to seek
opportunities to join “advanced”
alternative payment models (including
certain types of ACOs) under MACRA*

2016

 ACOs tend to show greater focus on
population health, wellness, and
disease prevention
 Many ACOs have shown cost
reductions and quality improvement

10

 30% of Medicare payments tied

to alternative payment models,
such as ACOs or bundled
payments (HHS met this goal)

2018
 50% of Medicare payments tied
to alternative payment models

*MACRA, the Medicare Access and CHIP Reauthorization Act of 2015, is bipartisan federal legislation signed into law on
April 16, 2015 that (among other things) establishes new ways to pay physicians caring for Medicare beneficiaries.
Source: Better Care. Smarter Spending. Healthier People: Improving Quality and Paying for What Works.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-03-03-2.html

What Does an ACO Look Like in Medicaid?
While there is no uniform definition of a Medicaid ACO,
key features are:





Value-based purchasing
Quality measurement
Data sharing and integration
On-the-ground care
management
• Provider and community
collaboration
• Social determinants of health

11

What Does an ACO Look Like in Medicaid?
Medicaid ACO models vary greatly, but we generally see
three models:
Provider-driven
 Provider establishes
collaborative
networks and
assumes
accountability for
cost of care

12

MCO-driven

Regional/Community
Partnership-driven

 MCOs retain
financial risk but
implement new
payment model and
partnerships with
providers

 Regional/community
organizations form
care teams with
providers and
receive payments

Current Medicaid ACO Landscape
ME
WA

VT

MT

ND

OR

WI

SD

ID
WY
CA

NY

MN

UT

CO

PA

IA

NE

NV

MI

KS

IN

WV VA

KY

MO

NC

TN
AZ

OK
NM

MS

TX
States with active
Medicaid ACO programs
States pursuing
Medicaid ACO programs

13

SC

AR
AL

MA
RI

OH
IL

NH

CT
NJ
DE
MD

GA

DC

LA
FL

Future of Medicaid ACOs
Version 1.0



Version 2.0

Fee-for-service payment models
(shared savings or P4P)

 Capitated or global payments

Physical health only

Behavioral health, LTSS, dental,
 pharmacy, social services

Medicaid only

 Multi-payer

Many quality measures

Fewer, more aligned quality
 measures

Payment tied to quality reporting /
performance on process measures

Payment tied to quality outcomes
 and care coordination metrics

14

The Medicaid ACO Learning Collaborative
 National initiative designed to help states plan and launch
Medicaid ACO programs
» Offer peer-to-peer learning and technical assistance
» Have helped 13 states develop/
design their ACO programs and
10 of those states launch ACOs

 Medicaid ACO Resource
Center
» Practical resource to help states
interested in designing a
Medicaid ACO program
» www.chcs.org/resource/
aco-resource-center/
15

Minnesota’s Medicaid ACOs:
Integrated Health Partnerships

MINNESOTA DEPARTMENT OF HUMAN SERVICES
J AN U ARY 2 0 1 7

The Context – Minnesota’s Medicaid Program
 1 million enrollees, approx. $11 billion annual expenditures (FY16)
 Families and Children and Adults without children: 800,000
 Medicaid and MinnesotaCare
 Seniors 65+ with MLTSS: 52,000 enrollees
 MSHO (voluntary-integrated with Medicare D-SNPs)
 MSC+ (mandatory default)
 People with Disabilities 18-65: 52,000 enrollees
 Special Needs Basic Care (opt out, does not include LTSS)
 Some plans are integrate D-SNPs
 Remaining 100,000 (approx.) enrollees are people with

disabilities opting out of managed care, other smaller populations, and
short-term FFS months
 IHP includes under 65, non-dual eligible in both Managed Care and FFS
17

Approach to MN Medicaid ACO development
• Integrated Health Partnership (IHPs) demonstration authorized
in 2010 by MN Statutes, 256B.0755
• Builds on a long history of reform in Minnesota
- Health Care Homes
- E-health Initiative
- Encounter Data Collection

- Standardized Quality Measures
- Community Care Teams
- Strong Collaborative Partnerships

• Define the “what” (better care, lower costs), rather then the
“how”
• Create a common framework of accountability for patient’s
total cost and quality of care, while ensuring flexibility
18

IHP Model Components
 Eligible recipients



Non-dual, under-65, across both FFS and all Medicaid MCO enrollees
Attributed using past encounters/claims

 Provider requirements




Voluntary contracts under model options “Virtual” (shared savings only) and
“Integrated” (negotiated gain/loss sharing) based on size and structure
Flexibility in governance structure and care models

 Payment and quality model



Defined core set of services, IHP may elect to include additional services
Existing payments persist with gain-/loss-sharing payments made annually
based on risk-adjusted TCOC performance, contingent on quality performance
(SQRMS)

 Provider supports



Data analytics and reporting feedback (monthly and quarterly files)
Learning collaboratives
19

IHP Successes: Growth and Savings
Minnesota ACOs: Integrated Health Partnerships (IHPs)
 Currently 21 ACOs covering over 460,000 lives
 Goal: by 2018 to have 500,000 enrollees covered


No providers have dropped out of the demonstration – first two
rounds have renewed for additional 3-year cycles

 Results:
 Significant savings in first three years
 14 percent reduction in inpatient admission and 7 percent
reduction in ER visits
 IHPs are achieving quality goals of improvement or
meeting/beating statewide benchmarks; receiving 85%+ of
payments at risk for quality
20

IHP Successes: Growth and Savings
MN Integrated Health Partnerships Growth & Savings
500,000
Enrollees

462,698

Annual Savings

450,000

$80,000,000

$76,662,498
400,000

$90,000,000

375,924

$70,000,000

$65,339,161

350,000

$60,000,000

300,000
$50,000,000
250,000

204,119

$40,000,000

200,000

145,869

150,000
100,000

$30,000,000

99,107

$20,000,000

$14,825,352
$10,000,000

50,000
0

$2013

ACOs = 6

2014

ACOs = 9

2015

ACOs = 16

2016

ACOs = 19

2017

ACOs = 21

• IHPs are helping to bend the cost curve. In first three years of project, they achieved an
estimated savings of nearly $156 million compared to trended targets.
21

How’s it going?
Participation can accelerate care delivery innovations that had already begun, such as
movement towards team-based care, community partnerships, a “super-utilizer” focus, etc.
BUT… Long-term sustainability is an open question. Innovations can be costly, and
potential shared savings may be years away. Continued shared savings isn’t always possible.
Data and reports have been essential , providing a “source of truth” and a view of patients not
readily available elsewhere.
BUT… Data rich, but sometimes still information poor.
Variations in capacities across IHPs, not always able to use the data effectively.
Timing of data can make it’s use difficult

Flexibility of model is key - every population is different; everything is local.
BUT… Not all provider models fit well into the current demonstration.
Partnerships are critical to the success of the model longer term – pushing IHPs to reach out
to unaffiliated providers and community partners is important.
BUT… Partnerships tend to be informal in nature, and there isn’t a formal mechanism
to ensure partners are involved in the value arrangement and risk models.
22

What’s Next? - IHP 2.0 Key Design Elements
 Include a population-based flexible prospective payment.
 Support exchange of electronic clinical event notifications








between IHPs and providers.
Incorporate IHP contract incentives that strengthen
partnerships with community supports and social service
organizations.
Ensure a track for IHPs that are not able to take on risk, but
are still accountable for patient care
Develop an advanced track where higher capacity systems can
take on increased accountability for patient population health
outcomes.
Strengthen alignment with Health Care Homes (MN’s PCMH
model), MACRA, and other programs.
23

Health System Transformation
in Oregon
Chris DeMars, M.P.H.
Director of Systems Innovation
Transformation Center

Oregon’s health reform timeline
• 2011: Oregon Legislature passed a bi-partisan bill proposing a
statewide system of coordinated care organizations (CCOs)
– CCOs are networks of all types of health care providers
(physical health, addictions and mental health, and dental
care) who work together to serve Oregon Health Plan
(Medicaid) members through implementing the
Coordinated Care Model.
• 2012: State legislation created CCOs; CCOs launched;
Medicaid waiver approved

25

26

Oregon’s Coordinated Care Model within
Coordinated Care Organizations
Before CCOs
Fragmented care

With CCOs

Coordinated care:
physical/behavioral/oral health
Disconnected funding streams
One global budget with a fixed
with unsustainable rates of growth rate of growth
No incentives for improving health Metrics with incentives to
(payment for volume, not value)
improve quality and access
Health care services paid for
Flexible services beyond
traditional medical care may
be provided to improve health
Health care delivery disconnected Community health
from population health
assessments and
improvement plans
Limited community voice and
Local accountability and
local area partnerships
governance, including a
27
community advisory council

Transformation Center
• Launched in 2013 via State Innovation Model Grant
• Mission: The Transformation Center is the hub for innovation and
quality improvement for Oregon’s health system transformation
efforts to achieve better health, better care, and lower costs for all.
– The Transformation Center identifies, strategically supports, and
shares innovation at the system, community, and practice levels.
Through collaboration, we promote initiatives to advance the
coordinated care model.

• Broad range of support: value-based payment, CCO incentive
metrics, behavioral health integration, community health, and the
Patient-Centered Primary Care Home program.
– 100+ learning collaborative meetings/large convenings
– 270+ episodes of technical assistance to CCOs

29

CCO Performance
OHA Accountability & CCO Incentives
State Performance Measures
• Annual assessment of statewide
performance on 33 measures.
• Financial penalties to the state if
quality goals are not achieved.
CCO Incentive Measures
• Annual assessment of CCO
performance on 17 measures.
• Quality pool paid to CCOs for
performance.
• Compare current performance
against prior baseline year.
HEALTH POLICY AND ANALYTICS DIVISION
Transformation Center
30

Better outcomes, lower costs

2012
HEALTH POLICY AND ANALYTICS DIVISION
Transformation Center
31

Better outcomes, lower costs

HEALTH POLICY AND ANALYTICS DIVISION
Transformation Center
32

Better outcomes, lower costs

HEALTH POLICY AND ANALYTICS DIVISION
Transformation Center
33

Savings to the state resulting from CCOs
Results:
•Oregon’s innovations have held down costs to 3.4 percent
growth in the past five years.
•Health transformation has avoided costs of $1.3 billion
since 2013 and is projected to save a total of
$10.5 billion by 2022.
•Oregon’s growth is below the 4.5%- 5.5% national average for
Medicaid increase.
•Oregon will hold cost growth to 3.4 percent
through 2020.
HEALTH POLICY AND ANALYTICS DIVISION
Transformation Center
34

Lessons Learned
• Importance of leadership
– from the top
– from health system, community members, Medicaid members

• Incorporate financial incentives
– Incentive measures drive behavior change

• Allow for flexibility & experimentation
• Foster culture of innovation
– Incorporate relationship-building and improvement science

• Build on work already happening
– E.g., Patient-centered Primary Care Homes, which preceded CCOs, are
a foundational element of Oregon’s health reform efforts
HEALTH POLICY AND ANALYTICS DIVISION
Transformation Center
35

Vermont Medicaid:
Evolving ACO-Based Health Care Reform

Alicia Cooper, MPH, PhD
Department of Vermont Health Access
January 17, 2017

2014-2016: The Vermont Medicaid
Shared Savings Program
37

State Innovation Model Testing Grant
 2013: VT Awarded $45 million SIM Testing Grant from
CMMI
 Vermont Health Care Innovation Project

 Design, Implement, and Evaluate alternative multi-payer
payment models in support of the Triple Aim
 2014: Launched commercial and Medicaid Shared
Savings Programs (SSPs)
 DVHA administers the Vermont Medicaid Shared Savings
Program (VMSSP)
 Three year program (2014-2016)

38

Shared Savings Programs in Vermont
 Shared Savings Program standards in Vermont were
developed as a result of collaboration among payers,
providers, and stakeholders, facilitated by the State
 Designed ACO SSP standards that include:






Attribution of Patients
Establishment of Expenditure Targets
Distribution of Savings
Impact of Performance Measures on Savings Distribution
Governance

39

Attribution Eligibility
 Eligible members:
 General Adult
 General Child
 Aged, Blind or Disabled Adults and Children

 Excluded members:





Individuals dually eligible for Medicare and Medicaid
Individuals with coverage through commercial insurers
Individuals with third party liability coverage
Individuals who are enrolled in Medicaid but receive a limited
benefits package

40

Beneficiary Attribution to an ACO SSP

People see their Primary Care
Provider (PCP) as they usually
do

If their PCP belongs
to an ACO, the ACO
can share savings
based on the cost
and quality of
services provided to
that person

ACO

Providers bill as they
usually do

41

Services for which ACOs are Accountable
 Examples of services
included:
 Inpatient hospital services
 Outpatient hospital
services
 Physician services
 Nurse practitioner services
 FQHC
 Home Health Services
 Hospice

 Examples of services
excluded:





Pharmacy
Nursing facility care
Dental services
Non-emergency
transportation
 Services delivered through
Designated Agencies and
other Departments within
the Agency of Human
Services

42

VMSSP Expenditure Targets

Projected Expenditures
Actual Expenditures
Shared Savings

Payer

Quality
Targets

Accountable
Care
Organizations

43

VMSSP 2014-2015 Results
Participating
ACO

2014
PMPM

2015
PMPM

2014
PMPM
Difference
from
Target

2015
PMPM
Difference
from
Target

2014
Aggregate
Savings

2015
Aggregate
Savings

2014
Quality
Score

CHAC

$189.83

OneCare
Vermont

$165.66

2015
Quality
Score

$182.06

$24.85

$7.03

$7.8M

$2.4M

46%

57%

$171.55

$14.93

($2.18)

$6.8M

($1.3M)

63%

73%

 Two year net aggregate savings of $15.7M
 Two-year improvement in quality scores
 ~79,000 Medicaid members impacted

44

2017 Onward: Medicaid NextGeneration ACO Model
45

A Medicaid Next Generation Model
 ACO will be paid a prospective all-inclusive, population
based payment for the array of services provided
 Program is based on Medicare’s Next Generation ACO
model but has Vermont- and Medicaid-specific
modifications
 Builds on the current Vermont Medicaid Shared Savings
Program
 The goal of this partnership is to improve the quality and
value of the care provided to the citizens served by the
State of Vermont’s public health care programs

46

Advancing innovations in health care delivery for low-income Americans

Question &
Answer

47

www.chcs.org | @CHCShealth

Questions?
To submit a question, please click the question mark icon
located in the toolbar at the top of your screen.
Answers to questions that cannot be addressed due to time constraints will be
shared after the webinar.

48

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49