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Health Policy Commission Looks at Connecticut, Accountable Care, Substance Abuse and Hospital Improvements - and more

Health Policy Commission Looks at Connecticut, Accountable Care, Substance Abuse and Hospital Improvements - and more

July 24, 2015

On Wednesday, the Health Policy Commission (HPC) Board met and tackled a number of issues, including updates on new Material Change Notices, planning for the 2015 Cost Trends Hearing and Cost Trends Report, developments in PCMH and ACO certification standards, new research in substance use disorders and opiate exposed newborns, and updates in the Phase 2 of the CHART investment program. You can download the slide deck with all the materials from the meeting here. And you can click on for our detailed breakdown.

Executive Director David Seltz began the meeting by introducing new board member Ron Mastrogiovanni, President of HealthView Services.

The discussion then looked at Connecticut's new health care law, signed by Governor Dan Malloy on June 30, 2015. It includes significant provisions that draw from Chapter 224 in response to rising costs and heightened concern that the recent consolidations of many hospitals is altering the health care landscape in the state. 

Connecticut's new health law parallels Massachsuetts C. 224

Katherine McCann, Associate Counsel, gave an overview of the key provisions of the law, which includes the following (slides 10-13):

  • Charging the Health Care Cabinet with studying health care cost containment models in other states, including Massachusetts, and submitting a report documenting “successful practices and programs that may be implemented” in Connecticut.  The report must include recommendations for administrative, regulatory and policy changes.
  • Revising the Certificate of Need Process and establishing cost and market impact reviews, similar to those required in MA.
  • Supporting community hospitals with financing option recommendations.
  • Convening a working group, led by the Insurance Commissioner, to study rising costs of health care and issue a report to the General Assembly with recommendations.
  • Restricting billing for emergency services by an out-of-network provider and “surprise bills” (defined as a bill for nonemergency health care services received by an insured for services rendered by an out-of-network provider when the insured did not knowingly elect to obtain those services from that out-of-network provider).
  • Requiring the CT Health Insurance Exchange to encourage carriers to offer tiered network plans and offer any such plans through the exchange.
  • Imposing additional requirements regarding facility fees and limitations on the actual facility fees collected.
  • Creating a number of new mechanisms for health care consumers to learn about their health care costs, quality and provider networks, such as through a consumer health website and also by expanding the practices considered to be unfair trade practices.
  • Requiring the notification of referrals to affiliated providers and that patients be notified that s/he is not required to see the affiliated provider.

Following the presentation, Chairman Altman and a number of Commissioners expressed the need for further research into the trends and impacts of patients in MA receiving surprise out-of-network bills, and recommended that these issues be included in the 2015 cost trends hearing and report.

Cost Trends and Market Performance Update

The Cost Trends and Market Performance update began with a discussion on recent material changes, presented by Kate Scarborough Mills, Policy Director for Market Performance (slides 16-18).  Notably, physician group mergers, acquisitions and network affiliations from April 2013 to the present occurred 12 times. Acute hospital mergers, acquisitions and network affiliations and clinical affiliations were both second with 8 transactions. 

The HPC also found that the affiliation between UMass Memorial Health Care and Quest Diagnostics, the acquisition of South Shore Medical Center by South Shore Physician Ambulatory Enterprise, and two joint ventures by Shields Health Care Group to operate and contract for PET/CT diagnostic imaging clinics do not represent a “negative impact on quality, access to care, or, [in the first two cases], to the competitive market” and elected not to proceed with any actions. 

This month, the HPC also made several updates to the Material Change Notice (MCN)/Cost and Market Impact Review (CMIR) process:

  • Released an FAQ clarifying timing and filing requirements for certain types of transactions requiring Notice
  • Reorganized the MCN/CMIR website to make it more user-friendly
  • Created a listserv for interested stakeholders to receive notice both when it receives MCNs and when it makes determinations of whether or not to initiate a CMIR. 

2015 cost trends report outline

Next HPC staff provided an overview of the upcoming 2015 Cost Trends report, due to be published in December (slides 21-22).  The 2015 report will focus on:

  • Trends in spending and delivery, including benchmark spending trends in MA and US, components of spending growth within MA, trends in provider markets, employer premium trends, access both financial and geographic, and quality of care
  • Progress in aligning incentives, including  payment reform trends in MA and US, ACOs, global payment, shared savings, P4Q, bundled payments, multi-payer alignment on APMs, providers’ needs for data and alignment, demand side incentives like network design, cost sharing, reference pricing and price transparency
  • Opportunities to increase quality and efficiency, including price variation in maternity spending and lab tests, improving acute care use, and improvement across non-acute care needs

The HPC will continue research for white paper topics like high cost drug spending, primary care access and preventable hospital use, employer perspective/insurance markets, and scope of practice.

The update concluded by outlining the draft agenda for the 2015 Health Care Cost Trends Hearing (October 5th and 6th), featuring several key speakers like Governor Charlie Baker and Attorney General Maura Healey (slides 24-25). Commissioner Rick Lord commented that the agenda should include more discussion on high deductible insurance products and that adding a panel on employer perspectives would be helpful. 

Care Delivery and Payment Transformation Update

The Care Delivery and Payment Transformation update focused on HPC Certification Programs. Katherine Barrett, the new Policy Director for Accountable Care, discussed progress in the HPC’s development of Patient Centered Medical Home (PCMH) certification standards (slides 29-31). The National Committee for Quality Assurance (NCQA) baseline recognition requirements, according to public comment and focus groups, are “difficult to achieve and require significant resources to change practice workflows, thereby adding an additional layer of administrative burden.”  Practices are not currently demonstrating advanced primary care in all four HPC domains, and most would advocate for fewer required domains so practices can allocate resources and efforts appropriately.  Thus, HPC will seize the opportunity to link PCMH and Accountable Care Organizations (ACOs) standards together in light of the finding that PCMH activities are most efficiently performed at different levels of care (e.g. within a larger system; practice setting with centralized support; by the practice alone). 

Next steps include:

  • Finalizing certification design and working with NCQA
  • Finalizing operationalization plan for program implementation
  • Designing and implementing technical assistance to promote behavioral health integration into primary care
  • Marketing, branding, data and benchmarking support, as well as aligning with MassHealth payment reform efforts.

Aco Certification process update

Director Barrett then gave a process update on ACO certification (slides 32-33):

  • HPC is drafting a plan for operationalizing ACO certification, delineating processes for evaluating applications, technical assistance platforms, marketing, and auditing
  • HPC will continue to engage stakeholders to obtain feedback on feasibility, efficacy, and impact of proposed ACO requirements
  • HPC will work with consultants to refine ACO criteria, and develop quality measures set for evaluating ACOs at initial certification and re-certification
  • HPC is collaborating with MassHealth and the Group Insurance Commission through the development of ACO criteria and program implementation in order to align with payment reform efforts.
  • HPC will also work closely with the Department of Mental Health and Department of Public Health to foster interagency feedback.

Quality Improvement and Patient Protection Update

The Quality Improvement and Patient Protection and Care Delivery and Payment Transformation Committees held a joint meeting focused on substance abuse and behavioral health. The HPC is currently working on a Substance Use Disorder Report, which will include recommendations on: improving the adequacy of coverage by public and private payers where necessary; improving the availability of opioid therapy where inadequate; and, identifying the need for further analyses by CHIA (slides 36-39). Through the report, the HPC is also seeking alignment and consistency with other Massachusetts activities, and aims to further contribute to policy around opioid abuse by, for example, identifying strategic opportunities for care delivery/payment reforms for substance use disorder treatment that are likely to reduce spending and improve quality/access.

Next, Katherine Record, Deputy Director for Behavioral Health Integration & Accountable Care, presented new research on Neonatal Abstinence Syndrome (NAS), which is on the rise and presents a significant cost to the Commonwealth (slides 41-50).  NAS is a clinical diagnosis resulting from the abrupt discontinuation of exposure to substances in utero (e.g. methadone, opioid pain relievers, buprenorphine, and heroin).  Symptoms include tremors, irritability, high-pitched, excessive crying, diarrhea, and in a small percentage of cases, seizures.  NAS is rarely fata but it results in short-term morbidity and prolonged hospital stays. 

Her presentation focused on the increasing incidence of NAS in Massachusetts and nationwide, the negative health outcomes for newborns with NAS, and the high costs of NAS in opiate exposed newborns. She then described several interventions that offer hope toward mitigating NAS incidence in the Commonwealth, which include but are not limited to: integrated family planning care, and pre-natal, post-natal and childhood care that includes wrap-around social services and coordinated multidisciplinary care.

Emerging best practices highlighted by the presentation included Boston Medical Center’s RESPECT Clinic, which combines multidisciplinary care with integrated prenatal, intrapartum, and postnatal support, and quality improvement initiatives aimed at reducing the length of stay for newborns with NAS.  Several other hospitals, based in Canada, West Virginia, New Hampshire, and Ohio, are having success utilizing a combination of the intervention strategies outlined above. The HPC is aiming to develop a pilot intervention based on best practices, to be developed through the Fall and implemented around July 2016. 

Community Health Care Investment and Consumer Involvement Update

The Community Health Care Investment and Consumer Involvement update assessed the Phase 2 status of the Community Hospital Acceleration, Revitalization, & Transformation (CHART) Investment Program and also the program’s Technical Assistance needs (slides 53-60).  The goals of Phase 2 of the CHART program are to maximize appropriate hospital use, enhance behavioral health care Improve hospital-wide (or system-wide) processes to reduce waste, and improve quality and safety. Margaret Senese, Program Manager for Strategic Investment, provided the update.

CHART Phase 2 currently operates in 28 hospitals and the implementation cost around $60 million dollars.  Implementation planning continues, with hospitals in various stages, but all have specified one target population.   16 hospitals aim to reduce readmissions by a median goal of 20% for their target populations within two years.  5 hospitals with reduce emergency department (ED) revisits by a median goal of 20% for their target populations within two years.  Lastly, three hospitals will reduce ED length of stay by a median goal of 20% for their target populations within two years. 

The update presented two examples of grantee hospitals and how they intend to achieve the aims of the CHART program:

  • Addison Gilbert Hospital and Beverly Hospital received $1.27M and $2.5M respectively to reduce 30-day readmissions for patients with a personal history of recurrent acute care utilization, social complexity, and/or in need of palliative care by 20% by the end of the two year period.  They hope to employ a complex care team, individualized care plans, referral to palliative care and hospice, and linkage to primary care providers in order to achieve this goal. 
  • Berkshire Medical Center received $3M to reduce 30-day admissions by 20% for all discharges of Northern Berkshire County residents by the end of the 2 year period.  They intend to partner with community-based social services, use comprehensive care plans, care coordination, Behavioral Health AfterCare Teams, chronic illness support, nutrition support, and electronic patient navigation to achieve their goal. 

The Technical Assistance update for CHART Phase 2 began with an anonymous survey indicating that the HPC should prioritize facilitating direct access to subject matter experts (91% of respondents), regional learning opportunities to share best practices (85%), HPC staff supports (81%), and data analyses (79%).  Senese therefore laid out a two-pronged assistance model that aims to engage CHART hospitals directly to respond to problems quickly, perform routine maintenance, and/or facilitate the sharing of best practices through cohort engagement.  The intensity of assistance provided by the HPC will differ based upon the needs of the hospital: whether they are lagging in performance and require focused, high intensity involvement or are excelling and simply need targeted engagement for specific issues.

The HPC is employing multiple approaches to assist each Phase 2 CHART hospital.  The HPC will hold two statewide meetings, one initial “launch” meeting and one interim meeting.  Additionally, there will be regional meetings for peer-learning and discussion of operational factors associated with effective implementation.  The HPC will include site visits at each Phase 2 CHART hospital biannually to engage executive teams in a discussion on implementation barriers and overall project progress.  The HPC will host 1-2 trainings annually to bolster the skills of front-line staff, managers, and leadership. There will be frequent virtual contact through phone calls for performance management and coaching activities.  Lastly, opportunities to engage current and emerging leaders are planned to sustain momentum after the CHART investments expire and promote long-term success. 

Administration and Finance Update

At the conclusion of the meeting, Executive Director Seltz provided an update on Administration and Finance (slides 73-88).  The State Fiscal Year (FY) 2016 Budget included:

  • $250,000 Pilot for Substance Exposed Newborns
  • $100,000 Pilot for Narcan Training
  • $250,000 Behavioral Health Technical Assistance for HPC’s Patient Centered Medical Homes
  • $250,000 Paramedicine Pilot Administered by HPC in the Quincy Area (affected by the recent closure of Quincy Hospital)
  • $500,000 Telemedicine Pilot Administered by the HPC
  • Confidentiality Language for CHART, PCMH, ACO and other HPC programs
  • New CHIA Oversight Council (with the Executive Director of HPC as a member)

The HPC Fiscal Year 2016 Budget recommendation is $13,475,444, with funds from Health Care Payment Reform Trust Fund and the Distressed Hospital Trust Fund. It is anticipated that HPC operating expenses will reach a steady-state (between $12-$14M) in future fiscal years.  The HPC has consistently finished under the Board-approved operating budget.  The Principles for the FY16 budget proposal include new investments that are limited, target, and essential.  In the beginning of FY17, HPC operations and programs will be funded by a new annual assessment on hospitals, surgery centers, and health plans. 

The next Commission Meeting is scheduled for September 9, 2015.

             -- Michelle Savuto