Federal Initiatives to Support State/Community-Based Approaches to Coordinated Care ASA-N3C-NYAM Symposium April 27, 2

1. Federal Initiatives to Support State/Community-Based Approaches to Coordinated CareASA-N3C-NYAM SymposiumApril 27, 2011 Julianne R. Howell, Ph.D. Senior Advisor State HIE Programs

2. Overview • Alignment through implementation of the Affordable Care Act • Strategic Framework on Multiple Chronic Conditions • National Quality Strategy • Federal HIT Strategic Plan • Partnership for Patients • Themes recurring across multiple initiatives: • Importance of care coordination • Focus on care transitions • Role of community-based services • Focus on the patient and family caregivers • Triple Aim: Better care, better health, lower cost 2

3. Multiple Chronic Conditions: A Strategic Framework December 2010 • Source • HHS Interagency Workgroup with input from public and stakeholders • Overarching Goals: • #1Foster health care and public health system changes to improve the health of individuals with multiple chronic conditions. • #2 Maximize the use of proven self-care management and other services by individuals with multiple chronic conditions. • #3 Provide better tools and information to health care, public health, and social services workers who deliver care to individuals with multiple chronic conditions. • #4 Facilitate research to fill knowledge gaps about, and interventions and systems to benefit, individuals with multiple chronic conditions. Multiple Chronic Conditions: A Strategic Framework http://www.hhs.gov/ash/initiatives/mcc/mcc_framework.pdf

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5. National Quality Strategy March 2011 • Aims • Better Care: Improve quality, by making health care more patient-centered, reliable, accessible, and safe • Healthy People and Communities: Improve health of population • Affordable Care: Reduce cost of quality health care • Six Priorities and Goalsto help focus public and private efforts: • Safer Care: eliminate preventable health care-acquired conditions • Effective Care Coordination • Person- and Family-Centered Care • Prevention and Treatment of LeadingCauses of Mortality: prevent and reduce harm caused by cardiovascular disease • Support Better Health in Communities • Make Care More Affordable National Quality Strategy http://www.healthcare.gov/center/reports/quality03212011a.html#append

6. Partnership for Patients April 2011 • Public-Private Partnership to make care safer, potentially save up to $50 billion • Two Goals of the Partnership: • Keep hospital patients from getting injured or sicker: decrease preventable hospital-acquired conditions 40% by 2013 cf. 2010 • Up to $500M from CMS Innovation Center • Help patients heal without complication: decrease preventable complications during transition from one care setting to another so that hospital readmissions will be reduced 20% by 2013 cf. 2010 • Up to $500M available through Community-Based Care Transitions Program authorized by Section 3026 of ACA

7. Illustrative Federal Programs to Support State/Community Initiatives • Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration • HITECH • Beacon Communities • State HIE Challenge Grants • Partnership for Patients • Community-Based Care Transitions Program ACA Section 3026 • State Demonstrations to Integrate Care for Dual Eligible Individuals 7

8. MAPCP Demonstration Overview 8 • 3-year demonstration open to states • Medicare will join Medicaid and private insurers in state health reform initiatives aimed at improving delivery of primary care • A multi-payer effort • Aligns economic incentives • Reduces administrative burdens • Provides resources that can be shared across practices

9. MAPCP Goals 9 • Goals include… • Improve safety, timeliness, effectiveness, and efficiency • Reduce unjustified variation in utilization and expenditure • Increase patient participation in decision making • Increase access to evidence-based care in underserved areas • Contribute to ‘bending the curve’ in health expenditures

10. Application Requirements 10 • Applicant had to be a State agency • Program operational prior to Medicare participation • Multi-payer participation • Medicaid FFS & managed care • Medicare Advantage • “Significant” private payer participation • Specifications to be an Advanced Primary Care Practice (APCP) • Evidence of physician support & participation • Community-based support • Coordination with state wellness/disease prevention efforts

11. Program Attributes 11 • 8 States: ME, VT, RI, NY, PA, NC, MI, MN • Some projects state-wide; others limited in geographic scope or # of practices • APCP requirements vary by state • Monthly payment to the practice for beneficiaries “assigned” using a state-specific algorithm • Some projects involve community health teams • Some projects include additional payment to state for administrative/evaluation services • Some states will launch July 2011; some October 2011

12. Eligible Practices 12 • Geographic range/size of project determined by state • Regional vs. state-wide • Planned expansion • Definition of APCP • Determined by state • NCQA-PCMH commonly used (often supplemented by additional requirements) • FQHCs participating in some states

13. Eligible Beneficiaries 13 • Reside in the state • Some states have county restrictions • Excludes beneficiaries who cross state lines (operational limitations/impacts) • Have Medicare A & B • Covered under traditional FFS Medicare • Not enrolled in MA or other Medicare health plan • No restrictions on other categories such as disabled, ESRD, hospice, etc. • Medicare must be primary payer

14. Payment Rates and Policy 14 • Monthly payments to APCP generally < $10 per beneficiary per month (pbpm) • Exception: Minnesota, which uses clinically risk-adjusted tiers (range: $0 - $60.81 pbpm; average: $14.43 pbpm estimated based on historic ACGs) • Variables determining APCP payment rate: • Age of beneficiary • NCQA-PCMH certification status of practice • Use of independent community teams vs. expecting practice to provide/contract for community-based care coordination services

15. HITECH Act (Health Information Technology for Economic andClinical Health) 15 • Section of the American Recovery & Reinvestment Act (ARRA) signed into law in February 2009 • Key components of the legislation • Codifies the Office of the National Coordinator for HIT • Creates Federal Advisory Committees on HIT Policy & Standards • Creates Medicare & Medicaid “Meaningful Use” (MU) incentives for physicians and hospitals to adopt EHRs • Creates new HIT and HIE (Health Information Exchange) Programs • State HIE Planning and Implementation grants • Regional Extension Center (RECs) grants • Workforce Training grants • New technology research & development grants • Increases privacy protections

16. HITECH Programs Address Barriers to Adoption, Meaningful Use, Exchange Intervention Barriers Funds Allocated MU Incentives Cost of EHR Adoption $27.3 B* Meaningful Use difficult to achieve for small providers REC and HITRC $643M $50M HIE Program Standards & Interoperability $548M Barriers to health information exchange $64.3M Lack of trained workforce Workforce $118M Privacy and Security Addressed across all Programs Lack of trust, policy framework Beacon Communities SHARP Need for “real world” examples of HIT contribution to Health Care Transformation $250M $60M *$27.3 B is high scenario

17. HITECH Programs and Goals: Where Are We Today? Regional Extension Centers 58,810 Enrolled Providers Adoption of EHRs Workforce Training 84 Community College Partners Curriculum Available Summer 2011 • Improved individual and population health outcomes • Increased transparency and efficiency • Improved ability to study and improve care delivery Medicare & Medicaid incentives Meaningful Use of EHRs 21,000 Total providers State HIE Grants Standards & Interoperability framework 46 Approved States 10 Challenge Grants Exchange of health information Security & Privacy framework Beacon Communities 17 Communities Research to enhance HIT 17 4 Awardees

18. Key Objectives • Align HITECH programs and initiatives to accomplish • Adoption of EHRs • Meaningful Use of EHRs • Exchange of information • Leverage HITECH programs to have a measurable impact on health care, health, cost • Improve transitions • Reduce readmissions • Reduce medication errors • Achieve better chronic care outcomes • Support health care transformation in each state

19. Beacon Communities Program • 17 communities selected to demonstrate feasibility and health care delivery benefits of widespread HIT adoption and exchange of health information. • Core Aims: • Build and strengthen community/regional health IT foundation to achieve long-term improvements in care quality, health outcomes, and cost efficiencies; • Demonstrate that health IT-enabled interventions and community collaborations can achieve concrete cost/quality performance improvements; • Test innovations to improve health and health care • 14 of 17 include a care transitions component

20. Beacon Communities

21. Beacon Communities’ Transitions Aims • To reduce hospital utilization, especially that arising from errors in transitions • To use HIT to improve care for individuals with high cost / high risk chronic conditions (e.g., DM, CVD, etc.) • To connect local hospital associations with primary and chronic care settings • To engineer electronic continuity and care plans, and to incorporate them into EHRs and HIEs • To build on initial successes by ongoing learning with other Beacon Communities and by seeking Community-Based Care Transitions funding

22. Beacon Communities Transitions Interventions • Three tiers of IT focus • Many Communities are using HIT systems to notify PCPs of hospital and/or ER use • Some are using HIT to provide hospital discharge information (e.g., medications, lab values) to next providers (e.g., nursing homes, FQHCs, PCPs) • A few are using HIT to facilitate making appointments for quick follow-up (e.g., PCPs to specialists) • IT tools are coupled with case management (e.g., self-management coaching, medication reconciliation, care coordination)

23. State HIE Challenge Grants • Program Goal: provide additional funding to recipients of State HIE Cooperative Agreements to spearhead development of technology and approaches focused on 5 “Challenge Themes”: • Achieving health goals through health information exchange • Improving long-term and post-acute care transitions • Encouraging consumer-mediated information exchange • Enabling enhanced query for patient care • Fostering distributed population-level analytics 23

24. Challenge Theme 2: Improving Long-Term and Post-Acute Care Transitions • Requirements • Identify types of long-term and post-acute care providers to be included • Describe technology and policy to achieve timely electronic exchange of clinical summaries, medication lists, advance directives and other information most relevant to transitions • Develop and monitor relevant quality measures • Identify barriers to timely electronic exchange and how they will be addressed • Grantees: Colorado, Maryland, Massachusetts, Oklahoma

25. Partnership for Patients: Community-Based Care Transitions Program 25 • 5 years beginning April 12, 2011; rolling application process • Program Goals: • Improve the quality of care transitions • Reduce readmissions for high-risk Medicare beneficiaries • Document measureable savings to the Medicare program by reducing unnecessary readmissions • Creates source of funding for effectively managing transitions from acute to community-based settings • Eligible entities paid on per-discharge basis for Medicare benes at high risk of readmission, including those with multiple chronic conditions, depression, or cognitive impairment.

26. Community-Based Care Transitions Program: Selection Criteria 26 • Preference given to Administration on Aging grantees that • Provide care transition interventions in conjunction with multiple hospitals and practitioners • Provide services to medically-underserved populations, small communities, and rural areas • Applicants must • Identify root causes of readmissions and define target population and strategies for identifying high-risk patients • Specify transition interventions, including improving provider communications and patient activation • Indicate how community and social supports and resources will be incorporated to enhance beneficiary post-hospitalization management outcomes

27. State Demonstrations to Integrate Care for Dual Eligible Individuals • Partnership between Federal Office of Integrated Care and the Innovation Center • Testing delivery system and payment reform that improves the quality, coordination, and cost-effectiveness of care for dual eligible individuals. • On April 14, 2011, 15 states awarded contracts for up to $1million to design new models for serving dual eligibles: • West: California, Colorado, Oregon, Washington • Midwest: Oklahoma, Michigan, Minnesota, Wisconsin • South: North Carolina, South Carolina, Tennessee • East : Connecticut, New York, Massachusetts, Vermont • Models will be person-centered and fully coordinate primary, acute, behavioral and long-term supports and services.

28. Further Information • Websites: • General http://www.healthcare.gov/ • Innovation Center http://innovations.cms.gov/ • Office of the National Coordinator for HIT http://healthit.hhs.gov/ • For Questions: julie.howell@hhs.gov 202-205-8124 28