45
2018 Budget Presentation to the Green Mountain Care Board July 13, 2017 OneCareVermont OneCareVT.org
2018 Budget Presentation to the Green Mountain Care Board
July 13, 2017
OneCareVermont
OneCareVT.org
Table of Contents
1. OneCare Overview
2. Budget Overview
3. Improving Population Health Outcomes
4. Changing Care Delivery
5. Supporting High Quality Care
6. Supporting Primary Care
7. Patient Experience of Care
OneCareVT.org 2
OneCare Overview
OneCareVT.org
OneCare Vermont
• Founded in 2012 O Pioneered concept of representational governance by provider type
o Offered shared savings if earned as a equal split between primary care and hospitals/other
providers
• Multi-Payer O In year 5 of MSSP (Medicare Shared Savings Program)
o In year 4 of XSSP (Commercial Exchange Shared Savings Program)
o In year 4 of Medicaid programs (first year of Vermont Medicaid Next Generation after 3
years in Vermont Medicaid Shared Savings Program )
o Current total attribution of approximately 100,000 lives
• Statewide Network O Hospitals of all types (tertiary/academic, community acute, critical access, psychiatric)
o FQHCs
o Independent physician practices
o Skilled Nursing Facilities
o Home Health
o Designated Agencies for Mental Health and Substance Abuse
o Other providers OneCareVT.org 4
Board of Managers
Seat Individual
Community Hospital - PPS (Prospective Payment System)
Community Hospital — Critical Access Hospital
Jill Berry-Bowen - CEO Northwestern Vermont Health Care
Claudio Fort - CEO North Country Hospital
FQHC
Kevin Kelley - CEO CHS Lamoille Valley
FQHC
Pam Parsons- Executive Director Northern Tier Center for Health
Independent Physician
Lorne Babb, MD - Independent Physician
Independent Physician
Skilled Nursing Facility
Home Health
Toby Sad kin, MD - Independent Physician
Judy Morton - Executive Director Genesis Mountain View Ctr.
Judy Petersen - CEO VNA of Chittenden/Grande Isle Counties
Mental Health
Mary Moulton - CEO Washington Country Mental Health
Consumer (Medicaid) Angela Allard
Consumer (Medicare)
Betsy Davis - Retired Home Health Executive
Consumer (Commercial) John Sayles - CEO Vermont Foodbank
Dartmouth-Hitchcock Health
Steve LeBlanc - Executive Vice President
Dartmouth-Hitchcock Health Kevin Stone - Project Specialist for Accountable Care
Joe Perras, MD — CEO Mt. Ascutney Dartmouth-Hitchcock Health
UVM Health Network
UVM Health Network
UVM Health Network
Steve Leffler, MD - Chief Population Health Officer
Todd Keating - Chief Financial Officer
John Brumsted, MD - Chief Executive Officer
OneCareVT.org 5
OneCare Vermont Highlights 4\Widkit,
147/11z.V R1110
• Highlights o Nationally prominent size and network model since inception
o Proposed and structured the idea of multi-payer aligned Shared Savings ACOs in Vermont
o First ACO in Vermont to contract with full continuum of care
o Proposed idea of stronger, more structured community collaboratives; received multi-year State Innovation Model grant funds and partnered with Blue print and other ACOs to implement
o Led vision and business plan for embracing risk and supporting Vermont All Payer Model
o One of 25 ACOs nationally approved in first application cycle for the Medicare Next Generation Program
o Designed and negotiated Vermont Medicaid Next Generation with DVHA with many advanced elements
o Constructive participation in every major initiative/collaborative affecting healthcare in Vermont
o Very strong quality improvement track record and reduced variation on total cost of care and utilization
o Advanced informatics already in place and in deployment to the field
• Setting Course for 2018 o Medicare Next Generation refreshed application
o Active negotiations with BCBSVT on risk-based Commercial ACO Program for 2018
o Process for renewing for Year 2 of VMNG with DVHA
o 2018 GMCB Budget
• Includes risk-based program targets, payment models, reform investments, ACO operational budget, and risk management approach
• Will include strong primary care and community-based provider support
OneCareVT.org 6
:•TTZ
IMM
vi
Bud
get
Ove
rvie
w
2018 Budget Accomplishes Much "Check Offs" in 2018 OneCare Budget
✓ All Payer Model
• Big step toward vision and scale of Vermont APM
✓ Hospital Payment Reform
• Prospective population payment model for Medicaid, Medicare, and Commercial
✓ Primary Care Support/Reform
• Broad based programs for all primary care (Independent, FQHC, Hospital-Operated)
• More advanced pilot reform program offered for independent practices
✓ Community-Based Services Support/Reform
• Inclusion of Home Health, DAs for Mental Health and Substance Abuse, and Area Agencies on Aging in
complex care coordination program
✓ Continuity of Medicare Blueprint Funds (Former Medicare Investments under
MAPCP — Multi-Payer Advanced Primary Care Program)
• Continued CHT, SASH, PCP payments included for full state
✓ Significant Movement Toward True Population Health Management
• RiseVT (a major feature/partner in OneCare's Quadrant 1 approach)
• Disease and "Rising Risk" Management (Quadrant 2)
• Complex Care Coordination Program (Quadrants 3 and 4)
• Advanced informatics to measure and enable model
• Rewarding quality
OneCareVT.org 8
Risk Management
approach
L, Payer ACO Operational
Support/Other Expenses
ACO Revenues ACO Payment
Reform and PHM*
Investments
Constructing the "Risk" ACO Budget
Key Point: Network Participation Changes Prior to 2018 Could Ripple Significantly Through the Plan
Providers in
Network
Payer Programs
Attribution
Projections
Program Target Trends/Forecast
Cascading and Highly Interrelated
Model
Full Revenues
and Expenses Model
*PHM = Population Health Management
OneCareVT.org 9
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'North Troy -Derby Une
'Mention
Prleans
Prand Isle
.South Hero •Faiff" \talon
Glans
Wilford. .Syranton .Enosburg Fans
•Shekkin
Barnet
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• Essex /unction .Stowe .ibedisicktr'd°"14:Lyndon Jericho Mornsvake•Wolcce
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Newbury
Falriee
nes
Middlebury. .East Midclebury
Hancock. .Shoreham
• Sr ander,
Dartmouth-Hitchcock
Pcaset Vanctlege
Manchester. Cent"' Samons Freer.
Jarnake Westmbster. •firl.gten
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way., Ascuiney
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•... University4Vermont MEDICAL CENTER
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Nesvlane. Putney Nest Cin.v.r
•Norton Fdls
:island Pond
2018 Risk Network Communities
Hospitals with Employed Attributing Physicians
pirrva Significant Attribution from Community Physicians
- Seven Vermont Communities
Bennington
- Berlin
Brattleboro
- Burlington
Middlebury
- St. Albans
- Springfield
- Plus Lebanon, New Hampshire
for BCBSVT program
- Local hospital participation in
all communities (required)
- Participation of other providers
in each Vermont community
OneCareVT.org
2018 Risk Network as of Budget Submission
Bennington Berlin Brattleboro Burlington Lebanon Middlebury St. Albans Springfield
Hospital SWVMC CVMC BMH UVMMC DH PMC NWMC SH
FQHC Declined Declined N/A CHCB N/A N/A NOTCH SMCS
Independent 6 Practices 1 Practice 2 Practices 14 Practices N/A 2 Practices 4 Practices NA
PCP Practices
Independent 5 Practices 4 practices 1 Practices 21 Practices N/A 5 Practices 4 Practices NA
Specialist
Practices
Home Health VNA & Hospice Central VT Bayada VNA N/A Addison Franklin N/A
of the Home Chittenden/ County Horne County Home
Southwest Health & Grand Isle; Health & Health &
Region; Bayada Hospice Bayada Hospice Hospice
SNF 2 SNFs 4 SNFs 3 SNFs 3 SNFs N/A 1 SNF 2 SNFs 1 SNF
DA United Washington NA Howard N/A Counseling Northwestern Health Care
Counseling County Center Service of Counseling & and
Service of Mental Addison Support Rehabilitation
Bennington Health County Services Services of
County Southeastern
Vermont
All other 2 other 1 other 1 (Brattleboro 2 other N/A NA NA 1 other
Providers providers provider Retreat) providers provider
(ft of TINs)
Note: AAAs contracted members of network but do not do traditional medical billing and therefore are not formally submitted TINs in our risk network
OneCareVT.org 11
OCV 2018 Program Summary
Payer
Program
Risk Model
Medicare • Modified Next Generation Medicare ACO Program under APM (MMNG)
• 100% or 80% Risk Sharing Percentage (Our Choice)
5% to 15% Corridor (Our Choice)
Budget assumes minimum model risk on
TCOC which is 4% (= 5% * 80%)
Medicaid • Vermont Medicaid Next Generation ACO • For 2017: 100% Risk Sharing Percentage
Program (VMNG) Year 2 Renewal on 3% Corridor
• Budget assumes continuity of that
model at 3% on TCOC
Commercial • Move Exchange Shared Saving Program • In discussion for 50% Risk Sharing
Exchan (XSSP) to 2-sided Risk with BCBSVT Percentage on a 6% Corridor
ge • Budget will apply that draft model for
total maximum risk of 3% on TCOC (= 6%
* 50%)
Glossary:
• Risk Sharing Percentage = Percentage of savings or losses
received by ACO within Corridor
• Corridor = Maximum Range of ACO Savings and Losses (Payer
covers performance outside of Corridor)
• TCOC = Total Cost of Care
OneCareVT.org
12
Network Attribution Model
Service Area ANIL
Medicare Medicaid BCBSVT TOTAL
Bennington 6,244 5,748 3,720 15,712
Berlin 6,077 6,790 5,310 18,177
Brattleboro 2,345 3,895 1,869 8,109
Burlington 17,306 24,053 17,290 58,649
Lebanon 0 0 2,703 2,703
Middlebury 3,637 4,261 3,382 11,280
Springfield 2,430 5,112 2,624 10,166
St. Albans 4,575 4,733 3,042 12,350
42,614 54,592 39,940 137,146
OneCareVT.org
Budgeting 2018 Program Targets
Trended from 2017 to 2018 based on:
OneCareVT.org 14
2018 Projected
OCV Population
Combined Target
$764.4M
Target Budget Methodology Modeled Target Calculation
$411.9M $170.7M $125.9M
Trended from 2016 to 2017 based on:
2014-2016 OCV
Actual Trend
adjusted with
Actuarial
Guidance
BCBSVT 2017 QHP
Rate Filing
Medical Trend
adjusted with
Actuarial
Guidance
2.0% 4.5%
OCV Medicare
2015 to 2016
Actual Trend
adjusted with
Actuarial
Guidance
BC1351/T 2016 Base Actual
BCBSVT Spend
MEDICARE 2016 Base Actual
Medicare Spend
MEDICAID 2016 Base Actual
Medicaid Spend
BCBSVT 2018 QHP , Rate Filing Medical
Trend adjusted with
Actuarial Guidance
if 2.0%
APM Medicare
One-Time "Floor"
of 3.5%
2014-2016 OCV
Actual Trend adjusted with
Actuarial Guidance
Medicare
Adjustment for
Blue Print Funds
Risk Management Model • Participating Hospitals to Bear the Risk under OneCare ACO Programs
o Current OneCare model has service area's "Home Hospital" (the one physically located in the
community) bearing the risk for the spending target for its locally-attributed population
o Other providers NOT at risk (e.g. FQHCs, Independent practices, other community providers)
• Budget Assumes "zero-sum" Performance on Risk Programs at ACO level o i.e. OneCare exactly meets targets on all programs
o Some programs have "up front" discounts applied where applicable
o Risk hospital payments are source of some "off the top" investments and operational expense
coverage; hospitals will need to generate savings to do well under fixed payments received
0 OneCare Risk Management Support o Risk declines (diversifies) with participation in multiple programs across Medicare, Medicaid, and
Commercial populations
o OneCare provides analysis and formal actuarial review to ensure program targets are understood and
acceptable
o OneCare to provide reinsurance program to limit risk from very high utilization year overall and/or much
larger number of very high cost cases
o WorkbenchOne analytic tools to (i) identify areas of opportunity and (ii) understand risk performance
throughout the year
o Community support and facilitation of clinical and quality models associated with high value,
prevention, and avoidance of waste
OneCareVT.org 15
2018 Operations Budget Summary Category Sub-Category Budgeted
Expense Percent of Operations
Budget
Personnel Finance and Accounting $840,144 6.7%
ACO Program Strategy $465,640, 3.7%
Clinical/Quality/Care Management
$2,560,416 20.5%
Informatics/Analytics $1,332,012 10.7%
Operations $1,149,066 9.2%
SUB-TOTAL PERSONNEL $6,347,277 50.8%
General Administrative Health Catalyst (Core Information System)
$1,084,680 8.7%
VITL Data Gateway $900,000 7.2%
Other $1,586,312 12.7%
Contracted Services Reinsurance $1,500,000 12.0%
Other Contracted Services $1,074,465 8.6%
TOTAL EXPENSES $12,492,735 100.0%
PHM/Payment Reform Program Investments
Program
Basic OCV PMPM for Attributing Providers
Complex Care Coordination Program
$
$
2018 Investment
5,348,694
7,580,109
Supporting Primary Care and
Community-Focused
Elements of PHM Approach RiseVT Program $ 1,200,000
CHT Funding Risk Communities $ 1,746,360
CHT Funding Non-Risk Communities $ 772,538
SASH Funding Risk Communities $ 2,417,942 Supporting Blueprint for Health
Continuity and Ongoing SASH Funding Non-Risk Communities $ 852,012
Collaboration with ACO Model
PCP Payments Risk Communities $ 1,319,336
PCP Payments Non-Risk Communities $ 654,313
Value-Based Incentive Fund $ 5,559,260 Rewarding High Quality
PCP Comprehensive Payment Reform Pilot $ 1,800,000 Supporting True Innovation in
Independent PCP Practices
Total $ 29,250,563
OneCareVT.org 17
ACO Payer Targets Revenues $764,430,113
2018 Budget Revenues and Expenses 4110
Payer-Provided Program Support $9,658,176
$1,200,000
$3,500,000
$371,851
$779,160,140
$289,626,898
$447,789,945
Rise VT Transformation Support
State HIT Support
Grants and MSO Revenues
TOTAL REVENUES
Expenses
Health Services Spending (Payer Paid FFS)
Health Services Spending (OneCare Paid Fixed/Capitated Payments)
Operational Expenses
$12,492,734
Population Health Management/Payment $29,250,563 Reform Programs
TOTAL EXPENSES
$779,160,140
NET INCOME $0
OneCareVT.org 18
Improving Population Health Outcomes
On eCa reVT.org
• . OP.
14-14aiapieposo4Piss
16% Lives
40% Spending
89% Multiple Chronic
67% MH Condition
Population Based Health Care Approach
44% of the population
> 40% of the population
> Focus: Maintain health through preventive care and community-based wellness activities
> Focus: Optimize health and self-management of
chronic disease
> Examples: • Rise VT primary prevention program • PCMH panel management • Wellness campaigns (e.g. 3-40-50, health
education and resources, wellness
Category 1:
classes, parenting education)
Healthy/Well
• Home visiting programs
unpredictable
(includes
unavoidable events)
LOW RISK
6% of the population
> Focus: Address complex medical & socia
challenges by clarifying goals of care, developing action plans, & prioritizing tasks ‘, Acute Catastrophic
Complex/High Cost Category 4:
Category 2: Early Onset/
Stable Chronic Illness
> Examples: • HTN Peer-to-Peer Learning Collaborative
• 01 Change Packages • CHT resources (e.g. tobacco cessation, , nutrition & physical activity coaching, diabete " :elf management
• r;atient resource library in Care Navigator (in .00,gress)
MED RISK
10% of the population
Category 3: Full Onset Chronic
Illness & Rising Risk'
> Focus: Active skill-building for chronic
condition management; identify & address co-occurring SDoH
VERY HIGH RISK HIGH RISK
voos cbo social deter,.o,N.
IN
> Examples: • Complex care coordination: lead care
coordinator, shared care plans, care conferences
• Community 01 projects on hospice utilization • Provider and patient education on palliative
care (e.g. September OCV Grand Rounds)
> Examples: • Embedded mental health in primary care • SDoH screening (e.g. food insecurity in/out
patient peds; VT Self Sufficiency Outcomes
Matrix for patients with complex CC needs)
• Care coordination: coordinate among care
team members; shared care plans;
Budget Check
OneCareVT.org
0V•6•••••
000 l..4001.0•••••••
.0•••••0
00••
10•••••••
20
Sample Activities Supporting Vermont APM Population Health Goals fins
• Percent of Adults with Usual Primary Care Provider
o Promote primary care connection for VMNG patients attributed to specialists
o Improve viability of primary care through payment reform
• Deaths Related to Suicide/Deaths Related to Drug Overdose
o Embedding mental health services in primary care
o Provider education & training: SBIRT, suicide prevention, new VPMS opiate prescribing requirements & clinical workflows
o Expand data sources to refine risk stratification to inform community-based care
coordination
• Statewide Prevalence of Chronic Disease: COPD, HTN, DM
o Disease-specific panel management through Care Navigator
o Conduct Quality Improvement (QI) Learning Collaborative on Controlling HTN
o Develop 01 initiatives on pre-HTN and pre-DM
o Community Collaboratives promote local primary prevention (e.g. RiseVT, 3-4-50,
VT Quit Line) Glossary:
Budget Check • •
VMNG = Vermont Medicaid Next Generation SBIRT = Screening, Brief Intervention, and Referral to Treatment (screening tool)
• VPMS = Vermont Prescription Monitoring System nr.** 1.41.10
• COPD = Chronic Obstructive Pulmonary Disease
• HTN = Hypertension (High Blood Pressure) .401/
I 11•11.
• DM = Diabetes Mellitus (Diabetes) 4.1.1
I
?VW.
--......
---..
OneCareVT.org 21
Budget Check
22
Social Determinants of Health
• Complex Care Coordination o Shared Care Plans
o Camden Cards
o VT Self Sufficiency Outcomes Matrix
o Plans to add SDoH to risk adjustment
• Primary Care
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o Increased screening (e.g. ACES, food insecurity, parental depression)
o Improved coordination of referrals and warm-handoffs to continuum of care
and social service providers
• Accountable Communities for Health
•
•
SS.
3 Category 4: > Focus: Address complex medical & social 4,?
, Complex/High Cost challenges by clarifying goals of care, s, Acute Catastrophic
developing action plans, & prioritizing tasks '
LOW RISK
VERY HIGH RISK
6% of the population
A.
8 10% of the population
Category 3: Focus: Active skill-building for chronic Full Onset Chronic
Illness & Rising Risk/ occurring social needs
HIGH RISK
condition management; address co-
(i.e. physical, mental, social needs) ‘, Category 2: 's, • Disease & self-management support* Early Onset/
Stable Chronic Illness
(i.e. education, referrals, reminders)
• Pregnancy education "A• di bl 4 unpre cta e
unavoidable events)
Category /: Healthy/Well
(includes
Care Coordination Model
(...> 40% of the population K44% of the population
D Focus: Maintain health through preventive care
and community-based wellness activities D Focus: Optimize health and self-management of
chronic disease
D. Key Activities: • PCMH panel management
• Preventive care (e.g. wellness exams,
immunizations, health screenings)
• Wellness campaigns (e.g. health
education and resources, wellness
classes, parenting education)
‘0.9sychosociaLcietemi .0th.
D Key Activities: Category 1 plus
• PCMH panel management: outreach (>2/yr)
for annual Comprehensive Health Assessment
MED RISK
> Key Activities: Category 3 plus
• Designate lead care coordinator (licensed)*
• Outreach & engagement in care coordination
(at least monthly)*
• Coordinate among care team members*
• Assess palliative & hospice care needs*
\,...
.,,,
• Facilitate regular care conferences *
> Key Activities: Category 2 plus
• Outreach & engagement in care
coordination (>4x/yr)*
• Create & maintain shared care plan*
• Coordinate among care team members*
• Emphasize safe & timely transitions of care
• SDoH management strategies*
atuesapieposolPs-
16% Lives
40% Spending
89% Multiple Chronic
67% MH Condition
OneCareVT.org
* Activities coordinated via Care Navigator software platform
23
^
Level 2:
PMPM for Team-Based Care Coordination (Top 16%)
Care Coordination Financial Model Summary Budget Check
011111••••1110111•1%
One time annual payment for intensive upfront work + adcrl PMPM for LCC Foci: • Lead Care Coordinator, designated by the
patient • Activate and engage patients in care
coordination • Lead development of patient-centered
shared care plan documented in Care Navigator
• Facilitate patient education & referrals • Monitor milestones, track tasks and
resolution identified goals & barriers • Coordinate communication among
team members • Plan care conferences
Mem.
gr., ......••••••
—
}'-..: ,............, ,....
WA* j. ••••••••••••••..•
Payment for panel management Foci: • Assess patient-specific needs &
deploy organizational resources to support patient goals
• Contribute to patient-centered shared care plans
• Participate in care team meetings, care conferences, and transitional care planning
Level 1: Community Capacity Payment One time annual payment per community. Foci: community-specific workflows; workforce readiness &
capacity development; analysis of community care coordination metrics, gap analysis and remediation
OneCareVT.org 24
Care Coordination Engagement Metrics
Care Navigator Trained Users
Patients with an Initial Lead Care
Coordinator Identified
350
300
250
500 +, 200
400 u 150
300 100
50 200
0 100
Dec Jan Feb Mar Apr May June July
0
Shared Care Plans Created, 2017 Jan Feb Mar Apr May June July
35
30 As of July 1, 2017:
• 599 patients > 1 care team member
• Range: 1-8 care team members 20
LI 15
10
5
0
Jan Feb Mar Apr May June July 0 neCa reVT.org 25
25
Clinical Priority Area-Related Projects
1. High Risk Patient Care Coordination • 33 projects across 11
HSAs 2. Episode of Care Variation
• 9 projects across 5
HSAs
3. Mental Health and Substance Use >. 40 projects across 12
HSAs 4. Chronic Disease
Management Optimization
31 projects across 12
HSAs 5. Prevention & Wellness
• 38 projects across 11
HSAs
26
Community Collaboratives: Showcasing Community Improvements in ACTION
Morrisville: • 30-day all-cause
readmission • Developmental screening
• COPD • Obesity • Hospice utilization
Newport:
Middlebury: • Decreasing opiate
prescriptions
• ED utilization
Rutland: • All cause readmission
• Tobacco cessation • CHF, COPD
Bennington: • CHF Admissions • ED utilization • All-cause readmission
• Care Coordination oneCareVT.org
St. Albans: • ED utilization
• Rise VT • 30-day all-cause
readmission • Developmental
screening
Burlington: • Hospice utilization
• ED utilization • Adolescent well child
visit rates
Berlin: • Adverse Childhood
Experiences
• SBIRT
• Hospice utilization • CHF
Windsor: • COPD
• Opioid use management
Brattleboro: • Hospice utilization • Decreasing post acute LOS
• Care coordination 40 MA 40 Mdes
OncCare Vermont Com muni Health Results
Decreasing Unplanned Transfers and 30 Day Readmission
Rates In Skilled Nursing Facilities
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Community Successes
OneCare Vermont Community Health Results
Reducing Re-Admissions with e Transitions of Care Program
at Rutland Regional Medical Center
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OncCarc Vermont Community Health Results
Implementing Evidence Based Developmental Screening Tools
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Spotlight on Southwestern Vermont Medval Center Initiative
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or• Ur*. ICCX.Sro.
SVMCs Outcomes
SVMC Decreased Rates of All Payer, Long Tenn Care 30 Day An Cause
All Cause 30 day Readmission and Readmission Rate 201S vs. 2016
Transfers to Hospital • enonived [COT emurnermeien free
YAW 65sHSVPAC OM hoes 5/1640216) IPA . meemeeel eed intereval polity of
denotentabon syntemeo donee el COM.. merewelsorroort inuning Pair
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monsoons mot mai Menges o • peones "Odom and non. •Cifirof *ay. e C411.0 11,.,R10.1 docrenod newtrwiwns to Me holrorrol from S.
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OneCareVT.org 27
Changing Care Delivery
OneCareVT.org
Medicare Next Generation Waivers
. Expanded patient benefits: o Access to skilled nursing facilities without a 3-day inpatient stay
requirement
o Access to two home health visits following hospital discharge
o Access to telehealth services not currently allowed by CMS
o Still accrues against ACO "risk" target but facilitates compliant service
delivery and revenue flow
. Future topics under consideration through Vermont
APM:
o "Virtual PACE program" — funding of adult day care for patients in
complex care coordination
o Home IV antibiotics
• Expansion to other payers
OneCareVT.org 29
Flexible Care Models
• "Virtual Visits" — store and forward enhancements to
electronic health record patient portals
• Telemedicine visits o Direct patient care
o Support of continuum of care community providers
Home Health agency
)> SASH
Designated Agencies
),=- Agency on Aging
• Pharmacist patient support and consultative services
• PCMH imbedded mental health services
• More Medication Assisted Treatment (MAT) in PCMH
• Population health compensation models
• RN performed Medicare Annual Wellness Visits
OneCareVT.org 30
A110
"The nurse spent a lot of time with me and was incredibly thorough, I will do this
again" Patient from Central Vermont
"I find the focused visits after the patient has had an AWV to be quite rewarding.
Patients are coming in to talk about specific questions related to their Advance
Directives or other issues found during their AWV, and we are able to devote the time to those things. Conversations are meaningful and less distracted by the
requirements of the AWV" - Clinician from Central Vermont
alp
Medicare Annual Wellness Visit
• Focuses on prevention, safety, and coordination of care
• Includes health risk assessments, measurements and screenings, and
personalized health advice and referrals
• OCV clinical priority area: aligns with 7 Medicare quality measures; OCV
performance <20% (2015); focus on primary or secondary prevention of chronic
disease
• Innovation:
o RNs perform Medicare AWV
o Developed & refined communication
o Staff Training
o Evaluated impact
• Outcomes:
o Increased patient satisfaction
o Increased provider & staff satisfaction
o Improved access to care
o Improved quality performance
o Improved revenue to practice
OneCareVT.org 31
Hospital SPeViCP Area econnsten Iterin Pattiebom Ourinpon Mokliebury Mmernie larapm fhtland 5rAlrohdd
Attributed TIN Alm Osernonn,992
Wrmate, Avery Wood terMetoro Memorial Florceal, Inc. Patlieboro Retreat Centrel Maw* Medical Certm Inc OAS Holes Am* Seam, P.C.
Omir.mtl c.o....,
Measure Reason Good Control WA:erect Date Mises Irfonnabon Cue to hems No Data Found No Data In Mearmentent Period tem-Numeric Remit Val* Non-Standard C.ocle in Maamernent Pen:d Poor Coned
Data Source OMMC one Woo No Data Aratatia &994 at EPIC VITI
Sending Facty .P Patient Name Attributed TIN
Ake Hyde Medal Certer Branielmo Meiroad tbsped Central Vermont MedcalCtriter, Sc. Champion Poky Physcians Hooped
^ ̂ • ^ .• • • N ^ • ^
Patient Name Patient 1 Pabent2 Patient3 Pober*4 PabereS Patent() 999e91 Patientli Pabent9 0.9,910
1 *
History
Prosider Name
HAKEY, DIANE JEAN BERGER, CLAUDIA UM*, SCOTT MERTZ, MICHELLE XTHIFER .19246, 6119 1
_ o Remilt Date Code Code Description ng Facility Result Sendi NI
Value Code 199941- IS 4548-4 141404.013IN A IC (A IC) 7.11UYH992Emc 1999-11.15 4549-4 III42.2/011INAIC (Al() 6.8 TIVAISCEIM 1999-11-15 45441.4 r429:4ov; AIC (MC) 7.1 LASISCEpc 199911.15 45404 HEMOGLOBIN AIC (AI() 7.21./MSKE9s 1999-11.17 4549-4 1.040a0eIN A IC (MC) 5.1 IIMINClps
Patent691
P.m./sky of Vermont Medical Center Ix. 908,91964
Lewersty of Vermont (Redo& Center Inc. 9a101*5871
Unversty 09 Varna* Medcal Condit Ito. PaheoteG34
Urprersity of Veromt Medea Center Inc. Pabent730
Wirer*, of Vermont Medal Center Inc.
Patients in Denorroinat or by Attribut ed TIN
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MtrIbuted TIN Provider Name Central Vermont Medcal Center, Inc ROBINSON, 1708ER Urreersty of Vermont Medcd Center— LURIA, SCOTT Nortnnestern Meded Center FITZGERALD, JOHN Wndsor Homed Corporaton WEBBER, CARRIE Central Vennont Moical Center, Inc BURGOME. R (p100,9 09 Vertert FINIcal Center... WAHEED, WAQAA brillAbCrOPIeniedaittosoRal. Inc. FULHAM. WAN /Scheel 1 Corson, FD PC CORRIGAN, MICHAEL Plorthwestern Medea' Certer FITZGERALD, 20re9 (Seventy of Vermont Heckel Center— Acces. ALICIA
Measure Reason Detail Data Reason Result Date Code
TO No Data Found Good Coded 1110/20164540-4
H. No Obta Found Non-Standard Code riMeasu... $/7/2016 tipb A10 CH
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CI Result Value Sending Fealty I
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10.71 Mirthwestern Medoff immersty of Vermont .
,
691
Workbench ne Analytics Platform Clinical data feeds from the VITL ACO Gateway enable:
• Population-level Dashboards
• Self-Service Analytic Applications
• Quality Measure Scorecards
• Standard Reports ILIEEMEEsm
gig
ACO 27 2016 - Diabetes Mellitus: Hemoglobin Al e Percereade at patents 18.75 sees at ape
dad,. 04,0 tad hemeleitm IMAM • 9.8.,cast +ecert Homo result is tours, or C Mere are no /MAI o tells Penomed and remit dootenertee Orris meestrernere
Organization AdreeldieklACO
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4,548 Fawner at or
3.325 Reverse Score Measure MOW Better)
OneCareVT.org 32
4 Eic ! ;
/ II: I al
2 4 it p I: 411 1, flii ill : aci tijg,71 h 11Glif h
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Post Speech Therapy Post SNF Swing Post SNF Non Swing Post Physical Therapy Post Outpatient Observation Post Office Visit Post Occupational Therapy Post LTAC Post Inpatient Rehab Post Inpatient Post Home Health Agency Post ED Post Cardiac Rehab Acute
Episodes of Care (Bundles) Analysis Care Standardization
- Acute hospitalization payments, physician billings, plus all post acute services for 90 days
• Large proportion of total cost of care
CMI and RUG risk adjusted data
• Mechanism to educate network concerning significant community variation in type and amount of services
o Hospital, skilled nursing, home health length of stay
— Post acute services "pathways"
o "SNF...ISTS" — onsite medical coverage in nursing homes — an important paradigm shift
• Promote patient engagement and setting post acute care expectations
OneCareVT.org 33
Hospital Readmission
t Emergency Room
Episode of Care (Bundle) Pathway
Hospital Discharge "Anchor Admission"
(90 day clock starts on day of discharge)
Acute Inpatient Rehabilitation -* (ex. age > 85, single knee le*
with BMI > 50)
Swing Bed 4-*
+ Skilled Nursing Facility 4E*
÷ Home with Home Health Services
Office Follow-up
Post—Acute Services Comprise 10%-60%
of the total 90-day episode expense Home with Outpatient
—1> Services
Supporting High Quality Care
OneCareVT.org
Quality Measurement,
Analysis, & Reporting
Clinical Priority Areas
Established
Community-wide and Facility-specific Quality Improvement Activities
Quality Improvement Strategies to Achieve the Triple Aim
• Timely and Accurate Data
o Identify gaps in care
o Drive decision-making
• Support Local Communities to Improve
o Aligned clinical priority areas
o Representation on clinical governance committees
o Blueprint/OCV aligned staffing & resources
• Resources, Training, and Tools
o A3 01 reporting processes
o All Field Team staff trainings
• Dissemination of Results
o Network Success Stories
o OneCare Grand Rounds, Topic Symposia, Conferences
o Facilitated sharing on clinical committees
OneCareVT.org 36
g
40 70 0
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Quality Measurement, Analysis, & Reporting
Appendix:
Raw Score Trends for Measures Included in all Performance Years (2013- 2016):
Medicare ACO 21, Stseenlog Ise High blood Prost. mod Follow.
Dossonweed AC013150e40Wu for FNMA
103 0362 117.13
SILK 64.41 7413 110 V.%
I - 4130 47.31
Medicare 2015 Quality Scores with Clinical and Claims Based Measures vs Risk Adjusted Total Cost of Care by HSA
•••
2011 2014 MIS 2017 11•0001407010 2021 2014 2012
awsonboonor KOS
ACO21:11,0004,0434n(137141:Ce4reling MO Wood Meow
0111 / 4119.0 1.••••• Irenrtalv Caltulatte CM 54424 434i 4%
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0.414 70.57 71.21 4011
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093031314 311 SI WAVY 162
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7014 1 won.. 7012 2015 Qs Swan vow
2005
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Medicare 2014 Quality Scores with Clinical and Claims Based Measures vs Risk Adjusted Total Cost of Care by HSA
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one%•C3 I V I .1JI 37
Value-Based Incentive Fund Distribution Method Approach:
Budget Check
••••••••••••
• Familiarize network with new measures • Recognize on-ramp for new practices in early years .11.
• Recognize the entire network in the transition to a value-based care delivery model • Move towards variable incentives that are aligned with measures
DISTRIBUTION OF FUNDS:
Measurement Year
Strategy
2017/18
Primary Care, 70%
2019+
• 70% to primary care based on attributed population
• 30% to rest of network based on % of total Medicaid spend in calendar year
• 70% variable to primary care based on practice-level performance on a standard measure set
• 30% variable to entire network based on HSA-level performance on a standard set of measures
OneCareVT.org 38
Support to Primary Care
OneCareVT.org
OCV Basic PHM
Payment $3.25 PMPM
High Risk
OCV Complex Care
Coordination $15-$25 PMPM
cow AGE WELL * H°wARD SAS
Unnrnaty4Vermont
)°- Value-Based Quality
Incentive (Annual Eligibility
for Attributed Lives)
Full Attributed Panel NOTE: PCP and OCV Collaborate with Full Continuum of Care
on Population Health
Workbench One (Performance Data and Analysis)
Supporting Data and Systems at No Charge
^
Bringing it Together: 2018 OneCare Primary Care Model
Attributed Population
Care Navigator (Population Health Management System)
NOTE: Base Revenue Model Remains as
usual FFS; Primary Care is Under
No Financial Risk
OCV Provides Blueprint Continuity for Medicare Practice Payments and
CHT Support Funds (plus SASH program)
Blueprint Payments/Programs Continue
Budget Check ••.•••••..*.*** VAG!
VERMONT BlueCross BlueShield AGENCY Of
or Vermont HUMws sources
OneCareVT.org
Independent PCP Comprehensive Payment
Reform Pilot //llio • Budget model includes a $1.8M supplemental investment to
develop a multi-payer blended capitation model for primary care services.
o Voluntary program offered to independent PCP practices with at least 500 attributed lives across all programs
o Would supplant and simplify model on previous page
o Designed to test sustainable model for independent practices <or> pilot offering to all primary care in future
years
• Operational model is monthly PMPM prospective payment to cover primary care services delivered to the attributed population by the practice.
• Enables innovation and more flexible care models
• Provides predictable and adequate financial resources for
the practice
• Exact model under development starting in August with eligible and interested practices.
Budget Check
14.14,41
OneCareVT.org 41
Reducing Practice Burdens
• Eliminating prior authorization of services in VMNG program
• Aligning quality measures (QM) across payer programs. For example, 2017
VMNG negotiations resulted in:
o Reduction in the number of QM
o Increase in the number of QM tied to claims, resulting in less interruption for
practices
o Alignment with Vermont APM measures
. ACO participation eliminates additional Medicare Incentive Payment
System (MIPS) reporting requirements
• Developing a set of clinical priority areas to drive focused QI activities
. OneCare and Blueprint leadership working in close alignment to identify
priorities and deploy shared resources
• Implementing current and future benefit waivers to improve access,
efficiency, effectiveness, and timeliness of care for patients
OneCareVT.org 42
Patient Experience of Care
On eCa reVT.org
Patient-Focused System of Health Vision: - Seamless, proactive, patient- and family-centered, community-based
care
Designed to help patients better engage in their own health care
Examples across PHM Model*: 9 yo boy with elevated BMI with access to new preferred walking route to school from his neighborhood and encouragement to do so by pediatrician and throughout community
42 yo woman with pre-diabetes referred to YMCA Diabetes Prevention Program (DPP) upon first elevated lab result
57 yo man with uncontrolled diabetes and ED visit for depression; care transition ambulatory follow up plan addressing transportation and insurance challenges
75 yo woman with multiple heart failure admissions with improved medication adherence and assignment of a lead care coordinator for further questions as a result of post-discharge home visit
*Population Health Management Model
OneCareVT.org 44
Summary
Making sure each person gets the care they need
in the right place at the right time
OneCareVT.org
