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  • Wellness Trust Funds for Accountable Care Communities
  • Develop Impact Equation (total savings = target population x engagement rate x savings/person/year)
  • ROI Accountable Care Communities goes back to the Trust

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  • Public health to join Accountable Care Organizations (ACOs) and bill insurance carriers for services (e.g., community health workers).

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  • Start-up 1-2 years for Designated Prevention Services Centers to come from foundations or SIM funds, and thereafter from billing to Primary Care Providers.
  • Anticipates legislation to establish the Health Enhancement Communities with a permanent Health Enhancement Community reserve fund. A portion of savings accrued in the Health Enhancement Communities will be returned to the Fund. Also, tax credits and other benefits to providers, etc. to invest in Health Enhancement Communities.

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  • No mention of long-term sustainability.

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  • No discussion of financing population health, just financing reforms to medical care – moving from fee-for-service to shared savings with quality incentives.

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  • Plan proposes to engage health economists to estimate monetary value of Hub interventions and ensuing return on investment. Then they will attempt to structure a sustainable funding model, taking into account the value of public health efforts to all community stakeholders, including employers. The idea is for regional wellness trusts to be funded by investments by regional stakeholders. (pg. 24).
  • Also, the Alliance is exploring social impact bonds for public health application.

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  • Multi-payer Accountable Care Organization (ACO); Value-based payment reforms using the Wellmark Value Index Score (VIS) as the main framework and then building out to add behavioral health, and long-term care services and supports measures. (pgs. 10-11,15, 114, 134). Accountable Care Organizations (ACOs) will be responsible for the total cost of care but will receive financial incentives (bonus to providers for enrollees receiving prevention/assessment services and rewards to providers). (pg. 12)

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  • Funding for the “Community Health Hubs” (CHHs) will be on a “pay and/or play basis: "Play": payer enrolls their superutilizers into the full Community Integrated Medical Home (CIMH) model.
  • “Pay and Play”: payer chooses to enroll in a partial set of CHH services; for example, just non-medical supports but not care coordination, if that is already provided in the Patient Centered Medical Home (PCMH).
  • “Pay”: Payer chooses to continue to offer its own services.
  • All fees for community interventions will be paid out of SIM grant funds in first 3 years. “Pending a positive ROI, payers will pay for services in year 4 and beyond.” (pg. 60)
  • Payers choosing not to play will be evaluated based on established benchmarks. At the end of year 2, if their performance does not meet the benchmark, they must participate in year 3 and beyond with their own funds.
  • CHHs will be paid on a severity-adjusted capitated basis and will bill fee for service (FFS) to those payers who are purchasing only limited services.

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  • Payment Reform: test models on a pay-for-performance continuum including shared savings, global payments, and partial capitation. (pgs. 96-107)
  • Community Health Innovation Regions must secure financial support from local public and private funding sources. (pg. 107)

New Hampshire:
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  • Spending will be projected for this population along with a projected savings amount. If saving's goal is met, the incentive pool savings will be distributed to payers, providers, and reinvested to further enhance the systems, such as Health Information Technology (HIT). (pg. 5) Four Step Approach - access, empowerment, payment reform, and incentives. (pg. 28)

New York:
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  • Couple the "Advanced Primary Care" (APC) model with innovative, tiered payments that cover cost of registries, care coordination, and care management; a variety of gain-sharing incentives for better managing care and costs and up front funding to help support technical assistance for practice transformation.
  • Harmonize with 1115 waiver and DSRIP program.
  • Value-based payment models (also focused on targeted populations).
  • Pg. 96 – Establish a flexible framework for value-based payment for APC – 1. Pay for performance; 2. Shared Savings; 3. Risk Sharing; 4. Care Coordination PMPM Payments.
  • Delivery System Reinvestment (pg. 166) and Program Investments. (pg. 167)
  • Net Savings – generate nearly $17B in gross value creation over five years. (pg. 168)

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  • Launching two models statewide – patient centered medical home and episode-based payments.
  • Value-based payment system.
  • Goal is to reach 50% of population in selected markets within 3 years and 80-90% of Ohio’s population.
  • Ohio plans to make a sizeable investment to launch and support both PCMH and episode-based payment models. Investments include the infrastructure required for payment innovation, as well as provider incentive dollars and funds for provider support as they shift care delivery to succeed under new models. (Pgs. 50-51)
  • Combined, the state is estimating projected costs to range from $35–75 million, depending on the path forward for implementation.
  • Expected cost savings will be reinvested in the model in the form of incentives for providers delivering cost-efficient, high quality, and well-coordinated treatment.

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  • Focus on two priority payment models – Accountable Provider Organizations (APOs) and Patient-Centered Medical Homes (PCMHs) with a specific focus on providing intensive care management services to high-risk consumers, and a third pilot – Episodes of Care (EOCs).
  • PCMH core competencies. (pg. 44)
  • APO core competencies. (pg. 48)
  • Descriptions of models with linkages and strategies. (pg. 69)
  • EOCs – HealthChoices managed care organzations (MOCs) implement EOC models with their APOs as a means to align payer-APO-provider incentives. More details on pg. 77.
  • APOs - Larger organizations that have already developed PCMHs and which possess other necessary infrastructure will develop APOs and will be able to realize greater financial rewards by assuming downside risk.
  • An APO is an organized group of providers which contracts with a commercial insurer, CHIP or Medicaid managed care organization, or with a plan administrator for self-funded employers on a population-based payment basis and thereby assumes responsibility for the cost, health and health care of a defined group of patients. “APO” differs from the ACO term used by CMS since Pennsylvania stakeholders envision a more flexible concept whose design and execution will not be in lock-step with the Medicare Shared Savings or Pioneer ACO Programs. (pg. 70)
  • PCMHs (pgs. 74-76)
  • Net savings to Medicaid are estimated at $13 million in the first year and $185 million in the fifth year. Some of the savings will likely be returned to providers as part of planned risk-sharing arrangements.
  • Cost savings plan (pg. 212)

Rhode Island:
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  • Goal is for 80% of Rhode Islanders to have access to care that functions in value-based payments such as Pay for Performance, Bundled Payments, & Shared Savings, Patient-Centered Medical Homes & Population-Based payment (global payment that must include behavioral health and ideally oral health in models).
  • Value-based care continuum (pg. 57)
  • Use regulatory and purchasing powers to set payment standards.
  • Total cost of care reductions (versus the trend) of over $1.25B over a five year period – primary driver of this will be increased care management that effectively reducse preventable utilization and improves health.

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  • 3 strategies to payment & delivery reform:
    1. Expansion and alignment of patient-centered medical homes & other population-based models to reward health care providers who care for their patients on an ongoing basis, promote prevention, treat chronic conditions, and coordinate care over time.
    2. Episode-based payment that rewards providers for delivering high quality and efficient care for an acute health care event.
    3. Payment and delivery system reform to address the specific needs of populations that require long term services and supports.

  • Patient Centered Medical Homes (PCMH):
    1. Major payers in Tennessee have agreed to “Population-Based Models Charter” committing to have 80% of members across books of business cared for through a population-based model within 5 years.
    2. The major payers in Tennessee have agreed to launch a multi-payer initiative in 1-2 metropolitan areas, characterized by investment into the same practices and a common approach to quality, provider enrollment and payment methodology. This initiative could be scaled statewide, if successful.
    3. The state will lead by example by increasing enrollment in PCMH models with their managed care organizations (MCO) and administrative services organizations (ASO) partners, and by developing common definitions and alignment of the PCMH approaches of the TennCare MCOs.
    4. The state will make targeted investments to accelerate PCMH adoption across all insurers in Tennessee. The state will determine the best manner to invest in infrastructure to support PCMH expansion, for example, through shared care coordination capacity or the development of uniform PCMH provider reporting.
  • Episodes of Care:
    • This approach seeks to reward high-quality care, promote the use of clinical pathways and evidence-based guidelines, encourage coordination, and reduce ineffective and/or inappropriate care. Episode-based payment is applicable for most procedures, hospitalizations, acute outpatient care (e.g., broken bones), behavioral health conditions (e.g., ADHD, depression, substance abuse treatment), and some forms of treatment for cancer.
    • The initiative has completed design and is on track for multi-payer implementation of a first wave of three episodes in Tennessee: perinatal care, total joint replacements, and acute asthma exacerbations. The initiative will begin reporting actionable information on the first wave of episodes to providers for commercial (including Benefits Administration members), TennCare, and CoverKids members in January 2014. Additional episodes will be designed and introduced thereafter; 75 episodes will be implemented in Tennessee over the next five years.

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  • Transition Away from Fee‐for‐service to Quality‐based Payment and adopt payment models that reward quality rather than volume of care (pg. 9 & 131)
  • "Health and Human Services Commission (HHSC) focus on ensuring an effective, comprehensive quality strategy within the managed care organization (MCO) contracting model e.g. STAR and STAR+PLUS (pg. 101)
  • Significant and meaningful investments in health IT technology, practice transformation, public health innovations and a wide variety of dissemination and collaboration activities (pg.191)
  • The Texas Health Services Authority (THSA) would convene a Finance Task Force to encourage the support of all public and private payers charged with overseeing the planning for the first two HIE sustainability strategies, provider payments for HIE utilization and HIE connectivity payment programs (pg.144)

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  • Payment reform will directs reimbursement from a fee-for-service model to a fee-for-results environment. Training in Quality Improvement methods, leadership and culture change to support team-based care will use adult learning models across practice setting and types of staff. Approaches to provide technical assistance should integrate the Utah SIM Plan elements so they do not compete with each other for provider attention. A holistic program or at least close coordination across programs will allow providers to make the most progress and not become overwhelmed.
  • Utah Medicaid has worked with its managed care plans to develop Utah Medicaid Accountable Care Organizations (ACOs) that receive capitated payments for covering enrollees each month. Over the last year, Utah Medicaid has met with the ACOs and interested stakeholders to develop quality measures that will be included in the ACO contracts. We believe the process and measures from the Utah Medicaid ACO quality effort will help serve as a basis for work that will be done under the Plan.
  • The Plan will pursue an approach that will allow these existing VBP efforts to progress and then use research techniques to identify what features or factors the most successful plans have in common. In addition, the research approach may also be able to identify which features or factors work better in different environments. This process of allowing existing VBP efforts to progress is consistent with the Governor’s general philosophy that private innovations should be encouraged and that they are more likely to be successful than government-created solutions.

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  • One of three key strategies in the overall plan includes, Washington will move away from a largely fee-for-service reimbursement system to an outcomes-based payment system that delivers better health and better care at lower costs. Specifically, within five years, Washington aims to move 80 percent of its State-financed health care to outcomes based payment and work in tandem with other major purchasers to move at least 50 percent of the commercial market to outcomes-based payment. (pg. iii) See pg. 42 for more details.
  • Requiring all providers of State-financed health care to collect and report common measures, implement evidence-based guidelines, and enable use of patient-decision aids.
  • Implementing accountable care organization models, reference pricing, and tiered/narrowed networks for State-financed health care.
  • Aligning public and private purchasing expectations with flexible benefit design efforts.
  • Generating actionable commitments in support of a well-defined strategy that will align payment and delivery system transformation across multiple payers, purchasers, and providers.
  • Accountable Communities of Health also will help structure and oversee Medicaid purchasing. They will partner with the State to bring order and synergy to programs, initiatives, and activities based on unique regional and local characteristics.
  • Potential to generate more than $730 million in return on investment. Financial Analysis begins on pg. 67