MA Primary Care Payment Reform: Progress Report on a Transformation

1. Session F4a Saturday, October 18, 2014 – 10:30 AM MA Primary Care Payment Reform: Progress Report on a Transformation Alexander Blount, EdD Director, Center for Integrated Primary Care Judith Steinberg, MD MPH Deputy Chief Medical Officer, Commonwealth Medicine University of Massachusetts Medical School Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

2. Faculty Disclosure • I/We have not had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Describe the way that the Massachusetts Primary Care Payment Reform fits into the national movement toward behavioral health integration as part of the Patient Centered Medical Home. • List the three tiers of behavioral health integration that are designated in the PCPR clinical model. • Discuss the advantages and challenges inherent in statewide Medicaid payment reform.

4. Bibliography / Reference Steinberg J.  Implementing integrated care in the Patient-Centered Medical Home: The MA experience. Part of SAMHSA-HRSA Center for Integrated Health Solutions Webinar: Integrated care within the Patient Centered Medical Home: The Health Center perspective, http://www.integration.samhsa.gov/about-us/webinars, November, 2012. Steinberg, J, Blount A. Health Care Reform and Behavioral Integration. Oral Presentation – MA Health Policy Commission, Joint Committee Meeting. Boston, MA. April 2014. Blount, A, Steinberg, J.  From Integration to the Patient Centered Home.  Oral Presentation – National Council for Behavioral Health Annual Conference, Washington, DC, May, 2014. Blount, A. (2012). Form(s) in the patient centered medical home. Families, Systems, & Health: 30, 189. Blount, A. (2010). A special issue on the Patient Centered Medical Home, Families, Systems, & Health: 28, 197. Blount, A.,Schoenbaum, M., Kathol, R., Rollman, B., Thomas, M. O’Donohue, W., & Peek, C.J. (2007). The economics of behavioral health services in medical settings: A summary of the evidence. Professional Psychology: Research andPractice, 38, 290-297. Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems & Health: 21, 121-134.

5. Learning Assessment • A question and answer period will be conducted at the end of this presentation.

6. Agenda • Background • Primary Care Payment Reform • Payment Model • Key Clinical Components • The Quality Strategy • Contract Milestones • Progress to Date

7. Original Joint Principles of the Patient-Centered Medical Home • Personal physician • Physician directed medical practice • Whole person orientation • Care is coordinated and integrated • Quality and safety are hallmarks • Enhanced access • Payment recognizes added value of patient-centered medical home

8. Integrating Behavioral Health into the PCMH Joint Principles Personal PCP Whole person orientation Care coordinated Quality and safety Enhanced access Appropriate payment Home of the team Requires BH service as part of care Shared problem & med lists Requires BH on team Includes BH for patient, fam & provider Funding pooled & flexible Ann Fam Med 2014; 183-185; Joint Principles from AAFP, ABFM, STFM

9. Accountable Care Organizations • Provider-led organizations with a strong base of primary care that are collectively accountable for quality and total per capita costs across the full continuum of care for a population of patients. • Payments linked to quality improvements that also reduce overall costs. • Reliable and progressively more sophisticated performance measurement McClellan M, McKethan AN, Lewis JL, et al. A national strategy to put accountable care into practice. Health Aff.2010;29(5):982–90.

10. PCMHs are the Foundation of ACOs Miller, HD. How to Create Accountable Care Organizations. Center for Healthcare Quality and Payment Reform, September 2009. Available at http://www.chqpr.org/downloads/HowtoCreateAccountableCareOrganizations.pdf .

11. MA Statewide Healthcare Reform Initiatives Affordable Care Act Primary Care Payment Reform Safety Net Medical Home Initiative Health Homes CHIPRA Medical Home MA Health Care Reform Legislation

12. Massachusetts Patient-Centered Medical Home Initiative • Multi-payer, statewide initiative • Sponsored by MA Health & Human Services, legislatively mandated • 44 participating practices • 3-year demonstration; Start: March 29, 2011 • Includes payment reform • Vision: All MA primary care practices will be PCMHs by 2015

13. Primary Care Payment Reform • MassHealth’s flagship alternative payment program that will enable MassHealth to move from fee-for-service reimbursement towards alternative payment models. • Goals: • To improve access, patient experience, quality, and efficiency through care management and coordination and integration of behavioral health • Increase accountability for the total cost of care • 28 participating practice organizations, 47 sites

14. The Payment Model

15. Comprehensive Primary Care Payment (CPCP) • Risk-adjusted capitated payment for primary care services • Options for including outpatient behavioral health services Payment Structure A Quality Improvement Payment • Annual incentive for quality performance, based on primary care performance B Shared savings payment • Primary care providers share in savings on non primary care spend, including hospital and specialist services C

16. Building 3 Behavioral Health Tiers into the Comprehensive Primary Care Payment • Tier 1 • Integrated care management • No fee-for-service behavioral health billable services • Tier 2 • BH services by Master’s or Doctoral level professional • Fee-for-service billable outpatient • Tier 3 • Fee-for-service billable outpatient BH services provided by prescribing clinicians and psychotherapists • Medication management • Psychiatric assessments • Psychotherapy

17. Determination of Comprehensive Primary Care Payment A Cost of outpatient billable Services Reimbursement to cover medical expenses Additional funding for implementation of care coordination, clinical care management, behavioral health integration and practice/clinic management B Medical Home Load Adjusted for panel complexity and estimation of utilization outside of PCC group

18. PCPR Key Clinical Components

19. PCPR aims to help practices transform to provide high quality care efficiently Patient-Centeredness Clinic System Integration Multidisciplinary Care Team-based Approach Patient Centered Medical Home with Integrated Behavioral Health Enhanced Access to Services Planned Visits and Follow-up Care Integration of Quality Improvement Strategies and Techniques Population-based Tracking and Analysis Self-management Support Care Coordination Clinical Care Management Services 19

20. Behavioral Health Integration Tier 2 • Maintain a master’s or doctoral level Behavioral Health Provider who is co-located at each Participating Practice Site, for no less than 40 hours per week • Possess the ability to schedule “first available” Behavioral Health Services appointments with a master’s or doctoral level Behavioral Health Provider at each Participating Practice Site within 14 days from time of request

21. Behavioral Health Integration Tier 3 • Psychiatrist, is co-located with Practice, as part of the Multidisciplinary Care Team, for at least 8 hours a week • Practice provides 24 hour / 7 day per week coverage for Panel Enrollees to a Behavioral Health Provider • Practice has 24 hour / 7 day per week access to the following components of the Behavioral Health record, for each Panel Enrollee: • Diagnoses • Medications • Acute safety issues

22. The Quality Strategy

23. Goals of the Strategy Measurement to support both quality improvement and payment reform • QI: regular feedback to practices of measure results support transformation efforts • Pay 4 Reporting: two-year ramp-up provides time to build capacity and competency at the PCC and practice site level in the timely, complete and accurate collection of data • Pay 4 Quality: phased implementation beginning in Year 2 with incentives tied to five well-established measures • Shared Savings: deliberate approach to implementation focused on gaining experience with practice-level measurement

24. Support for Transformation

25. Primary Care Payment Reform Transformation Plan • Member roster list • ED utilization • High risk members • Raw claims feed • Curriculum based on participant readiness review • Focus on BH integration • Participant feedback on program implementation • Quality reporting assistance • Targeted technical assistance for qualified participants

26. Approach to Learning Collaborative General principle: • Integrating Behavioral Health in Primary Care means integrating behavioral health in each component of the Patient-Centered Medical Home

27. Sequence of Training: Build the home from the foundation up Clinical Care Management Care Coordination Clinic System Integration Multidisciplinary Care Team Evidenced-based, Pro-active care delivery Patient-centeredness Leadership Engagement Patient Involvement in Transformation Data-Driven Quality Improvement

28. PCPR Progress to Date

29. Survey Tools • Transformation Assessment • Assesses level of “medical homeness” • Helps identify opportunities for improvement • 8 aspects of transformation • Behavioral Health Integration Assessment • Assesses: • level of behavioral health integration services, • patient & family centeredness • practice organization for bhi

30. Transformation Survey Results

31. Transformation Survey Results: By Practice Type

32. PCPR Support Activities and Timeline • Practices respond to RFA and are chosen- 2013 • Official Launch and start of payments – March, 2014 • Governance structure • Quality Reporting – P4R • Learning Collaborative: • Leadership conference – Jan 2014 • Practice Learning conference – Sept 2014 • Monthly webinars – starting April 2014 • Baseline Transformation and Behavioral Health integration practice assessments • Collaboration with University of Colorado • Technical assistance – preferred vendor list

33. Some of the many challenges… • IT and data systems • Additional grant program introduced to try to rectify infrastructure issues. • The tradition of using data to correct and improve care is new to many practices. • The trust that underlies many professionals’ willingness to change is hard to build without extensive face to face contact. • The staff “politics” of each practice is an unknown but possibly powerful factor. • The mental health/medical care mind set that we were all trained in is very durable because it underlies so much of how we think and perceive.

34. Summary 34 • PCPR is akin to a Level 1 ACO model • PCPR includes a robust payment reform model that incentivizes development of PCMHs with behavioral health integration, quality care and accountability • The transformation approach requires integration of behavioral health in each component of the PCMH • There are many challenges. It takes a lot to time and steering to turn a big ship around. • Integrated care management, supported by the provision and use of payer data, is a central component of PCPR

35. Acknowledgments • Jean Carlevale Co-Project Director, PCPR • Dr. Ann Lawthers, Director Quality Center, MassHealth Contact: judith.steinberg@umassmed.edu alexander.blount@umassmemorial.org

36. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!