Innovation in Health Service Delivery and Financing: Payer Perspectives

1. Innovation in Health Service Delivery and Financing: Payer Perspectives United Hospital Fund March 1, 2012 Foster Gesten, MD, FACP NYSDOH-Office of Health Insurance Programs

2. Medicaid FFS (~1.2 million) MMC (~3.6 million) Almost $60 Billion/year expended Heterogeneous population Women and children Minorities Disabled Behavioral health Multi-morbid Dually eligible Long term care Child Health Plus Commercial Managed Care Office of Health Insurance Programs

3. Medicaid Redesign…Direction More ‘efficient’, more ‘managed’ program Cost and quality concerns Integrated benefit package Managed care and ‘care management’ Risk adjusted payments Global budget/cap Extensive stakeholder process Open meetings Transparency Changing the experience of care ACCESS! Coordination Health promotion

4. Focus on: Care Delivery Medical Home 1.0 (Single Payer Incentives) Pay to play Enlarge the tent Build ‘critical mass’ Medical Home 2.0 Multiple payers (CHPlus, Commercial, Medicare) Training and care management/coordination support Health information exchange Medical Home 3.0 Level 3 Recognition is ‘entry ticket’ Neighborhood (specialists, hospitals, home care) ‘Health Home’/Behavioral Health Integration Pays for itself

5. Transforming Primary Care • Investments • Medical home incentives • Health home program • Payments to Medicare level • ACA • ARRA/HITEC/MU • HEAL • Expectations • Medical home standards • Collaboration • Multi-payer medical home • The Future Workforce • Hospital PCMH Demonstration

6. Summary Challenges Sufficient practice support PCMH HIT/HIE Care Management Collaboration Self insured/employers Meaningful inclusion of patient/family Results Early results on standardized quality and patient experience measures positive Utilization….mixed (but early for most demo’s)