PACE Program Description

State Demonstration to Integrate Care for Dual Eligible Individuals

Oklahoma Proposal

February 1, 2011

Introduction

The Oklahoma Health Care Authority (OHCA), Oklahoma’s single state Medicaid agency, is dedicated to exploring new innovations in health care delivery to enhance the quality of care afforded to our members. Members eligible for both Medicare and the Oklahoma Medicaid program (namely SoonerCare) present a unique challenge as they constitute a small percentage of the SoonerCare population, but represent a higher percentage of spending. Fragmented care and lack of coordination between providers for these dual eligibles often leads to poor health outcomes making this an area that provides ample opportunity for improvement and change. In response to the opportunity provided by the Center for Medicare and Medicaid Innovation, the OHCA would like to propose the following areas of research and development as potential strategies to improve the care integration, coordination, and health outcomes of the SoonerCare dual eligible population. The OHCA proposal involves taking a three pronged approach to determining the most efficient methods of care integration. Each of the three concepts identifies a different aspect of care forthe dual eligibles and will be developed to identify the feasibility and effectiveness of each concept.

Concept #1- The Tulsa Health Innovation Zone’s Pilot for Dually Eligible Oklahomans

Proposal This proposal describes our efforts to create an Accountable Care Organization with embedded medical education programs (Health Innovation Zone) that specifically serves high cost patients that are eligible for both Medicare and Medicaid. We have successfully installed 3 regional programs that provide a foundation for this initiative including patient centered medical home teams, a health access network care coordination initiative and a health information exchange. We propose a 4th program to be installed in the form of a set of teams focused on high risk high cost dually eligible patients. We would then organize these 4 components under an accountable care organization model that includes payment models that promote improved patient outcomes and an overall lower cost of care. Over the next year, planning would require dedicated project managers, in-depth data analysis, identification of high cost high risk patients, building of dedicated care teams, and the design of new payment methodologies.

Background: In contracts with the OHCA and the Office of the National Coordinator for Health Information Technology (ONC), the University Of Oklahoma School Of Community Medicine has led the first three installments of an innovative health system infrastructure in northeast Oklahoma. These are:

Installment #1 – Patient Centered Medical Home (2008) for SoonerCare members (Medicaid managed care)a system that reformed payment to a fee for service model plus a care management, and quality payment tiered to the sophistication of the PCMH elements of health information technology and proactive coordination of care

Installment #2 – Sooner Health Access Network (2010) created the PCMH neighborhood for providers of care to SoonerCare members that facilitates access from the PCMH to specialty services, helps advance PCP practices of PCMH, and measures, reports, and improves quality of care for the member PCMH practices.

Installment #3 – Greater Tulsa Health Access Network (2010) provides one of the most sophisticated health information exchanges in the nation for 11 counties in northeast Oklahoma and is funded with a $12 million contract from ONC to be a Beacon Community. The HIE will provide point of care medical information as well as the necessary analytics needed to create the attribution for modeling the payment model for an ACO, the analysis and reporting for coordination and improving care, and the data set for education and health services research central to a Health Innovation Zone.

Further Advancing the Quality and Efficiency of Health Care in the Tulsa Region: The Tulsa Health Innovation Zone (THIZ)

Responding to Oklahoma’s poor health status, health system performance, overall cost of care, access to care, health inequity and very low physician per capita ratio, a coalition of healthcare providers and payers in northeast Oklahoma has built the first three installments of a model health care delivery system to improve quality and access as well as improve the value and efficiency of care. In further advancing the quality and efficiency of the Tulsa region’s health system, this coalition is committed to create a unique Health Innovation Zone (HIZ) with a central Accountable Care Organization (ACO) and the incorporation of health professions education. Our HIZ will comprise the northeast Oklahoma (the Tulsa Beacon Community) teaching hospitals, physicians, andother providers. The proposed payors include the Oklahoma SoonerCare program, Medicare and area commercial insurance vendors. The proposed denominator population for measuring the effectiveness of the THIZ’s innovations would be about 50,000 persons from north, east and west Tulsa. 25,000 would be Medicaid, 10,000 Medicare, 8,000 BC&BS, and 7,000 uninsured. We estimate approximately 2,200 individuals within this population would be dually eligible for Medicare and Medicaid coverage. The distinguishing parts of the THIZ is that it incorporates community driven planning, innovative methods for the recruitment and training of future and current health care professionals, and proposes to use gain-sharing savings for public good to expand medical education programs.

The Tulsa Health Innovation Zone (THIZ) has 5Goals:

1. Create a pilot ACO that brings together patient care, payment and health information innovations into an organized system of care for the most vulnerable and costly patients - the dually eligible.
2. Demonstrate the Center for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation and Center for Medicare and Medicaid Integration leadership’s “triple aim” for better care, better outcomes and lower costs.
3. Create the platform for integrating several initiatives within the Health Resources and Services Administration, Center for Medicare and Medicaid Integration, Center for Medicare and Medicaid Innovation, and the Oklahoma Health Care Authority to improve care, lower costs and expand the health workforce.
4. Train a new generation of clinician leaders prepared to thrive in the patient-centered Accountable Care Model of care.
5. Create a value-added and efficient health system that can care for 100,000 newly insured Tulsa area citizens with great attention to the new insurance exchange, Medicaid and Medicare populations.

The THIZ will use 6 Strategies to meet these goals:

1. Develop the policies and procedures for delivering and teaching care in Patient Centered Medical Home primary care and disease specific interdisciplinary teams which are then seamlessly connected to the vast array of specialists, hospitals, community agencies, home health, durable medical equipment, and long term care services.
2. Incorporate health information technology (Health Information Exchange, EMRs, referral tracking systems, and clinical decision analytics) to provide proactive outreach services, care coordination and access to the most appropriate level of care.
3. Use performance metrics and lean production quality improvement techniques to improve the quality of care for high risk patients particularly the dually eligible.
4. Incorporate care teams, proactive prevention care and early interventions, care coordination and health information exchange to assure more appropriate utilization of health services and control the costs of care.
5. Use community-based participatory research methods to plan the THIZ’s ACO which will include patients receiving care, providers, and physician assistant students, nurse practitioner students, medical students and resident physicians in the planning, design, implementation and measurement of outcomes of these efforts.
6. Simplify and integrate the payment system of Medicare and Medicaid to stimulate seamless, coordinated, and value-added care for the dually eligible patients.

As depicted in the above diagram, our long term plan for health system and medical education redesign involves the development of several levels of programs working in concert (systems within systems) including a spectrum of primary and specialty care, high risk care teams, care coordination programs, health information exchange, medical education and research programs and a “co-op” of urban and rural serving medical schools that have pledged to share and replicate their clinical, research and education innovations.

Tulsa Health Innovation Zone High Coordinated Care for (Dually Eligible)

This planning grant proposal focuses on developing a pilot ACO that specifically manages the care of the 2,200 dually eligible patients. Conservatively, using Federal estimates, the cost of care for these 2,200 patients may be as much as $88,000,000 per year. From our clinical experience, we anticipate that these patients fall into several groupings including i) elderly, living at home, with multiple medical diagnoses including dementia, ii) elderly, living in care facilities, with multiple medical diagnoses including dementia, iii) middle-aged adults, living at home, with multiple medical or severe mental illnesses and iv) middle-aged adults, living in care facilities with multiple medical diagnoses or severe mental illness.

We anticipate these patients’ multiple medical problems to be i) chronic severe mental illnesses – e.g. Dementia, Schizophrenia, Bipolar Affective and Schizoaffective Disorders, ii) chronic pediatric disease – e.g. Type I Diabetes, Cystic Fibrosis, Sickle Cell Disease and iii) multiple chronic adult diseases – e.g. Congestive Heart Disease, Chronic Obstructive Pulmonary Disease, End-Stage Renal Disease, End-stage Cancer, Degenerative Neurological Disorders

We believe the highest cost components of the care of these patients include i) recurrent acute hospitalizations due to inadequate primary care and coordination of home provider and multiple specialty care, ii) multiple medications and iii) redundancy and duplication of care across providers and facilities

OU School of Community Medicine has experience with several models for providing coordinated care for high risk patients. For example, our IMPACT interdisciplinary team provides comprehensive community-based psychiatric and rehabilitative care to individuals with severe mental illness. After one year in the IMPACT program, patients symptoms are much improved, scores on independent living skills are higher, patient and family satisfaction is dramatically improved, hospitalization and incarceration rates are reduced by as much as 80% with a net reduction in annual cost of health care of $ 15,000 per patient has been seen. A similar set of results has been produced by our palliative care team which has reduced hospital length of stay by an average of 2 days and has significantly improved patient, family and hospital staff satisfaction. We have additional teams in place for high risk obstetrics, Type I Diabetes Mellitus and Child Abuse. Additionally, HillcrestMedicalCenter has a certified ambulatory aqua-pheresis program for heart failure patients that has dramatically reduced the need for hospitalizations.

Tulsa Health Innovation Zone Reimbursement – Reinvestment Model

As we have already experienced with those with severe mental illness within our IMPACT program, we anticipate that providing these high cost patients with diagnostic specific outreach teams will lower the cost of their care through reduced hospitalization and care facility placement while improving their quality of life and satisfaction with the services they have received. We support the concept of “Gain-sharing” where reductions in cost of care for these patients are shared with the Tulsa Health Innovation Zone. What makes this proposal unique is our willingness to re-invest those saving into further strengthening the health care delivery system in the Tulsa area by expanding medical education programs and supporting new outreach specialty services that in turn should further reduce the overall cost of care in the region.

Measurement of Effectiveness of THIZ’s ACO for Dually Eligible

Within the Tulsa Health Innovation Zone, we have proposed the following balanced score card of outcomes. For the dually eligible patients we would track the same outcomes. These are the measures that are going to be collected and reported in compliance with the ONC’s contract for the Tulsa Beacon Community.

Planning Schedule

Phase 1: (Months 0-3) Data Gathering and Analysis

• Identify the Dually Eligible population of patients for the ACO
• Aggregate the Medicaid and Medicare data for this population to determine the historical cost, service use pattern, morbidity,
• Conduct Community-Based Participatory focus groups to understand the needs and suggestions for improving care from a representative sample of the various groups that comprise the population for the ACO.
• Conduct focus groups with providers, service agencies, pharmacists, and social services that currently provide care for the population, and identify successful models existing in the community.
• Perform a literature review of the health services research regarding the care of dually eligible, particularly looking for reports of successful care coordination models.
• Engage RAND Corporation to assist in the data analysis

Phase 2: (Months 4-6) Value-Stream Mapping and Design

• Draw maps of the current care system from the patient’s perspective identifying opportunities for immediate improvement in the System.
• Develop new care management, coordination of care, decision support tools to implement the improvements in the care delivery process for the population
• Develop the payment model for the ACO integrating Medicaid and Medicare payment and eligibility policies and developing the waivers needed to implement the payment aspect of the pilot.

Phase 3: (Months 7-10) Rapid Cycle Tests of Change

• Perform rapid cycle tests of the policies and procedures, including the training of the providers and teams in the implementation of the processes and use of the technology that will be used in the ACO pilot.
• Collect data on the impact of the changes in the processes of care.
• Continually innovate based on the results of the multiple rapid cycle tests of change.

Phase 4 (Month 11-12) Report and Dissemination Strategy

• Analyze the results of the rapid cycle tests of change and write the document that describes the training and implementation of the new care process.
• Write the policies and procedures for reporting provider performance to payers and demonstrating continuous quality improvement.
• Write the dissemination plan for implementing the plan across the THIZ and across all providers for dually eligible patients in Oklahoma.

In developing a more in-depth plan for dually eligible patients, we would need a more detailed analysis of the demographics, location and needs of these patients. We would require the assistance of SoonerCare and Medicare to accomplish this. We also propose that the Tulsa Health Innovation Zone be a community driven ACO. This would require a process that allows for community input into design and implementation as well as board representation for on-going operations. In addition, we would hope for additional assistance from thought leaders in planning, design and implementation of these complex plans such as RAND Corporation and the Commonwealth Fund. If successful, the Tulsa Health Innovation Zone would serve as the state-wide training site for replication of successful components of this proposal.

Concept #2- New Benefit Plan for Dual-Eligibles, Patterned After a Shared-Savings Model

Oklahoma would like to begin exploring the feasibility of establishing a benefit plan and network, administered and operated by the state, in a somewhat similar fashion to models in operation in South Carolina and accountable care organizations being developed across the nation. We propose combining the funding streams from Medicare and the Oklahoma Health Care Authority (OHCA) and using these funds to purchase coverage through a plan and network developed and administered by OHCA. This product would be similar to the Individual Plan (IP) offered through the Insure Oklahoma Program. Insure Oklahoma (IO) is the state’s premium assistance program helping businesses and their modest and low-income employees, as well as those self-employed and unemployed Oklahoma families, gain and keep health insurance coverage. Beginning enrollment in November 2005, the IO program is funded by the state’s tobacco tax (approved by voters in 2004)and uses state and federal funds. A safety-net part of the program, Insure Oklahoma Individual Plan (IP) helps self-employed, unemployed individuals seeking work or employees working for small businesses that do not have access to group coverage. The IP provides a state-sponsored benefit plan and provider network (which differs significantly from traditional SoonerCare coverage) to qualifying Oklahomans.

Advantages

Purchasing one product at a local level should allow for a greater efficiency and responsiveness of the coverage. It’s recognized that for a state like Oklahoma, in which the delivery system ranges from sparse (such as in the Panhandle area) to metropolitan (such as Oklahoma City and Tulsa), financial coverage needs to be flexible to meet the needs of the members. In addition to geographical variability, over 100,000 Oklahoma dual eligibles are on a continuum of health status ranging from good to poor. We would envision the insurance product functioning as a standard payer for the more healthy population and in more rural areas of the state. For populations requiring more extensive chronic health care services, the existing managed care support functions of the agency, such as case management, would be used. Additionally, targeted programs such as home and community-based waivers or end stage renal disease programs could be used with the chronic health needs populations.