Payment Reform Quarterly Update February 2, 2015

Agenda I. Payment Reform Strategy I. APM Demonstration II. CP3 III.PCHH and 2703

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Purpose & Structure •

CPCA 2014-17 Strategic Plan – Health System Transformation – Health Center Transformation – California Health+

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Quarterly Webinars 4 x Year- in between board meetings Informed Members – leads to Engaged Members • Leads to Meaningful Work – leads to Major Outcomes!

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CPCA Payment Reform Strategy

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CPCA Payment Reform Strategy

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Legislative Update • Legislation- Introduced – SB 147, Senator Hernandez – Co-Sponsors: CPCA, CAPH, LA Care • SPA – Spring/Summer 2015 • Rate development – Fall 2015 • Implementation- July 2016 through June 2019

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APM Demonstration

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Today- PPS • DHCS sets rates for health plans • Plans pay primary care capitation to health centers • Health centers bill state a wraparound payment • Annual reconciliation

DHCS

Traditional Rate Setting

Health Plan

Primary care capitation

Wrap around payment

FFS for mental health

FQHC

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Future- APM Demonstration • Conversion of PPS visit to PPS equivalent PMPM – 4 PMPM by aid category – Child/Adult/SPD/MCE • •

EXAMPLE: $100 PPS x 3.5 Avg Adult Visits = $350 $1350/ 12 member months = $29.16 PMPM

• 3 year demonstration with volunteer health centers • Abide by Federal APM– PPS is Floor • Health centers will continue to: – Have site-specific rates – Have ability to do scope change (with State) – Receive annual MEI increases (State to pass to plans)

• Plans will have risk corridor – At risk for max of .75% of wrap cap amount. State responsible for rest. – Can benefit up to .75% of wrap cap if FQHC had to pay back. State 9 would get rest.

Future- APM Demonstration Phased Reconciliation Triggers • Year 1 - Reconciliation would be triggered if traditional visits increased by more than 5% or decreased by more than 30% • 2 - Triggered by more than 5-7.5% or decreased by more than 30% • 3 – Triggered by more than 7.5-10% or decreased by more than 30% Description

– FQHCs would be at risk for 5/7.5/10% of visits and reconciled to PPS for anything above. – FQHCs would keep the margin up to 30% if visits 10 drop, and at 30% reconciliation would be triggered.

Future- APM Demonstration • DHCS sets rates for health plans • Monthly, plan would tell State how many Medi-cal members are assigned to FQHC in demonstration. • State would pay the plan an additional “Wrap Cap” for that site(s) • Wrap around payment becomes a capitation payment that is AID Category specific • Health center would receive 4 per member per month payments (Child, Adult, SPD, Expansion) • Reconciliation between FQHC and plan.

DHCS Wrap CapChild Adult SPD Expansion

Traditional Rate Setting

Health Plan

Primary care capitation

FFS for mental health

FQHC

Wrap CapChild Adult SPD Expansion

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Future- APM Demonstration Benefits • Financial benefit if panel size increases • Flexibility to use the capitation to meet patient’s needs, improve quality, and be the provider of choice • PPS Rules Gone- billable providers/ same day visit/ groups / four walls – NO MORE! • Capitation is likely future – Demonstration is soft/protected launch • Active management and responsibility of assigned populations

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Counties Phase 1

Phase 2

Alameda

Kings

Contra Costa

Orange

Humboldt

Riverside

Los Angeles

San Diego

Merced

Stanislaus

Monterey

Tulare

Napa

Yolo

San Mateo Santa Clara Solano

Phase 1 • 20 organizations • 16 nonprofit FQHCs • 4 public FQHCs • 62 sites • 30 nonprofit FQHCs • 32 public FQHCs • 10 counties

Phase 2 • 11 organizations • 10 nonprofit FQHCs • 1 public FQHC • 26 sites • 16 nonprofit FQHCs • 16 public FQHCs • 7 counties 13

PCHH “Patient Centered Health Home” can refer to either…

1. CPCA PCHH Initiative or 2. CA Health Homes for Patients with

Complex Needs (HHPCN)

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PCHH- Review The California State Innovation Model + Section 2703 = CA Health Homes for Patients with Complex Needs (HHPCN) 15

PCHH- Review Section 2703 SPA • State Option to Provide Health Homes for Enrollees with Chronic Conditions as defined by each state • Funding for 2 years and requirement to demonstrate savings • 90% Federal/ 10% State funding • The California Endowment contributing California’s 10% • States can have more than one SPA • No deadline

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PCHH- Review What can Section 2703 fund? • • • • • •

Comprehensive care management Care coordination Health promotion Comprehensive transitional care & follow-up Patient and family support Referral to community and social support services

…basically, services not already funded by Medicaid

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PCHH Updates CalSIM Updates • California was NOT selected for a Round Two Model Test Award • 11 States selected • California WAS selected for a Round Two Model Design Award • $3 million to “design or further refine their plans” and resubmit to CMS within 12 mos 18

PCHH Updates 2703 Updates • Concept paper released November • HHPCN will target all three categories for health home eligibility with an emphasis on high-cost, high-risk, high-utilizers • 2 or more chronic conditions • 1 condition and at risk of a second • Serious mental illness (SMI) 19

PCHH Updates

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PCHH Updates • Eligibility criteria developed by DHCS • Eligibility determination run by DHCS or health plans • Providers may be able to refer patients • Patients able to opt-out • Medicaid expansion will be included • Medical acuity = tiered service and payments • Chronically homeless enrollees will have additional care management reqs 21

PCHH Updates

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PCHH Next Steps • DHCS communication to CPCA that 2703 implementation is moving forward • Uncertainty whether CA will pursue reapplication for SIM grant • 1115 Waiver proposition (JSI) – include TA and training so 2703 not dependent on CalSIM • CPCA working with TCE, JSI, CAPH on next steps for 2703 23

P4P & Shared Savings IHA Update • Medi-Cal P4P Southern CA Pilot – Completed Fall 2014 – Proposed next steps include expansion of reporting at the clinic level – Finding: Provider Orgs w/ Commercial P4P experience performed better

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P4P & Shared Savings IHA Update • Statewide P4P Survey – Preliminary Results – Survey 20/22 CA Medi-Cal Managed Care Plans – 16/22 plans offer some level of incentive plan – CPCA conducting parallel survey of providers

• IHA summary results here: http://www.iha.org/grants-projects-safety-netperformance-measurement.html 25

P4P & Shared Savings 1115 Waiver MCO/Provider Incentive Workgroup – Several models reviewed • P4P • Shared Savings (state to plan & plan to providers) & (plan to county behavioral health) • State also considering changes to the rate setting – –

No longer penalize efficiency Move some administrative costs to medical expense (Care coordination) 26

P4P & Shared Savings

CCHC Innovation: APM and CP3

Value Based Payment System Primary Care Transformation: CMS TCPI CalHIPSO Funding Opportunity

1115 Waiver – Medi-Cal Payers 27

Contact Andie Patterson Director of Government Affairs [email protected] re: APM

Samantha Jones Assistant Director of Programs [email protected] re: P4P Erynne Jones Associate Director of Policy [email protected] re: PCHH 28