Mountain Care Board July 13, 2017 OneCareVermont OneCareVT.org - - PowerPoint PPT Presentation

SLIDE 1

2018 Budget Presentation to the Green Mountain Care Board

July 13, 2017

OneCareVermont

OneCareVT.org

SLIDE 2

Table of Contents

• 1. OneCare Overview
• 2. Budget Overview
• 3. Improving Population Health Outcomes
• 4. Changing Care Delivery
• 5. Supporting High Quality Care
• 6. Supporting Primary Care
• 7. Patient Experience of Care

OneCareVT.org 2

SLIDE 3

OneCare Overview

OneCareVT.org

SLIDE 4

OneCare Vermont

• Founded in 2012

O Pioneered concept of representational governance by provider type

• Offered shared savings if earned as a equal split between primary care and hospitals/other

providers

• Multi-Payer

O In year 5 of MSSP (Medicare Shared Savings Program)

• In year 4 of XSSP (Commercial Exchange Shared Savings Program)
• In year 4 of Medicaid programs (first year of Vermont Medicaid Next Generation after 3

years in Vermont Medicaid Shared Savings Program )

• Current total attribution of approximately 100,000 lives
• Statewide Network

O Hospitals of all types (tertiary/academic, community acute, critical access, psychiatric)

• FQHCs
• Independent physician practices
• Skilled Nursing Facilities
• Home Health
• Designated Agencies for Mental Health and Substance Abuse
• Other providers

OneCareVT.org 4

SLIDE 5

Board of Managers

Seat Individual Community Hospital - PPS (Prospective Payment System) Community Hospital — Critical Access Hospital Jill Berry-Bowen - CEO Northwestern Vermont Health Care Claudio Fort - CEO North Country Hospital FQHC Kevin Kelley - CEO CHS Lamoille Valley FQHC Pam Parsons- Executive Director Northern Tier Center for Health Independent Physician Lorne Babb, MD - Independent Physician Independent Physician Skilled Nursing Facility Home Health Toby Sad kin, MD - Independent Physician Judy Morton - Executive Director Genesis Mountain View Ctr. Judy Petersen - CEO VNA of Chittenden/Grande Isle Counties Mental Health Mary Moulton - CEO Washington Country Mental Health Consumer (Medicaid) Angela Allard Consumer (Medicare) Betsy Davis - Retired Home Health Executive Consumer (Commercial) John Sayles - CEO Vermont Foodbank Dartmouth-Hitchcock Health Steve LeBlanc - Executive Vice President Dartmouth-Hitchcock Health Kevin Stone - Project Specialist for Accountable Care Joe Perras, MD — CEO Mt. Ascutney Dartmouth-Hitchcock Health UVM Health Network UVM Health Network UVM Health Network Steve Leffler, MD - Chief Population Health Officer Todd Keating - Chief Financial Officer John Brumsted, MD - Chief Executive Officer OneCareVT.org 5

SLIDE 6

OneCare Vermont Highlights

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• Highlights
• Nationally prominent size and network model since inception
• Proposed and structured the idea of multi-payer aligned Shared Savings ACOs in Vermont
• First ACO in Vermont to contract with full continuum of care
• Proposed idea of stronger, more structured community collaboratives; received multi-year State Innovation

Model grant funds and partnered with Blue print and other ACOs to implement

• Led vision and business plan for embracing risk and supporting Vermont All Payer Model
• One of 25 ACOs nationally approved in first application cycle for the Medicare Next Generation Program
• Designed and negotiated Vermont Medicaid Next Generation with DVHA with many advanced elements
• Constructive participation in every major initiative/collaborative affecting healthcare in Vermont
• Very strong quality improvement track record and reduced variation on total cost of care and utilization
• Advanced informatics already in place and in deployment to the field
• Setting Course for 2018
• Medicare Next Generation refreshed application
• Active negotiations with BCBSVT on risk-based Commercial ACO Program for 2018
• Process for renewing for Year 2 of VMNG with DVHA
• 2018 GMCB Budget
• Includes risk-based program targets, payment models, reform investments, ACO operational budget, and risk

management approach

• Will include strong primary care and community-based provider support

OneCareVT.org 6

SLIDE 7 :• TTZIMM vi

Budget

Overview

SLIDE 8

2018 Budget Accomplishes Much

"Check Offs" in 2018 OneCare Budget

✓ All Payer Model

• Big step toward vision and scale of Vermont APM

✓ Hospital Payment Reform

• Prospective population payment model for Medicaid, Medicare, and Commercial

✓ Primary Care Support/Reform

• Broad based programs for all primary care (Independent, FQHC, Hospital-Operated)
• More advanced pilot reform program offered for independent practices

✓ Community-Based Services Support/Reform

• Inclusion of Home Health, DAs for Mental Health and Substance Abuse, and Area Agencies on Aging in

complex care coordination program

✓ Continuity of Medicare Blueprint Funds (Former Medicare Investments under MAPCP — Multi-Payer Advanced Primary Care Program)

• Continued CHT, SASH, PCP payments included for full state

✓ Significant Movement Toward True Population Health Management

• RiseVT (a major feature/partner in OneCare's Quadrant 1 approach)
• Disease and "Rising Risk" Management (Quadrant 2)
• Complex Care Coordination Program (Quadrants 3 and 4)
• Advanced informatics to measure and enable model
• Rewarding quality

OneCareVT.org 8

SLIDE 9 Risk Management approach

L,

Payer ACO Operational Support/Other Expenses ACO Revenues ACO Payment Reform and PHM* Investments

Constructing the "Risk" ACO Budget

Key Point: Network Participation Changes Prior to 2018 Could Ripple Significantly Through the Plan Providers in Network Payer Programs Attribution Projections Program Target Trends/Forecast

Cascading and

Highly Interrelated Model

Full Revenues and Expenses Model *PHM = Population Health Management OneCareVT.org 9

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2018 Risk Network Communities

Hospitals with Employed Attributing Physicians pirrva Significant Attribution from Community Physicians

• Seven Vermont Communities

Bennington

• Berlin

Brattleboro

• Burlington

Middlebury

• St. Albans
• Springfield
• Plus Lebanon, New Hampshire

for BCBSVT program

• Local hospital participation in

all communities (required)

• Participation of other providers

in each Vermont community

OneCareVT.org

SLIDE 11

2018 Risk Network as of Budget Submission

Bennington Berlin Brattleboro Burlington Lebanon Middlebury

• St. Albans

Springfield Hospital SWVMC CVMC BMH UVMMC DH PMC NWMC SH FQHC Declined Declined N/A CHCB N/A N/A NOTCH SMCS Independent 6 Practices 1 Practice 2 Practices 14 Practices N/A 2 Practices 4 Practices NA PCP Practices Independent 5 Practices 4 practices 1 Practices 21 Practices N/A 5 Practices 4 Practices NA Specialist Practices Home Health VNA & Hospice Central VT Bayada VNA N/A Addison Franklin N/A

• f the

Home Chittenden/ County Horne County Home Southwest Health & Grand Isle; Health & Health & Region; Bayada Hospice Bayada Hospice Hospice SNF 2 SNFs 4 SNFs 3 SNFs 3 SNFs N/A 1 SNF 2 SNFs 1 SNF DA United Washington NA Howard N/A Counseling Northwestern Health Care Counseling County Center Service of Counseling & and Service of Mental Addison Support Rehabilitation Bennington Health County Services Services of County Southeastern Vermont All other 2 other 1 other 1 (Brattleboro 2 other N/A NA NA 1 other Providers providers provider Retreat) providers provider (ft of TINs) Note: AAAs contracted members of network but do not do traditional medical billing and therefore are not formally submitted TINs in our risk network OneCareVT.org 11

SLIDE 12

OCV 2018 Program Summary

Payer Program Risk Model

Medicare

• Modified Next Generation Medicare

ACO Program under APM (MMNG)

• 100% or 80% Risk Sharing Percentage

(Our Choice) 5% to 15% Corridor (Our Choice) Budget assumes minimum model risk on TCOC which is 4% (= 5% * 80%)

Medicaid

• Vermont Medicaid Next Generation ACO • For 2017: 100% Risk Sharing Percentage

Program (VMNG) Year 2 Renewal

• n 3% Corridor
• Budget assumes continuity of that

model at 3% on TCOC

Commercial

• Move Exchange Shared Saving Program
• In discussion for 50% Risk Sharing

Exchan (XSSP) to 2-sided Risk with BCBSVT

Percentage on a 6% Corridor

ge

• Budget will apply that draft model for

total maximum risk of 3% on TCOC (= 6% * 50%) Glossary:

• Risk Sharing Percentage = Percentage of savings or losses

received by ACO within Corridor

• Corridor = Maximum Range of ACO Savings and Losses (Payer

covers performance outside of Corridor)

• TCOC = Total Cost of Care

OneCareVT.org 12

SLIDE 13

Network Attribution Model

Service Area ANIL Medicare Medicaid

BCBSVT TOTAL Bennington 6,244 5,748 3,720 15,712 Berlin 6,077 6,790 5,310 18,177 Brattleboro 2,345 3,895 1,869 8,109 Burlington 17,306 24,053 17,290 58,649 Lebanon 2,703 2,703 Middlebury 3,637 4,261 3,382 11,280 Springfield 2,430 5,112 2,624 10,166

• St. Albans

4,575 4,733 3,042 12,350 42,614 54,592 39,940 137,146 OneCareVT.org

SLIDE 14

Budgeting 2018 Program Targets

Trended from 2017 to 2018 based on: OneCareVT.org 14 2018 Projected OCV Population Combined Target $764.4M

Target Budget Methodology Modeled Target Calculation

$411.9M $170.7M $125.9M Trended from 2016 to 2017 based on: 2014-2016 OCV Actual Trend adjusted with Actuarial Guidance BCBSVT 2017 QHP Rate Filing Medical Trend adjusted with Actuarial Guidance 2.0% 4.5% OCV Medicare 2015 to 2016 Actual Trend adjusted with Actuarial Guidance BC1351/T 2016 Base Actual BCBSVT Spend MEDICARE 2016 Base Actual Medicare Spend MEDICAID 2016 Base Actual Medicaid Spend BCBSVT 2018 QHP , Rate Filing Medical Trend adjusted with Actuarial Guidance

if

2.0% APM Medicare One-Time "Floor"

• f 3.5%

2014-2016 OCV Actual Trend adjusted with Actuarial Guidance Medicare Adjustment for Blue Print Funds

SLIDE 15

Risk Management Model

• Participating Hospitals to Bear the Risk under OneCare ACO Programs
• Current OneCare model has service area's "Home Hospital" (the one physically located in the

community) bearing the risk for the spending target for its locally-attributed population

• Other providers NOT at risk (e.g. FQHCs, Independent practices, other community providers)
• Budget Assumes "zero-sum" Performance on Risk Programs at ACO level
• i.e. OneCare exactly meets targets on all programs
• Some programs have "up front" discounts applied where applicable
• Risk hospital payments are source of some "off the top" investments and operational expense

coverage; hospitals will need to generate savings to do well under fixed payments received

OneCare Risk Management Support

• Risk declines (diversifies) with participation in multiple programs across Medicare, Medicaid, and

Commercial populations

• OneCare provides analysis and formal actuarial review to ensure program targets are understood and

acceptable

• OneCare to provide reinsurance program to limit risk from very high utilization year overall and/or much

larger number of very high cost cases

• WorkbenchOne analytic tools to (i) identify areas of opportunity and (ii) understand risk performance

throughout the year

• Community support and facilitation of clinical and quality models associated with high value,

prevention, and avoidance of waste OneCareVT.org 15

SLIDE 16

2018 Operations Budget Summary

Category Sub-Category Budgeted Expense Percent of Operations Budget Personnel Finance and Accounting $840,144 6.7% ACO Program Strategy $465,640, 3.7% Clinical/Quality/Care Management $2,560,416 20.5% Informatics/Analytics $1,332,012 10.7% Operations $1,149,066 9.2% SUB-TOTAL PERSONNEL $6,347,277 50.8% General Administrative Health Catalyst (Core Information System) $1,084,680 8.7% VITL Data Gateway $900,000 7.2% Other $1,586,312 12.7% Contracted Services Reinsurance $1,500,000 12.0% Other Contracted Services $1,074,465 8.6% TOTAL EXPENSES $12,492,735 100.0%

SLIDE 17

PHM/Payment Reform Program Investments

Program Basic OCV PMPM for Attributing Providers Complex Care Coordination Program $ $ 2018 Investment 5,348,694 7,580,109 Supporting Primary Care and Community-Focused Elements of PHM Approach RiseVT Program $ 1,200,000 CHT Funding Risk Communities $ 1,746,360 CHT Funding Non-Risk Communities $ 772,538 SASH Funding Risk Communities $ 2,417,942 Supporting Blueprint for Health Continuity and Ongoing SASH Funding Non-Risk Communities $ 852,012 Collaboration with ACO Model PCP Payments Risk Communities $ 1,319,336 PCP Payments Non-Risk Communities $ 654,313 Value-Based Incentive Fund $ 5,559,260 Rewarding High Quality PCP Comprehensive Payment Reform Pilot $ 1,800,000 Supporting True Innovation in Independent PCP Practices Total $ 29,250,563 OneCareVT.org 17

SLIDE 18 ACO Payer Targets Revenues $764,430,113

2018 Budget Revenues and Expenses

4110

Payer-Provided Program Support $9,658,176 $1,200,000 $3,500,000 $371,851 $779,160,140 $289,626,898 $447,789,945 Rise VT Transformation Support State HIT Support Grants and MSO Revenues TOTAL REVENUES Expenses Health Services Spending (Payer Paid FFS) Health Services Spending (OneCare Paid Fixed/Capitated Payments) Operational Expenses $12,492,734 Population Health Management/Payment $29,250,563 Reform Programs TOTAL EXPENSES $779,160,140 NET INCOME $0 OneCareVT.org 18

SLIDE 19

Improving Population Health Outcomes

On eCa reVT.org

SLIDE 20

• . OP

. 14

• 14aiapieposo4Piss

16% Lives 40% Spending 89% Multiple Chronic 67% MH Condition

Population Based Health Care Approach

44% of the population > 40% of the population > Focus: Maintain health through preventive care and community-based wellness activities > Focus: Optimize health and self-management of chronic disease > Examples:

• Rise VT primary prevention program
• PCMH panel management
• Wellness campaigns (e.g. 3-40-50, health

education and resources, wellness Category 1: classes, parenting education) Healthy/Well

• Home visiting programs
• unpredictable

(includes unavoidable events) LOW RISK 6% of the population > Focus: Address complex medical & socia challenges by clarifying goals of care, developing action plans, & prioritizing tasks ‘, Acute Catastrophic Complex/High Cost Category 4: Category 2: Early Onset/ Stable Chronic Illness > Examples:

• HTN Peer-to-Peer Learning Collaborative
• 01 Change Packages
• CHT resources (e.g. tobacco cessation,

, nutrition & physical activity coaching, diabete " :elf management

• r;atient resource library in Care Navigator (in
• .

00,

gress) MED RISK 10% of the population Category 3: Full Onset Chronic Illness & Rising Risk' > Focus: Active skill-building for chronic condition management; identify & address co-occurring SDoH VERY HIGH RISK HIGH RISK v

• os cbo social deter,.o,N.

IN

> Examples:

• Complex care coordination: lead care

coordinator, shared care plans, care conferences

• Community 01 projects on hospice utilization
• Provider and patient education on palliative

care (e.g. September OCV Grand Rounds) > Examples:

• Embedded mental health in primary care
• SDoH screening (e.g. food insecurity in/out

patient peds; VT Self Sufficiency Outcomes Matrix for patients with complex CC needs)

• Care coordination: coordinate among care

team members; shared care plans;

Budget Check

OneCareVT.org 0V•6••••• 000 l..4001.0••••••• .

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SLIDE 21

Sample Activities Supporting Vermont APM Population Health Goals

fins

• Percent of Adults with Usual Primary Care Provider
• Promote primary care connection for VMNG patients attributed to specialists
• Improve viability of primary care through payment reform
• Deaths Related to Suicide/Deaths Related to Drug Overdose
• Embedding mental health services in primary care
• Provider education & training: SBIRT, suicide prevention, new VPMS opiate

prescribing requirements & clinical workflows

• Expand data sources to refine risk stratification to inform community-based care

coordination

• Statewide Prevalence of Chronic Disease: COPD, HTN, DM
• Disease-specific panel management through Care Navigator
• Conduct Quality Improvement (QI) Learning Collaborative on Controlling HTN
• Develop 01 initiatives on pre-HTN and pre-DM
• Community Collaboratives promote local primary prevention (e.g. RiseVT, 3-4-50,

VT Quit Line) Glossary:

Budget Check

• VMNG = Vermont Medicaid Next Generation

SBIRT = Screening, Brief Intervention, and Referral to Treatment (screening tool)

• VPMS = Vermont Prescription Monitoring System

nr.** 1.41.10

• COPD = Chronic Obstructive Pulmonary Disease
• HTN = Hypertension (High Blood Pressure)

.401/ I 11•11.

• DM = Diabetes Mellitus (Diabetes)

4.1.1 I ?VW.

• -......
• --..

OneCareVT.org 21

SLIDE 22 Budget Check 22

Social Determinants of Health

• Complex Care Coordination
• Shared Care Plans
• Camden Cards
• VT Self Sufficiency Outcomes Matrix
• Plans to add SDoH to risk adjustment
• Primary Care

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SLIDE 23

• S

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• 3

Category 4: > Focus: Address complex medical & social 4 ,? , Complex/High Cost challenges by clarifying goals of care, s, Acute Catastrophic

• developing action plans, & prioritizing tasks

'

LOW RISK VERY HIGH RISK 6% of the population A. 8 10% of the population Category 3: Focus: Active skill-building for chronic Full Onset Chronic Illness & Rising Risk/

• ccurring social needs

HIGH RISK condition management; address co- (i.e. physical, mental, social needs) ‘, Category 2: 's,

• Disease & self-management support*

Early Onset/ Stable Chronic Illness (i.e. education, referrals, reminders)

• Pregnancy education

"A• di bl 4 unpre cta e unavoidable events) Category /: Healthy/Well (includes

Care Coordination Model

(...> 40% of the population

K

44% of the population D Focus: Maintain health through preventive care and community-based wellness activities D Focus: Optimize health and self-management of chronic disease D. Key Activities:

• PCMH panel management
• Preventive care (e.g. wellness exams,

immunizations, health screenings)

• Wellness campaigns (e.g. health

education and resources, wellness classes, parenting education) ‘0.9sychosociaLcietemi .0th. D Key Activities: Category 1 plus

• PCMH panel management: outreach (>2/yr)

for annual Comprehensive Health Assessment MED RISK > Key Activities: Category 3 plus

• Designate lead care coordinator (licensed)*
• Outreach & engagement in care coordination

(at least monthly)*

• Coordinate among care team members*
• Assess palliative & hospice care needs*

\,... .,,,

• Facilitate regular care conferences *

> Key Activities: Category 2 plus

• Outreach & engagement in care

coordination (>4x/yr)*

• Create & maintain shared care plan*
• Coordinate among care team members*
• Emphasize safe & timely transitions of care
• SDoH management strategies*

atuesapieposolPs- 16% Lives 40% Spending 89% Multiple Chronic 67% MH Condition OneCareVT.org * Activities coordinated via Care Navigator software platform 23

SLIDE 24 ^

Level 2: PMPM for Team-Based Care Coordination (Top 16%)

Care Coordination Financial Model Summary

Budget Check

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• •••1110111•1%

One time annual payment for intensive upfront work + adcrl PMPM for LCC Foci:

• Lead Care Coordinator, designated by the

patient

• Activate and engage patients in care

coordination

• Lead development of patient-centered

shared care plan documented in Care Navigator

• Facilitate patient education & referrals
• Monitor milestones, track tasks and

resolution identified goals & barriers

• Coordinate communication among

team members

• Plan care conferences

Mem. gr., ......•••••• —

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'-

..: ,............, ,.... WA* j. ••••••••••••••..• Payment for panel management Foci:

• Assess patient-specific needs &

deploy organizational resources to support patient goals

• Contribute to patient-centered

shared care plans

• Participate in care team meetings,

care conferences, and transitional care planning

Level 1: Community Capacity Payment

One time annual payment per community. Foci: community-specific workflows; workforce readiness & capacity development; analysis of community care coordination metrics, gap analysis and remediation OneCareVT.org 24

SLIDE 25

Care Coordination Engagement Metrics

Care Navigator Trained Users Patients with an Initial Lead Care Coordinator Identified 350 300 250 500 +, 200 400 u 150 300 100 50 200 100 Dec Jan Feb Mar Apr May June July Shared Care Plans Created, 2017 Jan Feb Mar Apr May June July 35 30

As of July 1, 2017:

• 599 patients > 1 care team member
• Range: 1-8 care team members

20 LI 15 10 5 Jan Feb Mar Apr May June July 0 neCa reVT.org 25 25

SLIDE 26

Clinical Priority Area- Related Projects

• 1. High Risk Patient Care

Coordination

• 33 projects across 11

HSAs

• 2. Episode of Care Variation
• 9 projects across 5

HSAs

• 3. Mental Health and

Substance Use >. 40 projects across 12 HSAs

• 4. Chronic Disease

Management Optimization 31 projects across 12 HSAs

• 5. Prevention & Wellness
• 38 projects across 11

HSAs 26

Community Collaboratives: Showcasing Community Improvements in ACTION

Morrisville:

• 30-day all-cause

readmission

• Developmental screening
• COPD
• Obesity
• Hospice utilization

Newport: Middlebury:

• Decreasing opiate

prescriptions

• ED utilization

Rutland:

• All cause readmission
• Tobacco cessation
• CHF, COPD

Bennington:

• CHF Admissions
• ED utilization
• All-cause readmission
• Care Coordination
• neCareVT.org
• St. Albans:
• ED utilization
• Rise VT
• 30-day all-cause

readmission

• Developmental

screening

Burlington:

• Hospice utilization
• ED utilization
• Adolescent well child

visit rates Berlin:

• Adverse Childhood

Experiences

• SBIRT
• Hospice utilization
• CHF

Windsor:

• COPD
• Opioid use

management

Brattleboro:

• Hospice utilization
• Decreasing post acute LOS
• Care coordination

40 MA 40 Mdes

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ICCX.Sro. SVMCs Outcomes

• SVMC Decreased Rates of All Payer, Long Tenn Care 30 Day An Cause
• All Cause 30 day Readmission and

Readmission Rate 201S vs. 2016 Transfers to Hospital

• enonived [COT emurnermeien free

YAW 65sHSVPAC OM hoes 5/1640216) IPA . meemeeel eed intereval polity of denotentabon syntemeo donee el COM.. merewelsorroort inuning Pair

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me temente losee to Me SW no Ming in the tun. OS Mine poem. tom ere emote in ...No Iroiro ...ger too toes OneCareVT.org 27

SLIDE 28

Changing Care Delivery

OneCareVT.org

SLIDE 29

Medicare Next Generation Waivers . Expanded patient benefits:

• Access to skilled nursing facilities without a 3-day inpatient stay

requirement

• Access to two home health visits following hospital discharge
• Access to telehealth services not currently allowed by CMS
• Still accrues against ACO "risk" target but facilitates compliant service

delivery and revenue flow

. Future topics under consideration through Vermont

APM:

• "Virtual PACE program" — funding of adult day care for patients in

complex care coordination

• Home IV antibiotics
• Expansion to other payers

OneCareVT.org 29

SLIDE 30

Flexible Care Models

• "Virtual Visits" — store and forward enhancements to

electronic health record patient portals

• Telemedicine visits
• Direct patient care
• Support of continuum of care community providers

Home Health agency )> SASH Designated Agencies ),=- Agency on Aging

• Pharmacist patient support and consultative services
• PCMH imbedded mental health services
• More Medication Assisted Treatment (MAT) in PCMH
• Population health compensation models
• RN performed Medicare Annual Wellness Visits

OneCareVT.org 30

SLIDE 31

A110 "The nurse spent a lot of time with me and was incredibly thorough, I will do this again"

Patient from Central Vermont

"I find the focused visits after the patient has had an AWV to be quite rewarding. Patients are coming in to talk about specific questions related to their Advance Directives or other issues found during their AWV, and we are able to devote the time to those things. Conversations are meaningful and less distracted by the requirements of the AWV"

• Clinician from Central Vermont

alp

Medicare Annual Wellness Visit

• Focuses on prevention, safety, and coordination of care
• Includes health risk assessments, measurements and screenings, and

personalized health advice and referrals

• OCV clinical priority area: aligns with 7 Medicare quality measures; OCV

performance <20% (2015); focus on primary or secondary prevention of chronic disease

• Innovation:
• RNs perform Medicare AWV
• Developed & refined communication
• Staff Training
• Evaluated impact
• Outcomes:
• Increased patient satisfaction
• Increased provider & staff satisfaction
• Improved access to care
• Improved quality performance
• Improved revenue to practice

OneCareVT.org 31

SLIDE 32 Hospital SPeViCP Area econnsten Iterin Pattiebom Ourinpon Mokliebury Mmernie larapm fhtland 5rAlrohdd Attributed TIN Alm Osernonn,992 Wrmate, Avery Wood terMetoro Memorial Florceal, Inc. Patlieboro Retreat Centrel Maw* Medical Certm Inc OAS Holes Am* Seam, P.C. Omir.mtl c.o...., Measure Reason Good Control WA:erect Date Mises Irfonnabon Cue to hems No Data Found No Data In Mearmentent Period tem-Numeric Remit Val* Non-Standard C.ocle in Maamernent Pen:d Poor Coned Data Source OMMC one Woo No Data Aratatia &994 at EPIC VITI Sending Facty .P Patient Name Attributed TIN Ake Hyde Medal Certer Branielmo Meiroad tbsped Central Vermont MedcalCtriter, Sc. Champion Poky Physcians Hooped ^ ^ • ^ .• • • N ^ • ^ Patient Name Patient 1 Pabent2 Patient3 Pober*4 PabereS Patent() 999e91 Patientli Pabent9 0.9,910 1 * History Prosider Name HAKEY, DIANE JEAN BERGER, CLAUDIA UM*, SCOTT MERTZ, MICHELLE XTHIFER .19246, 6119 1 _

• Remilt

Date Code Code Description ng Facility Result Sendi NI Value Code 199941- IS 4548-4 141404.013IN A IC (A IC) 7.11UYH992Emc 1999-11.15 4549-4 III42.2/011INAIC (Al() 6.8 TIVAISCEIM 1999-11-15 45441.4 r429:4ov; AIC (MC) 7.1 LASISCEpc 199911.15 45404 HEMOGLOBIN AIC (AI() 7.21./MSKE9s 1999-11.17 4549-4 1.040a0eIN A IC (MC) 5.1 IIMINClps Patent691 P . m./sky of Vermont Medical Center Ix. 908,91964 Lewersty of Vermont (Redo& Center Inc. 9a101*5871 Unversty 09 Varna* Medcal Condit Ito. PaheoteG34 Urprersity of Veromt Medea Center Inc. Pabent730 Wirer*, of Vermont Medal Center Inc. Patients in Denorroinat or by Attribut ed TIN 11161 11111,1111111111111.111.1.11. IPS '" X. n • 22* In op e4/ 44,

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• brillAbCrOPIeniedaittosoRal. Inc.
• FULHAM. WAN

/Scheel 1 Corson, FD PC CORRIGAN, MICHAEL Plorthwestern Medea' Certer FITZGERALD, 20re9 (Seventy of Vermont Heckel Center— Acces. ALICIA Measure Reason Detail Data Reason Result Date Code TO No Data Found Good Coded 1110/20164540-4 H. No Obta Found Non-Standard Code riMeasu... $/7/2016 tipb A10 CH 10,90 0,.. taz Data Found NA Data Mord Good Cortrol 2/25/2016 4548.4 Nervitanderd Cede in Flees, 5/4/2016 22192 N. FismStardard Code n 3125n016 liGIMP A Good Contrci 519f2016 4548.4 CI Result Value Sending Fealty I 6.7 Unversky CI %%MOM 7.1 Mt Ascutney Moped 5.4 Brattleboro mirromil '- 7.3 u.reaRy cf Verrone 10.71 Mirthwestern Medoff immersty of Vermont . ,

• 691

Workbench ne Analytics Platform

Clinical data feeds from the VITL ACO Gateway enable:

• Population-level Dashboards
• Self-Service Analytic Applications
• Quality Measure Scorecards
• Standard Reports

ILIEEMEEsm

gig

ACO 27 2016 - Diabetes Mellitus: Hemoglobin Al e Percereade at patents 18.75 sees at ape dad ,. 04, 0 tad hemeleitm IMAM • 9.8.,cast +ecert Homo result is tours, or C Mere are no /MAI o tells Penomed and remit dootenertee Orris meestrernere Organization AdreeldieklACO Denominator 4,548 Fawner at or 3.325 Reverse Score Measure MOW Better) OneCareVT.org 32

SLIDE 33 4 E

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..1861162 85,000 80,000 75,000 70,000 65,000 60,000 55,000 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 Post Speech Therapy Post SNF Swing Post SNF Non Swing Post Physical Therapy Post Outpatient Observation Post Office Visit Post Occupational Therapy Post LTAC Post Inpatient Rehab Post Inpatient Post Home Health Agency Post ED Post Cardiac Rehab Acute

Episodes of Care (Bundles) Analysis Care Standardization

• Acute hospitalization payments,

physician billings, plus all post acute services for 90 days

• Large proportion of total cost of care

CMI and RUG risk adjusted data

• Mechanism to educate network

concerning significant community variation in type and amount of services

• Hospital, skilled nursing, home health

length of stay — Post acute services "pathways"

• "SNF...ISTS" — onsite medical coverage in

nursing homes — an important paradigm

shift

• Promote patient engagement and

setting post acute care expectations

OneCareVT.org 33

SLIDE 34

Hospital Readmission

t

Emergency Room

Episode of Care (Bundle) Pathway

Hospital Discharge "Anchor Admission" (90 day clock starts on day of discharge)

Acute Inpatient Rehabilitation

• *
• (ex. age > 85, single knee le*

with BMI > 50) Swing Bed

4-*

+

• Skilled Nursing Facility

4E*

÷

• Home with Home Health

Services Office Follow-up

Post—Acute Services Comprise 10%-60%

• f the total 90-day episode expense

Home with Outpatient

—1

>

Services

SLIDE 35

Supporting High Quality Care

OneCareVT.org

SLIDE 36 Quality Measurement, Analysis, & Reporting Clinical Priority Areas Established Community-wide and Facility-specific Quality Improvement Activities

Quality Improvement Strategies to Achieve the Triple Aim

• Timely and Accurate Data
• Identify gaps in care
• Drive decision-making
• Support Local Communities to Improve
• Aligned clinical priority areas
• Representation on clinical governance committees
• Blueprint/OCV aligned staffing & resources
• Resources, Training, and Tools
• A3 01 reporting processes
• All Field Team staff trainings
• Dissemination of Results
• Network Success Stories
• OneCare Grand Rounds, Topic Symposia, Conferences
• Facilitated sharing on clinical committees

OneCareVT.org 36

SLIDE 37 g 40 70 ACO Tabus* Use Sereetolns and Cessation 44erventl3. 3137 Ilk67 10.41 07.34 2013 2014 2015 OM Sapaelbss ewe 2016 120 1 W .2

'

20 14.71 4.0010 DosonsaslonIssowily not 35.42 44313 2013 2014 2012 2056 010102.1.11, 430. 10. 1 .3 s. 540 0 213 ACO 14, Purvontative Caw an4 Susenlas,Indlown Inenessein0as, 71.1% 44.13 0.111 2017 2014 70/5 014111wasesats Yaw 111.11 1016 102 01 ACO Ceitatedal Qom Stneallte 01.3) 70.27 70.31 2011 1014 VS altoorlawnsor 2011 ACC115:Swonsonser.alVawlsatlaeStatos/ot Older Adults 44.70 10.31 77 73 Mee ton 2014 2013 2013 01.401111.1100‘110

Quality Measurement, Analysis, & Reporting

Appendix: Raw Score Trends for Measures Included in all Performance Years (2013- 2016): Medicare ACO 21, Stseenlog Ise High blood Prost. mod Follow. Dossonweed AC013150e40Wu for FNMA 103 0362 117.13 SILK 64.41 7413 110 V.%

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37

SLIDE 38

Value-Based Incentive Fund Distribution Method

Approach: Budget Check

• Familiarize network with new measures
• Recognize on-ramp for new practices in early years
• .11.
• Recognize the entire network in the transition to a value-based care delivery model
• Move towards variable incentives that are aligned with measures

DISTRIBUTION OF FUNDS:

Measurement

Year

Strategy 2017/1

8

Primary Care, 70%

2019+

• 70% to primary care based on attributed

population

• 30% to rest of network based on % of total

Medicaid spend in calendar year

• 70% variable to primary care based on

practice-level performance on a standard measure set

• 30% variable to entire network based on

HSA-level performance on a standard set

• f measures

OneCareVT.org 38

SLIDE 39

Support to Primary Care

OneCareVT.org

SLIDE 40 OCV Basic PHM Payment $3.25 PMPM High Risk OCV Complex Care Coordination $15-$25 PMPM

cow

AGE WELL * H°wARD SAS Unnrnaty4Vermont

• )°-

Value-Based Quality Incentive (Annual Eligibility for Attributed Lives) Full Attributed Panel NOTE: PCP and OCV Collaborate with Full Continuum of Care

• n Population Health

Workbench One (Performance Data and Analysis) Supporting Data and Systems at No Charge ^

Bringing it Together: 2018 OneCare Primary Care Model

Attributed Population Care Navigator (Population Health Management System) NOTE: Base Revenue Model Remains as usual FFS; Primary Care is Under No Financial Risk OCV Provides Blueprint Continuity for Medicare Practice Payments and CHT Support Funds (plus SASH program) Blueprint Payments/Programs Continue

Budget Check

• •.•••••..*.***

VAG! VERMONT BlueCross BlueShield AGENCY Of

• r Vermont

HUMws sources OneCareVT.org

SLIDE 41

Independent PCP Comprehensive Payment Reform Pilot

//llio

• Budget model includes a $1.8M supplemental investment to

develop a multi-payer blended capitation model for primary care services.

• Voluntary program offered to independent PCP practices

with at least 500 attributed lives across all programs

• Would supplant and simplify model on previous page
• Designed to test sustainable model for independent

practices <or> pilot offering to all primary care in future years

• Operational model is monthly PMPM prospective payment to

cover primary care services delivered to the attributed population by the practice.

• Enables innovation and more flexible care models
• Provides predictable and adequate financial resources for

the practice

• Exact model under development starting in August with eligible

and interested practices. Budget Check

14.14,41 OneCareVT.org 41

SLIDE 42

Reducing Practice Burdens

• Eliminating prior authorization of services in VMNG program
• Aligning quality measures (QM) across payer programs. For example, 2017

VMNG negotiations resulted in:

• Reduction in the number of QM
• Increase in the number of QM tied to claims, resulting in less interruption for

practices

• Alignment with Vermont APM measures

. ACO participation eliminates additional Medicare Incentive Payment

System (MIPS) reporting requirements

• Developing a set of clinical priority areas to drive focused QI activities

. OneCare and Blueprint leadership working in close alignment to identify

priorities and deploy shared resources

• Implementing current and future benefit waivers to improve access,

efficiency, effectiveness, and timeliness of care for patients

OneCareVT.org 42

SLIDE 43

Patient Experience of Care

On eCa reVT.org

SLIDE 44

Patient-Focused System of Health

Vision:

• Seamless, proactive, patient- and family-centered, community-based

care Designed to help patients better engage in their own health care

Examples across PHM Model*:

9 yo boy with elevated BMI with access to new preferred walking route to school from his neighborhood and encouragement to do so by pediatrician and throughout community 42 yo woman with pre-diabetes referred to YMCA Diabetes Prevention Program (DPP) upon first elevated lab result 57 yo man with uncontrolled diabetes and ED visit for depression; care transition ambulatory follow up plan addressing transportation and insurance challenges 75 yo woman with multiple heart failure admissions with improved medication adherence and assignment of a lead care coordinator for further questions as a result of post-discharge home visit

*Population Health Management Model

OneCareVT.org 44

SLIDE 45

Summary

Making sure each person gets the care they need

in the right place at the right time

OneCareVT.org