Download Update on Vermont Health Care Reform

Update on
Vermont Health Care Reform
AcademyHealth State Coverage Initiatives Program
National Meeting
Albuquerque, New Mexico
July 30 - 31, 2009
Susan Besio, Ph.D., Director
Vermont Health Care Reform
Vermont Health Access (Medicaid)
Vermont Health Care Reform
60+ Initiatives
Improve Quality
Increase Coverage
• New Coverage Options
• Premium Assistance
• Integrated Marketing and Outreach
• Provider Access
• Promote Wellness / Prevention
• Blueprint for Health
• Accountable Care Organizations
• Health Information Technology
• Quality Transparency
Contain Cost Growth
All of Above PLUS
• Cost Transparency
• Statewide Health Resource Planning and Review
• Prescription Drug Cost Containment
• Administration Simplification
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Expanding Coverage: Green Mountain Care
 New Catamount Health Plan offered by private carriers (Individual
Market)
 New Premium Assistance for Catamount Health and ESI
 Integrated marketing, outreach and enrollment across all statesponsored programs (50% eligible for existing programs but not enrolled)
Dr. Dynasaur
Medicaid
VHAP
or ESI
Premium
Assistance
100% +
other criteria
150 - 185%
Catamount
Health
Catamount or
ESI Premium
Assistance
300%
Over 300%
Income Eligibility: Federal Poverty Level
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Enrollment Results
(since November, 2007)
Enrolled
New Programs
Catamount Full Cost
Catamount w/Premium Asst
Catamount ESIA
VHAP ESIA
Sub-total
1,243
7,710
577
948
10,478
Existing Programs
Adult Medicaid Increase
VHAP Increase
Dr. Dynasaur Increase
Sub-total
13,405
TOTAL
23,883
Uninsured rate:
ALL
Children:
2,336
7,022
4,047
Fall, 2005
9.8%
4.9%
Fall, 2008


7.6%
2.9%
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Snapshot of Selected Initiatives
to Address
Access, Quality and Cost
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Provider Access
Safety Net

8 FQHCs (40 sites) and 14 Rural Health Clinics

Free Clinics
•
•
•
10 free clinics and 2 dental programs
In 2008, served 6,188 patients, provided 12,435 services and received over $2
million in-kind support for medications, services, labs and hospital support.
Provide access to health care for uninsured and underinsured by providing:
 Assistance with enrollment in Green Mountain care programs,
 Provide care for urgent medical needs, including low-cost medications
 Assistance to find a primary care home
Medicaid Rates

PCPs protected in FY2010 Medicaid rate reductions
•

Pay at 2006 Medicare rate for Evaluation and Management codes
Dental Dozen (Medicaid – Health collaborative)
Fair Contracting Standards

To support providers in negotiations with carriers
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Loan Repayment Fund
• Vermont’s program has one of the highest retention rates in the country
• 99% stay in VT for one year after receiving award; 89% stay from time
they received award. Due to service commitment AND community
engagement/support
2009
(Snapshot as of
Jan 20, 2009)
Primary Care
Maximum
annual
award
allowed
# of
Apps
received
$700,000
$20,000
174
$ 83,542
104
$6,731
$195,000
$20,000
19
$ 162,325
16
$12,188
$400,000
$10,000
293
$ 28,011
113
$3,540
$115,000
$20,000
15
$ 47,297
13
$8,846
501
$ 42,668
246
$5,732
Allocation
Average
(mean)
debt of
applicants
#
awarded
Average
(mean)
award in
2009
(1997)
Dentists
(2000)
Nurses
(2002)
Nurse
Educators/Faculty
(2006)
TOTAL
$1,410,000
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Blueprint for Health Integrated Projects

Single approach across 3 Primary Carriers and Medicaid in 3 (of 12)
Hospital Service Areas during 2008 and 2009 for:
•
Medical Home: evidenced-based practice, clinical micro-systems support
•
Community Health Teams (joint funding by all payers); integration with Medicaid CCI
•
Payment Reform (single methodology across all payers for provider metrics and incentive
payments)
•
Health IT
Hospitals
Behavioral Health
& Substance
Abuse Services
PCMH
PCMH
Community Health Teams
Nurse Coordinator
Social Workers
Dieticians
PCMH
Community Health Workers
OVHA Care Coordinators
Public Health Prevention Specialist
PCMH
Public Health Prevention
Health IT Framework
Global Information Framework
Evaluation Framework
Operations
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Blueprint Integrated Pilot Summary
1. Financial reform (2 major
components)
•
•
•
Payment to practices based on NCQA
PCMH standards
Shared costs for Community Care Teams
Medicaid & commercial payers
2. BP subsidizing Medicare
Multidisciplinary care support teams
(CCT Teams)
•
•
3.
Local care support & population
management
Prevention specialists
4.
Community Activation & Prevention
•
•
•
5.
Prevention specialist as part of CCT
Community profiles & risk assessments
Evidence based interventions
Evaluation
•
•
•
•
•
NCQA PCMH score (process quality)
Clinical process measures
Health status measures
Multi payer claims data base (VCHURES)
Population Indicators
Health Information Technology
•
•
•
•
•
Web based clinical tracking system
Visit planners & population reports
Electronic prescribing
Updated EMRs to match program goals
and clinical measures in DocSite
Health information exchange network
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Accountable Care Organizations
 An ACO is an entity that enables networks of health care providers
to become accountable for the overall costs and quality of care for
the population served by:
•
•
•
Bending the medical cost curve – savings over projected trend line of costs
Improving the health of the community population and the patient experience
Capturing part of shared saving to reinvest in local community health system
 Work focuses on payment reform, data collection and care
delivery models
 Goal: Test the ACO concept in a small number of ‘early adaptor’
community provider networks that have key integrator capabilities
3/09-12/09 Customize design







Identify qualified ACO pilot networks/sites
Encourage shared savings pool across multiple commercial payers
Plan for Medicaid participation and waiver filing
Advocate federal legislation for Medicare participation
Create financial impact model for ACO
Continue broad based stakeholder workgroup for design input
Coordinate/integrate design with Blueprint medical home
Q2 2010
Startup of initial pilot
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Health IT


Goals:
•
common level of high quality healthcare for individual patients and
populations across all practice and human service settings
•
guideline based health maintenance & prevention, care for chronic
conditions, and eRx
•
provide the suite of health IT and data services that meets the needs of
different practice settings
Progress to Date
•
VT Information Technology Leaders (VITL) - statewide HIE
•
Statewide Health IT Plan
•
Health IT Fund: 0.2% fee on paid medical claims for 7 yr
 Electronic Health Record: fund implementation for primary care
practices
 Fund state-wide Health Information Exchange infrastructure
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HIT: Fitting the pieces together
Federal HIT/HIE Policy, Oversight, & Standards - Office of the National Coordinator (ONC)
State HIT/HIE Policy, Oversight, & Standards – OVHA/HCR
State Government & Public Health
Public Health surveillance,
registries, & other public
health functions
Medicaid health programs
case management
functionality and connectivity
Other Medicaid & AHS case
management functionality and
connectivity
Other state agency & dept.
case management
functionality and connectivity
Law Enforcement,
Corrections, & Court System
Vermont Health Care Providers & Institutions
Health
Information
Exchange
(HIE)
“Cloud”
for interchange of health records,
demographic data, image files,
clinical messaging, & other
digitized health information
Tertiary and Community Hospitals
Primary Care & Specialty Providers
Federally Qualified Health Centers
& Rural Health Clinics
Free Clinics
Mental Health/BH/SA Providers
Long Term Care Providers
Operated by VITL
Home Health & Hospice Providers
Individual Vermonters: connectivity to EHR
Portals, Personal Health Records (PHR),
Health 2.0 applications and Ix Services
Community Human Service
Agencies (Family Centers, Area
Agencies on Aging, etc.)
Quality Transparency
Hospital Report Cards


Vermont hospitals required to publish annual reports on:






Quality of Care
Infection Rates and Prevention Measures
Patient Safety
Nurse Staffing
Financial Health
Costs for Services
BISHCA web-site contains comparative Report Cards across Hospitals
Consumer Price & Quality System
•
•
•
•
Purpose: to empower people to make economically sound and medically appropriate
decisions
Insurers with at least 5% of the commercial market must file Consumer Information
Plans describing how they will provide price and quality information to their members
Hospitals and Hospital-owned Practices must file Consumer Information Plans
describing how they will provide price and quality information to uninsured
consumers
Phased-in to full implementation in 2013
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Health Care Quality Organizations
 Vermont currently has a private, non-profit Vermont Program for
Quality in Health Care with a board made up of hospitals,
insurers, physicians, and consumer representatives
• Funded by hospitals and insurers
 BISHCA required to study health care quality organizations in
other states
 How do other states and countries analyze quality and ensure
quality improvement?
 Report due on January 15, 2010 to include recommended
modifications to existing program if appropriate
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Cost Transparency

BISHCA Certificate of Need (CON) process for state approval of health care
facility expenditures for :
•
•
•

high cost construction, purchase, or renovation ($3 m for hospitals, $1.5 m for other
health care facilities),
purchase or lease of diagnostic or therapeutic equipment ($1 m), or
offering of a health care service or technology that has an annual operating expense
that exceeds $500,000 for either of the next two budgeted fiscal years
BISHCA monitors and controls increases in hospital costs through annual
binding hospital budget review process
 Public Oversight Commission (POC) makes recommendations to BISHCA
regarding annual hospital budgets and Certificate of Need applications
 Health Resource Allocation Plan (HRAP)
•
•
•
Legislatively-required plan developed by BISHCA
Includes an inventory of specified health care resources, and recommendations for
appropriate supply and distribution of those resources
Purposes:
 Resource document for state policymakers and for certificate of need process;
 Introduce new science, technology, standards and benchmarks to support regulatory functions;
 Introduce new ideas and policy considerations for feedback and further discussion
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Cost Containment:
Variation in Utilization Study
 Legislative-mandated Study by BISHCA with report by January 15, 2010)
 Report must identify treatments or procedures
 for which the utilization rate varies significantly among geographic regions
within Vermont, or
 where the utilization rates are changing faster in one geographic region than
another
 Report shall “determine the reasons for the variation”
 Report shall contain “recommendations for containing health care costs by
reducing variation, including promoting the use of equally or more effective
lower cost treatment alternatives, prevention or other methods of
appropriately changing utilization.”
• BISHCA must consult with hospitals, Vermont Medical Society, and insurers to
make recommendations regarding variation in utilization analysis
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Cost Containment:
Health Plan Administrative Costs
 Legislature mandated BISHCA, in collaboration with the Agency
of Human Services, to provide an administrative cost report
 The report shall “identify a common methodology based on the
current rules of insurer reports to BISHCA for calculating costs of
administering a health plan in order to provide useful
comparisons between the administrative costs of:
• Private insurers
• Entities administering self-insured health plans, including the state
employees and retiree health benefit plans
• Offices and departments of the Agency of Human Services
 The report shall “compare administrative costs across the
entities in Vermont providing health benefit plans.”
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Pharmacy Cost Containment
in Vermont Law
 Pharmaceutical Manufacturer Disclosure of gifts or other
economically-valued marketing to prescribers
 Pharmaceutical Marketer Disclosure of the average wholesale
price of the drug being marketed
 Protection of Prescribing Information from Pharmaceutical
Marketers
 Pharmacist Disclosure to consumers of the usual and customary
retail price of the drug (upon request)
 Mandatory Pharmacist Alternative Drug Selection of lowest priced
therapeutically equivalent drug
 Fee Imposed on Manufacturers ($ .10 / claim for publicly funded
programs) to Promote Generics and other Low-cost Alternatives
• Academic Detailing for Prescribers
• Generic Voucher Pilot for Free Samples
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VCHURES (Vermont Healthcare Claims
Uniform Reporting & Evaluation System)
 Multi-payer claims database administered by the State
 Includes eligibility and medical and pharmacy claims data for private
comprehensive major medical benefits (insured and self-funded),
Medicare Parts C and D, and Medicare Supplement.
• May include Medicaid and Medicare claims data if approved by CMS
 Resource for reviewing health care utilization, expenditures, and
performance
 Harmonized with similar claims data collection initiatives in other
states to support uniform reporting standards for insurers, and
future regional and national research
 July 2009 - First consolidated eligibility and claims data set for the
paid claims period of January 2007 through December 2008
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For more information
Vermont Health Care Reform Web-site:
www.hcr.vermont.gov
Health Care Coverage Information:
www.GreenMountainCare.org
1-800-250-8427
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