OneCare Vermont Accountable Care Organization, LLC Board ... · 2/4/2019 · OneCare Vermont...

OneCare Vermont Accountable Care Organization, LLC

Board of Managers Meeting Agenda

February 19, 2019

4:30 p.m. – 7:00 p.m.

Central Vermont Medical Center – Conference Rooms 1 & 2

Time Agenda Item Presenter

4:30 p.m. Call to Order Steve Leffler

4:32 p.m. Consent Agenda-Approval of Minutes and Reports*

January 15, 2019 Board of Managers Meeting Minutes

Committee and CMO Reports

December Monthly P&L

Steve Leffler

4:40 p.m. Governance Actions

Nomination Policy

Vote to Approve Nomination Policy as Recommended

by Management Vacant Seat Nominations

o FQHC o CAH o Risk Strategy Committee

Vote to Approve Election of Nominees to fill the respective vacant Board seats as recommended by the Nominating Committee

Independent PCP Seat Status Report Proposed Board Seat Staggered Terms

Vote to Approve Staggered Board Seat Terms as

Proposed by Management

Population Health Strategy Committee Membership*

Vote to Approve FQHC nominee as member of

Population Health Strategy Committee as

recommended by Nominating Committee

Kevin Stone/Vicki

Loner

4:55 p.m. Government Affairs

Legislative Outreach Activity*

Bills of Interest to the ACO*

Kevin Stone/ Lucie

Garand/Amy Bodette

5:05 p.m. 2018 Payer Programs

YTD Summary Performance*

VMNG Performance-Legislative Report Findings*

Tom Borys/Norm Ward

5:15 p.m. Value Based Care

Innovation Fund RFP Progress

Sara Barry

5:20 p.m. Communications & Operations

New Website

2020 PY Contracting Timeline*

New Board Meeting Technology

Amy Bodette

Joan Zipko

Vicki Loner

5:30 p.m. Public Comment Steve Leffer

5:35 p.m. OneCare Executive Session Steve Leffler

6:55 p.m. Votes

1. Vote to approve Executive Session Minutes from

January 15, 2019

2. Vote to Approve Executing CEO Search Firm Contract

Steve Leffler

7:00 p.m. Adjourn Steve Leffler

*Denotes Attachment

Attachments:

1. Draft of OneCare Board of Manager Minutes from January 15, 2019

2. Board Committee Report outs,

3. CMO’s corner,

4. December Financial P&L Report

5. Nomination Policy

6. Staggered Terms Proposal

7. FQHC/Bi-State Population Health Strategy Committee Nominee Bio

8. Legislative Outreach Summary

9. Legislative Bills Grid

10. 2018 YTD Payer Program Summary Dashboard Performance Report

11. VMNG Annual Legislative Performance Update

12. PY 2020 Contracting Timeline

13. Social Determinants of Health Article (FYI Only)

Note: Reasonable expenses of managers for attendance at board meetings may be paid

or reimbursed by OneCare Vermont.

1

ONECARE VERMONT ACCOUNTABLE CARE ORGANIZATION, LLC

BOARD OF MANAGERS MEETING JANUARY 15, 2019

MINUTES

A meeting of the Board of Managers of OneCare Vermont Accountable Care Organization, LLC (“OneCare”) was at OneCare offices on January 15, 2019.

I. Call to Order

Steve Leffler called the meeting to order at 5:05 p.m.

II. Minutes

The minutes from December 18, 21 and 27, 2018 were approved unanimously.

III. CEO Update

Todd Moore thanked the board members (past and present) for their commitment to OneCare and willingness to attend all of the Board meetings over the past 6 years. Mr. Moore also noted that the Blue Cross Blue Shield contract was finalized and signed this week.

IV. Committee Updates

Executive Committee: The Committee discussed interim CEO transition planning, invoking of fraud and abuse waivers, the Board Governance for 2019 and payer program updates.

Finance Committee: The Finance Committee discussed the plan for analyzing the updated Medicare numbers. They also discussed the specialist payment reform pilot and how that will function. CMS notified OneCare that All Inclusive Population Based claims will be not be able to be processed until February. A Participating hospital has identified a methodology to help reconciliation process from 2018, and other hospitals are now going back to look at the numbers and run the reconciliation. The monthly Financials for November were reviewed. Upon a motion that was seconded, November Monthly Financials were approved unanimously by the board.

Population Health Strategy Committee: The committee discussed the release of the innovation fund RFP. There is a lot of interest and they will be due January 31st. Patient and Family Advisory Committee: The committee continued to discuss the previous meeting in which the Healthcare Advocate was in attendance. The PFAC members felt uncomfortable with the format and style of the meeting. They discussed possible plans for how to address the HCA meeting next time. They group then discussed some of the major projects OneCare will be working on going forward.

2

V. CMO Update

Dr. Norman Ward updated the Board on clinical activities that are highlighted in the CMO’s Corner document in the public packet. Sara Barry gave an update on the innovation RPF process, including the screening criteria and the expected number of submissions is expected be quite large, There will be informational webinars for potential applicants to learn more as well.

VI. Program Updates:

Tom Borys updated the Board on the Year to Date Payer Program Summary Dashboard. He noted the favorable performance over benchmarks; and that Medicare exceeds corridor on the positive side and that we are expecting shared savings. The claims runout process is still occurring as well.

VII. Public Comment:

There was no public comment.

VIII. Recess

IX. Executive Session

X. Voting

a. The Executive Session Minutes from December 18, 21 and 27, 2018 were approved unanimously.

b. The motion to approve the resolution invoking Fraud and Abuse Waivers as allowed by Medicare and Medicaid was approved by a supermajority of the Board.

c. The motion to approve Vote to Approve Resolution Amending Operating Agreement as Recommended by Executive Committee was approved by a supermajority of the Board.

d. The motion to approve the resolution allowing Management to amend Service Agreement was approved by a supermajority of the Board.

e. The motion to approve Dr. Steve Leffler as Chair of the Board of Managers was approved by a supermajority of the Board.

f. The motion to approve Dr. Joe Perras as Vice Chair of the Board of Managers was approved by a supermajority of the Board.

g. The motion to approve Dr. Joe Perras and Steve Gordon being added to the Executive Committee was approved by a supermajority of the Board

h. The motion to approve Tomasz Jankowski appointment to the Board to fill the Designated Agency/Mental Health manager seat was approved by a supermajority of the board.

XI. Other Business

Kevin Stone informed the Board that he was stepping down from the board effective immediately and will officially start as OneCare Interm CEO effective January 28, 2019.

3

XII. Adjourn

Upon a motion that was seconded, the meeting adjourned at 6:11 p.m.

4

Attendance: OneCare Board Members

☒ Sierra Lowell ☐ Steven Gordon ☒ Joseph Perras, MD ☒ Todd Keating ☒ Judy Peterson ☒ Jill Berry-Bowen ☐ Steve LeBlanc ☒ Toby Sadkin, MD ☒ John Brumsted, MD ☒ Steve Leffler, MD ☒ John Sayles ☒ Betsy Davis ☒ Judy Morton ☒ Kevin Stone ☐ Mary Moulton ☒ Pamela Parsons

OneCare Risk Strategy Committee

☒ Tom Dee ☐ Tom Manion ☒ Jeffrey Haddock, MD ☐ Anna Noonan

OneCare Leadership and Staff

☒ Todd Moore ☒ Tom Borys ☒ Linda Cohen Esq. ☒ Vicki Loner ☒ Sara Barry ☒ Spenser Weppler ☒ Karen Lee ☐ Susan Shane ☒ Amy Bodette ☒ Norm Ward, MD ☐ Joan Zipko ☒ Greg Daniels

☐ Martita Giard

OneCare Board of Manager Committee Report-outs

Executive Committee

At its February 6th meeting, committee discussed governance including the nomination policy, nominees for FQHC, Critical Access Hospital and the At-Large Risk Strategy seat as well as the process for the Independent Primary Care Physician Seat. The committee also discussed the staggered term proposal from Management. An update was given on the CEO search process which will include key stakeholder input. The committee also continued to discuss the Medicare Benchmark for 2019 as well as scale targets under the All Payer Model. Lastly, Kevin Stone updated on his time so far in the interim role including testifying in the legislature as well as an upcoming Green Mountain Care Board Panel that will focus on Reports from the field around the All Payer Model.

Finance Committee

At its February 13th meeting, the committee was updated on the commercial contract status and continue to discuss the 2019 Medicare Benchmark. There was discussion around the 2018 All-inclusive population base payment reconciliation process as well as an update on the 2019 claims processing issue, which is still on track to be live by February 18th. There was discussion around Risk Mitigation for 2019 as well as the 2018 budget order deviation request that OneCare will be asking of the Green Mountain Care Board later this month. Lastly there was a review of the 2018 program performance and the committee approved the December monthly financials to be sent to the full Board.

OneCare Vermont Board of Managers – 2.19.19

CMO Corner – Norman Ward, MD

1. Vermont Medicaid Next Generation 2018 Legislative Report Results - (next

page) Highlighted utilization comparisons (0-17 and 18+y) of OneCare Vermont

Medicaid Next Generation attributed patients to non-attributed Vermont Medicaid

patients. Generally, a good story of higher rates of primary care services, lower

ED use, higher use of home health services, and higher use of mental health

services in our attributed population. These comparisons do not permit risk

adjustment of the two populations.

2. 2019 Vermont Medicaid Select Condition Prevalence (page3)

3. Regional Clinician Representative Orientation Trips - Dr. Rousse/ St.

Johnsbury 2.15.19, Dr. White/Randolph 2.18.19 , Drs. Lapp/Fjeld/Rutland

2.19.19, Dan Moran/Dartmouth 2.28.19

4. AMA Resolution on Research Uses of CMS ACO Data – Dr. Ward with the

help of Linda Cohen and with the endorsement of the Vermont Medical Society

will present a resolution at the annual AMA meeting in Chicago hoping to

facilitate use of ACO data for publishing quality improvement studies.

5. ADHD Grand Rounds – 2.12.19 – Dr. Wasserman moderated a WebEx for

some 90 participants concerning diagnosis and treatment of ADHD, effective use

of school nurses in managing this condition, and a poignant parent presentation

about her family’s journey with this condition.

6. Medicare QIN-QIO Sepsis Grand Rounds – May 2019 – planning efforts are

underway to cosponsor this symposium on recognition of this very serious health

condition by both clinicians, patients, and families

7. Zero Suicide Press Conference - 2.14.19 – Dr. Ward participated in Zero-

Suicide Day at the statehouse, which included a joint press conference with

Secretary Gobeille, and representatives of Blueprint, VPQHC, VDMH.

8. Home Infusion analysis – efforts are underway to analyze potential impacts on

patients and the care system of home infusions for multiple pharmaceuticals.

OneCare VermontStatement of Assets, Liablilities and Equity

December 31, 2018

Current Month

Previous

Month Change

Cash - Unrestricted 4,136,567 444,553$ 3,692,014$

GMCB - Required Reserve Funding 1,100,000 1,100,000$ -$

Additional Reserve Funding (CMS) 4,140,826 4,140,826$ -$

VBIF Funding 4,243,973 3,921,133$ 322,840$

Advance Funding - VMNG 10,771,335 5,333,880$ 5,437,455$

Network Receivable 25,812,018 1,288,766$ 24,523,252$

Accounts Receivable 12,576,225 3,714,597$ 8,861,628$

Prepaid Expense 27,253 736,926$ (709,673)$

Total Assets 62,808,196 20,680,680$ 42,127,516$

Unearned Revenue 553,926 2,062,514$ (1,508,588)$

Accrued Expenses 26,997,725 202,518$ 26,795,207$

Network Payable 26,483,770 9,447,890$ 17,035,880$

Due to UVMHN - CMS Reserve Funding 4,124,849 4,124,849$ -$

Due to UVMMC - CY18 3,092,476 2,901,483$ 190,993$

Due to DHH - CY18 - -$ -$

Total Liabilities 61,252,746 18,739,254$ 42,513,492$

Capital Contribution UVMMC 777,725 970,713$ (192,988)$

Capital Contribution D-H H 777,725 970,713$ (192,988)$

Total Equity 1,555,451 1,941,426$ (385,975)$

Total Liabilities and Equity 62,808,196 20,680,680$ 42,127,516$

NOTE: This statement is created for the benefit of the member

organizations of OneCare Vermont and is not representative of a GAAP

Balance Sheet.

OneCare Vermont2018 P&L

December 31, 2018

Current Month

OCV YTD

Actual

YTD

Budget

$ Variance

Fav/(Unfav)

% Variance

Fav/(Unfav)

Annual

Budget

Rise VT YTD

Actual

Adk ACO YTD

Actual

VMNG Revenue 238,810$ 3,086,480$ 3,134,352$ (47,872)$ -1.5% 3,134,352$ -$ -$

VMNG PHM Program Pilot - Complex CC 298,075$ 2,901,190$ 2,980,045$ (78,855)$ -2.6% 2,980,045$ -$ -$

BCBSVT Reform Pilot Support 58,220$ 743,600$ 1,000,000$ (256,400)$ -25.6% 1,000,000$ 100,000$ -$

Self-Funded Pilot Revenue 79,923$ 750,972$ 1,075,896$ (324,924)$ -30.2% 1,075,896$ -$ -$

CMS Medicare Blueprint Replacement 648,063$ 7,776,760$ 7,762,500$ 14,260$ 0.2% 7,762,500$ -$ -$

SOV PHM Program Pilot - Primary Prevention -$ -$ 1,500,000$ (1,500,000)$ -100.0% 1,500,000$ -$ -$

Informatics Infrastructure Support 291,666$ 3,500,000$ 3,500,000$ (0)$ 0.0% 3,500,000$ -$ -$

Other Grants/Contracts - RWJ 51,851$ 51,851$ 51,851$ -$ 0.0% 51,851$ -$ -$

Other Grants/Contracts - Adirondack 18,000$ 216,000$ 216,000$ (0)$ 0.0% 216,000$ -$ -$

Other Grants/Contracts - Cigna 11,609$ 139,289$ 104,000$ 35,289$ 33.9% 104,000$ -$ -$

Other Revenue 252,599$ 370,826$ -$ 370,826$ 0.0% -$ 339,738$ 713,911$

Participation Fees 1,449,945$ 17,399,336$ 18,459,071$ (1,059,735)$ -5.7% 18,459,071$ -$ -$

Total Income 3,398,761$ 36,936,305$ 39,783,715$ (2,847,410)$ -7.2% 39,783,715$ 439,738$ 713,911$

Basic OCV PMPM 302,175$ 3,990,100$ 4,781,010$ 790,911$ 16.5% 4,781,010$ -$ -$

Care Coordination 485,333$ 5,633,580$ 7,064,722$ 1,431,142$ 20.3% 7,064,722$ -$ -$

PCP Comprehesive Payment Reform Pilot 63,148$ 715,806$ 1,800,000$ 1,084,194$ 60.2% 1,800,000$ -$ -$

VBIF 283,979$ 4,243,973$ 4,305,223$ 61,250$ 1.4% 4,305,223$ -$ -$

Community Program Investments 305,701$ 897,801$ 1,577,600$ 679,799$ 43.1% 1,577,600$ -$ -$

Blueprint 650,393$ 7,780,517$ 7,762,500$ (18,017)$ -0.2% 7,762,500$ -$ -$

Salaries/Fringe 634,151$ 6,613,907$ 6,583,992$ (29,915)$ -0.5% 6,583,992$ 274,040$ $ 637,939

Purchased Services 153,503$ 1,238,647$ 845,766$ (392,881)$ -46.5% 845,766$ 14,345$ 21,747$

Contract & Maintenance 533,112$ 3,270,618$ 2,925,467$ (345,151)$ -11.8% 2,925,467$ 14,271$ -$

Lease & Rental 45,306$ 265,294$ 321,051$ 55,757$ 17.4% 321,051$ -$ -$

Utilities 12,264$ 77,650$ -$ (77,650)$ 0.0% -$ 2,229$ -$

Other Expenses 315,670$ 702,959$ 1,816,384$ 1,113,425$ 61.3% 1,816,384$ 134,852$ 54,225$

Total Expenses 3,784,737$ 35,430,852$ 39,783,715$ 4,352,863$ 10.9% 39,783,715$ 439,738$ 713,911$

Net Income / (Loss) (385,976)$ 1,505,452$ -$ 1,505,452$ -$ -$ -$

Policy Title: Board of Managers Nomination Policy, Designated Managers

Responsible Department/s:

Accountable Care Services

Author: Vicki Loner

Date Implemented: 2/18/2019

Date Reviewed/Revised: 2/18/2019

Approved by: Board of Managers

Next Review Date: 2/18/2020

Purpose: This Policy outlines the process that Management will follow when soliciting nominees for designated at large Managers for the OneCare Board of Managers. This policy implements a process for such nominations described in the Sixth Amended and Restated Operating Agreement, Section 6.1(a)(iv) (hereinafter “Operating Agreement”) and practices that promote a fair and open nominating process to yield qualified nominees. Statement: OneCare shall maintain an identifiable, distinct governing body that has ultimate responsibility for oversight and strategic direction of the ACO (the “Board of Managers.”). The Board of Managers will hold OneCare’s management team accountable to the ACO’s activities. There will be a defined processes for nominating designated, at-large managers to its Board. Actions/ Responsibilities: Administration: The Board of Managers assigns to the Chief Operating Officer (COO), or her/his delegate(s), the authority to supervise the process by which candidates are nominated and chosen to stand for election to the Board of Managers. Eligibility: Qualified nominees must:

1. Participate in at least one core ACO program as defined annually by ACO Policy; 2. Understand and agree to commit to the responsibilities to serve on the Board of Managers,

including having a fiduciary duty and duty of loyalty to OneCare; and 3. Meet the requirements for nomination outlined in the Operating Agreement

Preference will be given to those nominees that are in all core programs and operating under a value based payment structure. Call for Designated At-Large Managers Nominations:

I. For each qualified vacancy on the Board of Managers, the COO will send a notice to all Managers who are members of the nominating group for the vacancy and/ or the Association representing the nominating group asking for nominations of qualified candidates to stand for election to the Board of Managers. By each nominating group the process shall be as follows:

1. Federally Qualified Health Centers: Bi-State Primary Care Association will coordinate the

nomination process for FQHCs. In the event that a participating FQHC in the nominating group is not a member of Bi-State then Bi-State will either include the participating FQHC in the nomination process or coordinate with the OneCare COO to develop processes for inclusion.

2. Critical Access Hospitals and Community Prospective Payment Systems Hospitals: The Vermont Association of Hospitals and Health Systems (VAHHS) will coordinate the nomination process for Critical Access and Community PPS Hospitals. In the event that a participating hospital in the nominating group is not a member of VAHHS then VAHHS will either include that non-member hospital in the nomination process or coordinate with the

of 3

OneCare COO to develop processes for inclusion. Qualified Independent Private Practices (2): OneCare Management will coordinate the nomination process for all independent Private Practices. Management will solicit nominees from each qualifying independent practice Participant TIN by communication with the TIN’s contractual designee for notices. The solicitation will provide information about the required qualifications and Board preferences for the manager to be nominated. Each TIN will have one opportunity to provide a nominee and must verify that the person(s) nominated is/are willing to serve if selected. Management will forward nominees to the Nominating Committee who will determine which nominee(s) will move forward to the full Board for elections. For CY 2019, the Board has directed that qualified candidates must be independent primary care physicians actively practicing.

3. Skilled Nursing Facilities (SNF): The Vermont Health Care Association (VHCA) will coordinate the nomination process for skilled nursing facilities. In the event that a participating SNF in the nominating group is not a member of VHCA, then VHCA will either include the non-member SNF in the nomination process or coordinate with OneCare COO to develop processes for inclusion.

4. Home Health Agencies VNAs of Vermont and BAYDA will coordinate the nomination process for qualified Home Health Agencies.

5. Designated Agency for Mental Health and Substance Abuse: Vermont Care Partners (VCP) will coordinate the nomination process for Designated Agencies. In the event that a participating Designated Agency in the nominating group is not a member then VCP will either include the non-member in the nomination process or coordinate with OneCare COO to develop processes for inclusion.

II. The COO shall forward all nominations received from the aforementioned processes to the Nominating Committee of the Board for discussion and recommendation to the Full Board of Managers.

III. The COO will, without undue delay after nominations have been closed, notify the Nominees or the nominating Association(s) of the Nominating Committee’s decision whether to forward the nominee to the Full Board of Managers for election.

IV. In the event that there are an insufficient number of nominees for election, the members of the Nominating Committee (via the COO) will recruit additional nominees, by processes to be determined by the Nominating Committee in consultation with the COO, to ensure that there are at least as many nominees as there are vacant positions for the annual election.

Withdrawal of a Nomination: Any Nominee may request the withdrawal of his/her nomination before the COO gives the nominee list to the Nominating Committee Rejection of a Nomination: The Nominating Committee may determine not to pass a nominee’s name to the full Board for election based on a nominee's qualifications for inclusion, known conflicts, criminal background checks or any reason it determines in good faith to be in the best interests of the ACO. If the Nominating Committee declines to move nomination forward, the COO shall communicate to the nominee. Location on Shared Drive: S:\Groups\Managed Care Ops\OneCare Vermont\Policy and Procedures\Policies Management Approval: _________________________________________________________________________________________ Director, ACO Public Affairs Date

of 3

_________________________________________________________________________________________ Chief Operating Officer Date Board of Manager Approval: _________________________________________________________________________________________ Chair, OneCare Board of Managers Date

Board of Mangers 1st Term End Dates

Manager Name OCV Board Start Date

First Term End Date

Jill Berry-Bowen March 2017 March 2020

Betsy Davis November 2015 November 2021

Steve Gordon January 2018 January 2021

Tomasz Jankowski February 2019 February 2022

Sierra Lowell October 2018 October 2021

Judy Morton July 2014 July 2020

Pam Parsons June 2017 June 2020

Judy Peterson January 2016 January 2021

Toby Sadkin February 2014 February 2020

John Sayles October 2014 October 2020

CAH Seat March 2019 March 2022

FQHC Seat March 2019 March 2022

Ind. PCP Seat March 2019 March 2022

At Large Risk Strategy Seat

March 2019 March 2021

All Managers Will be considered to be starting their “First” Term as this point in time.

If Board Manager Started in 2019, their First Term End Date will be in 2022 with the exception

of the At Large Risk Strategy Seat which will end in 2021

Bio Sketch for Kari White - Director of Quality Initiatives and Compliancy/Privacy Officer At Northern Counties Health Care, St. Johnsbury, VT Kari grew up in rural central Vermont before heading off to college and the big wide world. After Kari's early career in investment banking and development in NYC and theatre and retail in England, she moved back to VT where she spent five years with the VT Department of Health, working with mothers and young children as part of the WIC program. In her current role as the Director of Quality Initiatives and Compliancy/Privacy Officer at Northern Counties Health Care (NCHC), Kari has become a passionate leader with ever-increasing experience and responsibility for building a systemic culture of excellence and driving positive change in the health and well-being of our communities. She is committed to compassionate innovation in achieving the Quadruple Aim and providing relational leadership focused on building teams capable of sustainable, flexible and humane implementation of healthcare payment and delivery reform frameworks including Accountable Communities for Health, Patient-Centered Medical Home, Accountable Care Organization, and Blueprint for Health. Kari directs NCHC’s award-winning, high performance Quality Improvement/Quality Assurance and Compliance efforts, and leads cross-sector, multi-agency, results-driven Collective Impact workgroups addressing the social determinants of health including the Mentally Healthy Collaborative Action Network of the nationally-recognized NEK Prosper! Caledonia-So. Essex Accountable Health Community. As such, Kari is an in-demand advocate and presenter on the challenges and solutions to healthcare system and payment reform. Kari lives in an old farmhouse with her supportive and patient husband, Neil, and four incredible girls in the Northeast Kingdom of Vermont.

Government Relations

Please welcome Lucie Garand our Senior Government Relations Specialist from Downs Rachlin Martin. We couldn’t be more pleased to have Lucie working the halls for us.

2019 Testimony

Senate Health and Welfare

• Introduction to OneCare (1/24) • Adverse Childhood Experiences (2/1) • Social Services Integration (2/15)

Senate Finance

• DVHA gave an ACO update. Vicki Loner was in the room and gave 10 (impromptu) minutes of testimony. (2/6)

House Ways and Means

• Impact of Billback on ACO (2/12) – Tom Borys discussed impact of Billback on the network.

House Health Care

• Introduction to OneCare (scheduled for 2/20)

Meetings with Legislators

Kevin Stone and Vicki Loner met with Senator Ginny Lyons and Representative Bill Lippert (1/31). As a follow-up, they will come to OneCare for a technology demonstration (2/18).

Kevin and Vicki also met with Rich Westman of Lamoille (1/24).

Questions and hot topics from our testimony and conversations:

• ACES • Is OneCare a for-profit organization? • governance structure • How does the cash flow? • Is OneCare regulated enough?

Bill Tracking

With the help of Lucie we are closely tracking several bills in the legislature including universal primary care, primary care spending, Billback, ACO audit, Social Services Integration, etc. Please see grid in the packet.

Public Affairs Report •February 2019•

Other State House Events

Participated with RiseVT in the VAHHS sponsored Healthier State House health fair.

Dr. Norm Ward was a speaker at Suicide Prevention Day at the State House. He detailed OneCare’s commitment to reducing deaths by suicide.

Upcoming Event

The Green Mountain Care Board is hosting a panel discussion on February 27th from 9-11 am in the Pavilion Auditorium in Montpelier. The theme is “All-Payer Reports from the Field.” This is an opportunity to showcase how the All Payer Model and health care reform efforts are changing communities.

The panel features:

• Steve Leffler • Judy Peterson • Jill Lord and Carla Kamel from Mt. Ascutney (Joe Perras will be in attendance) • Carrie Wulfman and Alison Wurst from Porter Medical Center • Joe Haddock from Thomas Chittenden Health Center • Northwestern Medical Center

At the conclusion of the panel discussion there will be an opportunity to make a public comment. We encourage you to participate and share your experiences.

FY20 Federal Funding Requests

We made three submissions for FY20 Federal Funding. Topics of request: telemedicine, embedded mental health clinicians, and medically tailored meals. Thanks to VNAs and John Sayles for the support in these submissions. So far we have seen some traction on medically tailored meals and we will keep our fingers crossed on funding for all of them.

Communications

Recent Press Coverage

In January, Vicki Loner and Marissa Parisi appeared on “On the Waterfront with Melinda Moulton.” If you missed it (and their December appearance on “What Matters this Week with Lauren Maloney”), you can find links on our social media platforms. We post on Twitter and LinkedIn—follow us!

Website Redesign

We are preparing to go live with our revamped website and refreshed logo. This is a three phase project. Phase 1) re-design Phase 2) adding content Phase 3) provider portal development. Stay tuned for a demo next month.

BodyBill

NumberAuthor Title Location Summary Status

Notes

H 52 Till (D) Green Mountain Care BoardHouse Health Care

Committee

Relates to requiring at least one

member of the Green Mountain

Care Board to be a health care

professional.

01/18/2019 -

INTRODUCED.;01/22/2019 - To HOUSE

Committee on HEALTH CARE.

(See S.42)

H 89 Conquest (D)Health Care Spending Allocation

Proportion

House Health Care

Committee

Relates to increasing the proportion

of health care spending allocated to

primary care.

01/24/2019 -



(See S.53)

H 129 Cina (D)Universal Publicly Financed Primary

Care Program

House Health Care

Committee

Relates to a universal, publicly

financed primary care program.

01/30/2019 -



Universal Primary Care proposal - no

committee discussion or hearings yet

H 181 Donahue (R)State Auditor Accountable Care

Records Access

House Health Care

Committee

Relates to providing the State

Auditor with access to accountable

care organization records.

02/06/2019 - INTRODUCED.To HOUSE

Committee on HEALTH CARE

Requires a certified accountable care

organization to provide the Office of

the Auditor of Accounts with access

to the accountable care

organization’s records as needed to

enable the Auditor to audit the

accountable care organization’s

financial statements, receipt and use

of federal and State monies, and

performance. Just introducted - no

hearings scheduled yet.

H 195 Wood (D)Miscellaneous Public Health

Provisions

House Health Care

Committee

Relates to miscellaneous health

provisions

02/07/2019 -


Committee on HUMAN SERVICES.

This bill proposes to implement

miscellaneous provisions related to

Vermonters’ health and wellness. It

would

require restaurants licensed by the

Department of Health to serve only

children’s meals that meet certain

nutritional standards. It would also

establish a legislative Sugar-

Sweetened Beverage Working Group.

The bill would appropriate funds for

community bicycle and pedestrian

initiatives.

S 7 Lyons (D)Evaluation of Social Service

Integration


Committee

Relates to the evaluation of social

service integration with accountable

care organizations.

01/14/2019 -

INTRODUCED.;01/15/2019 - To

SENATE Committee on HEALTH AND

WELFARE.

Page 1 18990192.1

BodyBill

NumberAuthor Title Location Summary Status

Notes

S 42 Lyons (D)Green Mountain Care Board

Member Requirement


Committee

Relates to requiring at least one

member of the Green Mountain

Care Board to be a health care

professional.

01/18/2019 -



WELFARE.

Legislative Counsel has given

overview of bill - would allow

physicians employed by regulated

entity to serve on the GMCB - but

would prohibit medicial professionals

in a managerial or administrative role

from serving on the board.

S 53 Ashe (D)Proportion of Health Care Spending

Increase


Committee

Relates to increasing the proportion

of health care spending allocated to

primary care.

01/23/2019 -



WELFARE.

Requires more significant spending

growth in primary care than in other

areas - Follows Rhode Islands model.

After GMCB and other stakeholders

determine appropriate spend,

regulated entities have to submit

plan on how they will achieve it.

committee is interestedin pursuing

H ? FY2020 Budget

Will be sent to House

Appropriations Committee

after introduction

The Administration has proposed a

cut to the GMCB of $2.5 million and

recommended that the GMCB bill

back to the regulated entitites to

make up for the funding cut. The

current proposal is for the state to

pay 26%, 37% by the hospitals, 24%

by health insurance companies and

certain hospitals, and 7.4% by ACO's.

Page 2 18990192.1

PY2018 Executive Performance DashboardOneCare Vermont Total

Reporting Period: Thru September 2018

Target Actual Target Actual

328,363 Member Months (YTD) Inpatient 259.82$ 244.48$ ($15.33) -6% Inpatient 180 214 34 19%

$872 Target Total Cost PMPM¹

Outpatient 261.76$ 231.05$ ($30.71) -12% Outpatient 31,671 33,010 1,339 4%

$808 Actual Total Cost PMPM Professional 154.00$ 133.53$ ($20.47) -13% Professional 19,479 20,177 698 4%

$286,306,351 Target Total Cost¹

DME 14.73$ 12.62$ ($2.11) -14% DME 1,470 1,490 20 1%

$265,410,896 Actual Total Cost (FFS Equiv.) PAC 103.61$ 116.27$ $12.66 12% PAC 2,430 3,428 998 41%

$20,895,455 Under Target (Gross) Confidential 60.27$ 60.27$ $0.00 0% Confidential N/A N/A N/A N/A

$11,452,254 Shared Savings² Total (Gross) 854.19$ 798.23$ ($55.96) -7% Total (Gross) N/A N/A N/A N/A


363,596 Member Months (YTD) Inpatient 50.06$ 47.36$ ($2.69) -5% Inpatient 48 49 0 1%

$247 Target Total Cost PMPM Outpatient 73.03$ 59.47$ ($13.56) -19% Outpatient 6,022 4,045 (1,977) -33%


$89,943,619 Target Total Cost DME 6.52$ 5.67$ ($0.85) -13% DME 322 368 46 14%

$87,589,445 Actual Total Cost PAC 3.40$ 3.82$ $0.42 12% PAC 325 362 37 11%

$2,354,174 Shared Savings³ Confidential 24.43$ 19.02$ ($5.41) -22% Confidential N/A N/A N/A N/A

$8,021,137 FPP Savings⁴ Total (Gross) 247.37$ 220.31$ ($27.06) -11% Total (Gross) N/A N/A N/A N/A


173,865 Member Months (YTD) Inpatient 56.11$ 67.13$ $11.02 20% Inpatient 26 25 (1) -4%

$531 Target Total Cost PMPM Outpatient 213.26$ 214.83$ $1.56 1% Outpatient 3,405 3,523 117 3%


$92,340,794 Target Total Cost DME 6.34$ 5.92$ ($0.43) -7% DME 230 253 23 10%

$89,667,745 Actual Total Cost Community 1.24$ 2.02$ $0.77 62% Community 61 91 30 48%

$2,673,048 Under Target (Gross) Confidential 95.90$ 84.19$ ($11.71) -12% Confidential N/A N/A N/A N/A

$1,109,315 Shared Savings⁵ Total (Gross) 525.57$ 507.56$ ($18.01) -3% Total (Gross) N/A N/A N/A N/A

BCBS QHP (18,086 active members)

Risk Settlement Status

Footnotes:¹Includes Blueprint payment of $5,821,875 ($18 PMPM) which accounts for 2% of Medicare Total Cost of Care

²Represents shared savings/losses taking into consideration the risk corridor and 80% share for Medicare

³Represents shared savings/losses taking into consideration the risk corridor

⁴FPP (Fixed Prospective Payment) Savings are not part of the cash settlement for Medicaid

⁵Represents shared savings/losses taking into consideration the risk corridor, paid to allowed ratio and 50% share for BCBS QHP

NOTICE: All data produced by OneCare VT is for the sole use of its

contracted OneCare VT Participants and must not be distributed to other

individuals or entities who do not hold a legally binding contract with

OneCare VT. These materials are confidential and may only be used in

connection with OneCare VT activities. The use of these materials is

subject to the provisions of the Business Associate Agreement and/or

Participation or Collaboration Agreement with OneCare VT.

Medicare (36,028 active members)


Medicaid (38,228 active members)


Medicare claims paid through: 12/28/18

Medicaid claims paid through: 12/28/18

BCBS QHP claims paid through: 12/31/18

FFS Equivalent PMPM Target to Actual

Variance

Utilization PKPY Target to Actual

Variance

FFS Equivalent PMPM Target to Actual

Variance

Utilization PKPY Target to Actual

Variance

FFS Equivalent PMPM Target to Actual Utilization PKPY Target to Actual

Variance Variance

-10%

-5%

BP

(-2

%)

Targ

et

+5%

+10%

Actual: -7.30%

-10%

-3% Targ

et

+3%

+10%

Actual:-2.62%

-10%

-6%

Targ

et

+6%

+10%

Actual:-2.89%

1

Submitted by the Agency of Human Services to Senate Health and Welfare, House Health Care, House Human Services.

1-15-2019

Report to the Vermont Legislature

Delivery System Reform Report: 2018 Act 113, Section 12; Act 82, Section 7

2

CONTENTS

Statutory Charge ........................................................................................................................................................ 3

Executive Summary ................................................................................................................................................... 4

Section 1: PAYMENT REFORM AS A PROCESS............................................................................................................ 5

Planning ................................................................................................................................................................. 5

Design .................................................................................................................................................................... 6

Implementation ..................................................................................................................................................... 7

Evaluation .............................................................................................................................................................. 8

Section 2: MEDICAID PAYMENT AND DELIVERY SYSTEM REFORM ........................................................................... 8

Vermont Medicaid Next Generation (VMNG) ACO program ............................................................................. 9

Applied Behavior Analysis (ABA) ...................................................................................................................... 11

Children’s and Adult’s Mental Health .............................................................................................................. 12

Residential Substance Use Disorder (SUD) Programs ...................................................................................... 14

Developmental Disabilities Services ................................................................................................................ 16

Pediatric Palliative Care ................................................................................................................................... 17

3

STATUTORY CHARGE

Section 12 of Act 113 of 2016 requires the Secretary of the Agency of Human Services to embark upon a multi-year process of payment and delivery system reform for Medicaid providers that is aligned with the Vermont All-Payer Accountable Care Organization Model and other existing payment and delivery system reform initiatives. This report is the third of five reports required by Act 113.

STATUTORY CHARGE:

(a) The Secretary of Human Services, in consultation with the Director of Health Care Reform, the Green Mountain Care Board, and affected providers, shall create a process for payment and delivery system reform for Medicaid providers and services. This process shall address all Medicaid payments to affected providers and integrate the providers to the extent practicable into the all-payer model and other existing payment and delivery system reform initiatives.

(b) On or before January 15, 2017 and annually for five years thereafter, the Secretary of Human Services shall report on the results of this process to the Senate Committee on Health and Welfare and the House Committees on Health Care and on Human Services. The Secretary’s report shall address:

(1) all Medicaid payments to affected providers;

(2) changes to reimbursement methodology and the services impacted;

(3) efforts to integrate affected providers into the all-payer model and with other payment and delivery system reform initiatives;

(4) changes to quality measure collection and identifying alignment efforts and analyses, if any; and

(5) the interrelationship of results-based accountability initiatives with the quality measures in subdivision (4) of this subsection.

This report also incorporates the work contemplated by Section 7 of Act 82 of 2017, which required a plan to integrate multiple sources of payment for mental health and substance abuse services to the designated and specialized service agencies (DAs and SSAs).

FULL TEXT

Act 82, Sec. 7. PAYMENTS TO THE DESIGNATED AND SPECIALIZED SERVICE AGENCIES The Secretary of Human Services, in collaboration with the Commissioners of Mental Health and of Disabilities, Aging, and Independent Living; providers; and persons who are affected by current services, shall develop a plan to integrate multiple sources of payments for mental and substance abuse services to the designated and specialized service agencies. In a manner consistent with Sec. 11 of this act, the plan shall implement a Global Funding model as a successor to the analysis and work conducted under the Medicaid Pathways and other work undertaken regarding mental health in health care reform. It shall increase efficiency and reduce the administrative burden. On or before January 1, 2018, the Secretary shall submit the plan and

4

any related legislative proposals to the Senate Committee on Health and Welfare and the House Committees on Health Care and on Human Services.

_____________________________________________________________________________________

This is the third annual report required by Section 12 of Act 113 of 2016. The first annual report detailing progress on delivery system and payment reform for Medicaid providers can be found here:

• First Annual Report Filed 1/3/2017: http://legislature.vermont.gov/assets/Legislative-Reports/Act-113-Sec-12-Medicaid-Pathway-Report-12-30-16.pdf

The second annual report detailing progress on delivery system and payment reform for Medicaid providers can be found here:

• Second Annual Report Filed 1/15/2018: https://legislature.vermont.gov/assets/Legislative-Reports/Delivery-System-Reform.Medicaid-Pathways-Report-1.15.18.pdf

EXECUTIVE SUMMARY

The State of Vermont continued to make progress on payment and delivery system reform in 2018. Specifically, health care providers, regulators, and policymakers continue the slow and steady work of creating an integrated system of care that spans the entire care continuum. Vermont continues this work through the expansion of current value-based payment models and the creation of additional value-based payment models, each aligned with the Vermont All-Payer Accountable Care Organization (ACO) Model Agreement (APM).1

The APM is Vermont’s first-in-the-nation pilot payment model where a network of hospitals and providers use an ACO to take on the fiscal responsibility for the care and health of their patients. The goal is to create incentives to change the way care is delivered in pursuit of better health, higher quality health care, and more sustainable costs. The APM made significant progress in 2018:

• adding additional payers to join Medicaid in the APM, • increasing the number of people and providers in the APM across all participating payers, • having Medicaid complete an entire program year, including financial reconciliation and quality

measurement, and; • progress on Medicaid’s payment and delivery reform efforts, which seek to use value-based

payments to better align Medicaid services with the APM in order to strengthen the entire care continuum.

Medicaid payment and delivery system reform is the focus of this report, per the statutory charge.

The report attempts to demystify payment and delivery system reform by describing the process and daily work that occurs within AHS and with our stakeholders. Specifically, the report will consist of two basic elements. First, a description of the payment reform process, which is typically facilitated by the Payment Reform team at the Department of Vermont Health Access (DVHA). Second, the report

1 See http://gmcboard.vermont.gov/sites/gmcb/files/documents/10-27-16-vermont-all-payer-accountable-care-organization-model-agreement.pdf.

http://legislature.vermont.gov/assets/Legislative-Reports/Act-113-Sec-12-Medicaid-Pathway-Report-12-30-16.pdf

http://legislature.vermont.gov/assets/Legislative-Reports/Act-113-Sec-12-Medicaid-Pathway-Report-12-30-16.pdf

https://legislature.vermont.gov/assets/Legislative-Reports/Delivery-System-Reform.Medicaid-Pathways-Report-1.15.18.pdf

https://legislature.vermont.gov/assets/Legislative-Reports/Delivery-System-Reform.Medicaid-Pathways-Report-1.15.18.pdf

http://gmcboard.vermont.gov/sites/gmcb/files/documents/10-27-16-vermont-all-payer-accountable-care-organization-model-agreement.pdf

http://gmcboard.vermont.gov/sites/gmcb/files/documents/10-27-16-vermont-all-payer-accountable-care-organization-model-agreement.pdf

5

provides an update on completed and in-progress payment reform activities, using the enumerated statutory criteria:

• Medicaid payments to affected providers; • changes to reimbursement methodology and the services impacted; • efforts to integrate affected providers into the APM and with other payment and delivery

system reform initiatives; • changes to quality measure collection and identifying alignment efforts and analyses, if any; and • the interrelationship of results-based accountability initiatives with the quality measures

referenced above.

The following payment and delivery system reform initiatives were either completed or in-progress in 2018:

• Vermont Medicaid Next Generation (VMNG) ACO program • Applied Behavior Analysis (ABA) • Children’s and Adult’s Mental Health • Residential Substance Use Disorder (SUD) Program • Developmental Disabilities Services • Pediatric Palliative Care

SECTION 1: PAYMENT REFORM AS A PROCESS

PLANNING

Payment reform is a multi-step and iterative process co-produced by staff with relevant expertise, providers, and stakeholders. At AHS, the Payment Reform team at DVHA serves as the primary facilitators of this process. The first payment reform activity is planning, which generally contains five specific steps.

1. Establish the long-term goals of the health care service or initiative and identify if, and how, payment reform can be a mechanism to make progress towards that long-term goal.

2. Identify and gather subject matter experts to acquire a comprehensive understanding of the current process and workflow from start to finish. A thorough examination will include identifying all internal and external units that interact with the process; business or policy rules associated with the process; reporting requirements (both State and Federal); as well as any timeline or budgetary restraints.

3. Conduct research about other payment reform efforts, rate comparisons, quality measures and standards, shared challenges, and innovative solutions emerging in other states and nationally.

4. Convene stakeholders to learn the advantages and disadvantages of the current process and to learn how payment reform would be of value to the beneficiaries, providers, and Vermonters.

5. Engage in quantitative research and data analysis, looking at claims data to evaluate historic utilization, population variations, service trends, etc.

6

DESIGN

Vermont is not alone in pursuing payment reform. There are several existing payment model options, and the first step in the design phase is to identify which of the available options may further the goals and objectives of a particular project. These options generally focus on whether payments will be made fee for service, in a bundled payment, or in a population-based (or capitated) payment. These options can, and frequently are, customized and combined.

Fee for Service Options

Revise Rates Maintains the fee for service framework but revises the rates to adjust to practice and service changes.

One-time Incentive Maintains the fee for service framework but provides an upfront one-time, flexible incentive payment for meeting a specific objective.

Ongoing Add-on Incentive Maintains the fee for service framework but provides an ongoing payment for meeting an objective or series of objectives.

Bundled Rate Options

Per Diem Rate Multiple units of a single service or category of services to be included in a single price per day.

Monthly Case Rate Multiple units of a single service or category of services to be included in a single price per month.

Episodic Rate Multiple units of a single service or category of services to be included in a single episode of care. Requires a clearly identifiable start and end to process (for example, inpatient admission, or pregnancy).

Single-factored Tiered Rate A system of rates that include multiple payment ranges. Appropriate for when you have a single variation/population that needs to be stratified or if you want to incentivize a single criterion.

Multi-factored Tiered Rate A system of rates that include multiple payment ranges. Appropriate for when you have a single variation/population that needs to be stratified or if you want to incentivize multiple criteria.

Population-Based Options

Condition-specific Rate Payment is not directly triggered by service. Clinicians and organizations are instead paid and accountable for all the care of a beneficiary for an agreed upon time period through a fixed and predictable payment (for example, a payment per member per month) for a sub-set of services required by that member.

Comprehensive Rate Payment is not directly triggered by service. Clinicians and organizations are instead paid and accountable for all the care of a beneficiary for an agreed upon time period through fixed and predictable payment (for example, a payment per member per month) for all services required by that member.

The next step in the design phase is to develop potential rates, to understand the mechanism for payment, and to consider the budgetary impact. This must include a review of implementation costs, ongoing operational costs, and any expected cost-savings from efficiencies made to process. Figure A demonstrates the series of steps typical to most rate development processes.

7

Figure A. General Rate Development Process

The last step in the design phase is to identify the performance metrics by which to evaluate the performance of both the program and the model itself. When available, the payment reform unit uses nationally endorsed performance measures and benchmarks. When those measures are not available, the payment reform unit uses results-based accountability to identify performance measures. Performance targets are typically developed in collaboration with providers, and efforts are made to align performance measure requirements across programs and initiatives to the extent possible. Once performance measures and targets have been identified, they are vetted through AHS leadership and Medicaid stakeholders (via standing committees and workgroups) to ensure the alignment of goals and objectives.

IMPLEMENTATION

The next phase in the payment reform process is implementation. Most payment reform models share similar objectives during the implementation phase, which are: increasing or maintaining the accountability and transparency of services delivered; streamlining multiple program-specific budgets and cross-departmental funding sources into a single payment; delivering payments in a more timely and predictable manner; and aligning with the APM.

A new payment model may require obtaining timely State and/or Federal approvals. The State also works closely with DXC Technologies, the Medicaid claims processor, to ensure payments can be made to providers as designed for a new payment model and to allow the system to continue accepting claims. Providers are still required to submit claims for all services that are zero-paid, which are often referred to as “shadow claims.” These shadow claims are then used to monitor the services delivered and to calculate the value of those services (according to the Medicaid fee-for-service fee schedule) that were covered by the payment.

In the final phase of implementation, all affected parties collaborate to develop a transition strategy and ensure operational readiness, this may include: training staff; setting up new reporting queries; changing the business process and workflows; providing proper public notice; and adopting any IT changes and

Define the population

Estimate the Penetrations

Rate

Define the Categories of

Services

Estimate Case Mix/

Define Parameters

Estimate the Utilization

Estimate the Cost per Unit

of Service

Run the Calculations Set the Rate

8

systems upgrades. During the early phases of implementation, the State continues to work closely with DXC and providers to identify unforeseen operational challenges and to develop solutions. These relationships continue throughout implementation as a part of continuous process improvement.

EVALUATION

The final phase in the payment reform process is evaluation. During the evaluation phase the short, medium, and long-term outcomes are reviewed to measure the overall performance. A primary goal of payment reform is to use flexible, value-based payment as an incentive for providers to provide services, which are often not “billable” under a fee-for-service model, but which have a significant impact on a member’s health outcomes (such as coordination of care and preventative care outreach). Consequently, the impacts of payment reform are frequently not immediate. Therefore, it is important to approach evaluation cautiously and with a focus on the long-term goals and objectives.

The evaluation considers data collected in a variety of areas, most commonly: program and/or provider performance; delivery system impacts; process improvements; member experience and improvements to quality of life; fidelity to the design; effectiveness at achieving the policy objectives; and health outcomes of the reform. Data analysis will also include monitoring for new problems and/or unintended consequences of the design or implementation. Revisions and corrective action plans are employed as needed.

During the evaluation phase, the shadow claims allow the State to assess how much would have been paid under the fee for service model. Those expenditures are compared to the amount that was actually paid under the new payment model. The shadow claims also provide the State with information on the type and amount of services provided to the member, which is used to monitor changes to service delivery. These comparisons are used as indicators of overall performance.

The final step in the evaluation process is communication. Clear and effective communication ensures that Vermonters have the information able to assess and understand the changes to Medicaid payment and delivery system reforms. This communication often happens through reports and information briefs, and in presentations to stakeholder groups.

SECTION 2: MEDICAID PAYMENT AND DELIVERY SYSTEM REFORM

Multiple AHS departments are using the process described in Section 1 to develop and implement payment reform projects that impact other Medicaid-enrolled providers and other Medicaid-covered services. Section 2 of this report provides a description of six active payment reform projects:

• Vermont Medicaid Next Generation (VMNG) ACO Program • Applied Behavior Analysis (ABA) Payment Reform • Children’s and Adult Mental Health Payment Reform • Residential Substance Use Disorder (SUD) Treatment Payment Reform • Developmental Disabilities Payment Reform • Pediatric Palliative Care Payment Reform

These efforts are discussed in the remainder of Section 2.

9

VERMONT MEDICAID NEXT GENERATION (VMNG) ACO PROGRAM The Vermont Medicaid Next Generation (VMNG) ACO Pilot program represents the initial phase of Medicaid’s participation in the integrated health care system envisioned by the Vermont APM Agreement with the Centers for Medicare and Medicaid Services (CMS). ACOs are provider-led and -governed organizations, with a substantial regional clinical leadership role, that have agreed to assume accountability for the quality, cost, and experience of care. The model’s goal is an integrated health care system that has aligned incentives to improve quality and reduce unnecessary costs. The VMNG ACO Pilot program pursues this goal by taking the next step in transitioning the health care revenue model from Fee-for-Service payments to Value-Based payments. This transition is meant to focus health care payments on rewarding value, meaning low cost and high quality, rather than volume of services provided. The VMNG program allows the DVHA to partner with a risk-bearing ACO. Together, DVHA and OneCare are piloting a financial model designed to support and empower the clinical and operational capabilities of the ACO provider network in support of the Triple Aim of better care, better health, and lower costs. Primary goals of the program are to increase provider flexibility and support health care professionals to deliver the care they know to be most effective in promoting and managing the health of the population they serve. This will contribute to improving the health of Vermonters and moderating health care spending growth in future. The 2017 program results indicate sufficient, incremental progress that warrants cautious optimism and a continued commitment to the program.

RESULT 1: DVHA AND ONECARE LAUNCHED THE PROGRAM SUCCESSFULLY. • In 2016, DVHA issued a Request for Proposals (RFP) for a new ACO program based on

Medicare’s “Next Generation” ACO Program. OneCare Vermont was selected as the Apparently Successful Bidder.

• DVHA conducted a readiness review prior to the launch of the 2017 program year. OneCare Vermont satisfied the majority of requirements before January 1, 2017 and completed all outstanding Readiness Review items prior to the end of the first quarter of 2017.

• DVHA worked with DXC Technologies to change Medicaid payment systems to make fixed prospective payments to OneCare Vermont.

• Processes for ongoing data exchange between DVHA and OneCare have been implemented and are regularly evaluated for potential improvements.

• DVHA and OneCare prepare and maintain an operational timeline to ensure contractually required data sharing and reporting occurs in a timely manner.

• OneCare and DVHA have established a forum for convening operational teams on a weekly basis, and for convening subject matter experts monthly. These forums have allowed the teams to identify, discuss, and resolve multiple operational challenges, and have resulted in several process improvements to date.

• DVHA and OneCare have worked together to monitor and report on program performance on a quarterly basis.

10

RESULT 2: THE PROGRAM IS GROWING. Additional providers and communities have joined the ACO network to participate in the VMNG program for the 2018 performance year, and more are expected to do so for the 2019 performance year.

2017 Performance Year 2018 Performance Year 2019 Performance Year Hospital Service Areas 4 10 13 Provider Entities Hospitals, FQHCs,

Independent Practices, Home Health Providers, SNFs, DAs, SSAs

Hospitals, FQHCs, Independent Practices, Home Health Providers, SNFs, DAs, SSAs

Hospitals, FQHCs, Independent Practices, Home Health Providers, SNFs, DAs, SSAs

Unique Medicaid Providers

~2,000 ~3,400 ~4,300

Attributed Medicaid Members

~29,000 ~42,000 ~79,000

RESULT 3: THE ACO PROGRAM SPENT LESS THAN EXPECTED ON HEALTH CARE IN 2017. DVHA and the ACO agreed on the price of health care upfront, and the ACO spent approximately $2.4 million less than the expected price. Financial performance was within the ±3% risk corridor, which means that OneCare Vermont and its members are entitled to save those dollars. RESULT 4: THE ACO MET MOST OF ITS QUALITY TARGETS. The ACO’s quality score was 85% on 10 pre-selected measures. Notably, OneCare’s performance exceeded the national 75th percentile on measures relating to diabetes control and engagement with alcohol and drug dependence treatment. Examining quality trends over time will be important in order to understand the impact of changing provider payment on quality of care. RESULT 5: DVHA IS SEEING MORE USE OF PRIMARY CARE AMONG ACO-ATTRIBUTED MEDICAID MEMBERS. Based on preliminary analyses of utilization, the cohort of attributed members has had higher utilization of primary care office-visits than the cohort of members who are eligible for attribution but not attributed. As further information about utilization becomes available, DVHA will conduct more robust analyses to determine whether differences between cohorts are statistically significant, and to understand the impact of the program on utilization patterns over time. The APM Agreement’s initial focus is on hospital and physician services. Yet, the APM also calls out the need to include other services necessary to achieve the population health and quality outcomes over the period of the agreement. These services include mental health, substance use disorder, home- and community-based services, and long-term institutional services. Expanding services will involve strategic planning and collaboration. By December 31, 2020, the state must have developed two plans: one involves coordinating financing and delivery of Medicaid mental health and substance use disorder services with the APM Agreement financial and quality targets; the second involves coordinating the financing and delivery of Medicaid home- and community-based services with APM Agreement targets.

M237737

Highlight

11

Beginning on January 1, 2021, Medicaid Long-Term Institutional Services will be included in the APM Agreement as financial target services. While these deadlines are still several years away, initial planning and preparation has already begun.

APPLIED BEHAVIOR ANALYSIS (ABA)

“Applied behavior analysis” (ABA) consists of the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior. ABA includes a wide variety of evidence-based strategies to impact behaviors for individuals with core impairments in behavior and skills associated with autism and other developmental disabilities. The term includes direct observation, measurement, and functional analysis of the relationship between environment and behavior.

The Social Security Act requires state Medicaid programs to provide Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services to all Medicaid eligible individuals under age 21, which includes ABA services. However, a national shortage of licensed ABA providers has impacted Designated Agency and independent practices’ ability to secure enough staff to meet all the medically-necessary needs of Vermont Medicaid members. The payment reform initiative for this project came in response to providers’ feedback that the administrative components of ABA, namely the prior authorization process and the complexity of the billing codes, interfered with their ability to deliver services to clients.

Therefore, Vermont Medicaid will transition from traditional fee-for service reimbursement to a single-factored tiered rate. As a result of this reform, providers will no longer be required to complete prior authorization requests, nor must they wait for approvals of changes to treatment plans. The tiered rate allows providers to determine the appropriate treatment type and to adjust and respond immediately to changes in their patients medically-necessary service needs. Providers are no longer limited to restrictions placed on codes when delivering ABA services. Going forward, utilization management and clinical integrity will instead be monitored through chart audits, site visits, and the standardization of tools and reporting.

Payments to providers will become more predictable and timely. The payment for each client will be delivered prospectively each month and will not be tied to the submission of Medicaid claims data. Each of the tiers has a “monthly floor,” or a minimum number of hours required to validate the rate. The DVHA Quality and Clinical Integrity unit will monitor claims data monthly and review with providers (as needed) to ensure that utilization and payments are closely aligned. Once yearly, Vermont Medicaid will reconcile the differences between payments delivered and services rendered at the client level.

Through this payment reform, DVHA hopes to increase access and utilization for Medicaid beneficiaries by giving providers the flexibility to innovate and to use staff more efficiently. While there is currently no value-based component, the ABA payment reform establishes a monitoring framework that could be used to pay for outcomes in the future.

The payment model change is expected to go into effect for all members for whom Medicaid is the primary payer on July 1, 2019. In the next phase of work on the ABA payment model, DVHA will

12

collaborate with providers and member recipients to review population indicators and to develop performance measures.

Summary Overview: Applied Behavior Analysis Payment Reform

Program: Applied Behavior Analysis

Impacted Providers: • Designated Agencies • Kingdom Autism and Behavioral Health • Keene Perspectives • BEL Center • Benchmark • Seeds of Change • SD Associates • Independent practicing, licensed clinicians

Anticipated Impacted Beneficiaries: ~160

Estimated funds allocated for new payment model (SFY2020)

~$3,900,0002

Type of Payment Reform: Fee for Service to a monthly case rate

Implementation Date: July 1, 2019

CHILDREN’S AND ADULT’S MENTAL HEALTH

The Department of Mental Health (DMH) and DVHA are collaborating on a payment reform project that transitioned Vermont Medicaid payments to all Designated Agencies (DA) and and Pathways Vermont (a Specialized Services Agency or SSA), from traditional reimbursement mechanisms (a combination of program-specific budgets and fee for service) to a monthly case rate. Although the scope of services is narrower, the new payment model relies heavily on prior experience through the Integrating Family Services pilot and expands the case rate approach to child and adult populations statewide. Each child and adult case rate is unique to the individual Agency’s child and adult population, comprised of their mental health allocation from DMH and their historical DVHA fee for service expenditure. Under the new model, Agencies are paid a fixed amount prospectively at the beginning of each month and are expected to meet established case load targets by delivering at least one qualifying service to an individual in a given month.

Value-based payments are made through a separate quality payment. During each measurement year, DMH will withhold a percentage of the approved adult and child case rate allocations for these payments. The value-based payment model uses three types of performance metrics to assess the quality and value of services: monitoring; reporting; and performance.

2 The estimated funds allocated for the new ABA payment model may be affected by multiple transitions taking place for ABA in Calendar Year 2019 including: the adoption of new CPT codes; the transfer of ABA from Northwestern Counseling and Support Services (NCSS) IFS funds to the new ABA payment reform; and uncertainty regarding utilization.

13

• Monitoring Measures are those measures that are used to assess the health and access to care of population and/or catchment areas. Monitoring measures do not impact the distribution of value-based payments.

• Reporting Measures are those measures that are used to establish a baseline and/or gather data. Reporting Measures do impact the distribution of value-based payments according to a Designated Agency’s ability to meet specific reporting criteria.

• Performance Measures are those measures that assess an agency’s work and/or outcomes of work. Performance Measures do impact the distribution of value-based payments according to the Designated Agency’s ability to meet specific targets and/or outcomes.

In the first year, providers will earn their value-based incentive for the reporting of complete, accurate, and timely information. Agencies will also use the first year to gather baseline data. In subsequent years, the incentive will be earned for performance on certain quality measures, and the baseline data will be used to set performance targets. DMH has established a Mental Health Payment Reform Scoring and Metrics Advisory Committee to make recommendations to DMH on the development of new measures and the establishment of performance targets. The committee consists of 14 members, with equal representation from the State and provider networks. The value-based payment model is expected to reach maturity in year five (see Figure B; however, the performance measures and targets may continue to evolve over time as program priorities shift and as necessary to support continuous quality improvement.

Figure B. Payment Reform Five-Year Plan

Key goals of the mental health payment reform are to improve the predictability of payments to providers of mental health services, and to increase their flexibility to meet the needs of the Vermonters they serve. Successful implementation of mental health payment reform represents a strong commitment on behalf of both the AHS and the Designated Mental Health Agency network to support movement towards population-based payments. The new payment model shares many characteristics of other value-based payment models that the State is implementing or considering for future implementation; such alignment contributes to both State and provider readiness for an increasingly integrated health care delivery system and aids the State in developing a strategy for inclusion of additional services in All-Payer financial targets in the future. As opportunities arise, DVHA and DMH

Year One•Monitoring: 9•Reporting: 4•Performance: 0

Year Two•Monitoring: 9•Reporting:1-2•Performance: 4

Year Three• Monitoring: 9•Reporting: 1-2•Performance: 5-6

Year Four•Monitoring: 9•Reporting: 1-2•Performance 6-8

Year Five•Monitoring: 9•Reporting: 0•Performance: 7-10

14

will continue to improve upon this foundation, to decrease the limitations of the fee-for-service model and move towards increased provider flexibility and accountability.

The payment change went into effect for all mental health services delivered on or after January 1, 2019 for Medicaid beneficiaries receiving treatment at all Vermont DAs and one SSA (Pathways). In the next phase of work on the mental health payment model, DMH and DVHA will continue to collaborate with providers and member recipients to develop performance measures, transition to “pay for performance,” and to increase transparency and accountability by transitioning information about additional services and client populations into the Medicaid Management Information System (MMIS).

Summary Overview: Children’s and Adult’s Mental Health Payment Reform

Program: Children’s and Adult’s Mental Health

Impacted Providers: • Designated Agencies • Pathways

Anticipated Impacted Beneficiaries: ~92,000 (42,550 kids and 49,190 adults)

Estimated funds allocated for new payment model (CY2019)

~$98,000,000 (~$40,000,000 for the child case rates and ~$58,000,000 adult case rates)

Type of Payment Reform: Fee for Service to a monthly case rate

Implementation Date: January 1, 2019

RESIDENTIAL SUBSTANCE USE DISORDER (SUD) PROGRAMS

The Vermont Department of Health (VDH) and DVHA are collaborating on a payment reform project that transitioned Vermont Medicaid payments to residential substance use disorder treatment providers from a per diem rate to an episodic payment. An episodic payment was selected as it would: provide a framework to pay for outcomes rather than discrete services; incentivize innovation and cost-containment through increased provider flexibility; and ensure financial stability through the delivery of more predictable payments.

Figure C. Residential Episodic Payment

The episodic payment covers the entire episode of care which includes both the residential detoxification and the residential treatment, with pharmaceutical benefits continuing to be billed separately. The payment covers

the full length of stay, from pre-admission through discharge, and all providers and services utilized for treatments at the facility.

Episodic Payment

Length of Stay

Pre-admission

Residential Stay Discharge

Providers & Services

Physicians and other

staff

Treatment Services at the Facility

15

The payment model includes eight potential episodic payment rates. The amount of the payment is determined by two factors: the primary diagnosis and, if present at intake, a co-morbidity. This multifactored episodic rate was designed to incentivize providers to admit only those patients that need the full resources of residential care and only for a medically-necessary length of stay, thereby promoting the good stewardship of public resources and ensuring people receive appropriate types and levels of care. Prior to January 1, 2019, Vermont Medicaid reimbursed SUD residential providers based on rates separately negotiated by each provider, resulting in three different per diem rates for the same services. Through payment reform change, Vermont Medicaid now accounts for variations in populations and acuity in a way that is consistent throughout the state and across providers and better aligns with federal requirements that State Medicaid agencies pursue payment structures in which all payment rates are “consistent with efficiency, economy, and quality of care,” (42 CFR §447.200, Payments for Services, Payment Methods: General Provisions) and that the payment is (a) based on the utilization and delivery of services, and (b) directs expenditures equally, and using the same terms of performance, for a class of providers providing the service under the contract (42 CFR § 438.6(c)(2)).

In year two of this payment reform initiative, a portion of the episodic payment will be withheld for value-based payments. The Residential Treatment providers will be able to earn value-based payments through demonstration of improved outcomes in the following areas:

• clients initiating outpatient treatment within seven days of discharge; • reducing readmissions; and • clients visiting a Primary Care Physician within 30 days of discharge.

The change went into effect for all episodes of care beginning on/after January 1, 2019 for Medicaid beneficiaries at all residential treatment providers in Vermont (Valley Vista: Vergennes, Valley Vista: Bradford, and Serenity House). VDH and DVHA will begin work on the second phase of this payment reform, implementing the value-based component, at the end of January 2019.

Summary Overview: SUD Residential Treatment Payment Reform

Program: SUD Residential Treatment

Impacted Providers: • Valley Vista: Vergennes • Valley Vista: Bradford • Serenity House

Anticipated Impacted Beneficiaries: ~1,500


~$5,729,000

Type of Payment Reform: Per diem rate to Episodic Payment

Implementation Date: January 1, 2019

16

DEVELOPMENTAL DISABILITIES SERVICES

The Department of Disabilities, Aging and Independent Living (DAIL) and DVHA are collaborating on a payment reform project to transition from the current Developmental Disabilities Services (DDS) home- and community-based services (HCBS) daily rates to a new form of payment for individuals with intellectual and developmental disabilities.

The State has initiated this project to meet several objectives:

• Comply with the State’s APM Agreement with the federal Centers for Medicare & Medicaid Services, which obligates the Agency of Human Services to develop a plan to coordinate payment and delivery of Medicaid Home and Community-based Services with the State’s delivery reform efforts for health care;

• Increase the transparency and accountability of DD services, consistent with recommendations in the 2014 State Auditor’s Report;

• Improve the validity and reliability of needs assessments; • Improve equity and consistency in funding of individual services; • Increase flexibility in addressing individual needs, services and outcomes, within the limits of

available funding; and • Support a sustainable provider network.

Representatives from the State, provider network, consumers, family members, and other stakeholders have begun work on the project scope and planning. In the Fall of 2018, representatives split into three initial workgroups:

• Standardized Assessment: focused on the adoption of a uniform, valid, reliable, standardized assessment tool for determining what services individuals need. This included a review of some assessment tool options with a preliminary recommendation. Future considerations include the details of a possible transition to a new tool, considering the broader workflow from application and eligibility through funding and service planning.

• Payment Model: focused on designing a payment mechanism by which providers would be paid to provide services. This workgroup is considering payment model options, including implications for providers and people receiving services.

• Encounter Data: focused on developing a process by which providers would report all covered services that are delivered to individuals to the Medicaid Management Information System.

17

All three workgroups report up to the DS Payment Reform Statewide Advisory Committee on a monthly basis.

Figure D. DS Payment Reform Workgroup structure

The State has also engaged Burns & Associates, as the consulting firm, to conduct a provider rate study to evaluate the actual cost to providers of delivering services which will inform the new payment model and assist in the development of provider reimbursement rates.

The payment reform has a preliminary target date of January 1, 2020.

Summary Overview: Developmental Disabilities Services Payment Reform

Program: Developmental Disabilities Services

Impacted Providers: • Designated Agencies • Specialized Services Agencies • Supportive Intermediary Service Organization

Anticipated Impacted Beneficiaries: ~3,200


~$212,000,000

Type of Payment Reform: TBD

Implementation Date: Targeted for January 1, 2020

PEDIATRIC PALLIATIVE CARE

In partnership with VDH, Vermont Medicaid is contemplating a transition from traditional fee for service reimbursement to a new form of reimbursement. The model is currently in the design phase. A target implementation date for a new payment model will be identified pending additional input from leadership, providers, and stakeholders.

DS Payment Reform Statewide Advisory

Committe

Payment Model Standardized Assessment Encounter Data

18

Summary Overview: Pediatric Palliative Care Payment Reform

Program: Pediatric Palliative Care

Impacted Providers: • Addison County Home Health & Hospice • Caledonia Home Health Care & Hospice • Central Vermont Home Health & Hospice • Franklin County Home Health Agency • Lamoille Home Health & Hospice • Orleans, Essex VNA & Hospice • University of Vermont Health Network Home Health

Hospice • VNA & Hospice of the Southwest Region • Visiting Nurse and Hospice for Vermont & New Hampshire

Anticipated Impacted Beneficiaries: ~50

Estimated funds allocated for new payment model (TBD)

~$91,000

Type of Payment Reform: TBD

Implementation Date: TBD

onecarevt.org 1

Network Contracting Timeline for PY20202019 Timeline

Jan Feb Mar Apr May Jun Jul Aug Sept Oct

Begin OneCare

legal review of contracts

Provider Letter of Interest

External preliminary legal review of

contracts (excluding Program of

Payment)

BOM Approval

of Program

of Payment

to support initial

budget

Finalcontracts

to network*

(including Program of Payment)

Signed contracts

due

Final budget

approval by BOM

Submit Medicare Roster

GMCB Budget

Submiss-ion

Submit Medicaid

& BCBSVT Rosters

2019 Primary Timeline Improvements • Draft Contract Review

• OneCare will provide draft contracts 3 months earlier• Final Contract to providers

• OneCare will distribute final contracts 6 weeks earlier

* Contract Language now states:• Contracts, Program of Payments and Policies must be distributed to providers by June 30 (at least 60 days

prior to the non-renewal date of August 31)

Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Healt... Page 1 of 12

Health Affairs

HEAL TH AFFAIRS BLOG

RELATED TOPICS: SOCIAL DETERMINANTS OF HEAL TH I ACCESS TO CARE I COSTS AND SPENDING I SYSTEMS OF CARE

Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Health Brian Castrucci, John Auerbach

JANUARY 16, 2019 DOI: 10.1377 /hblog20190115.234942

https://www.healthaffairs.org/do/10.1377 /hblog20190115.234942/full/ 1/26/2019

Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Healt... Page 2of12

Until recently, efforts to improve the health of Americans have

focused on expanding access to quality medical care. Yet there

is a growing recognition that medical care alone cannot address

what actually makes us sick. Increasing health care costs and

worsening life expectancy are the results of a frayed social

safety net, economic and housing instability, racism and other

forms of discrimination, educational disparities, inadequate

nutrition, and risks within the physical environment. These

factors affect our health long before the health care system ever

gets involved.

Hospitals and health care systems have started to address

these social determinants of health through initiatives that buy

food, offer temporary housing, or cover transportation costs for

high-risk patients. The prevalence and initial success of these

efforts are clear in headlines such as: "What Montefiore's 300%

https://www.healthaffairs.org/do/1 0.1377 /hblog201901l5 .234942/full/ 1/26/2019


ROI from Social Determinants Investments Means for the Future

of Other Hospitals," "Social Determinants of Health Gain Traction

as UnitedHealthcare and lntermountain Build New Programs,"

and "How Addressing Social Determinants of Health Cuts

Healthcare Costs.!." But when you take a closer look, these

articles aren't about improving the underlying social and

economic conditions in communities to foster improved health for all - they're about mediating patients' individual social

needs. If this is what addressing the social determinants of

health has come to mean, not only has the definition changed,

but it has changed in ways that may impede efforts to address

those conditions that impact the overall health of our country.

In 2008, the World Health Organization's Commission on the

Social Determinants of Health defined those determinants as

the "conditions in which people are born, grow, live, work, and

age" and "the fundamental drivers of these conditions." This

term prioritizes a broad, community-wide focus on the

underlying social and economic conditions in which people live,

rather than the immediate needs of any one individual. While

health care leaders have realized that programs to buy food,

offer temporary housing, or cover ridesharing programs are less

expensive than providing repeat health care services for their

highest cost patients, such patient-centered assistance does not improve the underlying social and economic factors that affect

the health of everyone in a community. While targeted, small

scale social interventions provide invaluable assistance for

individual patients, we must also remain focused on the social


Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Healt. .. Page 4of12

determinants that perpetuate poor health at the community

level.

A recent speech by Health and Human Services (HHS) Secretary

Alex Azar highlighted the dichotomy between individual-level

"social needs" and community-level "social determinants."

Secretary Azar emphasized that factors like housing and

transportation have an important effect on Americans' health.

He asked rhetorically, "How can someone manage diabetes if

they are constantly worrying about how they're going to afford

their meals each week? How can a mother with an asthmatic

son really improve his health if it's their living environment that's

driving his condition?" And he appropriately noted that we "can't

simply write a prescription for healthy meals, a new home, or

clean air."

In his discussion of how to address health-related community

conditions, Secretary Azar, like a growing number in health care,

focused on the social needs of individual patients. In his speech,

he recounted the success of the Accountable Health

Communities model, noting that "participating providers screen

high utilizers of healthcare services for food insecurity, domestic I

violence risk, and transportation, housing, and utility needs. If

needed, patients are set up with navigators, who can help

determine what resources are available in the community to

meet the patient's needs." He even went so far as to suggest

that Medicaid may allow hospitals to pay for housing, healthy

food, and other services. But in order to improve our nation's

health, we must look beyond "superutilizers," Medicaid

https ://www.healthaffairs.org/do/10.1 377/hblog20190115.234942/fulV 1/26/2019

Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Healt ... Page 5of12

recipients, and those who are already sick. Secretary Azar

appropriately noted that health care navigators "can help

determine what resources are available in [a] community."

However, while growing in popularity, health care navigators and

similar enhancements to health care can't actually change the

availability of resources in the community. They can't raise the minimum wage, increase the availability of paid sick leave, or

improve the quality of our educational system. These are the

systemic changes that are necessary to truly address the root

causes of poor health.

Efforts To Address Social Needs Are Necessary, But Not Sufficient

Even if they don't address broader social conditions within

patients' communities, health providers' efforts to meet

individuals' non-medical needs are praiseworthy and potentially

life-saving. In Chicago, Advocate Health Care saved nearly $5

million by screening for malnutrition risk factors and

establishing an enhanced nutrition care program. In Boston, a

six-months-or-longer, home-delivered meals benefit for dual

Medicare-Medicaid eligible patients was associated with

significant reductions in emergency room visits and overall

health care cost savings. An initiative to link WellCare Medicaid

and Medicare Advantage plan members to social service organizations resulted in an annual savings of $2,400 per

person. In Hennepin County, Minnesota, millions of dollars were

saved by offering unconventional services to patients with

https://www.healthaffairs.org/do/10.13 77/hblog20190115.234942/full/ 1/26/2019

Meeting Individual Social Needs Falls Short Of Addressing Social Determinants OfHealt... Page 6of12

complex health, housing, and social service needs.

The University of Illinois at Chicago reduced costs by 18 percent

by identifying homeless patients who could benefit from housing

support. These are just a few of the studies and reports

documenting the health care system's efforts to go beyond its

own walls to improve health outcomes, decrease consumption

of medical services, and reduce costs.

While individual-level interventions are beneficial, characterizing

them as efforts to address social determinants of health

conveys a false sense of progress. These strategies mitigate the

acute social and economic challenges of individual patients, but

they do so without implementing long-term fixes. They are often

limited to a small segment of the population - those who are in

the worst health and have the greatest health care costs.

Meanwhile, those patients who do not rank among the "sickest

and most expensive" are ignored.

We Need Policy Changes That Target Social Determinants Of Health

Policy makers have the power to address the social and

economic conditions that affect community health. For example,

in Kansas City, Missouri, voters recently approved a ballot

initiative empowering health inspectors to respond to tenant

complaints about a broad range of housing conditions, funded by an annual fee of $20 per unit for landlords. Earlier this year,

the City Council of Alexandria, Virginia voted to raise the city's

meal tax to fund affordable housing. These communities and

https://www.healthaffairs.org/do/10.1377 /hblog201901l5.234942/ful l/ 1126/2019

Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Healt.. . Page 7of12

others like them have embraced the need for policy intervention

to improve the social determinants of health for their citizens.

National initiatives offer states and local communities a roadmap for identifying and implementing gold-standard

strategies to improve public health. In an initiative known as

Health Impact in 5 Years (or Hl-5), the Centers for Disease Control and Prevention (CDC) developed a list of 14 evidencebased policies to improve population health. CityHealth, an initiative of the de Beaumont Foundation and Kaiser

Permanente, provides city leaders with a package of nine policy

solutions that can help millions of people live longer and better lives.

Hospitals and health systems may be stepping up by referring a

patient with mold in his or her apartment to a tenant's right

advocate, feeding a patient who needs food, or providing an on

site exercise program. But these interventions do not address the mold in that patient's next-door neighbor's apartment, community access to healthy food, or the availability of low-cost

exercise options. These community-level changes can only be

made through policy action. While they work to address their patients' immediate needs, hospitals and health systems would

do well to recognize and support community-level policy actions.

Not An Either/Or - Social Needs And Social Determinants Must Both Be Addressed

https://www.healthaffairs.org/do/ l 0.1377 /hblog20190115.234942/full/ 1/26/2019

Meeting Individual Social Needs Falls Short Of Addressing Social Determinants OfHealt... Page 8of12

This isn't about picking one approach over another - we need

social and economic interventions at both the community and

individual levels. We often discuss health using the metaphor of

a stream, with upstream factors bringing downstream effects.

Social needs interventions create a middle stream (Exhibit 1 ).

They are further upstream than medical interventions, but not

yet far enough. Social needs are the downstream manifestations

of the impact of the social determinants of health on the

community. Improvements in our nation's health can be

achieved only when we have the commitment to move even

further upstream to change the community conditions that make

people sick. The demand for social needs interventions won't

stop until the true root causes are addressed. This should ring

especially true as the movement to Accountable Health

Communities and value-based care gains momentum. Any

success these new payment structures enjoy will be short-lived

if the underlying social conditions in the communities where

they work remain unchanged. While the allure of short-term

economic gains from mediating patients' social needs nearly

ensures media and stakeholder attention, the incentives to

advance policy, legislation, and regulation to improve health

more broadly are often less clear. Redefining the meaning of

"social determinants" to be mostly or only about the immediate

social needs of expensive patients makes it harder to focus on

the systemic changes necessary to address root causes of poor health.

Exhibit 1

https://www.healthaffairs.org/do/10.13 77/hblog20190115.234942/fulV 1/26/2019


SOCIAL DETERMINANTS AND SOCIAL NEEDS: MOVING BEYOND MIDSTREAM

Source: Created by Authors

https://www.healthaffairs.org/do/10.13 77/hblog20190115.234942/full/ 1/26/2019

Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of He ... Page 10of12

Words Matter: For Understanding. For Clarity. For Change.

In 2003, David Kindig and Greg Stoddart offered a

comprehensive definition of population health. Twelve years

later, Kindig expressed concern that the use of the term had grown too broad, writing that it's "growing use, most notable in

the Triple Aim and in clinical settings, has resulted in a

conflicting understanding of the term today." Is the term "social

determinants" heading for a similar fate? If we, even

inadvertently, imply that the social determinants of health can be

solved by offering Uber rides to individual patients or by

deploying community health navigators, it will be challenging, if

not impossible, for public health advocates to make the case for

proven policies like alcohol sales control, complete streets, and

healthy food procurement.

Words matter. Common definitions ensure that we understand

each other. When health care leaders and public health officials

use "social determinants of health" to mean different things, it

becomes more difficult for us to engage meaningfully with community partners, who will struggle to differentiate between

these complementary but different approaches. This may seem

like semantics, but when we use this term too broadly, we risk

losing the specificity needed when calling on partners to make

far-reaching social change, and we weaken our ability to

implement the community-level efforts necessary to improve

https://www.healthaffairs.org/do/10.1377 /hblog20190115.234942/full/ 1126/2019

Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of He ... Page 11 of 12

community health. And, ultimately, that doesn't help any of us

get healthier.

Related

CONTENT

Culture Of Health

TOPICS

Social Determinants Of Health

Access To Care

Costs And Spending

Systems Of Care

Cite As

"Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of

Health, " Health Affairs Blog, January 16, 2019.

DOI: 10.1377 /hblog20190115.234942

Health Affairs Comment Policy

Comment moderation is in use. Please do nots

comment twice -- it will appear shortly.


Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of He ... Page 12 of1 2

Health Affairs 7500 Old Georgetown Road, Suite 600

Bethesda, Ma_ry/and2DB 7 4

T 307 656 7407

F 30 7 654 2845

customerservice@healtha ffa1rs. org Terms and conditions Privacy Project HOPE

Copyright 1995 - 2019 by Project HOPE: The People-to-People Health Foundation, Inc., elSSN 1544-5208.

Health Affairs is pleased to offer Free Access for low-income countries. and is a signatory to the DC principles for Free

Access to Science. Health Affairs gratefully acknowledges the support of many funders.

https://www.healthaffairs.org/do/1 0.1377 /hblog20190115.234942/full/ 1/26/2019

1

ONECARE VERMONT ACCOUNTABLE CARE ORGANIZATION, LLC

BOARD OF MANAGERS MEETING FEBRUARY 19, 2019

MINUTES

A meeting of the Board of Managers of OneCare Vermont Accountable Care Organization, LLC (“OneCare”) was held at Central Vermont Medical Center on February 19, 2019.

I. Call to Order

Steve Leffler called the meeting to order at 4:35 p.m. Introductions were made around the room and by those on the phone.

II. Minutes, Committee Reports and Monthly P&L

The minutes from January 15, 2019, the Executive and Finance Committee report outs and the December Monthly P&L were all approved unanimously.

III. Government Affairs Update

Lucie Garand from Downs Rachlin and Martin gave a government affairs update. Kevin Stone and Vicki Loner have been meetings with individual Healthcare committee chairs as well as the Green Mountain Care Board members as part of our education and outreach efforts. Major topics in the legislature so far is the administration’s proposed reduction to the Green Mountain Care Board’s budget, which would be filled by increasing the amount of the bill back on the hospital, payers and the ACO to supplement. Another topic is the reduction of state funding to SASH and its relationship to the ACO. In general the discussions at the statehouse have revolved around education and updating on care delivery and integration that is being done across the continuum of care as well as other community providers.

The GMCB is hosting a “Report-out” from the field on the All-Payer Model later in February. It will have a panel of providers including members of the OneCare Board as well as others from the state who will discuss how being a part of OneCare and the All-Payer Model is impacting care delivery on the ground. Everyone was encouraged to attend.

There was a discussion around if OneCare should take positions on certain social agendas/causes that are in the legislature. The Board agrees that it should remain neutral as much as possible as we represent a consortium of providers and that individual organizations and providers should be allowed to decide independently whether they support a cause. This does not preclude the OneCare Board from offering their input or feedback on select bills.

IV. Governance

Vicki Loner summarized the Nomination Policy that management was asked to bring forth to the Board as part of updating the OneCare Operating Agreement. The policy outlines how the

2

nomination process would work for specific seats on the Board. (See public packet for policy). A motion was made, and upon being seconded, the nomination policy was approved by a supermajority of the Board. The Nomination Committee is recommending Grant Whitmer, Executive Director of the Community Health Centers of the Rutland Region to fill the Federally Qualified Health Center seat that was vacated by Tim Ford. Upon a motion being made and was seconded, Grant Whitmer was elected to the Board by a supermajority effective March 1. The Nomination Committee is recommending Dan Bennett, CEO of Gifford Health Systems, to fill the Critical Access Hospital seat. Upon a motion being made and was seconded, Dan Bennett was elected to the Board by a supermajority effective March 1. The Nomination Committee is recommending Tom Dee, CEO of Southwestern Vermont Medical Center to fill the At-Large seat, which the Board has determined it wants to be filled by a member of the Risk Strategy Committee. Tom Dee has served on the Risk Strategy Committee for the past year and attended a majority of the Board meetings. Upon a motion being made and seconded, Tom Dee was elected to the Board by a supermajority effective March 1. Ms. Loner updated that the nomination process for the Independent Physician seat is currently underway. Nominees will be brought to the Nomination Committee at the March Executive Committee call and then to the full board for a vote in March. Kevin Stone summarized the staggered terms proposal that management was asked to bring forth to the Board as part of the updated of the Operating Agreement. (See public packet for proposal). The staggering of Board Members terms will result in members being up for renewal in 2020, 2021, and 2022 respectively. A motion was made and upon being seconded, the staggered terms proposal was approved by a supermajority of the board.

V. Payer Performance Update

Tom Borys gave an update on YTD payer performance (see YTD payer performance in public packet). Overall performance is favorable in all risk programs. Included in the report was information on high cost cases across the network, and discussion regarding inpatient utilization over the last few months.

Dr. Norm Ward highlighted specifically OneCare’s performance in the Vermont Medicaid Next Generation (VMNG) Program using tables from the Department of Vermont Health Access’s report to the legislature (see tables in CMO corner in public packet). Dr. Ward also briefly touched based on other topics in his CMO report.

VI. Value Based Care Update

Sara Barry gave an update on the Innovation Fund RFP process. There were 45 applications over all. 42 were eligible based on the RFP criteria. After an initial screening, 17 proposals were chosen after scoring high on the screening criteria that was established. These proposals will now go to a subcommittee off the Population Health Strategy Committee and up to 5 will be referred to

3

the full Committee for review. The full committee will review and move forward to the board which proposals they endorse for approval.

VII. Communication and Operations Update

Amy Bodette noted that the OneCare website is being updated to be more modern, easier to navigate, and to provide more detail about our work efforts. It is in the final stages of testing before being launched. A demo will be provided to the full Board at its March meeting.

Ms. Loner gave a brief update on the contracting timeline for 2020. A timeline was provided in the packet and the non-binding Letter of Intents (LOI’s) will be going out next week. The timeline incorporates feedback that was received from participants last year. It represents a more aggressive timeline in order to establish interest well ahead of Budget modeling and development.

Ms. Loner and Mr. Stone also noted that going forward the Board meetings will utilize software to allowed board members to remote into the meeting by webcam while also working on trying to improve the sound quality for those calling in. More information will be provided to the Board as the new meeting format is rolled out.

VIII. Public Comment:

There was no public comment.

IX. Recess

X. Executive Session

XI. Voting

a. The Executive Session Minutes from January 15, 2019 were approved unanimously.

b. The motion to approve the resolution to remain in the Medicare Payer Program based on the parameters as outlined by Management and amended during discussion was approved by a supermajority of the Board.

c. The motion to approve the interim CEO executing the CEO Search Firm Contract was approved by a supermajority of the Board.

XII. Other Business

Judy Peterson wanted to highlight the Health Affairs article on Social Determinants of Health that was included in the public packet and which had been shared by John Sayles. Mr. Stone explained that at a future board meeting a more substantive conversation will be had on SDoH including the work that has taken place in the Algorex Pilot.

XIII. Adjourn

Upon a motion that was seconded, the meeting adjourned at 6:42 p.m.

4

Attendance: OneCare Board Members

☒ Jill Berry Bowen ☒ Sally Kraft, MD ☐ Joseph Perras, MD ☒ John Brumsted, MD ☒ Steve LeBlanc ☒ Judy Peterson ☒ Betsy Davis ☒ Steve Leffler, MD ☒ Toby Sadkin, MD ☒ Steve Gordon ☒ Sierra Lowell ☒ John Sayles ☒ Tomasz Jankowski ☒ Judy Morton ☒ Todd Keating ☐ Pamela Parsons

OneCare Risk Strategy Committee

☒ Tom Dee ☒ Tom Manion ☒ Jeffrey Haddock, MD ☐ Anna Noonan

OneCare Leadership and Staff

☒ Kevin Stone ☒ Tom Borys ☒ Linda Cohen Esq. ☒ Vicki Loner ☒ Sara Barry ☒ Spenser Weppler ☒ Karen Lee ☐ Susan Shane ☒ Amy Bodette ☒ Norm Ward, MD ☐ Joan Zipko ☐ Greg Daniels

☒ Martita Giard

OneCare Vermont Accountable Care Organization, LLC Board ... · 2/4/2019 · OneCare Vermont...

Documents

Transcript of OneCare Vermont Accountable Care Organization, LLC Board ... · 2/4/2019 · OneCare Vermont...