Health Policy Commission talks CHART program, Patient Centered Medical Homes and Health Care Costs
The Health Policy Commission (HPC) met on Wednesday, September 11th for its eighth full meeting. As noted by the HPC, the theme of this particular meeting was twofold, to highlight how far the Commission has come and discuss how far it has left to travel moving into 2014. This theme was evident in the topics on the agenda: the Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program (formerly the Distressed Hospital Fund), the Patient Centered Medical Home (PCMH) program, quality improvement and patient protection and cost trends and market performance.
The consolidated meeting presentation is here (pdf), and our full report is on the backside, so click on.
After Executive Director Seltz' report was an update from the Community Health Care Investment and Consumer Involvement Committee, chaired by Commissioner Paul Hattis.
The update began with a discussion of the CHART program that focused on approval of the final CHART regulations (previously referred to as the Distressed Hospital Fund). The objective of the CHART investment program is to promote sustainable hospital innovations by providing funding to specific community hospitals. Commissioner Hattis led the discussion on the regulations by reminding the HPC that the CHART investment program is meant to improve quality of care at community hospitals.
Executive Director Seltz and Iyah Romm, Director for System Performance and Strategic Investment at the HPC, then walked through a summary of the regulation and results of the public hearing and comment process. The CHART program regulations establish the program’s operating structure and process. The regs outline the Request for Proposal (RFP) development and application process, the criteria used to review, select and award the grants, and the process for monitoring and evaluating the grantees.
Many stakeholders provided comments on the regulations, including Health Care for All. Comments focused on eligibility criteria, program framework and investment priorities (slide 13). The goals HCFA recommended, which were adopted, include improving access and quality, enhancing care coordination, and increasing community-clinical linkages. One proposed amendment included making changes to application requirements by adding more substantive language to clarify and more explicitly state the goals of the CHART investment program. Another proposed amendment was to change the definition of teaching hospital so that smaller hospitals with affiliations at larger teaching hospitals could be eligible for a CHART grant. The original definition excluded all teaching hospitals and their affiliates.
The Board voted unanimously to approve the final CHART investment program regulation. Further addressing the application process, Romm then led the commissioners through the framework for CHART investments, beginning with a map of Massachusetts that shows the 30 or so hospitals eligible for the CHART grants as of July 10, 2013 (slide 21). The grants will be given out in two phases with eligible hospitals having to submit a RFP in both phases. Phase 1 (to begin fall 2013) provides funding for “activities to prime system transformation.” Phase 2 (to begin spring 2014) provides funding to “drive system transformation.” The Commissioners raised a number of concerns regarding the process for Year 1 (Phase 1) investments. The first concern was that investment priorities may be too narrow. In response to this concern, EOHHS Commissioner John Polanowicz emphasized that the priorities list is not nearly as constraining as some might perceive.
The second concern was that the timeline for hospitals to submit the CHART grant RFP was too short (October-November 2013). Commissioner Marylou Sudders led the charge on this concern, emphasizing that organizations who have not prepared for the RFP or lack the funds to do so in adequate time will be left out or put at a huge disadvantage. In response, several Commissioners noted that many hospitals have already taken steps necessary to begin a RFP as they have known about the grant program since the law was passed last year. Executive Director Seltz noted that while the timeline is aggressive, it may be revisited if needed. HPC Chair Dr. Stuart Altman further noted that a critical part of the CHART investment program success is the link between payers and providers. It is crucial, Chairman Altman noted, that payers work with providers and change the way they pay in order to make delivery transformation happen. He encouraged proposals that indicate such discussions with payers.
Next on the agenda was an update from the Care Delivery and Payment System Reform Committee, led by Commissioner Dr. Carol Allen. Allen began with an overview of the framework for the Patient Centered Medical Home (PMCH) program, and the work of the committee and staff in developing standards for PCMH certification. She emphasized that the goal is value-based, performance driven transformation of health care, resulting in meaningful change while minimally burdening providers. After reviewing the statutory obligations for PCMHs, Executive Director Seltz added that under a recent statutory amendment, there will be a designation process for model PCMHs, which will in turn receive preferential contracting with state-funded health insurance plans. (similar to the state contract priority given to model ACOs in Ch. 224).
Dr. Patricia Boyce, Director of Policy for Care Delivery and Quality then walked through a presentation of the considerations and options for developing the HPC’s PCMH certification program and the HPC’s role (slides 36-46). Director Boyce explained that the underlying consideration in determining the approach for PCMH certification is weighing the value of certain criteria and standards in transforming care vs. the burden on providers. While the goal is rigor in terms of expectations for transformation of care delivery models, the burden and cost on providers should be minimized so as to incentivize PCMH certification.
Commissioner Hattis noted that minimizing burden should not necessarily mean lowering standards and that a tiered approach could push providers to higher levels. Director Boyce outlined the four options for certification standards: 1. Use nationally established standards; 2. Validate national accreditation; 3. Add HPC- specific criteria, or 4. Focus on HPC-specific criteria for certification and validation (slide 42). As recommended by the HPC staff, the Care Delivery and Payment System Reform Committee determined that option four would be the most appropriate process, allowing the HPC to choose the MA-specific standards for certification. The Committee recommended tiered certification levels (with those in the top tier being model PCMHs) in order to promote PCMH improvement and advancement. The Commissioners agreed to the process of developing more limited criteria. The Committee will next further define the standards and criteria for PCMH certification and continue to solicit stakeholder input in this process. Commissioner David Cutler ended the discussion by reiterating the need for payers to be involved in this process.
The third Committee update came from Marylou Sudders, chair of the Quality Improvement and Patient Protection Committee. Sudders reported on the completion of the Behavioral Health Taskforce Report . She further reported that following the Office of Patient Protection (OPP) listening session on internal and external insurance appeals processes, OPP is in the process of revising the regulations. Jennifer Bosco, Director of OPP, then presented internal and external review data for 2012. The data revealed that 53% of the 12,783 internal reviews were denied and that 62% of the 287 cases eligible for external review were approved (full data set on slides 51-57). The data will soon be available on the OPP website. Behavioral health cases were the single largest category of internal and external reviews. The Commissioners were interested in learning more about the data and how it could be used to shape future policy development.
The final agenda item was an update from the Cost Trends and Market Performance Committee, chaired by Commissioner David Cutler. Karen Tseng, Policy Director for Market Performance, discussed the material change notices received by the HPC and provided an update on those that did not initiate cost and market impact review (CMIR) (slides 61-62). For example, the acquisition of Jordan Hospital by Beth Israel Deaconess Care Organization was not subject to a CMIR. On this topic, Commissioner Sudders commented that when an activity is considered for a CMIR, its impact on health care services and quality should be examined. She noted that essential services, especially those related to behavioral health, are often eliminated when larger mergers or acquisitions occur. This can have adverse health consequences on communities, populations and individuals. Karen Tseng and other HPC members noted that these factors are taken into consideration when reviewing a material change notice as required by Chapter 224. Executive Director Seltz then provided an update on the objectives and agenda for the HPC’s Annual Cost Trends Hearing scheduled for October 1st and 2nd (slides 65-72).
The next HPC meeting will take place on Monday October 16, 2013.