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Academy Health State Coverage Initiatives


Academy Health State Coverage Initiatives Vermont Site Visit June 8, 2009 Susan Besio, Director, OVHA and Health Care Reform Wendy Davis, Commissioner, VDH – PowerPoint PPT presentation

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Title: Academy Health State Coverage Initiatives

  • Academy Health State Coverage Initiatives
  • Vermont Site Visit
  • June 8, 2009
  • Susan Besio, Director, OVHA and Health Care
  • Wendy Davis, Commissioner, VDH
  • Craig Jones, Director, Blueprint for Health
  • Christine Oliver, Deputy Commissioner, BISHCA
  • Jim Hester, Director, Health Care Reform
  • Hunt Blair, Deputy Director, Health Care Reform

  • Vermont Health Care Reform
  • Susan Besio

Vermont Health Care Reform Legislation
  • 2006 Legislation
  • Health Care Affordability Acts (Acts 190, 191)
  • Common Sense Initiatives (Appropriations Bill)
  • Safe Staffing and Quality Patient Care (Act
  • 2007 Legislation
  • Corrections and Clarifications to the Health Care
    Affordability Acts of 2006 (Act 70)
  • An Act relating to Ensuring Success in Health
    Care Reform (Act 71)
  • 2008 Legislation
  • An Act Relating to Health Care Reform (Act 203)
  • An Act Relating to Managed Care Organizations and
    the Blueprint for Health (Act 204)
  • 2009 Legislation
  • An Act Relating to Health Care Reform (Bill
  • An Act Relating to Containing Health Care Costs
    (Bill S.129)

Health Care Reform Goals
Increase Access
Improve Quality
60 Initiatives
Contain Costs
Goal Increase Access to Affordable Health Care
  • Enhance Private Insurance Coverage
  • New Catamount Health Plans for the Uninsured
  • Promotion of Employer-Sponsored Insurance
  • Exploration of Private Insurance Market Reform
  • Improve Outreach to Uninsured
  • Comprehensive Marketing,
  • Outreach
  • Public Private Partnership
  • New Enrollment Web-site
  • 1-800 number
  • Eligibility Systems Re-designs
  • VT Household Health Insurance
  • Surveys (2005, 2008, 2009)
  • Assist with Affordability
  • Catamount Premium Assistance
  • ESI Premium Assistance
  • Catamount Eligibility for High Deductible
  • Individual Plans

Goal Improve Quality of Care
  • Promote Wellness
  • Blueprint for Health Prevention Focus
  • Immunizations Programs and Registry
  • Community Wellness Plans and Grants
  • Healthy Worksite Best Practices
  • Nutrition Guidelines for Schools
  • Trans Fats Restaurant Labeling in Restaurants
    Elimination in Prepared Foods
  • Catamount Health Plans (no cost-sharing)
  • Healthy Lifestyles Insurance Discounts
  • Enhance Care for Chronic Conditions
  • Blueprint for Health
  • Medicaid Chronic Care Initiatives
  • Catamount Health Plans (no cost-sharing)

Goal Improve Quality of Care, cont.
  • Focus on Transparency / Quality Improvement
  • Hospital Report Cards
  • Quality of Care
  • Infection Rates
  • Nurse Staffing
  • Price and Financial Reports
  • Consumer Health Care Price Quality System
  • Adverse Events Monitoring
  • Multi-payer Database (VCHURES)
  • Academic Detailing Program
  • Increase Provider Availability
  • Loan Repayment and Forgiveness Programs
  • FQHC / VT Rural Health Alliance Funding
  • Dental Dozen Initiative
  • Changes for Fair Contracting, Restrictive
    Covenants, and Workers Compensation Claim
  • Promote Health Information Technology
  • VT Information Technology Leaders (VITL) -
    statewide HIE
  • Statewide Health IT Plan
  • Health IT Reinvestment Fund
  • Electronic Health Record Projects
  • Blueprint Information Exchange

Goal Contain Costs
Previous Goals, Plus.
  • Change Provider Financial Incentives
  • Blueprint For Health Financial Reform
  • Accountable Care Organization Study
  • Health Resource Planning / Oversight
  • Health Resource Allocation Plan
  • (HRAP)
  • Certificate of Need (CON)
  • Simplify Health Care Administration
  • Developing uniform standards for claims
  • administration
  • Claims Submission Processing
  • Procedures
  • Member Identification Cards
  • Patient invoices Explanation of Benefits
  • Forms
  • Uniform Provider Credentialing Form
  • Monitor Cost Shift
  • Standardized Policy for Hospital
  • Uncompensated Care / Bad Debt
  • Employer Health Care Contribution Fund

  • Health Reform in Vermont
  • The Role of Public Health
  • Wendy Davis, MD

Vermont Characteristics
  • Population 621,254 (2007 est.)
  • Land Area 9.249 square miles
  • VDH is one of centralized public health
    departments (12 District Offices)
  • 2009 400th Anniversary Samuel de Champlains
    arrival at headwaters of lake that bears his name

Vermont Agency of Human Services
  • Office of the Secretary
  • Department for Children and Families (Child Dev.,
    OCS, Family/Econ Svcs.)
  • Department of Corrections
  • Department of Disabilities, Aging and Independent
    Living (DAIL)
  • Department of Health
  • Department of Mental Health
  • Office of Vermont Health Access (Medicaid, VHAP,
    Dr Dynasaur, Catamount Health ESI premium
    Assistance) and Health Care Reform

VDH Organization
  • Alcohol and Drug Abuse Programs
  • Health Promotion and Disease Prevention
  • Blueprint for Health
  • Health Surveillance
  • Local Health
  • Maternal and Child Health
  • Medical Practice Board
  • Public Health Preparedness
  • Business, IT, Communications, Public Policy

A Brave New World
Samuel de Champlain
President Obama
Governor Douglas, VT
Champlains Plan
  • 1603 expedition French governor urges
    exploration of North American land granted by
    Henry IV
  • 1608 Quebec settlement
  • 1609 Coalition with the Montagnais, Algonquins
    and Hurons (against Iroquois)
  • July 14, 1609 Champlain enters lake by canoe
    bestows his own name

The Plan (VDH) 10 Essential Public Health
Services (CDC)
  • Monitor health status to ID/solve community
    health problems
  • Diagnose and investigate health problems/hazards
    in the community
  • Inform, educate, and empower people about health
  • Mobilize community partnerships/ action to
    identify and solve health problems
  • Develop policies and plans that support
    individual and community health efforts
  • Enforce laws and regulations that protect health
    and ensure safety
  • Link people to needed health services and assure
    provision of health care when otherwise
  • Assure competent public and personal health care
  • Evaluate effectiveness, accessibility, and
    quality of personal and population-based health
  • Research for new insights and innovative
    solutions to health problems

Healthy Vermonters 2010 (2008 update)
  • Behaviors, Environment Health
  • Physical activity/nutrition
  • Tobacco use
  • EtOH/drug use
  • Providing for Better Public Health
  • Access to health care
  • Maternal/child health
  • IZ/Infectious disease
  • Oral health
  • Mental health
  • Chronic Diseases and Health Conditions
  • Heart disease/stroke
  • Cancer breast, cervical, colorectal, lung,
    prostate, skin
  • Diabetes
  • Respiratory disease
  • Arthritis/osteoporosis
  • HIV, AIDS, STDs, Hep C

(No Transcript)
Were 1
Health Status of Vermonters Accomplishments
  • Tobacco use declining rates of smoking
    prevalence (16.8 in 2008 per BRFSS!)
  • Obesity slower rate of rise than national
  • Breastfeeding 85 initiation in hospital
    improvement opportunity for sustained rates at 6
    12 months

BUT . . .
  • More than half of adult Vermonters have one or
    more chronic conditions (cost of care gt75 of
    Vermonts 2.8 billion annual health care

State Public Health Leadership Role in
Comprehensive Health Reform
  • Public Policy
  • Community resources and development
  • Self-management
  • Clinical practice redesign
  • Health information exchange
  • Financial reform

Model for Health Prevention
Referrals Communication
Hospital -Educators -Transitional
care -Ambulatory center (wellness programs)
  • Primary Care PCMH
  • Docs
  • NPs
  • Staff

Community Care Team (CCT) e.g. NP, RN, MSW,
Dietician, Behavior Specialist, Community Health
Worker, VDH Public Health Specialist
Support for evidence based public health,
prevention, policy
Vermont Health Information Platform (VITL)
Referral care support
Education Improvement
Public Health Prevention
An Integrated Model for Health Functional Map
Public Health Operations
VDH Programs
VDH Prevention Teams
  • Program content
  • Best practices
  • Domain expertise
  • Data analysis
  • Reporting
  • Input
  • Review
  • Domain expertise
  • Coordination
  • Planning
  • Central Public Health Prevention Team
  • State level assessments
  • State level strategic planning
  • Data review interpretation
  • Design campaigns / programs
  • Technical assistance / support

Mental Health
Rural Health
Children Families
Business Office
  • Regional Public Health Prevention Teams
  • Local assessments
  • Local intervention planning
  • Organizing coordination
  • Multidisciplinary Services

State Local Coalitions
Community Care Team 1
Community Care Team 2
Community Groups
Community Care Team 3
Community Stakeholders
Community Care Team 4
Community Health Teams
Prevention Strategies for Tobacco Use
Increased tax on tobacco
products Smoking restrictions
(workplaces, schools, restaurants,
public places) Reduced access to underage
youth Community coalitions Media
Smoking cessation services Provider
Prevention Strategies for Obesity
  • Menu labeling
  • Built environment (rail trails)
  • Community gardens
  • Changes in school cafeteria
  • selections (Farm to School)
  • Running/bike/hiking clubs
  • Weight control programs
  • Increased awareness
  • Health care provider recommendation

Community Activation Prevention
Community Profile
Community Assessment
Community Intervention
  • Community Snapshot
  • Demographic risk factors for chronic disease
  • Survey answer risk factors for chronic disease
  • Relationship to hospitalizations / costs
  • VDH data sources
  • VDH health statistics team
  • Plan Targeted Assessment
  • In depth qualitative assessment
  • Key stakeholders community members
  • District public health prevention specialists
  • VDH health surveillance team
  • VDH HPDP team
  • Blueprint team
  • Plan Intervention
  • Key stakeholders community members
  • District public health prevention specialists
  • District Director
  • Blueprint team
  • Community Inventory
  • Resources
  • Key health issues
  • Meet with key leaders stakeholders
  • Public health designee
  • Qualitative Assessment
  • Focus groups
  • Formal key leader interviews
  • Continue interviews until no new themes
  • Analyze data
  • Test themes in new interviews
  • Test ideas / findings in community forums
  • Health surveillance team (data collection)
  • District public health prevention specialists
  • Blueprint team

Population Health Indicators Sources Analyses
  • VDH Health Surveillance
  • Behavioral Risk Factor
  • Surveillance Survey Data
  • Hospital Discharge Data
  • Traffic Accident Data
  • Department of Labor Data
  • Adult Tobacco Study Data
  • Vital Statistics Data (Deaths)
  • US Census Data
  • Vermont Department of
  • Transportation Data
  • Medical Practice Board Survey
  • Data
  • Vermont Department of Labor
  • Data
  • Community Snapshots
  • Rates of risk factors in each
  • community
  • 5 Year Aggregate Data (2002
  • 2006)
  • 2006 Statewide Comparison
  • State Level Assessment
  • Factors assoc with
  • hospitalizations costs
  • 10 year trend analysis
  • Univariable multivariable
  • modeling

Key to Success Partnerships
  • Communities
  • Not for profit organizations (ACS, AHA)
  • UVM College of Medicine
  • AHEC (VDH Office of Primary Care/Rural Health)
  • VCHIP (Blueprint Evaluation)
  • OVHA Medicaid Medical Director, CCMP
  • Professional Organizations
  • AAP, AAFP, VT Medical Society

Federal, state/local partnership
  • Requires funding through governmental public
    health system
  • Requires sustained state public health capacity
  • Requires flexibility in application across
    programs (core elements for all states)

Explorersthen and now
Samuel de Champlain
  • Blueprint Integrated Pilots
  • Craig Jones

Blueprint Integrated Pilots Building a Scalable
  • Build a model for effective and sustainable
  • Multi Insurer Financial Reform (PCP payment,
  • Financial Incentives (balance volume quality)
  • Environment (PCMHs, CCTs, PH specialists, Health
  • Focus (quality, wellness, prevention)
  • Evaluation (multidimensional, routine)
  • Culture (self management, engaging yet objective)

Blueprint Integrated Pilots Coordinated Health
Community Care Team Nurse Coordinator Social
Workers Dieticians Community Health Workers OVHA
Care Coordinators Public Health Prevention
Mental Health Substance Use Disorders
Public Health Prevention
Health IT Framework
Global Information Framework
Evaluation Framework

  • BISHCAs Role in the Blueprint
  • Evaluation and Enforcement
  • Christine Oliver

The Vermont Healthcare Claims Uniform Reporting
Evaluation System
  • VHCURES, formerly referred to as the Multi-payer
    Claims Database, is administered by BISHCA as a
    resource for reviewing health care utilization,
    expenditures, and performance in Vermont under a
    statutory mandate. (18 V.S.A. 9410)
  • VHCURES includes collection and consolidation of
    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.
  • VHCURES reporting requirements are harmonized
    with similar claims data collection initiatives
    in other states to support uniform reporting
    standards for insurers and future regional and
    national research.
  • VHCURES may include Medicaid and Medicare claims
    data if approved by CMS.

VHCURES Applicability to Health Care Reform
Evaluation (1 of 2)
  • June/July 2009- Target date for first
    consolidated VHCURES eligibility and claims data
    set for the paid claims period of January 2007
    through December 2008
  • Catamount Health enrollment in plans offered by
    VT insurers began in October 2007
  • VHCURES reporting requirements include Payer
    Identifiers and Insurance Group Policy Number on
    records. Can identify CH enrollees by insurer.
    Members are de-identified via encryption by
    insurers prior to data submission to VHCURES.
  • SHARE study anticipates using the State Employees
    health benefit plan as a control group. Records
    for this group can be identified for use in the
  • Eligibility and claims records by specified
    insured group will be used for analyses of cost
    (paid amount) and utilization.

VHCURES Applicability to Health Care Reform
Evaluation (2 of 2)
  • July 2008- Implementation of Blueprint Medical
    Home Integrated Pilot Communities with
    participation of three major insurers BCBS VT,
  • Three pilot communities with successive start
    dates of July 2008, October 2008 and January
  • The 3 participating insurers are flagging member
    eligibility records in the required VHCURES data
    submissions for attribution to Blueprint
  • Eligibility and claims records for
    Blueprint-attributed members will be segregated
    for analyses of cost and utilization trends
  • May be able to link members back to
    pre-implementation period for comparative
    reporting and/or use the congruent hospital
    service area as basis for pre-implementation
    baseline reporting on cost and utilization.

Blueprint Enforcement
  • Catamount Health Design - The Blueprint was built
    into the design of Catamount Health by requiring
    health insurance carriers to waive cost sharing
    for chronic care services if an individual is
    participating in a chronic care management
  • Carriers are required to offer chronic care
    management programs for at least the following
    diabetes, asthma, low back pain and depression
  • As additional conditions are added to the
    Blueprint, carriers will be required to offer
    additional programs.

Blueprint Enforcement
  • BISHCA Statutory Enforcement Authority (1 of 2)
  • 8 V.S.A. 4088h Health Insurance Plans
  • A health insurance plan shall be offered, issued
    and administered consistent with the Blueprint
  • BISHCA authorized to enforce compliance with the
    Blueprint when approving rate and form requests
    and in addressing consumer complaints.
  • Act 204 (2008)An Act Relating to Managed Care
    Organizations, the Blueprint for Health, and
  • BISHCA authorized to require health insurance
    carriers to participate in the Blueprint Pilot

Blueprint Enforcement
  • BISHCA Statutory Enforcement Authority (2 of 2)
  • 18 V.S.A. 9414(b) Managed Care Quality Assurance
  • A managed care organization shall establish a
    chronic care program as needed to implement the
    blueprint for health. The program shall include
  • Appropriate benefit design
  • Material, training and follow-up necessary to
    support members and providers and
  • Payment reform methodologies

  • ACO Pilots
  • Jim Hester PhD

Bending the Cost Curve
  • Conceptual framework for community health system
  • Every system perfectly designed to obtain the
    results it achieves
  • Approach System redesign at multiple levels
  • Patient level Medical homes
  • Community provider networks to achieve the Triple
  • State/region infrastructure and support
  • Payment reform
  • Necessary, but not sufficient element
  • One of most difficult, particularly integrating
    across payers
  • Phase I Link primary care incentives to NCQA
    medical home functions
  • Phase II ACO pilot links community health
    system incentives to IHI Triple Aims
  • Use pilot communities to start

Phase II Payment Reform
  • Focus on community health system level
    (Accountable Care Organization)
  • Translate potential system wide savings into
    actual savings
  • Capture part of shared saving to reinvest in
    local community health system
  • Transition funding for adjusting to reallocation
  • Investments in population health, primary care,

Goals of The ACO Pilot
  • Improve performance in IHI triple aims
  • Bend the medical cost curve significant savings
    over projected trend line of costs (2-4/yr)
  • Improve the health of the community population
    and the patient experience
  • Test the ACO concept in a small number of early
    adaptor community provider networks that have
    key integrator capabilities.

Process and Timeline
  • VT Legislation
  • 5/08 Health Care Reform Commission conduct ACO
    pilot feasibility study
  • 5/09 Support development of Vermont provider
    application for national ACO learning
  • State supervision of process provides anti-trust
  • Technical assistance
  • Time line
  • 6/08-1/09 Assessed feasibility
  • 3/09-12/09 Customized design
  • Q2 2010 Startup of initial pilot

ACO Pilot Feasibility Study
  • Created working design and assessed critical
    issues and tasks in
  • Scale and scope of pilot e.g. minimum
    population, covered services
  • Responsibilities and criteria for ACO site
  • Financial model, including incentive structure
  • Funding of new integrator roles and pilot
  • Educated broad based workgroup of stakeholders in
    the ACO concept

Current Tasks for ACO Pilot
  • 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
  • Create financial impact model for ACO
  • Continue broad based stakeholder workgroup for
    design input and communication
  • Coordinate/integrate design with Blueprint
    medical home

  • Health Information Technology
  • Hunt Blair

The Distributed Network Paradigm
Federal HIT/HIE Policy, Oversight, Standards -
Office of the National Coordinator (ONC)
State HIT/HIE Policy, Oversight, Standards
Vermont Health Care Providers Institutions
State Government Public Health
Public Health surveillance, registries, other
public health functions
Tertiary and Community Hospitals
Health Information Exchange (HIE) Cloud for
interchange of health records, demographic data,
image files, clinical messaging, other
digitized health information Operated by VITL
Primary Care Specialty Providers
Medicaid health programs case management
functionality and connectivity
Federally Qualified Health Centers Rural Health
Free Clinics
Other Medicaid AHS case management
functionality and connectivity
Mental Health/BH/SA Providers
Long Term Care Providers
Other state agency dept. case management
functionality and connectivity
Home Health Hospice Providers
Community Human Service Agencies (Family Centers,
Area Agencies on Aging, etc.)
Law Enforcement, Corrections, Court System
Individual Vermonters connectivity to EHR
Portals, Personal Health Records (PHR), Health
2.0 applications and Ix Services
  • For more information
  • Vermont Health Care Reform Web-site
  • Health Care Coverage Information
  • 1-800-250-8427