Today’s Agenda Duals Demonstration Update Pre-Existing Condition Plan (PCIP) Update State Innovation Model (SIM) Update Obstetrics P4P 2
Duals Demonstration: Overview Through the Demonstration, stakeholders and the Department seek to create and reward innovative local systems of care and supports that provide better value over time by: • integrating medical, behavioral and non-medical services and supports • providing financial incentives to achieve identified health and client satisfaction outcomes 3
Duals Demonstration: Overview (cont.) • Connecticut’s Demonstration will feature two models: • An enhanced Administrative Services Organization (ASO) model (Model 1) • A “health neighborhood” model (Model 2) 4
Duals Demonstration: Key Structural Features • Enhanced Administrative Services Organization (ASO) Model • Under the Demonstration, the ASO will address the need for more coordination in providing services and supports, through such means as: • integration of Medicaid and Medicare data • predictive modeling • Intensive Care Management (ICM) • electronic tools to enable communication and use of data 5
Duals Demonstration: Key Structural Features (cont.) • Expansion of Person-Centered Medical Homes (PCMH) pilot to serve dual eligible individuals (“MMEs”) • Under the Demonstration, the Department will extend the enhanced reimbursement and performance payments to primary care practices that serve MMEs 6
Duals Demonstration: Key Structural Features (cont.) • Procurement of 3-5 “Health Neighborhoods” (HNs) • HNs will reflect local systems of care and support and will be rewarded for providing better value over time • HNs will be comprised of a broad array of providers, including primary care and physician specialty practices, behavioral health providers, long-term services and supports providers, hospitals, nursing facilities, home health providers, and pharmacists 7
Duals Demonstration: Past Activities • The Department submitted the final application to CMMI on May 31, 2012 • Final submission reflected revisions related to feedback received during the thirty-day public comment period • Application is posted on Department’s web site: http://www.ct.gov/dss/lib/dss/pdfs/mmedemo.pdf 8
Duals Demonstration: Past Activities (cont.) • The Department mapped best practices associated with other integrated care initiatives and produced white papers on: • care coordination • structure of provider networks • performance measures 9
Duals Demonstration: Past Activities (cont.) Further, the Complex Care Committee heard presentations from Connecticut stakeholders on existing models of care coordination (medical and behavioral health ASOs, Access Agencies, behavioral health partnerships), as well as coordination of providers across disciplines 10
Duals Demonstration: Current Activities The Department and its state agency partners (DMHAS, DDS) are in process of drafting an operations plan for the proposed “health neighborhoods,” three to five of which are expected to be procured by RFP in 2013 11
Duals Demonstration: Current Activities (cont.) • CMS and DSS must determine the most appropriate legal authorities under which to operate the demonstration • CMS has forwarded questions regarding Connecticut’s application and DSS has drafted responses for review by the Complex Care Committee 12
Duals Demonstration: Procedural Update • CMS recently issued additional guidance for implementation funding • Each of the 15 states that received planning grants is being asked to submit an additional application detailing plans for implementation activities • Connecticut will submit this April 1 13
Duals Demonstration: Procedural Update (cont.) • Implementation funding will be based on a reserved pool of $95 million • Application instructions are available at this link: http://apply07.grants.gov/apply/opportunities/instructions/oppCMS-1I1-13-001-cfda93.628-cidCMS-1I1-13-001-016200-instructions.pdf 14
Duals Demonstration: Procedural Update (cont.) • Note that the Demonstration project is distinguishable from the “health home” project, planning for which is being led by the Department of Mental Health and Addiction Services (DMHAS) 15
Today’s Agenda Duals Demonstration Update Pre-Existing Condition Plan (PCIP) Update State Innovation Model (SIM) Update Obstetrics P4P 17
CT Pre-existing Condition Insurance Plan (PCIP) Enrollment Suspension • On February 15, 2013, CMS notified states that enrollment in all Pre-existing Condition Insurance Plans (PCIP) must be suspended. • PCIPs are part of a temporary program for those unable to access the current insurance marketplace. The program has a limited amount of funding from Congress.
CT Pre-existing Condition Insurance Plan (PCIP) Enrollment Suspension (cont.) • This suspension will help ensure that funds are available through 2013 to continuously cover people currently enrolled in PCIP.
CT Pre-existing Condition Insurance Plan (PCIP) Enrollment Suspension (cont.) • Under the terms of state contracts, enrollment may be suspended as early as the date of the notice but no later than Saturday, March 2, 2013. • CT PCIP cannot accept new applications received after Thursday February 28, 2013. DSS is continuing to process applications received on or before that date.
CT Pre-existing Condition Insurance Plan (PCIP) Enrollment Suspension (cont.) • Applicants who are receiving benefits under a federal/state PCIP in another state and who are relocating to Connecticut are exempt from this suspension and will be considered for enrollment. • There are no changes to benefit coverage or premiums at this time.
CT Pre-existing Condition Insurance Plan (PCIP) Participation
CT Pre-existing Condition Insurance Plan (PCIP) Top Ten Presenting Conditions
CT Pre-existing Condition Insurance Plan (PCIP) Enrollment Suspension (cont.) • The Charter Oak Health Plan remains an option through December 2013 for many who qualify for the CT PCIP. • People will be able to apply for health insurance coverage choices in health insurance marketplaces when open enrollment begins on October 1, 2013. Coverage begins on January 1, 2014. Visit www.healthcare.gov/marketplace to learn more from the federal government.
CT Pre-existing Condition Insurance Plan (PCIP) Enrollment Suspension (cont.) • In Connecticut, Access Health CT is preparing the health insurance exchange/marketplace. Please visit www.accesshealthct.com for further information.
Today’s Agenda Duals Demonstration Update Pre-Existing Condition Plan (PCIP) Update State Innovation Model (SIM) Update Obstetrics P4P 26
State Innovation Model (SIM) Update • On February 22nd, Lieutenant Governor Wyman announced that Connecticut has received notice from the Centers for Medicare and Medicaid Innovation (CMMI) of an award of up to $2,852,335 to develop a State Health Care Innovation Plan. 27
State Innovation Model (SIM) Update (cont.) • Connecticut will collaborate with public and private stakeholders to design a transformed health care delivery system that incorporates: • promotion of integrated care models • use of the Health Insurance Exchange to inform and connect consumers to coverage • expanded supply of primary care physicians and other professionals • increased engagement among regulators, providers and consumers 28
State Innovation Model (SIM) Update (cont.) • The resulting payment and delivery system model will advance greater alignment across multiple payers on contracting and payment strategies that promote value over volume, greater consistency in quality and other performance metrics, and expanded primary care. 29
Today’s Agenda Duals Demonstration Update Pre-Existing Condition Plan (PCIP) Update State Innovation Model (SIM) Update Obstetrics P4P 30
Obstetrics Pay for Performance (P4P) - Program Objectives • improving early access to prenatal care, improving birth outcomes and reducing the incidence of premature births • reducing Neonatal Intensive Care Unit (NICU) admissions and lengths of stay • reducing the percentage of births by Caesarean Section • reducing Medicaid costs
Background • Medicaid pays for 38% of all births to Connecticut women • 35% of Medicaid covered births are by C-section • in 2010, Medicaid payment for each C-section (not counting post-partum care of the baby) was $4,325 higher than for vaginal births ($13,327 vs. $9,002).
Background (cont.) • during the past 12 months: • 1,798 babies were admitted to a NICU within 24 hours of birth • these babies spent 17,149 total days in the NICU • average NICU length of stay was 9.54 days per baby • Medicaid paid a total of $28.8 million for all NICU days
Brief Program Summary • The proposed obstetrics pay-for-performance program (P4P), is designed to reward obstetrics providers with bonuses for documentation of care resulting in the following outcomes: • timely completion of online OB notification forms • timely first OB visit after confirmation of pregnancy • timely postpartum visit after delivery
Brief Program Summary (cont.) • full-term, vaginal delivery after spontaneous labor whenever medically possible • appropriate use of 17-alpha hydroxyprogesterone when there is prior history of preterm labor
Online OB Notification Form • Provides an efficient means for OB providers to identify and enroll members in: • OB Pay for Performance (P4P) • ASO Intensive Care Management for members who present with high risk pregnancies • Low Risk Perinatal Coaching for members who present with normal (low) risk pregnancies
OB Notification Form Provider Member Demographic Information OB History Risk Indicators Social Behavioral Medical BMI (Body Mass Index) • Demographic Information • Planned Hospital for delivery • Perinatal Appointments • Completed Member Screenings • Depression/Behavioral Health • Social Risk • Medical Risk • Pre Term Labor/Delivery Risk
2013 Proposed OBP4P-Model for Performance Payment - DRAFT In relation to care for each client, an obstetrics care provider can accrue the following: Allocation: Divide the total pool of available funds by total points accrued over all practices. Each practice then receives their share of the pool, according to their total accrued points.
OB P4P Investment Analysis • an investment of $1.2 million has been proposed to fund P4P incentives • the P4P initiative will operate between July 1, 2013 and June 30, 2014 • during this period, P4Pdata will be collected and analyzed
OB P4P Investment Analysis (cont.) • Performance payments will relate to achievement of two goals: • Goal 1: reduction in rates of unnecessary Cesarean section (C-section) • Goal 2: reduction in newborn ICU (NICU) days following birth
OB P4P Investment Analysis (cont.) • Investmentof $1.2 million OB P4P Payment assumes: • 0.43% C-section rate reduction (22 averted C-sections) • 4% of overall NICU cost reduction (decreased length of stay of 0.35 days)