Medicaid Payment Reform Demonstration Project in Pediatrics

Presented by John Lovelace at the Executive Leadership Summit on March 24 - 26, 2015.

UPMC High Value Care for Kids is a Robert Wood Johnson Foundation funded project. Conducted over a three-year period from May 15, 2012 to May 14, 2015, the work involves a series of overlapping design, implementation, and evaluation phases. The aim is to examine the impact of implementing an innovative Medicaid payment model to better serve children with medically complex conditions. The project is a collaborative effort involving members from Children’s Hospital of Pittsburgh, Children’s Community Pediatrics, the Primary Care Center, as well as representatives from families, community and governmental agencies. Together, they developed a value-based payment model with three main components: (1) comprehensive, coordinated service delivery rather than more, not necessarily better, care; (2) cost and quality transparency to achieve an efficient and effective care continuum; and (3) patient and family input to ensure needs, values, and preferences are adequately met rather than “medicalized.” The end goal is for the care recipient to be treated as a person, not just a patient. Preliminary findings show improvement in patients’ experiences and savings beyond the initial program investment; we are currently in the final phases of program evaluation and financial analysis.

Transcript

1. John Lovelace, President UPMC for You
2. Redesigning Medicaid Payment Policies: A New Pathway for Achieving High-Value Care for Medically Complex Children* *Funded by the Robert Wood Johnson Foundation and UPMC for You for You & 2
3. UPMC is an integrated global health enterprise with a top- ranked clinical delivery system and an actively expanding international and commercial services division. UPMC for You, is the largest Medical Assistance program in western Pennsylvania and the number one quality plan in Pennsylvania for eight out of nine years in a row, according to the National Committee for Quality Assurance. UPMC (University of Pittsburgh Medical Center) 3
4. • 2.5 Million Members • 2nd Largest Provider Owned Insurer • Annual Revenues $5.5B • Integrated Population Health and Productivity Products • 10% Average Annual Growth YOY • 10,000+ Employer Groups • #1 Ranked Commercial HMO in WPA U.S. News & World Report (2014) • Fastest Growing Medicaid and CHIP Plan in PA • 4 Star HMO MA Plan • Highest Provider Satisfaction • J.D. Power Certified Call Center • National Business Group on Health Platinum Winner Times Five • 2013 ICMI Global Call Center Award Best Customer Experience Program UPMC Launched Health Insurance Products in 1996 4
6. The Challenge END RESULT: Child Is Ever More a Patient, Not a Person (1) Reinforce More, Not Better (2) Ignore Cost & Quality (3) Medicalize Needs 6
7. • In 2012, UPMC for You, the physical health Medicaid managed care organization of UPMC Insurance Services Division, was awarded a $440,000 grant from the Robert Wood Johnson Foundation (RWJF) to develop a new pathway for Medicaid payment reform. • The UPMC for You High-Value Care for Kids initiative is one of only four projects that Robert Wood Johnson Foundation funded out of 50 that were submitted in response to its 2011 nationwide call for proposals around “Payment Strategies for High Value Care.” Redefining Medicaid Payment Reform For Our Most Vulnerable Populations 7
8. Components of a Value-Based Payment Model 8
9. Vision 9
10. Deborah Moss, MD, MPH, co-director of the UPMC for You High-Value Care for Kids project, conducts a checkup with a Medicaid patient at the Children‟s Hospital of Pittsburgh of UPMC medical office building in Oakland, a neighborhood of Pittsburgh. Photographer: James Knox, Pittsburgh Tribune-Review Partners Multi-Stakeholder Collaborative Project Team: •Pediatricians •Children’s Hospital •Clinical administration & leadership •Insurers •Federal, state and local health & behavioral health policy makers •Patient and family representatives 10
11. Generic Data Elements Specific Data Elements for UPMC for You Demonstration project Age and/or gender Any individual under 21 years of age as of June 30, 2012 Insurance product UPMC for You members Place of residence Resides in Allegheny County, Pennsylvania Comprehensive claims data Medical, pharmacy, and behavioral health claims data Number of claims years Two years of claims data with at least three months of claims run-out Active member months At least one member month in calendar years 2010 and 2011 Specific conditions of interest Medically-complex conditions, other related chronic conditions Service utilization by provider Pediatric/primary care, specialty/ancillary care Population 11
12. • Identified the top 10 percent of spenders (N=1,272) among the UPMC for You pediatric population served through Medicaid in calendar years 2010 and 2011, recognizing that this group would present the greatest potential for cost savings. • Total of 263 children and youth (average age in 2012: 8.1 years; 40% female) were distributed by practice as follows: – Practice A-146; – Practice B-30; – Practice C-30; – Practice D-57. Target Group 12
13. Project Timeline 13
14. (1) Clinical Best Practices Value-Based Payment Model Components (3) Consumer-Direction in Purchasing (2) Cost/Quality Transparency of Payers & Providers 14
15. Clinical Best Practices • Thorough review of patient medical records; • Development of individualized care plans; • Consultation with other providers, especially specialists, who care for the same patient; and • Care team discussions about care-related goals that may also include the patient and/or caregiver. 15
16. • Prospective funding for care coordination with practice based care managers • Prospective funding for care coordination with practice based care managers • Expanded payments for other needed clinical services not currently reimbursed: • Expanded payments for other needed clinical services not currently reimbursed: New Types of Provider Payments • Upfront payments to support salary and benefits of practice-based care coordinators; • New reimbursements to support non face-to-face care coordination services undertaken by primary care billing providers (i.e., physicians); • New reimbursements to support care coordination activities undertaken by non-billing providers (i.e., other non-physician staff such as nurses, dieticians, etc.). These payments were not available to the care coordinators who were already being financially supported by the project 16
17. Cost/ Quality Transparency of Payers & Providers • Monthly patient profiles including service utilization & cost data • Quarterly quality reports • Periodic financial reports 17
18. Consumer-Direction in Purchasing • Consumer-directed accounts to cover predefined non-clinical goods & services identified by patients/families as important to them • Informed by feedback from parents and caregivers in focus groups 18
19. Consumer Directed Account (CDA) • One-time distribution of $500 for 100 patients/families for items not traditionally covered by the MCO to enhance quality of life for the child • Offered to children ages 10-19 (beginning to plan for transition to adult care) • Did not restrict what the families could purchase with their $500 account 19
20. Consumer Directed Account • Care coordinators worked with families to make decisions about purchase opportunities • Examples: – Special mattress – Portal ramp – LCD technology – Refrigerator for insulin for college student – Gym membership 20
22. • A family was being interviewed the Child Welfare system due to non compliance with physician appointments for a diagnosis of failure to thrive. • The care coordinator spent extra time talking with mom and it was determined that mom was scared the office would think she „was not a good parent” and she was scared to bring the child to the office. • After talking in detail with the care coordinator, mom‟s fears were resolved and the child is attending appointments regularly again and has started school. Care Coordination Examples 22
23. • Care coordinator reported that after a parent was given their name as a direct contact in the office, the communication with the family greatly improved. Parent had previously been verbally abusive with staff due to frustration of sharing the same story with multiple individuals and now is very pleasant when working with the care coordinator. • A child with a rare skin disorder was a recipient of the CDA and mother was able to purchase a homeopathic skin lotion that has been proven to greatly improve lesions, etc. Care coordinator also linked mother to the National organization that helps support individuals with the rare condition. Care Coordination Examples 23
24. Financial Impact 24 • Baseline (2012) to Year 1 (2013) • Approximately $400,000 in cost reductions after accounting for: o care coordinator salaries o estimated consumer account funds o catastrophic claims (>$75,000 on a single claim) • Preliminary results showed reductions were not the result of regression to the mean • Key areas of impact: o Inpatient Medical/Surgical o Emergency Room o Home Care o Specialist Services • Year 2 (2014) results to be calculated in April 2015
25. Stakeholder Engagement • Multiple perspectives needed • Takes time to learn how to speak a common language and build trust Designing Payment Model • Not feasible to develop and test condition-adjusted per child payments; historic health care expenditures for the target populations used to develop an acuity based global payment model for children with medically complex conditions • Providers & payers need to agree on metrics of performance up front Implementing the Payment Model • Changing the way providers are paid does not automatically lead to different or better service delivery. (Buy-in, tools, coordination with families needed). Key Lessons 25
26. Implementing Different Clinical Practices • Practice-based care coordination has improved the care that families receive • Continuity with families is key • Comprehensive care planning and interdisciplinary conferencing is a challenge. Persistence required Overall • Payment reform demonstration projects can serve as groundwork for accountable care models • Sustaining and replication efforts will require infrastructure, payer-provider dialogue, and efforts to disseminate results Key Lessons …. 26
27. • Conduct a detailed analysis • Prepare to share • Discussions re ACO formation Next Steps 27
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