Key Findings: Paying for Self-Management Supports as Part of Integrated Community Health Care Systems

July, 2012

2A nonprofit service and advocacy organization © 2012 National Council on Aging

Introduction

As follow up to the May 2012 Expert Panel on Evidence-Based Health Promotion/Self-Management Supports: Moving to Integrated Community Health Care Systems, the Administration for Community Living/ Administration on Aging (AoA) and the National Council on Aging (NCOA) conducted interviews with selected health care organizations to gain a more detailed understanding of the implementation and funding opportunities for self management supports in response to recent health reform initiatives.

The interviews focused on the current efforts and future plans to pay for and partner with community based organizations to provide self management supports (SMS).

Between June and July 2012, 10 interviews were conducted with:– For profit and not-for-profit integrated

provider and payer health care systems:• Physician Led• Hospitals and Physician Network• Founded by Community Health

Centers• Consumer-Governed

– For profit and not-for-profit health insurance plans

– Large not-for-profit physician organization

– State pension fund that provides retirement, disability and survivor benefit programs for public employees

Purpose Interviews Conducted

3A nonprofit service and advocacy organization © 2012 National Council on Aging

Trends

Self-insured commercial and employee retiree benefits plans are innovative, flexible, and receptive to self-management supports Health care organizations are searching for opportunities to

move from fragmented services & costs to integrated care and community based approach• Shift in strategic focus to “community” clearly articulated by both

payers and providers Many are moving from Disease Management (single disease

focus) to an integrated model of care driven by care team and care plan• Growing Care Management Capacity• Using predictive software to risk stratify patients to develop care

plan and target interventions All are re-defining systems to deliver cost-effective programs

and recognize the need for a progression of strategies to improve quality and reduce costs

“We have an ethical obligation to provide effective SMS”

Health Plan

4A nonprofit service and advocacy organization © 2012 National Council on Aging

Barriers

Health care culture • Preference for professional vs. peer led services• Clinical outcomes rather than quality of life outcomes are valued• Past experience based on building and owning vs. buying and partnering

Existing infrastructure is inadequate to monitor quality, outcomes and cost across health care and community service systems• Investment needed to develop integrated monitoring and reporting

process• Significant technical hurdles to bill CMS and other payers

Current focus is on high risk/high cost patients with less consideration of lower risk patients who may see greatest benefit from self-management support (SMS)

Primary Care Physicians (PCPs) need more support and information to refer patients

Lack of knowledge about the range of evidence-based self management offerings available through community-based organizations (CBOs)

No standard criteria for selection of high quality partners/vendors

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Opportunities

ACA fosters partnering with CBOs to broaden the array of non-clinical services New models of care delivery (ACOs/PCMHs) provide flexibility for service design and payment to

include SMS Greater focus on patient motivation and engagement Growing awareness of effectiveness of SMS and value of

partnering with community resources Strong interest in online programs (needs to be combined

with other strategies)

“ With the dual eligible plan, we are ‘coloring

outside the lines’ more and looking for creative

ways to bring good health outcomes to the enrollees. ” Health Plan

6A nonprofit service and advocacy organization © 2012 National Council on Aging

Facilitators to Achieve Sustainable SMS

Aligning payments with incentives for patients, providers and payers

Having infrastructure to support data for tracking, evaluating outcomes and billing across health care and community organizations• Provide “real time” feedback that programs are meeting

needs of patients• Feedback between community organization, health

plan/payer, primary care practice and patient about results of SMS

Communicate results of engaged and activated patients who achieve “real” behavior/lifestyle change

Ability to independently evaluate effectiveness at the plan/payer level

7A nonprofit service and advocacy organization © 2012 National Council on Aging

Recommendations

Create incentives to increase uptake of SMS• Member incentives to increase participation, engagement and

completion• Primary care practice incentives to integrate referral to SMS into

standard patient care• Health care organization incentives to include SMS offerings• CBO incentives to partner with health care providers to deliver SMS

Establish a billing code to cover SMS and link claims data with outcomes to evaluate impact

Build affiliated networks of CBOs to deliver consistent services, meet performance standards and report outcomes

Address regulatory and technical implementation and billing barriers

Continue to develop online capacity as part of a comprehensive SMS strategy

“ We are moving to EMR, using chart

rooms now as wellness centers. ”

Health plan