HRSA Strategic Planning & Performance - nastad

“It Takes a Village…” to Raise an AIDS Free Generation: HRSA in the Federal ‘Neighborhood’ Laura Cheever, MD, ScM Associate Administrator HIV/AID Bureau, HRSA

Overview • Setting the stage • The Health Resources and Services Administration’s (HRSA) HIV/AIDS Bureau (HAB) contributions in getting to zero new infections • Working across agencies and departments • Expanding the federal efforts to partners at the state level

Retention and Viral Suppression Race/Ethnicity, RSR 2010-2013 White Asian American Indian

Black Native Hawaiian Hispanic

Retention

90%

White Native Hawaiian Multi-racial

Black American Indian

Asian Hispanic

Viral Suppression

90% 85%

85%

80% 80%

75% 70%

75% 65% 70%

60%

2010

2011

2012

2013

2010

2011

2012

2013

Viral Suppression by State, RSR 2013

Viral suppression: had at least one OAMC visit, at least one viral load count, and last viral load test 1 year)

 Limited in Medicare fee-forservice  Majority of Medicare payments now are linked to quality

 Hospital value-based purchasing  Physician ValueBased Modifier  Readmissions / Hospital Acquired Conditions Reduction Program

 Accountable care organization  Medical homes  Bundled payments

 Eligible Pioneer accountable care organizations in years 3-5  Some Medicare Advantage plan payments to clinicians and organizations  Some Medicare-Medicaid (duals) plan payments to clinicians and organizations

 Varies by state

 Primary care case management  Medicaid Health Homes Medicaid  Some managed care models

 Shared savings models  Some Medicaid waivers for  Episodic-based payments delivery reform  Medicaid waivers for delivery reform  Some Medicaid managed care incentive payments plan payments to clinicians and  Some managed care models organizations  Some Medicare-Medicaid (duals) plan payments to clinicians and organizations

Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.

Category 4: Populationbased Payment

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In January, HHS announced payment goals for Medicare AND encouraged Medicaid, private payers, and others to align goals

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Target percentage of payments in ‘FFS linked to quality’ and ‘alternative payment models’ by 2016 and 2018 Alternative payment models (Categories 3-4) FFS linked to quality (Categories 2-4) All Medicare FFS (Categories 1-4)

2011

2014

2016

2018

30%

50%

85%

90%

0% ~20% 68% >80%

Historical Performance

Goals

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CMS is aligning with private sector and states to drive delivery system reform CMS Strategies for Aligning with Private Sector and states

Convening Stakeholders

Incentivizing Providers

Partnering with States

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The Health Care Payment Learning and Action Network will accelerate the transition to alternative payment models  Medicare alone cannot drive sustained progress towards alternative payment models (APM)

Network Objectives

 Success depends upon a critical mass of partners adopting new models

• Match or exceed Medicare alternative payment model goals across the US health system -30% in APM by 2016 -50% in APM by 2018

 The network will

• Shift momentum from CMS  Convene payers, purchasers, consumers, states and to private payer/purchaser federal partners to establish a common pathway for and state communities success  Identify areas of agreement around movement to APMs • Align on core aspects of alternative payment design  Collaborate to generate evidence, shared approaches, and remove barriers  Develop common approaches to core issues such as beneficiary attribution  Create implementation guides for payers and purchasers 10

Delivery System Reform and Our Goals CMS Innovation Center

Centers for Medicaid and CHIP Services

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The CMS Innovation Center was created by the Affordable Care Act to develop, test, and implement new payment and delivery models “The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished to individuals under such titles”

Section 3021 of Affordable Care Act

Three scenarios for success 1.

Quality improves; cost neutral

2.

Quality neutral; cost reduced

3.

Quality improves; cost reduced (best case)

If a model meets one of these three criteria and other statutory prerequisites, the statute allows the Secretary to expand the duration and scope of a model through rulemaking 12

The Innovation Center portfolio aligns with delivery system reform focus areas Focus Areas

CMS Innovation Center Portfolio* Test and expand alternative payment models  Accountable Care

 Bundled Payment for Care Improvement

‒ Pioneer ACO Model ‒ Medicare Shared Savings Program (housed in Center for Medicare) ‒ Advance Payment ACO Model ‒ Comprehensive ERSD Care Initiative

Pay Providers

‒ ‒ ‒ ‒ ‒

 Primary Care Transformation

Model 1: Retrospective Acute Care Model 2: Retrospective Acute Care Episode & Post Acute Model 3: Retrospective Post Acute Care Model 4: Prospective Acute Care Oncology Care Model

 Initiatives Focused on the Medicaid

‒ Comprehensive Primary Care Initiative (CPC) ‒ Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration ‒ Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration ‒ Independence at Home Demonstration ‒ Graduate Nurse Education Demonstration

‒ ‒ ‒ ‒

Medicaid Emergency Psychiatric Demonstration Medicaid Incentives for Prevention of Chronic Diseases Strong Start Initiative Medicaid Innovation Accelerator Program

 Dual Eligible (Medicare-Medicaid Enrollees) ‒ Financial Alignment Initiative ‒ Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents

Support providers and states to improve the delivery of care  Learning and Diffusion

Deliver Care

‒ Partnership for Patients ‒ Transforming Clinical Practice ‒ Community-Based Care Transitions

 Health Care Innovation Awards

Distribute Information

 State Innovation Models Initiative ‒ SIM Round 1 ‒ SIM Round 2 ‒ Maryland All-Payer Model

 Million Hearts Initiative

Increase information available for effective informed decision-making by consumers and providers  Information to providers in CMMI models

* Many CMMI programs test innovations across multiple focus areas

 Shared decision-making required by many models

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Delivery System Reform and Our Goals CMS Innovation Center Center for Medicaid and CHIP Services

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Increasing Coverage and Expenditures

CHIP, 6.2 million

Medicaid 70.1 million Medicare, 54.3 million

Uninsured, 27.3 million

Other Private (including Marketplaces), 24 million

Medicaid, $531 billion Employer Sponsored Insurance, 172.4 million

Other Private (including Marketplaces) $91 billion

CHIP, $15 billion

Medicare, $669 billion

Other Public, $398 billion

Employer Sponsored Insurance, $1,009 billion

Source: CMS, Office of the Actuary, http://cms.hhs.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2012.pdf

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Coverage Expansion Expanding Medicaid Not expanding Medicaid to date

So far, 29 states and DC are expanding Medicaid to low-income adults in 2015 – discussions continue to evolve.

DE DC

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Medicaid/CHIP Innovation Core authorities • State Plan Amendments • Alternative payment models: • Shared savings in 3 states; Bundles/episodes in 1 state

• Managed care: • Majority of beneficiaries • Lots of flexibility and innovation today • NPRM on 5/26/15: allows states to require plan alignment with broader payment reforms

• Health Homes: • 24 programs approved in 19 states

• LTSS and Home and Community-Based Services • 1115 Demonstrations, including DSRIPs 17

Home and Community-Based Services • Allow states to go beyond medical services to support community integration • Typically offered through 1915 waiver authority • Success of waivers has led to new state plan options that are gaining popularity with states • Grant programs support change • Money Follows the Person • Balancing Incentive Program • Real Choice Systems Change Grants for Community Living program 18

Health Home Provision • Created through the Affordable Care Act • States can elect the health home option under their Medicaid State plan

• Provides a comprehensive system of care coordination for Medicaid individuals with: • two or more chronic conditions, • one condition and the risk of developing another, • or at least one serious and persistent mental health condition.

• Increased Federal Match • 90 percent match for the first eight fiscal quarters that a State plan amendment is in effect.

• Currently 24 programs in 15 states 19

Medicaid Innovation Accelerator Program • Joint Innovation Center-CMCS collaboration launched in July 2014 • Four year commitment to build state capacity and accelerate ongoing innovation in Medicaid • through targeted program support: • Four key program areas • Four key functional areas

• States receive targeted program support • not grant or contracting funding

• Complements state efforts for delivery and payment system reform • 1115 Demonstrations • CMMI SIM initiative

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Medicaid IAP Program Priority Areas • What’s launched and what will be launching: Substance Use Disorders

Beneficiaries with High Needs & High Costs/ Superutilizers

Community Integration – Longterm Services & Supports

Physical Health/Mental Health Integration

Launched with 7 selected states Jan 2015

Opportunity announced June 29, 2015

*Opportunity to be announced early fall 2015

*Opportunity to be announced in winter 2015

High-intensity learning collaborative formally ends Dec 2015 - HILC states are offered addt’l 1:1 program support

Work begins with selected states September 2015.

Work begins with selected states late fall 2015.

Work begins with selected states early 2016.

* Target timeframes 21

Medicaid IAP Functional Areas • Data analytics • Develop tools to assist states to analyze data on Medicaid populations and patterns of care in a way that can be benchmarked with other states

• Quality measurement • Develop and/or refine metrics, and support better alignment across existing metrics

• Rapid-cycle learning • Support states in applying Continuous Quality Improvement (CQI)

• Payment modeling and financial simulations • Support states in designing and implementing value-based purchasing strategies 22

States Participating in IAP SUD Activities* WA MT

VT NH ME

ND

MN

OR ID WY

WI

UT

AZ

CO

MI PA

KS

WV

MO

OK

NM

VA

KY

NC

TN AR

NJ

CT

RI

DE MD DC

SC

MS AL

GA

LA

TX

AK

OH

IN

IL

MA

NY

IA

NE

NV CA

SD

FL

HILC (High Intensity Learning Collaboratives)

HI

Puerto Rico

Virgin Islands

Guam

* as of April 2015

Am. Samoa

No Marianna

TLO (Targeted Learning Opportunity)

HILC/ TLO

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What can you do to help our system achieve the goals of Better Care, Smarter Spending, and Healthier People? 

Eliminate patient harm



Focus on better care, smarter spending, and healthier people within the population you serve



Engage in accountable care and other alternative payment contracts that move away from fee-for-service to model based on achieving better outcomes at lower cost



Invest in the quality infrastructure necessary to improve



Focus on data and performance transparency



Help us develop specialty physician payment and service delivery models



Test new innovations and scale successes rapidly



Relentlessly pursue improved health outcomes

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Thank You Contact information

Ellen-Marie Whelan, NP, PhD, FAAN Acting Chief Population Health Officer , CMCS Senior Advisor, CMMI Centers for Medicare & Medicaid Services

[email protected] innovation.cms.gov 252525