All-Payer Model Progression
February 2017
Goals of Today’s Discussion

Provide a big picture overview of efforts to transform
Maryland’s health care system in the context of the
All-Payer Model

Dive deeper into the All-Payer Model and its
progression strategy
2
Background
What Are We Trying to Do?
Maryland’s All-Payer Model Goals:
 Fundamentally transform the Maryland health
care system

Provide person-centered care

Improve care delivery and outcomes

Moderate the growth in costs
4
What Are We Trying to Do?
Transform the delivery system:
Provider Centered
Old Model
Treat
Test
Treat
Person Centered
New Model
Prevent
Manage
Coordinated
High Quality
Episodes
Preventable utilization
Waste
Less care in facilities
5
Why?
Cost and Outcomes
 Higher costs (affordability)/less favorable outcomes
 Population health/health equity
Aging of Population
 37% increase in Maryland’s population >65-years-old over
next 10 years
 Profound impact on federal and state budgets and
delivery system needs
6
Why Start with Hospitals?
100%
All Other Costs, 6.5%
End Stage Renal Disease Costs, 2.5%
Imaging Costs, 2.7%
Laboratory and Other Test Costs, 2.9%
Home Health Costs, 3.0%
90%
Part B Drug Costs, 3.8%
80%

Procedure Costs, 6.7%
70%

Skilled Nursing Facility Costs, 7.1%

Evaluation and Management
Costs, 10.2%
60%
50%
Outpatient Department
Costs, 17.7%
40%
30%
Inpatient
Costs, 36.9%
20%
~75%+ of Medicare expenditures are
tied to a hospitalization

Hospitals ~56%
Post-acute ~12%
Facility related physician fees ~10%

Agreed to save $330 million in
Medicare’s hospital costs over 5 years

Importance of Medicare waiver
10%
0%
7
2015 Maryland Medicare Dollar %
Implementation Since 2014
2014 - 2015
CHANGE THE HOSPITAL
PAYMENT SYSTEM
2015 - 2016
IMPROVE HOSPITAL CARE
Global budgets--move away AND TRANSITIONS
from volume-based payments
Improve transitions and
Value-based payments— coordination from hospitals
safety, satisfaction, outcomes to the community
Improve safety
Develop infrastructure-Organize data, information
and supports for complex
patients
Enhance C.R.I.S.P.
8
2017-2018
Where We Are Today
Maryland’s All-Payer Model




Initial 5-year duration (through 2018)
Testing a hospital model that is population and value-based
Value created-- Over first 3 years, hospital spending growth
slowed and quality improved
Generally positive view from CMS

9
Concept expanded for rural hospitals in Pennsylvania
Where We Are Today (cont.)
To continue success. . .


Need to align efforts and incentives with other providers
Need to scale up supports for chronic and complex patients
Governor Hogan submitted a proposed Progression Plan
to CMS
 Submitted December 2016
 Proposes a second term beginning in 2019
 Maryland Comprehensive Primary Care Model plan also
submitted for implementation in 2018
10
Progression
Payment and Care Delivery Alignment
Current
Planned

Hospitals on Global Budgets
with quality targets

Hospitals and Providers with
aligned quality targets

Providers on volume-based care
without quality targets

Sharing information

Driving down costs

Improving the health of populations

Little coordination of care
2017 and 2018: Engage Physicians and
Other Providers
2014 - 2015
2015 - 2016
2017 - 2018
ALIGN EFFORTS WITH
OTHER PROVIDERS
Implement supports for high
needs patients and coordinate
episodes with physicians and
other providers
Initiate state-wide
Comprehensive Primary Care
Model for Medicare patients
Begin alignment of efforts and
incentives
13
Care Redesign Amendment: Two Initial
Programs


Two initial care redesign programs aim to align hospitals and
other providers
Voluntary participation
Hospital Care Improvement
Program (HCIP)
Complex and Chronic Care
Improvement Program (CCIP)
• Designed for hospitals and
providers practicing at hospitals
• Focus on efficient episodes of
care
• Goal: Facilitate improvements in
hospital care that result in care
improvements and efficiency
• Designed for hospitals and
community providers and
practitioners
• Focus on complex and chronic
patients
• Goal: Enhance care management
and care coordination
14
14
Maryland Comprehensive Primary Care
Program: Summary
CMS
Coordinating
Entity
Care Transformation
Organization
Patient
Centered
Home
15
Patient
Centered
Home
Care Transformation
Organization
Patient
Centered
Home
Patient
Centered
Home
Maryland Primary Care Model:
What does a transformed practice look like to a patient?

I am a Medicare beneficiary

Provider selection by my historical preference

I have a team caring for me led by my Doctor

My practice has expanded office hours

I can take advantage of open access and flexible scheduling:

Telemedicine, group visits, home visits

My care team knows me and speaks my language

My records are available to all of my providers

I get alerts from care team for important issues

My Care Managers help smooth transitions of care

I get Medication support and as much information as I need

I can get community and social support linkages (e.g., transportation, safe housing)
16
Maryland’s Planned Progression:
Synergistic Models
Person-Centered Care Tailored to Needs
Hospital
Global Model
Tools
Core Approach— Person-Centered Care
Tailored Based on Needs
•
•
•
•
•
•
•
High system use—
frequent hospitalizations
and ED use
Frail elderly, poly-chronic,
urban poor
Psycosocial and
socioeconomic barriers
More limited
stable chronic
conditions
At risk for
procedures
•
•
High
need/
complex
Chronically ill
but at high risk
to be high need
•
•
•
Care coordinators (RNs or social
workers)
Address psychosocial and nonclinical barriers
Community resource navigation
Intensive transition planning
Frequent one-on-one interaction
•
•
•
Chronically ill but
under control
•
•
Reduce practice variation
Systematic-care and
evidence based medicine
Team-based coordinated
care
Chronic care management
Scalable care team
•
Healthy
Minor health
issues
•
Healthy
•
Focus: Complex
and high needs
patients
Focused coordination
and prevention
Movement toward
virtual, mobile, anytime
access
Convenience/access is
critical
Risk stratification
Complex and high needs case
management/interventions
Care coordination
Medication reconciliation
Chronic care management
Comprehensive
Primary Care
Model
Focus: Rising
need patients,
prevention
Goal: Improve Outcomes, Reduce Avoidable Utilization
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Progression Plan for 2019 and Beyond




Build on global revenue model with value incentives
Continue transformation to focus on complex and
chronic care, episodes
Continue to implement and expand Comprehensive
Primary Care Model, increasing focus on prevention
Payment and delivery alignment beyond hospitals


MACRA bonus-eligible programs
Increasing responsibility for system-wide costs/goals


18
Dual Eligibles ACO
Geographic Incentive Model
Progression Plan: Key Strategies
Foster accountability for care and health outcomes by
supporting providers as they organize to take responsibility
for groups of patients/a population in a geographic area.
Align measures and incentives for all providers to work
together, along with payers and health care consumers, on
achieving common goals.
Encourage and develop payment and delivery
system transformation to drive coordinated efforts and
system-wide goals.
Ensure availability of tools to support all types of
providers in achieving transformation goals.
Devote resources to increasing consumer
engagement for consumer-driven and person-centered
approaches.
I.
II.
III.
IV.
V.
19
Potential Timeline
MACRA
2017
• Care
Redesign
Amendment
• Negotiations
with CMS for
second term
20
Begin to implement
MACRA bonus
eligible models
2018
• Primary Care
model
• Geographic
incentives in
value based
payments
MACRA bonus
available
2019
• Geographic
partners and
ACOs take on
more
responsibility
• Dual Eligible
ACOs
2020
TBD
• Post-acute
• Behavioral
health
• Long-term
care
Opportunities for HFMA members
Be Proactive
Get Coordinated
• Be a watchdog
• Contribute to the transformation of
the state’s healthcare delivery system
• Coordinate your patients’ care with
other providers across clinical and
community settings
• Work with case managers to address
the medical and social needs of
complex patients
Participate
Get Connected
• Use data and information to help
improve outcomes and lower costs
• Consider an ACO, Comprehensive
Primary Care Model, geographic
initiatives, etc.
• Get involved in outcomes-based
payment programs, etc.
• Utilize CRISP encounter alerts,
common care histories, and other care
management tools
• Address gaps in patients’ health
21
Thank you for the opportunity to work
together to improve care and health for
people and communities that receive care
in Maryland!
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Appendix
All-Payer Model: Performance to Date
24
Major Impact of Federal Legislation Referred to as
“MACRA” (Medicare Access and CHIP Reauthorization Act of 2015)

Bi-partisan federal legislation referred to as MACRA
dramatically alters physician reimbursement for Medicare
 Focuses on moving from volume to value
 Physicians subject to potential payment reductions (or
bonuses) up to 9% by 2022
 Creates 5% bonus for physicians in Advanced Alternative
Payment Models (“Advanced APMs”)

Maryland will adapt its approaches to optimize opportunities
for MACRA bonuses that can align performance goals under
the All-Payer Model
25
Progression Plan: Strategies & Key Elements
26