HHSC Value-Based

Purchasing RoadmapTexas Policy Summit

Andy Vasquez, Deputy Associate Commissioner

MCS, Quality & Program Improvement Section

1October 19, 2017

HHSC Value-Based Purchasing Roadmap

Topics

• HHS Healthcare Quality Plan

• Value-Based Purchasing Roadmap• Key Concepts

• Quality Initiatives

• Summary

2

Sunset Commission Report

Sunset Advisory Committee staff report findings:

1. Need for better coordination and organization across major quality initiatives (HHS System Transformation)

2. Need to establish a cohesive vision for improving quality and value (HHS Healthcare Quality Plan)

3. Need to promote value-based incentives for providers working through Medicaid Managed Care Organizations (Value-Based Payment Roadmap)

3

Healthcare Quality Plan

Required by Sunset Law to meet the following

purposes:

• Include broad goals for improving healthcare value in Texas, prioritizing Medicaid and the Children's Health Insurance Program (CHIP)

• Lead to consistent approaches across major quality initiatives

• Facilitate the evaluation of quality initiatives' statewide impact

4

HHS Healthcare Quality Plan

Strategic Priorities

1. Keeping Texans healthy

2. Providing the right care in the right place at the right time

3. Keeping patients free from harm

4. Promoting effective practices for chronic disease

5. Supporting patients and families facing serious illness

6. Attracting and retaining high performing providers and other healthcare professionals

5

HHS Healthcare Quality Plan

Quality Improvement Tools

1. Contracting for Value

2. Aligning Payments with Value

3. Empowering Individuals

4. Simplifying Administrative Processes

5. Leveraging Business Intelligence

6. Increasing Health Information Technology and Exchange

7. Expanding Public Reporting

6

HHS Healthcare Quality Plan

Quality Improvement Tools

1. Contracting for Value

3. Empowering Individuals

4. Simplifying Administrative Processes

5. Leveraging Business Intelligence

6. Increasing Health Information Technology and Exchange

7. Expanding Public Reporting

7

VBP Roadmap

Key Concepts

8

Guiding Principles of VBP

1.Continuous engagement of stakeholders

2.Harmonize efforts

3.Administrative simplification

4.Data-driven decision making

5.Movement through the VBP continuum

6.Reward success

9

APM Continuum

10

APM Framework

Source: HCP-LAN.org, APM Framework 11

VBP/APM Keys to Success

• Clients/Consumers must always come first

• Accountability at all levels (patient to payer)

• Increase level of VBP readiness and willingness across MCOs and providers

• Build in administrative simplification and maintain it

• Patient Attribution – identifying which providers have primary responsibility for a patient’s health

• Align financial and clinical models between multiple payers, provider types, and populations

12

Challenges to Address

VBP Keys to Success

13

Alignment of Clinical & Financial Models

RHP DSRIP Hospital

and Other

Performing

ProvidersQuality Measures and

Initiatives

Medicaid and CHIP MCO

Quality Measures and

Initiatives (P4Q, MCO VBP, PIPs)

Medicaid Fee for Service Programs

Commercial

CarriersQuality Measures and

Initiatives

Medicare Quality Measures and Initiatives

(ACOs, Hospital Value Based

Purchasing, Hospital Readmissions Reduction Program, MACRA)

VBP/APM Keys to Success

• Rural providers and small practices

• Progress through the APM continuum

• Timely, comprehensive data and enhanced analytics

• Examine MCO rate setting for opportunities to support and sustain VBP/APM

• How to assess value of APMs and measure performance

• This is a complex and long term endeavor that is evolving in a dynamic state, federal, commercial environment – plan accordingly 14

Challenges to Address, continued

VBP Roadmap

Quality / VBP Initiatives

15

Core Value-Based Purchasing (VBP) Programs

• Managed Care Organization Pay for Quality

• Dental Maintenance Organization Pay for Quality

• Hospital Pay for Quality

• MCO payment reform (VBP) effort with providers

• Delivery System Reform Incentive Payment (DSRIP) Program

• Nursing Home Quality Incentive Payment Program (QIPP)

16

Medical Pay for Quality Program

• 3% of MCO capitation is placed at-risk, contingent on performance on targeted measures

• MCOs will earn or lose money based on three factors:

• Performance compared to Benchmarks

• Performance compared to Self (prior year)

• Bonus Pool (no risk)

• Medical P4Q program measures focus on:

• Prevention

• Chronic Disease Management, including Behavioral Health

• Maternal and Infant Health

17

UMCC: APM Requirements

New UMCC and UMCM Requirements:

• Minimum threshold:

• 25% Provider payments in APMs

• 10% Provider payments in Risk-Based APMs

• 4 Year Goals

• Exceptions for high quality

• Penalties for low performance

• Provider data sharing

• Measurement period begins January 1, 2018 (aligned with P4Q)

Source: HCP-LAN.org, APM Framework 18

DSRIP Overview

• The Delivery System Reform Incentive Payment (DSRIP) program is designed to provide incentive payments to hospitals, physician practices, community mental health centers and local health departments.

• These payments are an investment in delivery system reforms that: • increase access to health care

• improve the quality of care

• enhance the health of patients and families

• Originally approved as a five year waiver from December 2011 – September 2016

Page 19

Integrated Behavioral Healthcare in DSRIP• 90 DSRIP projects focus on integration of

behavioral healthcare (BH) with primary care (PC)• Most focus on individuals with complex BH needs

• Over 80 projects focus on individuals with co-occurring mental health and substance abuse

• Most common outcomes selected for integrated BH/PC projects

• Screening and treatment plan for clinical depression

• Controlling high blood pressure

• Depression remission at twelve months

• Also outcomes related to quality of life, patient satisfaction, diabetes HbA1c control, and reducing emergency department visits for BH/substance abuse

Page 20

Integrated Health Care Initiative (RHP 10)

• MHMR Tarrant County (MHMRTC), Fort Worth (RHP 10)

• Partnership with JPS Health Network to co-locate primary care and behavioral health services at MHMRTC’s homeless/crisis services center for individuals with severe mental, developmental, and addictions disorders who may also be homeless, and who are not otherwise able to access primary care services.

• Services • Wellness checkup exams, well woman checks, smoking cessation,

specialty referrals, medication reconciliation, community-based case management services, substance abuse treatment, counseling, peer support and group classes, community/field-based case management and rehabilitation services, RN care coordination

• Community outreach teams to refer individuals living in campsites or on the street into the integrated care initiative

Page 21

Integrated Health Care Initiative (cont.)• 559 individuals served in demonstration year 5

• Outcome measures• Controlling High Blood Pressure (HEDIS) and SF-36 Quality of Life

instrument

• 185 integrated care patients had a diagnosis of hypertension or a high blood pressure reading (>140/90) recorded in EPIC (EHR) between August 1, 2016 and January 31, 2017. Of those individuals 68% had at least one follow-up blood pressure reading between February 1 and March 31, 2017. Overall, 41% had controlled blood pressure (<140/90) at their most recent reading.

• Sustainability planning• Collaboration with managed care plans to develop innovative

contractual ventures

• Integration of primary care services into clinical locations system wide

Page 22

DSRIP Transformation to VBP

DSRIP Provider Sustainability Template

• Providers report what efforts they have taken to evaluate or move toward the sustainability of DSRIP project activities.

• HHSC learns of providers’ sustainability work to date, including any value-based purchasing (VBP) initiatives, and where there are gaps that HHSC may help facilitate provider sustainability

• HHSC seeks thorough and thoughtful responses to every question.

23

DY7 Category C Overview

1.Category C builds on pay-for-performance quality measures from Category 3 in DY2-DY6.

2.Hospitals and physician practices will select Measure Bundles from the Measure Bundle Menu.

a.Measure Bundles have both required and optional measures.

3.Hospitals and physician practices must select Measure Bundles worth enough points to meet the Minimum Point Threshold (MPT).

24

Measure Points

Each measure is assigned a point value based on the following criteria:

25

Points Description

3 Points Patient clinical measures for which improvement in the measure represents an improvement in patient health outcomes or utilization patterns. (Most measures that were standalone measures in DY2-6 will be 3-point measures in DY7-8)

2 Points Cancer screening measures and hospital safety and infection measures

1 Point Measures of clinical practice, immunization rates, and measures related to quality of life or functional assessment

0 Points Innovative measure that are pay-for-reporting (P4R)

Hospital & Physician Practice

Measure Bundle Base Point Value

• The base point value of a Measure Bundle is determined by adding the points for the required measures in the Measure Bundle.

• Some bundles are designated a “High State Priority” or a “State Priority” which results in an increase to the base point value.

• High State Priority are multiplied by 2.

• State Priority are multiplied by 1.5.

• State priority bundles align with HHSC Medicaid/CHIP quality strategies.

26

Hospital & Physician Practice

Measure Bundles (A1 – D4)

Bundle

ID

Hospital & Physician Practice Measure Bundles Base Points Possible

Addition-al

Points

Max

Possible

Points

A1Improved Chronic Disease Management: Diabetes Care

[State Priority (SP)]12 3 15

A2Improved Chronic Disease Management: Heart Disease

(SP) 12 3 15

B1Care Transitions & Hospital Readmissions

6 - 6

B2Patient Navigation & ED Diversion

4 3 7

C1 Primary Care Prevention - Healthy Texans (SP)9

- 9

C2Primary Care Prevention - Cancer Screening & Follow-

Up6 3 9

C3Hepatitis C

5 - 5

D1Pediatric Primary Care (SP)

12 1 13

D3Pediatric Hospital Safety

6 - 6

D4 Pediatric Chronic Disease Management: Asthma (SP) 11 3 14

27

Hospital & Physician Practice

Measure Bundles (E1 – J1)

Bundle

ID

Hospital & Physician Practice Measure Bundles Base Points Possible

Addition-al

Points

Max

Possible

Points

E1

Improved Maternal Care

[High State Priority (HSP)] 12 1 13

F1Improved Access to Adult Dental Care

6 - 6

F2Preventive Pediatric Dental

2 - 2

G1Palliative Care

6 - 6

H1Integration of Behavioral Health in a Primary Care

Setting (SP)8 - 8

H2 Behavioral Health and Appropriate Utilization (SP) 9 6 15

H3Chronic Non-Malignant Pain Management (HSP)

4 3 7

H4Integrated Care for People with Serious Mental Illness

(SP) 3 - 3

I1Specialty Care

2 - 2

J1Hospital Safety

8 - 8

28

DY7 BH Measure Bundle

H1: Integration of Behavioral Health in a Primary or Specialty Care Setting

• Objective: Implement depression, substance use disorder, and behavioral health screening and multi-modal treatment in a primary or non-psychiatric specialty care setting.

• H1 measure bundle is a State Priority

• Target Medicaid/CHIP & Low Income Uninsured Population: Individuals receiving primary care services or specialty care services

29

DY7 Bundle: Integration of Behavioral Health

ID Measure Steward NQF # Req’d Req’d

Measures

Points

H1-105 Preventive Care & Screening: Tobacco Use:

Screening & Cessation Intervention

(BAT recommendation to stratify as two rates, ages 18+

and 12 - 17)

NCQA 0028 N

H1-146 Screening for Clinical Depression and Follow-Up Plan

(CDF-AD)

(BAT recommendation to stratify as two rates, ages 18+

and 12 - 17 and to expand to screening for general

behavioral health concerns including anxiety)

CMS 0418 Y 1

H1-255 Follow-up Care for Children Prescribed ADHD

Medication (ADD)

NCQA 0108 N

H1-286 Depression Remission at Six Months

(BAT recommendation to stratify as two rates, ages 18+

and 12 - 17)

MN Community

Measurement

0711 Y 3

30

DY7 Bundle: Integration of Behavioral Health

ID Measure Steward NQF # Req’d Req’d

Measures

Points

H1-317 Preventive Care and Screening: Unhealthy Alcohol

Use: Screening & Brief Counseling

(BAT recommendation to stratify as two rates, ages 18+

and 12 - 17)

AMA-convened

Physician

Consortium for

Performance

Improvement

2152 Y 1

H1-T04 Innovative Measure: Engagement in Integrated

Behavioral Health

TBD N/A N

31

• Providers should:• Learn about alternative payment models

• Conduct a self-assessment from payer point-of-view

• Explore opportunities for collaboration

• “Market” directly to MCOs using all of the above

32

VBP Roadmap

What can providers do to participate in value-

based care?

Summary

• HHSC and DSHS have numerous VBP initiatives focused on quality and efficiency designed to achieve the Triple Aim: Better Care, Healthier People and Communities, and Smarter Spending

• Many VBP models are underway, many are in development.

• Progress is slow, but this is complicated work and a paradigm shift

• The science, tools, and methods are evolving

• Big lift-but very doable and this is where healthcare is going

• DSRIP can be a valuable guide for what works and what does not work in VBP

33

Summary

• Links at HHS.Texas.Gov:• Quality Improvement

• 1115 Transformation Waiver (DSRIP)

• MCO Pay for Quality (P4Q)

• LTC Quality

• QIPP

• Quality Mailbox: HCPC_Quality@hhsc.state.tx.us

• DSRIP Mailbox: TXHealthcareTransformation@hhsc.state.tx.us

34