Confidential draft / Policy under development / Statements are not binding on MassHealth Primary Care Payment Reform Open Meeting: Clinical Delivery Model Wednesday, October 17th Confidential draft / Policy under development / Statements are not binding on MassHealth Agenda • Recap of program • Summary of clinical delivery model • Timing and requirements • RFI feedback • Discussion 2 Confidential draft / Policy under development / Statements are not binding on MassHealth Overview of Primary Care Payment Reform • The goal of our strategy is improving access, patient experience, quality, and efficiency through care management and coordination and integration of behavioral health • We believe that primary care and behavioral health are important in improving quality and efficiency while preserving access, through the patient-centered medical home capabilities with integrated behavioral health services • The payment mechanism that supports that delivery model is a comprehensive primary care payment (CPCP) combined with shared savings +/- risk arrangement and quality incentives • This program would span MassHealth managed care lives across the PCC Plan and the Managed Care Organizations. We propose to launch a procurement for PCCs to participate in the program and MCOs will participate in a similar payment structure with these organizations • We plan to implement on an aggressive timeframe, with an RFP release planned in January 2013 and with 25% of members participating by July 2013, 50% of members participating by July 2014, and 80% by July 2015 3 Confidential draft / Policy under development / Statements are not binding on MassHealth Proposed payment structure The payment structure will not change billing for non-primary care services (specialists, hospital); PCP’s will not be responsible for paying claims for these services. However, we are evaluating complementary alternative payment methodologies to hospitals and specialists for acute services. 4 Comprehensive Primary Care Payment (CPCP) • Risk-adjusted capitated payment for primary care services • May include some behavioral health services Quality Incentive Payment • Annual incentive for quality performance, based on primary care performance Shared savings payment • Primary care providers share in savings on non primary care spend, including hospital and specialist services Confidential draft / Policy under development / Statements are not binding on MassHealth This is the second in our open meeting series Six topic specific open meetings on a weekly basis: • 10/10, 1:30-3pm, Transportation Building, Conference Room 5, Boston: Overview • 10/17, 1-2:30pm, South Street Amphitheatre, Shrewsbury: Clinical Delivery Model • 10/22, 2:30-4pm, Worcester Public Library, Saxe Room, Worcester: Quality metrics • 10/31, 1:30-3pm, Transportation Building, Conference Room 5, Boston: Shared savings • 11/7, 1:30-3pm, Worcester Public Library, Saxe Room, Worcester: Comprehensive Primary Care Payment • 11/15, 1:30-3pm, 1 Ashburton Place, 21st floor, Boston: Provider eligibility and technical assistance 5 MassHealth Confidential draft / Policy under development / Statements are not binding on MassHealth Agenda • Recap of program • Summary of clinical delivery model • Timing and requirements • RFI feedback • Discussion 6 Confidential draft / Policy under development / Statements are not binding on MassHealth Overview of clinical delivery model 1. Participants will have the functional capacity to provide 12 PCMH components, all of which are fundamental to care integration. 2. Participants will integrate behavioral health and primary care by implementing defined integration elements. 3. The approach to care integration may vary, based on practice setting and patient need, and may form a continuum of care. 4. With components of the PCMH and care integration elements in place, participants will routinely assess patient complexity and develop care approaches that are customized to the individual patient and his/her needs. 7 MassHealth Confidential draft / Policy under development / Statements are not binding on MassHealth Overview of clinical delivery model 1. Participants will have the functional capacity to provide 12 PCMH components, all of which are fundamental to care integration. 2. Participants will integrate behavioral health and primary care by implementing defined integration elements. 3. The approach to care integration may vary, based on practice setting and patient need, and may form a continuum of care. 4. With components of the PCMH and care integration elements in place, participants will routinely assess patient complexity and develop care approaches that are customized to the individual patient and his/her needs. 8 Confidential draft / Policy under development / Statements are not binding on MassHealth Review of 12 PCMH capabilities 9 • Patient/family centeredness • Self management support • Multi-disciplinary team-based approach to care • Patient and family education • Shared decision making, patient action plans • Planned visits & follow-up care • Evidence based care • Registry use for population and patient management • Integration of QI • Enhanced access • Care coordination • Care management for high risk patients Confidential draft / Policy under development / Statements are not binding on MassHealth Defining care management and care coordination 10 Care Management Care Coordination Wellness & Prevention Diagnosis & Treatment Confidential draft / Policy under development / Statements are not binding on MassHealth Overview of clinical delivery model 1. Participants will have the functional capacity to provide 12 PCMH components, all of which are fundamental to care integration. 2. Participants will integrate behavioral health and primary care by implementing defined integration elements. 3. The approach to care integration may vary, based on practice setting and patient need, and may form a continuum of care. 4. With components of the PCMH and care integration elements in place, participants will routinely assess patient complexity and develop care approaches that are customized to the individual patient and his/her needs. 11 MassHealth Confidential draft / Policy under development / Statements are not binding on MassHealth Defining behavioral health integration • “Behavioral health care” is used as an umbrella term, which refers to a continuum of services, including mental health care, unhealthy substance use diagnosis and treatment, and support to address unhealthy lifestyles that influence chronic conditions and quality of life • PCMHs will integrate behavioral health and primary care by implementing defined integration elements. • The approach to care integration may vary, based on practice setting and patient need, and may form a continuum of care. 12 Confidential draft / Policy under development / Statements are not binding on MassHealth Elements and approaches to integration MassHealth Element 1: Relationship and Communication Practices Element 2: Patient Care and Population Impact Element 5: Clinic System Integration Integrated Approaches ^Element 3: Community Integration Element 4: Care Management 13 Confidential draft / Policy under development / Statements are not binding on MassHealth Elements of behavioral health integration Relationship & Communication Practices Patient Care and Population Impact Community Integration Care Management Clinic System Integration Triaged access BH screening and referral Self help & community resource connections Coordination of integrated treatment plan Schedule accessibility Smooth hand-offs BH skills used by primary care team Specialty mental health & substance use referral Use of behavioral health skills Program Integration Team membership Integrated clinical pathways Use of community resources Health information exchange Health care team leader Coordinated scheduling and same day visits Family focused care Patient safety practices Patient feedback Supporting health behavior change 14 Confidential draft / Policy under development / Statements are not binding on MassHealth Overview of clinical delivery model 1. Participants will have the functional capacity to provide 12 PCMH components, all of which are fundamental to care integration. 2. Participants will integrate behavioral health and primary care by implementing defined integration elements. 3. The approach to care integration may vary, based on practice setting and patient need, and may form a continuum of care. 4. With components of the PCMH and care integration elements in place, participants will routinely assess patient complexity and develop care approaches that are customized to the individual patient and his/her needs. 15 MassHealth Confidential draft / Policy under development / Statements are not binding on MassHealth Managing diverse patient needs MassHealth Low-Moderate Complexity High Complexity • Primary care site is the main locus of care • Primary care or BH site is the main locus of care, by patient preference • Care delivery model includes 12 PCMH components • Care delivery includes 12 PCMH components • PCMH provides primary care services, including regular behavioral health screening and follow-up and support for health behavior change. May include on- site behavioral health provider • Clinical care management with care coordination are important components of care. Clinical care manager coordinates the development and implementation of an integrated treatment plan • Primary care team manages patients with less complex behavioral health conditions, supported by behavioral health - primary care provider to provider consultations and formalized patient referral for specialty behavioral health care • Co-leadership of health care team by primary care and behavioral health providers. Formalized agreements between primary care and behavioral health providers underpin care • More intensive use of community resources and specialty services 16 Confidential draft / Policy under development / Statements are not binding on MassHealth Agenda • Recap of program • Summary of clinical delivery model • Timing and requirements • RFI Feedback • Discussion 17 Confidential draft / Policy under development / Statements are not binding on MassHealth Timing for achieving requirements 18 Minimal requirements for participation • Practices meet the requirements of being a PCC (providing primary care services, referrals, etc.) • Practices have an EMR system, a patient registry, have received HIT incentive payments (except pediatric practices), and can report on quality metrics Requirements for transformation plan • The transformation plan evaluates current capacity against the specified delivery model and plans how to achieve the delivery model, with metrics and milestones. This includes hiring, process changes, IT investments, collaboration agreements, trainings, etc. Requirements at 6 months • Elements are being put in place for delivering on the model – staff are being hired, protocols are being developed, training programs are coming into place, relationships with other providers are forming Requirements at 1.5 years • The transformation plan is fully operationalized Confidential draft / Policy under development / Statements are not binding on MassHealth Agenda • Recap of program • Summary of clinical delivery model • Timing and requirements • RFI Feedback • Discussion MassHealth 19 Confidential draft / Policy under development / Statements are not binding on MassHealth Review of RFI feedback (1/3) MassHealth 20 RFI Comment MassHealth response • There are significant legal barriers to sharing information between primary care and behavioral health providers / It is important to protect patient privacy in sharing behavioral health information with PCPs • Any information sharing will have to comply with existing federal laws, which largely require patient consent for information exchange • We can facilitate sharing best practices on acquiring patient consent for information exchanges; some practices in the state have been innovating on establishing information sharing protocols consistent with current regulations • There are significant regulatory barriers to co-locating primary care and behavioral health services • We are working with DPH to reduce regulatory barriers to co-location • Please help us identify specific additional regulatory barriers that we or other state agencies could alleviate • Access to behavioral healthcare providers is a historic problem for MassHealth • Our hope is that payment through this model will alleviate access problems by promoting treatment of behavioral health conditions in primary care settings where appropriate Confidential draft / Policy under development / Statements are not binding on MassHealth Review of RFI feedback (2/3) MassHealth RFI Comment MassHealth response • Small practices may not have sufficient scale to support on-site behavioral health service provision • Small practices can band together and share behavioral health providers, or partner with behavioral health providers to provide part-time on-site coverage • We allow practices in “coordinated but not co-located” models to participate, but would encourage them to move to further integration • What are the protections in place to support adequate access to behavioral health services in a model where behavioral health services are included in the CPCP? • Practices opting to include behavioral health services in the CPCP (tiers 2 and 3) would be required to demonstrate the ability to provide the included services through licensed professionals • An improved relationship with behavioral health providers will enable primary care sites to be better able to assess and meet / refer out for the behavioral health needs of their patients • What is the appropriate interaction between payer-based care management and practice-based care management? • We believe payer-based care management and practice-based care management serve distinct and complementary roles, where payers can support practices in providing care management services 21 Confidential draft / Policy under development / Statements are not binding on MassHealth Review of RFI feedback (3/3) MassHealth RFI Comment MassHealth response • Practices will require historical data in advance to understand their patient population to deliver medical home services • We are planning to release databooks to applicants with basic information on panel size and characteristics based on claims and encounter data • Will practices be required to become NCQA certified? • We are considering requiring NCQA certification by the end of the second year of the program • We are interested in feedback on the appropriate timing and level of certification requirements, or whether they are required at all • Behavioral health providers bringing primary care onsite may have difficulty in meeting these requirements • We acknowledge that it is challenging for behavioral health providers to bring primary care on-site, but would be excited to support behavioral health providers if they choose to enroll as PCCs and participate • We are interested in feedback on the unique challenges BH providers who bring primary care on-site would face in implementing this model 22 Confidential draft / Policy under development / Statements are not binding on MassHealth Agenda • Recap of program • Summary of clinical delivery model • RFI Feedback • Timing and requirements • Discussion 23 Confidential draft / Policy under development / Statements are not binding on MassHealth Questions for discussion • Do this vision and timeline seem realistic for a broad range of practices to achieve? What are the major barriers? • We are striving to create a model applicable to the broad range of members in our managed care programs – are there unique needs of certain populations we need to additionally consider? • Should we require NCQA certification? If so, when and what level? • How can we further facilitate primary care – behavioral health integration in this model? • We look forward to continuing to receive your feedback. Please visit our website at http://www.mass.gov/eohhs/gov/newsroom/MassHealth/providers/primary- care-payment-reform-initiative.html • Our next open meeting will be 10/22, 1-2:30pm, Worcester Public Library, Saxe Room on Quality Metrics 24