MaineCare Accountable Communities Initiative SIM Payment Reform Subcommittee

1. MaineCare Accountable Communities Initiative SIM Payment Reform Subcommittee • November 12, 2013 • http://www.maine.gov/dhhs/oms/vbp/accountable.html

2. Accountable Communities Timeline

3. Strategy to Achieve the Triple Aim Accountable Communities will achieve the triple aim of better care for individuals, better population health, and lower cost through four overarching strategies: • Shared savings based on quality performance • Coordination across the continuum of care • Practice-level transformation • Community-led innovation

4. MaineCare Accountable Communities • Open to any willing and qualified providers statewide • Participation not required • Qualified providers will be determined through a Request for Application (RFA) process • Accountable Communities will not be limited by geographical area • Members retain choice of providers • Alignment with aspects of other emerging ACOs in the state wherever feasible and appropriate • Maintains fee for service system with the potential for retrospective shared savings payment

5. Accountable Communities: Shared Savings Model $ Calculated per Member per Month Total Cost of Care (TCOC) • Based on risk-adjusted actuarial analysis of projected costs. Benchmark TCOC Savings accrued to state Actual TCOC Savings accrued to AC Base Year Performance Year Historical

6. Who Can be an Accountable Community? • One or multiple provider organizations represented by a Lead Entity • Providers must be MaineCare providers • Include providers that directly deliver primary care services • Have partnerships to leverage DHHS care coordination resources • Demonstrate collaboration with the larger community

7. Lead Entity Requirements Legal Entity will contract with the Department • Receive and distribute any payments • Hold contractual agreements with other providers sharing in savings/ loss under the AC • Ensure the delivery of Primary Care Case Management (PCCM) services (1905(t)(1) of the Social Security Act • Primary Care Providers that “Locate, coordinate and monitor” health care services • 24 hour availability of information, referral and treatment in emergencies

8. Governance • Structure, roles, processes • Transparency • Includes two MaineCare members

9. Shared Savings/ Loss Models

10. “Core” Services for Inclusion in TCOC Accountable Communities must be accountable for the cost of all “core” services. AC’s need not directly provide all services.

11. Services Optional for Inclusion in TCOC • Optional Service Costs • In addition to the core services, AC’s may choose to include the cost of the following services in their TCOC: Services, not Members, may be excluded

12. Services Excluded from TCOC • Excluded Services • The following services are excluded from the TCOC calculation: Services, not Members, may be excluded

13. Stepwise Attribution Methodology • Member has 6 mo continuous eligibility or 9 mo non-continuous eligibility ? YES NO • Member enrolled in a Health Home practice that is part of an AC? NO YES • Member has a plurality of primary care visits with a primary care provider that is part of an AC? • Evaluation and Management, preventive, and wellness services, Federally Qualified Health Centers, Rural Health Centers NO YES • Member has 3 or more ED visits with a hospital that is part of an AC? NO YES • Attributed to AC • NOT Attributed to AC

14. Data Adjustments In order to calculate the projected benchmark TCOC, the baseline TCOC amount is adjusted for: • Policy changes • Trend • Risk Dollars will be removed above threshold claim caps for members based on AC size.

15. Data Feedback to Providers Reports to Accountable Community providers will include the following: • Utilization report for high risk members (monthly) • Attributed member roster (quarterly) • Actual TCOC compared to benchmark (quarterly) • Claims-based quality performance measures for attributed population (quarterly) Under the State Innovations Model (SIM) grant, HealthInfoNet will be providing real-time notifications of Members’ Emergency Department visits and inpatient admissions to provider care managers.

16. Quality Framework Team • DHHS • MaineCare • Office of Continuous Quality Improvement • SAMHS • HealthInfoNet • Maine Quality Counts • Maine Health Management Coaltion • Pathways to Excellence (PTE) • Accountable Care Implementation (ACI) • Aligning Forces for Quality • Muskie • Improving Health Outcomes for Children

17. Criteria for Metric Selection • Reflective of Medicaid population • Alignment with other measures (Health Homes, Medicare ACO, Improving Health Outcomes for Children (IHOC)) • Ease of reporting/ pay for performance vs pay for reporting • Current performance on measure

18. Quality Domains • Patient Experience (10%) • Care Coordination/ Patient Safety (30%) • Preventive Health (30%) • At Risk Populations (30%) • Selection of Measures: All AC’s will be scored on the same set of 15 core measures. In addition, each AC must select 4 elective measures (out of 7 possible). Additional measures will be used for monitoring and evaluation purposes only.

19. Quality Measures

20. Quality Measures, cont.

21. Draft Quality Scoring, cont. • Points allocated based on percentile scoring • The resulting quality score % is multiplied times the maximum shared savings rate under each mode

22. Thank you!michelle.probert@maine.govhttps://www.maine.gov\dhhs\oms\vbp