Next Generation Integrated Care Funding Models 3/17/2017 Dale Jarvis, CPA - PowerPoint Presentation

Next Generation Integrated Care Funding Models3/17/2017 Dale Jarvis, CPA dale@djconsult.net Lynnea E. Lindsey, PhD, MSCP HealthThink💭

Healthcare Reform’s Achilles Heel… We are doing a good job cooking up new service delivery models.We are NOT changing the payment models fast enough to sustain the new delivery models.Note: Payment Model is MORE THAN how the payor pays the provider!2

Lifecycle of a Typical Integrated Care Project Hurray, we got a grant to start an integrated pilot! But the grant lasts for only 2 years and we don’t think we can generate billings to cover the cost… That’s okay. Let’s get the program started and we’ll figure it out. We have 2 years. Time passes…. 2 years are up, and nothing has been done to build the business case to sustain the program. 3

There’s A Better Way: Our Agenda Work from a Theory of ChangeFocus on the Sustainability Triangle4 While tackling barriers that arise

5 Theory of Change

Theory of Change 6

Executive leaders:Address barriers to team hiring & team formationDevelop collaborative cross system relationships 7

Including:Care Team RolesKey Performance MetricsQI Methods & Tools (e.g. Patient Registry) Core Competencies (e.g. outreach skills, patient self-management, measurement-based care)8

A Patient Registry is Critical To determine what’s working for whom and what’s notAnd identify care plan changes on an ongoing basis9

Identify high cost, high risk patientsPredictive modeling tools such as the Hopkins ACG toolFollowed by chart review to identify best “candidates” 10

Adjusted Clinical Groups Tool The ACG Tool measures Morbidity BurdenACG UsesDisease PatternsAgeGenderAnd Groups people into one of six morbidity cohorts Adjusted Clinical Groups 11

Behavioral Health Clinicians added to Primary CarePrimary Care added to Behavioral HealthCare Managers and Data Analytics added to Both Calculate Additional Costs above and beyond Funding CapabilitiesUse Return on Investment Calculator to project savings12

Use of new processes and new tools and new team members ALWAYS requires “tuning” 13

Based on pre-arranged agreement with payors to share savingsRecycling that money into round 2, round 3, etc. Serving the next group of high need, high cost individuals 14

For Questions… 15

The Sustainability Tricycle Evidence-Based Clinical DesignsSustainable Financial ModelsData Tracking and Reporting Systems16

Where Seriously Behavioral Health Conditions are Treated Primary Care $Specialty Ambulatory (Secondary) Care $/$$Acute Hospitalization/ Emergency Department (Tertiary Care) $$$ 17 Never really looks like this! 👀

Clinical Models that Work 18 Collaboration*Co-location*Integration Deciding upon a clinical Model alone is not enough *There are no “Plug and Play” models Organizational alignment and Operational infrastructure adjustments required Financial cost and need for sustainability must be detailed Must know RISK of your population Policies/procedures and job descriptions must be clearly defined/revised Changing roles and scopes must be discussed and written down 3x rule

19 Local Determinants of Health Where to start?

Evidence-Based Clinical Designs Primary Care Medical Homes - Integrated Oregon Health Authority (OHA) – Patient Centered Primary Care Medical Home (PCPCH) National Committee for Quality Assurance (NCQA) Patient Centered Medical Home (PCMH) 20

Minimum Standards for Clinical Integration Integrated behavioral and physical health services are provided as part of routine care including licensed Behavioral and Physical Health Clinicians delivering an array of services onsite. Integrated BHC and PHC provide a broad array of comprehensive evidence-based behavioral and physical health services. Integrated BHCand PHC provides same-day open access behavioral and physical health services. Primary care and behavioral health clinicians and all staff utilize shared medical records and have a mechanism in place for collaborative care planning and co-management of patients. Primary care and behavioral health clinicians and all staff utilize shared physical space and both the PHC and the BHC(s) participate in practice activities such as team meetings, daily huddles, pre-visit planning, and quality improvement projects. Site utilizes a population-based approach to delivering and coordinating integrated behavioral and physical health services. The integrated team includes psychiatric consultative resources. - Adapted from Integration IBHAO and AHRQ Minimum Standards 21

Evidence-Based Clinical Designs Behavioral Health Medical Home – IntegratedBehavioral Health Home (OHA Learning Collaborative)Certified Community Behavioral Health Clinic (CCBHC)22

Sustainable Financial Models Key QuestionsWhat Additional Costs are required to support the intervention?Who is the Population that will be served, what is the Current Level of Expenditure for that group?Potentially Preventable CostsAll Other CostsWhat type of Return On Investment can we shoot for? What is the best Payment Model to support the intervention? Base Payment Layer Bonus/Shared Savings Layer 23

Step 1: Added Costs: OHA Has “Cool” Modeling Tools from the YCCO Project 24

Step 2: Current Level of Expenditures 25

Step 3: Public Domain ROI Calculator from Washington State 26

Step 4: Payment Models At-A-Glance Transformation Funding Layer = Seed Funding.Let’s dig into the other two layers.27

Step 4: Payment Model Layers Layer 1The Base Payment LayerOne Size Does Not Fit AllThere are 4 Base Payment Models Layer 3 The Bonus/Shared Savings Layer Married at the Hip with Key Performance Measures Needs to be a Substantial % of the Total Payment 28 http://azpaymentreform.weebly.com/

Data Tracking and Reporting SystemsHistorical Reliance on Claims-based Data and Health Plan Tracking Medical Home, Meaningful Use and other Reporting has shifted some data and tracking to provider/clinic based reportingCenters for Medicaid and Medicare as well as CCOs have rapidly moved to requiring structured data reporting from Electronic Health Records29

Measurement: More than Counting 30

Data and Metrics: Process to Outcomes 31

For Questions… 32

Contemplating Barriers Potential BarriersLimited knowledgeable workforce: clinical & operationalLack of accountability structure: “Are you following through on your promises?”Technology limitations and cost of developmentInsufficient seed money for design and startupFragmented models/metrics reporting across multi-payer system 33

Small Group Discussion Instructions:Stay where you are.Introduce yourselves.Identify a Scribe and a Reporter for your group.Be prepared to report out your most exciting discovery and turn in your notes.Dig into the questions to the right.Questions What important questions about Integrated Care Funding Models do you still have? What other Barriers are you running into as you attempt to sustain integrated care? 34

References/Resources 35Oregon Health Authority (OHA) – Patient Centered Primary Care Medical Home (PCPCH) Standard 3C3: Integrated Behavioral Health Alliance of Oregon (IBHAO) of CCO Oregon www.ccooregon.org Benefits of NCQA Patient-Centered Medical Home Recognition www.ncqa.org/Portals/0/Programs/Recognition/PCMH/NCQA1005-1016_PCMH%20Evidence_Web.pdf Certified Community Behavioral Health Clinic (CCBHC) www.oregon.gov/oha/bhp/Pages/Community-BH-Clinics.aspx OHA Analytics Behavioral Health Measures Library http://www.oregon.gov/oha/analytics/MetricsDocs/Behavioral-Health-Measures-Library.pdf IBHAO Recommended Measures: Primary Care Behavioral Health Integration-November 2016 http://www.ccooregon.org/media/uploads/IBHAORecommendedMeasuresFinal.pdf