From Serving a Program to Serving a Person · 2015-08-26 · Principal Accountable Provider (PAP) Payment approach Incentivizing quality Reporting examples Overview of Universal Assessment

From Serving a Program to Serving a Person

Data for Decisions

Tuesday

September 1, 2015

From Serving a Program

to Serving a Person

Kim Shaver, Brian Keltch & Jay Shannon

Facilitator- Beverly Roberts

IT Solutions Management (ISM) Conference 2015

September 1, 2015

Agenda

Overview of the Arkansas Health Care Payment Improvement Initiative

Episodes of care

Principal Accountable Provider (PAP)

Payment approach

Incentivizing quality

Reporting examples

Overview of Universal Assessment System (UAS)

Benefits of UAS

Key requirements of UAS

Integrating to deliver the UAS

Primary functions of UAS

Description of UAS functions

Demo of UAS

Approved for Public Release, #15-0474; Unlimited Distribution

Arkansas Health Care Payment Improvement

Initiative

*Information/Graphic is from the Arkansas Health System Transformation – State Innovation Plan as submitted to CMS and

CMMI September 12, 2012


Paying for Episodes of Care

Episodes of Care

Principal Accountable

Provider (PAP)

Payment Model

• An assembly of services or treatment for a particular medical problem/condition

• Examples: (e.g. hip replacements, congestive heart failure, perinatal)

• Provider identified by the payer for managing the individual’s episode of care

• PAPs are incentivized to coordinate care and communication for more effective outcomes

• Initially retain current reimbursement schedule as services are performed

• Adjust payment retrospectively based on cost thresholds for risk or gain sharing adjustments, includes quality targets


Payment Approach

Increased desire for quality outcomes drives payment reform

Provider submits claim for service

Reimbursements for established fee schedules

Payment sent to provider with

financial relationship to

provider

At end of 12 month

performance period, final

determination of gain sharing, risk

sharing or no payment change

Quality aspects are included and

must be exceeded to

obtain incentive payments

Quality metrics that are linked to

payment are “pass” metrics and others are

for reporting and tracking


Incentivizing Quality Care with Gain Sharing

Retrospective determination following 12 month performance period

Utilization Performance

Cost

Quality

• Levels of performance thresholds:

– Commendable & Acceptable

• Providers with total average episode costs below “commendable” and who qualify based on quality, receive incentive payments (gain sharing)

• Providers with total average episode costs above “acceptable”, subject to payment loss for excess costs


Dashboard Reporting

Excluded Episodes





Universal Assessment

The Universal Assessment System (UAS)

• Is an integrated application that supports:

• Assessment

• Budgeting

• Care management

• Payment reform

• Is for individuals that are currently receiving fee based services via Medicaid waivers

• Serves four divisions within ADHS that are responsible for different elements of case management

The Universal

Assessment System


Benefits of the Universal Assessment System

A standardized assessment offers significant benefits for both consumers and state staff:

Objectively assess the applicant’s

needs

Informs the development of

individual service plans

Determines an individual’s

level of need

Aligns needs with the most appropriate

level of services in the least restrictive setting of care.


Key System Requirements for UAS

System must align with state’s payment reform initiative

• Support a patient centric approach,

• Focus on care coordination,

• Link payment to need and services provided

• Facilitate conflict free workers/ independent third parties conducting assessments

• Provide a common repository for conducting and storing assessments

• Allow multiple parties secure access to view client records

• Track budgets linked to the assessments/ care plans and linking those outcomes to services

• Be interoperable with critical state systems such as the MMIS for claims processing and the Medicaid eligibility system

• Support real-time or near real time interfaces to critical systems


Integrating to Deliver the Universal Assessment

System (UAS)

CoCENTRIXccp

Rules Engine

Workflow Mobile

Technology

interRAI instruments

Northrop Grumman Integration

Team

Universal Assessment System


Primary UAS Functions


Description of the Primary UAS Functions

Wavier PII Functions UAS Function Description Primary System Interfaces (Data Flows)

Develop Payment Improvement Initiative (PII) Episodes,

Algorithms, Models

Results of this function are input into UAS. UAS needs to be able to store information.

- interRAI->UAS (Assessments,

Screens, Budget)

Referral, Intake, Financial Assessment

Referral Intake initially recorded in Medicaid Eligibility

System. UAS to retrieve intake/application and status

from Arkansas Networked System for Welfare, Eligibility,

and Reporting (ANSWER)/Eligibility and

Enrollment Framework (EEF).

ANSWER/ EEF

UAS <-> ANSWER/EEF

(Financial Eligibility Status, Life Changes, etc.)

Conduct Assessments, Resource Utilization Group (RUG) Scores, Set Budgets

UAS provides ability to conduct assessments. Score calculation

and budget calculations are provided (where assessment related). UAS is system of

record for Assessments/Scores/Budgets.

UAS provides assignment of Assessors and Scheduling,

Tracking, and Maintenance of Assessments.

Budget information -> MMIS.

Clients/providers can view Assessments/Budgets.

UAS

UAS -> Medicaid Management Information System (MMIS)

UAS -> ANSWER/EEF

UAS -> Arkansas Analytic Engine

(Budgets, Eligibility Periods, Limits, etc.)


Description of the Primary UAS Functions (Cont.)


Provider Selection or Assignment

Assessors work with clients, caseworkers, and case

managers to select provider and appropriate services.

UAS is system of record for these selections.

UAS -> MMIS Providers Selection

UAS -> Arkansas Analytic Engine Selection

UAS

UAS -> MMIS

UAS -> Arkansas Analytic Engine

(Client-Provider Data and Budgets)

Plan of Care Development, Transition Plan

Case managers, clients, and providers agree on provided

services or transition. UAS

UAS-> ANSWER/EEF (Service Dates)

Service Delivery, Clinical Management, Case

Management

Case managers record notes on delivery. Initiate changes in

status through ANSWER/EEF or transition processes.

UAS

Electronic Health Record (EHR) Functionality

Record charting service, and delivery. Medication management, clinical

outcomes, and pharmacy management.

UAS and Provider Systems

UAS -> Arkansas State Health Alliance for Records Exchange

(SHARE)


Description of the Primary UAS Functions (Cont.)


Outcome Measures, Performance Data

Client-based metrics during service delivery will be

collected by and stored in UAS. The Arkansas Analytic Engine

will store Provider-based Metrics.

Arkansas Analytic Engine

Consolidated Tracking, Reporting, Decision Support

Standard and custom reports and tracking for client-based

information that is UAS system of record.

UAS, MMIS, Enterprise Data Warehouse (EDW)

UAS-MMIS-Arkansas Analytic Engine-ANSWER/EEF- EDW

Determine Reimbursement Adjustment

Based on provider performance Data calculate a share gain or

loss. Arkansas Analytic Engine

Pay Providers

Providers will continue to bill MMIS directly with significant modifications to the process.

Provider adjustments (Quarterly or Annually) will be addressed by Arkansas Analytic

Engine and MMIS. Not recorded in UAS.

MMIS will track minimum encounter data from per

member per month (PMPM) payments.

MMIS

MMIS -> UAS

MMIS -> ANSWER/EEF

Minimum Data Set (MDS) -> MMIS


Universal Assessment Demo

Thank You

Please provide feedback on the

APHSA Conference App Download from your App Store or at https://crowd.cc/s/6r3C

Search APHSA Conferences

Visit vendors in Exhibit Hall B to continue

today’s conversations and learn more.

Help ISM raise 7,500# of food for Philabundance

Technology for a Cause. Donate during registration

or visit the APHSA booth (#232).

https://crowd.cc/s/6r3C

https://crowd.cc/s/6r3C

Documents

From Serving a Program to Serving a Person · 2015-08-26 · Principal Accountable Provider (PAP) Payment approach Incentivizing quality Reporting examples Overview of Universal Assessment