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An Overview of The New Jersey Medicaid Accountable Care Organization Business Planning

Toolkit

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An Overview of Th N J M di id A bl CThe New Jersey Medicaid Accountable Care 

Organization Business Planning Toolkit Rob Houston, MBA, MPP - CHCS

Tricia McGinnis, MPH, MPP - CHCSBruce Dees Applied Health StrategiesBruce Dees - Applied Health Strategies

Derek DeLia, PhD - Rutgers Center for State Health Policy

July 12, 2013

www.chcs.org

July 12, 2013

How to Ask Questions During the Webinar

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Agenda

• ACO Toolkit Overview• The New Jersey Medicaid

ACO DemonstrationACO Demonstration Project

• ACO Demonstration• ACO Demonstration Project Nuts and BoltsTh T l• The Tools

• Q & A

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The New Jersey Medicaid Accountable Care Organization Business Planning Toolkitg g

• A primer designed to accelerate ACO planning effortsp g

• Funded by the Nicholson Foundation

• Authored by CHCS, Applied Health y , ppStrategies, and Rutgers Center for State Health Policy

• Tools:► Readiness Assessment► Business Plan Template► Business Plan Template► Sample Work Plan

• Download at chcs.org

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How to use the ACO Toolkit

• Sections:► The Concept Level► The Essential Level► The Advanced Level

• Can be read “vertically” or “hori ontally”“horizontally”

• All levels correspond to the Readiness Review Tool inReadiness Review Tool in the Appendix

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The New Jersey Medicaid ACO Demonstration ProjectDemonstration Project

• NJ P.L. 2011, Chapter 114 enacted August 18, 2011► Allows the formation of Accountable Care Organizations to serve Medicaid► Allows the formation of Accountable Care Organizations to serve Medicaid

beneficiaries in New Jersey through a three-year demonstration• Requirements:

► Form a New Jersey nonprofit corporation► Define a designated area that includes:

At least 5,000 Medicaid beneficiariesSupport of all general hospitals within the designated areaSupport of 75% of Primary Care Providers in the designated areaSupport of 75% of Primary Care Providers in the designated areaParticipation of at least four qualified behavioral health providers

► Establish a governing board and shared governance► Define a gain-sharing arrangement ► Define a quality plan► Define a community engagement process

• Draft regulations released on May 6, 2013• 60 day comment period ended July 8 2013• 60-day comment period ended July 8, 2013

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ACO Toolkit Nuts & Bolts

• Establishing a Leadership and Governance Structure

• Partnering with StakeholdersPartnering with Stakeholders• Performing Data Analysis and Building an IT

InfrastructureInfrastructure• Improving Care Delivery• Ensuring Quality Improvement

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Establishing a Leadership and Governance StructureStructure

• Legal Structure► Nonprofit Status► Bylaws

• The Board of Directors► Board Composition

V i O i► Voting Options

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The Governance Team

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Partnering with Stakeholders

An ACO must partner with health care, community, and other stakeholders in order to succeed

Health Care Stakeholders Community Organizations Other Stakeholders

• Hospitals• PCPs• Behavioral Health

• Community Service Organizations

• Faith-Based

• State and Local Public Health Resources

• Social ServicesProviders

• FQHCs and Clinics• Specialists

Organizations• Housing and Homeless

Services

• Government Officials• Community Residents

• MCOs • Food Pantries and Soup Kitchens

• Transport ServicesP ti t Ad t

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• Patient Advocates

The Stakeholder Partnership Process

IdentifyIdentifyHealth care, community, and other stakeholders with interests in the designated area

EngageStakeholders through discussions with ACO representatives,

h d dintegrating their interests in ACO structure and mission and envisioning a role for them in the ACO leadership

C ll bCollaborateWith stakeholders after the ACO launch to build an effective ACO structure that the community can embrace through formal and informal means

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through formal and informal means

Performing Data Analysis and Building an IT InfrastructureBuilding an IT Infrastructure

• Advice from the Camden Coalition of Health CareAdvice from the Camden Coalition of Health Care Providers: “Just get started”

• State and Federal Regulationsg► HIPAA► New Jersey regulations

• Types of Data► Patient-level data► Population-level data

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Types and Sources of Data

Types of Data Sources of DataTypes of Data Sources of Data

• Claims• Inpatient admissions /

• MCOs• Hospitalsp

discharge• Ambulatory• Immunization

p• Providers• NJ Medicaid• Public Health Departments• Immunization

• Pharmacy• Patient Experience

• Public Health Departments• Individuals

• Electronic Health Records

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Data Analysis Techniques

• Hotspotting

D t i i• Data mining

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IT Infrastructure and Personnel

• Three key questions for IT infrastructure► How do you access your data?► What kind of data are you receiving?► What kind of resources do you have to devote to data

analysis?

• Personnel► Director of Research and Evaluation► Director of Research and Evaluation► Data Analyst► Evaluation Manager

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Improving Care Delivery

• Identifying populations and patients► Referrals► Health risk assessments► Data mining► Data mining

• Promoting effective care coordination► Building a care team

• Building a care model and workflow► Stratification of patients► Stratification of patients► Patient engagement► Developing a care plan

bili i d d i i► Stabilizing and graduating patients

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Ensuring Quality Improvement

► 21 core quality measures in the areas of:

P ti d

► 6 “voluntary” quality measures

O ti dPrevention and effectiveness of care Acute care

One prevention and effectiveness of care measureFi h i ditiBehavioral health

Chronic conditionsResource and utilization

Five chronic conditions measures

► Additional quality Patient experience measures

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ACO Quality Requirements by Year

Year ACO Measurement RequirementYear ACO Measurement Requirement

1 Reporting only performance is not measured1 Reporting only, performance is not measured.

2Relative performance improvement must be shown for at least

2p p

two quality measures.

Relative performance improvement must be shown for at least five3

Relative performance improvement must be shown for at least five quality measures, and absolute improvement must be shown for at least two quality measures.

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Nuts & Bolts Q&A

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Answers to questions that cannot be addressed due to time constraints will be qshared after the webinar.

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The ToolsThe Tools

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SavingsMeasurement

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Issues in Savings Measurement

• Gainsharing presupposes existence of savings• Pre/post trend is not sufficient• Pre/post trend is not sufficient• Need to assess “the counterfactual”• Gold standard: Rigorous comparison groupGold standard: Rigorous comparison group

► Difficult/time-consuming

• Alternative: Comparison to statewide trend► Can be done with claims data► Precedent in Medicare & other shared savings► Precedent in Medicare & other shared savings

arrangements► Recommendations in CSHP report

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Framework for Statewide Trend Comparison

• Key quantities► Baseline & performance year per capita spending► Baseline & performance year per capita spending► Statewide trend in Medicaid spending growth► Benchmark spending = Baseline spending + statewide trend p g p g

factor

• Performance year spending < benchmark spending ==> savings are established

• Important issues► Risk adjustment► Random variation

I fl i dj► Inflation adjustments

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Savings Measurement Q&A

To submit a question please click the question mark i l t d i th t lb t th t ficon located in the toolbar at the top of your screen. Your questions will be viewable only to panelists.

Answers to questions that cannot be addressed due to time constraints will be qshared after the webinar.

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hThe Business Plan

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The Business Planning Process

• Forces managers to think through financial and operational matters unfamiliar to most providers

• Promotes the concept of Value-Based Purchasing of health care services► Movement away from volume

(payments for clinic visits)

d d h h f► And toward higher payments for measurably higher quality care and healthier peoplep p

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The Business Planning Process

• Reduces nebulous concepts into metrics that can be reasonably forecasted (e.g. lives, revenue, etc.)

• Allows the responsible management of limited resources, which is a key to sustainability

• Brings the question of “who is the customer?” front and center

• Drives the shift to population management thinking

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Population Management Thinking

• How can we manage the health of 30,000 l ?people?

• What is the Total Cost of Care (“TOC”)?

• What are member months and PMPMs?

• How do we forecast and measure our return o do e o ecast a d easu e ou etuon investment (“ROI”) in the Care Coordination Team?

• How much care coordination can we afford?

• What is extensibility?What is extensibility?

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Population Management Business Thinking

• What model of care coordination will we adopt?

• What is the “right” mix of professionals in the care coordination team(s)?

• Who and what providers of “care” are already in the community, and how do we engage them?

• What care coordination resources do those providers already have? Are there PCMHs?

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The People Connection

PP

SS

PFQHC ACG ACG PCP PCPPCP ?

SS

P

S

S

S

SS ACO

Clinicians

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S

Business Planning Q&A

To submit a question please click the question mark i l t d i th t lb t th t ficon located in the toolbar at the top of your screen. Your questions will be viewable only to panelists.

Answers to questions that cannot be addressed due to time constraints will be qshared after the webinar.

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hTheWork Plan

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Sample Work Plan

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Work Plan Q&A

To submit a question please click the question mark i l t d i th t lb t th t ficon located in the toolbar at the top of your screen. Your questions will be viewable only to panelists.

Answers to questions that cannot be addressed due to time constraints will be qshared after the webinar.

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C iCommunity Readiness Assessment

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Community Readiness Assessment

• 3 levels► Conceptual Level► Essential Level► Advanced Level

• It is recommended that ACOs achievethat ACOs achieve the “Essential Level” for all questionsfor all questions before participating in the demonstration

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Community Readiness Assessment Q&A

To submit a question please click the question mark i l t d i th t lb t th t ficon located in the toolbar at the top of your screen. Your questions will be viewable only to panelists.

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General Q&A

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Answers to questions that cannot be addressed due to time constraints will be qshared after the webinar.

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Wrap Up

Download The New Jersey Medicaid Accountable CareMedicaid Accountable Care

Organization Business Planning Toolkit:

htt // h / bli ti 3http://www.chcs.org/publications3960/publications_show.htm?doc_

id=1261530#.UcHbMZEmF1M

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