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Maryland Rural Health Association Meeting October 6, 2016 Alana Knudson, PhD Rebecca Oran, BA Exploring the Issues Impacting Alternative Payment Models for Maryland’s Rural Communities
Maryland Rural Health Association Meeting
October 6, 2016
Alana Knudson, PhD
Rebecca Oran, BA
Exploring the Issues Impacting Alternative Payment Models for Maryland’s Rural Communities
• Balanced Budget Act of 1997
• Established Critical Access Hospitals
– Have 25 or fewer acute care inpatient beds
– Located more than 35 miles from another hospital
– Maintain an annual average length of stay of 96 hours or less for
acute care patients
– Provide 24/7 emergency care services
• Medicare Rural Hospital Flexibility Program (Flex Program)
– Supports new and existing CAHs
– Provides payment and financial information
– Shares funding information (e.g., FORHP, HHS and USDA grant
opportunities)
• 1,332 certified Critical Access Hospitals (as of April 2016)
• Some regulatory and quality reporting expectations differ from
other hospitals
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Types of Payment Models for Rural Providers:
Cost-Based Reimbursement
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Type of Payment Models for Rural Providers
Accountable Care Organizations (ACO)
• ACOs are groups of physicians, hospitals, and other health care providers,
who come together voluntarily to give coordinated high quality care to their
Medicare patients.
• Goal: coordinated care ensures that patients, especially the chronically ill, get
the right care at the right time, while avoiding unnecessary duplication of
services and preventing medical errors.
• Success: deliver high-quality care efficiently which results in savings for the
Medicare program which are shared with the providers
• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ACO/index.html?redirect=/Aco
• Medicare offers several ACO programs:• Medicare Shared Savings Program—a program that helps a Medicare fee-for-service program
providers become an ACO. Apply Now.
• Advance Payment ACO Model—a supplementary incentive program for selected participants
in the Shared Savings Program.
• Pioneer ACO Model—a program designed for early adopters of coordinated care. No longer
accepting applications.
• Comprehensive Primary Care Plus (CPC+) Program • National advanced primary care medical home model
• Provides practices with a robust learning system
• Provides actionable patient-level cost and utilization data feedback, to
guide their decision making
• To support the delivery of comprehensive primary care, CPC+ includes
three payment elements:
– Care Management Fee (CMF)
– Performance-based incentive payment
– Payment under the Medicare Physician Fee Schedule
– Track 1 continues to bill and receive payment from Medicare FFS as usual
– Track 2 practices also continue to bill as usual, but the FFS payment will be
reduced to account for CMS shifting a portion of Medicare FFS payments into
Comprehensive Primary Care Payments (CPCP)
• https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus
• http://www.caravanhealth.com/category/comprehensive-primary-care-
plus/
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Type of Payment Models for Rural Providers:
Medicare Shared Savings Program for Rural Providers
Types of Payment Models for Rural Providers:
Maryland’s Total Patient Revenue and Global Budget
• All-payer Rate Setting
• Rates set by the Health Services Cost Review Commission
(HSCRC), an independent Commission with seven volunteer
commissioners appointed by the Governor
• Since 1977, sets rates for all payers, including Medicare and
Medicaid
• Total Patient Revenue
• Implemented in 2010 in 10 hospitals
• Available to hospitals without or limited overlapping service areas
• Provided strong incentives to treat its community of patients in
the most efficient and clinically effective manner
• HSCRC monitored hospital performance, such as
readmissions and ED visits
Source: Maryland Health Services Cost Review Commission
Common Elements of Value-Based Payment Models
• Goals to shift from volume to value-based payment models
• Better care – improved patient outcomes
• Improved community health
• Decreased health care costs
• Requires a robust data infrastructure
• Establish systems to support data and reporting
• Track financial and quality metrics
• Include inflation adjustments
• Promotes care coordination
• Creates a change in culture
• Necessitates enhanced communication
• Providers, staff, boards, patients, and community stakeholders
• Select a Care Coordination model that meets the unique needs of the
patients, the relationships and agreements between health care
providers, the health information technology infrastructure, and
community characteristics
• Develop partnerships across sectors to address the needs of the
“whole” person including health care, public health, social services,
and community-based organizations
• Include diverse disciplines, such as health care providers,
pharmacists, social workers, and behavioral health professionals on
the care coordination team
• Engage health care providers before implementation of the care
coordination program – buy-in from the health care team (including
the rural and the tertiary providers) is essential to the program’s
success
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Care Coordination Toolkit – Lessons Learned
• Provide education to patients and families about the care
coordination program’s goals and clearly define roles and
responsibilities
• Recruit the “right” person to serve as care coordinator
• Establish the evaluation metrics before the program is
implemented
• https://www.ruralhealthinfo.org/community-health/care-
coordination
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Care Coordination Toolkit – Lessons Learned
• Rural communities are implementing programs that
integrate health and human services to:
• Increase access to health care
• Link people to human services
• Promote collaborative and coordinated care
• Important for children and families living in poverty
• There is a need to identify and disseminate promising
practices and resources on services integration in rural
communities
• https://www.ruralhealthinfo.org/community-
health/services-integration
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Services Integration
• Senate Bill 707 Freestanding Medical Facilities-
Certificate of Need, Rates and Definition (SB 707)
• Established the Rural Health Care Delivery Workgroup
– oversees a study of healthcare delivery in the Middle Shore region
– develops a plan for meeting the health care needs of the five
counties -- Caroline, Dorchester, Kent, Queen Anne’s and Talbot
• Maryland Health Care Commission contracted with the University
of Maryland School of Public Health and the NORC Walsh Center
for Rural Health Analysis to provide the following support to
inform the Workgroup’s deliberations:
– Conduct data analysis
– Gather input from stakeholders
– Identify rural health care delivery and payment options
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Next Steps for Maryland’s Rural Health Providers
• Rural Health Information Hub
• https://www.ruralhealthinfo.org/
• Medicare Shared Saving Programs and Rural Providers
• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/sharedsavingsprogram/Downloads/ACO_Rural_Factshe
et_ICN907408.pdf
• Rural Health Value
• http://cph.uiowa.edu/ruralhealthvalue/
• Federal Office of Rural Health Policy
• http://www.hrsa.gov/ruralhealth/
• Maryland Health Care Commission
• http://mhcc.maryland.gov/mhcc/pages/home/workgroups/workgro
ups_rural_health.aspx
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Resources
Thank You!
Alana Knudson, PhD Rebecca Oran, BA
Email: [email protected] [email protected]
Phone: 301-634-9326 301-634-9375
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