Colorado State Innovation Model
Application for Funding for Test Assistance JULY 21, 2014
Abstract The Colorado State Innovation Model touches nearly every aspect of our health system, setting the stage for a sweeping transformation that will help us accelerate our progress toward the Triple Aim of lower costs, better care and improved population health. It will also allow us to reach our goal of becoming the healthiest state. Our vision is bold. Central to transforming the Colorado health system is the integration of behavioral health and primary care, a necessary step in our accelerated achievement of the Triple Aim. Our integration efforts will be supported by an improved public health infrastructure. In turn, behavioral health integration will improve population health by addressing behavioral factors that often impede the management of chronic health problems, especially obesity, smoking and diabetes. Improving access to behavioral health services and programs for most Coloradans is the cornerstone of the Colorado transformation effort. Under our plan, we will offer truly integrated physical and behavioral health care. A broad range of public health programs will extend health care, including disease prevention, on a population-wide scale. Payment systems will evolve to ensure that our new model of care is sustainable for the long haul. Data will be used effectively and securely to support innovation. And Coloradans will be at the center, with the power and opportunity to make the best choices possible for their own health. Our vision is attainable, particularly because we are building on important work that is already underway. And Coloradans know how to work together to accomplish big projects. Today, stakeholders throughout the state and from the full spectrum of the health community are on board to collaborate on our SIM proposal. Key partners include eight leading commercial payers and primary care providers covering the majority of the state population. There is urgency in our work. While we have a strong, collaborative foundation, health costs continue to rise, patients receive fragmented care and key population metrics must be improved. SIM will allow Colorado to strengthen our efforts in primary and behavioral care and broaden our reach to most Coloradans. The overarching goal of Colorado SIM is to improve the health of Coloradans by providing access to integrated primary care and behavioral health services in coordinated community systems, with value-based payment structures, for 80 percent of state residents by 2019. There is strong evidence that treating physical health, mental health and substance use disorders together will help us take aim at the ever-increasing burden of chronic disease. Our plan, called The Colorado Framework, creates a system of supports, both clinic-based and through expanded public health efforts, to spur integration. But while integrated care is necessary, it is not sufficient to achieving the healthiest state possible. We recognize that health outcomes are strongly impacted by social, economic and environmental factors. Based on the social determinants of health model, the Colorado SIM proposal leverages the efforts of public health to support the clinical health transformation. We will focus on 12 core population health target areas. Colorado seeks SIM funding of $86.9 million across four years. These resources will help us integrate physical and behavioral health care in more than 400 primary care practices and community mental health centers (CMHCs) with about 1,600 primary care providers; bring the majority of payers into shared risk and savings programs by 2019; expand information technology efforts, including telehealth; launch a robust evaluation program that measures both processes and outcomes; and finalize our statewide plan to improve population health. We project total cost of care savings of $126.6 million over the course of the SIM program, with annual savings of $85 million thereafter to help sustain Colorado’s model.
1. Plan for Improving Population Health: Colorado’s SIM aims to improve population health through two primary vehicles – an improved public health system and a transformed health care delivery system with integrated primary care and behavioral health services – that will work together to create an effective and sustainable community-based system. Colorado’s SIM Goal: We will improve the health of Coloradans by providing access to integrated primary care and behavioral health services in coordinated community systems, with value-based payment structures, for 80 percent of the state’s residents by 2019.
Establishing a strong and ongoing partnership between our public health, behavioral health and primary care sectors is crucial because health outcomes are strongly impacted by factors beyond the clinical setting, including social,
economic and environmental influences. Based on the social determinants of health model, our plan leverages the work of public health to reinforce strides in our clinical health delivery system. Working together, the two systems will build a collaborative and outcomes oriented model of primary care and public health integration that helps us reach our SIM goal. Colorado has a head start on developing our statewide plan to improve population health. Governor John Hickenlooper set the stage in 2013 for Colorado to become the healthiest state in the nation when he unveiled the administration’s sweeping health agenda, The State of Health: Colorado’s Commitment to Become the Healthiest State. The Winnable Battles provide a framework for progress across a broad set of public health goals. Led by the Colorado Department of Public Health and Environment (CDPHE), multiple state agencies and community partners have prioritized Colorado’s 10 Winnable Battles – focus areas such as obesity, substance use and mental health, and oral health – in which Colorado can make population-level progress in a relatively short period of time. The Winnable Battles and their associated target areas - the majority of which have a direct connection to clinical care and/or are reflected in our SIM metrics, noted with asterisks below - include: Colorado SIM
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Table A-1. Winnable Battles & Targets Winnable Battle Mental Health and Substance Abuse**
Obesity**
Injury Prevention**
Infectious Disease Protection**
Colorado SIM
Targets By 2016, decrease to 12 percent the percentage of adults who report binge drinking in the past 30 days By 2016, decrease to 20 percent the percentage of high schoolers who report binge drinking in the past 30 days By 2016, increase to 60 percent the percentage of parents who are asked by a healthcare provider about development, communication, or social behavior of their child ages 1-5. By 2016, increase to 80 percent the percentage of mothers who report a healthcare provider talked to them about what to do if they felt depressed during pregnancy or after delivery. By 2016, reduce to 5 percent the percentage of high schoolers who report attempting suicide in the previous 12 months. By 2016, reduce to 5 percent the percentage of adults who report suffering from depression. [Additional metrics presented in State of Health are: By 2014, identify opportunities within existing data collection systems to better measure effectiveness of behavioral health services and individual behavioral health outcomes, implement necessary changes to data collection systems, and set statewide performance benchmarks. By 2016, reduce the prevalence of nonmedical use of prescription pain medications in Colorado by 92,000 Coloradans, reducing our rate of misuse from 6 percent to 3.5 percent.] By 2016, decrease the percentage of high schoolers who are overweight or obese to 17 percent. By 2016, decrease the percentage of children aged 2-14 years who are overweight or obese to 20 percent [Presented in State of Health as preventing 14,000 Colorado children from becoming obese] By 2016, decrease the percentage of adults who are overweight or obese to 50 percent [Presented in State of Health as preventing 135,000 Colorado adults and 14,000 Colorado children from becoming obese] By 2016, increase the percentage of mothers who report some breastfeeding of their infants at 6 months of age from 61 to 65 percent By 2016, decrease the rate of fall-related hospitalization among adults ages 65 and older to 1,636 per 100,000 adults. By 2016, ecrease teen motor vehicle death rates to 10.5 per 100,000 teens ages 15-19 By 2016, increase the use of seat belts from 82.1 percent to 90 percent By 2016, increase by 2 percent the number of kindergartners in Colorado who are up-to-date on immunizations when they enter school. By 2016, ensure a 50 percent reduction of central line-associated bloodstream infections in intensive care units and inpatient wards. By 2016, increase gonorrhea among Colorado’s 15- to 29-year olds by 3 Page 2 of 28
Tobacco**
Oral Health
Safe Food
Unintended Pregnancy
Clean Air
Clean Water
percent a year By 2016, decrease to 16 percent the percentage of high school students who currently smoke cigarettes By 2016, decrease to 5 percent the percentage of minors who smoke and are able to buy tobacco By 2016, decrease the percentage of adults who currently smoke to 12 percent By 2016, decrease the percentage of children who live with a smoker in the home and are exposed to secondhand tobacco smoke to 28 percent By 2016, 75 percent or more of the population served by community water systems receives optimally fluoridated water [Presented in State of Health as ensuring 637 of 881 community water systems have optimally-fluoridated water] By 2016, increase to 4.6 percent the percentage of infants who get a dental checkup by age 1 year [Presented in State of Health as ensuring 7,500 additional children visit a dentist by age 1] By 2016, increase to 39 percent the percentage of third-graders who have dental sealants on permanent molars By 2016, decrease the occurrence of three or more foodborne illness violations in Colorado restaurants by 5 percent By 2016, decrease the percent of inspections resulting in food being thrown out due to unsanitary conditions by 2.5 percent. By 2016, reduce the number of young women ages 15-17 who give birth from 20 women per 1,000 to 16 or fewer By 2016, increase to 80 percent the percentage of sexually active adults ages 18-44 using an effective method of birth control By 2016, increase to 30 percent the percentage of sexually active high schol students using an effective method of birth control By 2018, phase in mercury emission standards for electrical generating units and power plans to a 90 percent capture rate By 2018, reduce Nitrogen Oxide emissions by 27 percent statewide By 2016, 60 percent of Colorado river and stream miles will meet core protection standards By 2016, 40 percent of lakes and reservoirs will meet core protection standards By 2016, reduce number of public water systems exceeding uranium or radium standards to only 16 systems serving 4,116 people
SIM will allow us to make greater strides toward these goals. Similar to SIM, The State of Health has a broader reach across the care spectrum and across multiple state agencies. It details 21 metrics across 18 initiatives to improve Colorado’s health and is built around four core areas that frame our shared goals: ● Promoting Prevention & Wellness; Colorado SIM
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● Expanding Coverage, Access & Capacity; ● Improving Health System Integration & Quality; and ● Enhancing Value & Strengthening Sustainability A complete copy of the report is attached as Attachment 9 (submitted 9/8/2014). In addition to providing express support for the Winnable Battles as noted above, The State of Health explicitly supports integrating behavioral health and primary care (Core Area 3, Initiative 4) and advancing payment reform in the public and private sectors (Core Area 4, Initaitive 2). The State of Health metrics that align with Colorado’s SIM efforts include: ● By 2015, recruit and retain 148 primary care and dental providers through the Colorado Health Service Corps. ● By 2015, provide network access to more than 400 hospitals, behavioral health providers, clinics, and other providers throughout rural and urban Colorado. ● By 2016, connect an additional 555,000 Coloradans with a patient-centered medical home through the Accountable Care Collaborative. ● By 2015, at least 4 million Colorado residents will receive care from providers who have achieved Meaningful Use in the Medicare and Medicaid Electronic Health Record Incentive Programs. ● By 2015, at least 3.8 million Colorado residents will be served by healthcare providers that are connected to an integrated health information exchange infrastructure that supports appropriate, bi-directional sharing of health information and includes exchange with public health and across state borders. We also have sound leadership in place as we move forward. The state’s 55 local public health agencies (LPHAs), already key players in Colorado’s public health model, are helping to
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prioritize local health needs, important in a state with wide regional and demographic variations in disease prevalence. They excel at collaborating with regional partners, leveraging shared strengths to achieve better population health. Overarching leadership will be provided by the Governor’s Office; CDPHE; the Colorado Department of Health Care Policy and Financing (HCPF), which administers Medicaid; Colorado Department of Human Services (CDHS), which oversees behavioral health and social services; the Department of Personnel Administration (DPA); and the Colorado Department of Regulatory Agencies (DORA), which oversees the regulation of insurance and professional licensing. (See the Operational Plan). Connecting providers and patients to community resources that support physical and behavioral health needs, chronic disease management, and the social determinants of health is essential to Colorado’s SIM plan. Colorado will develop its statewide plan for improving population health within this conceptual framework: Population Health Transformation Collaboratives: Population Health Transformation Collaboratives will be comprised of community health leaders and will disseminate evidencebased strategies, assist with setting priorities and goals, support collaboration toward population health goals using established metrics, and distribute resources to local agencies. Collaboratives will work with our newly created Health Extension Service (See Section 2: Health Care Delivery System Transformation Plan) to strengthen work underway at the local level and will be defined around existing state divisions to maximize shared resources. There are a number of activities that will be undertaken by the collaboratives. For example, as more than 23 percent of Colorado’s population is children, a Child Mental Health Coordinator will be tasked with developing targeted population health initiatives for prevention and early intervention of mental
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health problems in very young children. Providers will also receive training in depression, obesity and other behavioral disorders. Evidence-based practices, such as Mental Health First Aid, will also be made available statewide. Targeted LPHAs will receive funding to increase access to covered preventive services, improve community prevention work, and create linkages between practices, community resources and public health. Population Metrics and Shared Data: Colorado proposes to track our progress in 12 core population health target areas, including tobacco use, obesity and diabetes. Our enhanced connectivity through Health Information Technology (HIT) and state Health Information Exchanges (HIEs), will build upon and expand the Comprehensive Primary Care initiative (CPCi) centralized data hub that integrates clinical and claims data, and use other sources of shared information. Our population health plan will outline in detail how Colorado will use these data to inform interventions by communities and to help providers translate population-level metrics into actionable patient care improvement efforts. We will work with the Center for Medicare & Medicaid Innovation’s (CMMI’s) national evaluator to ensure aligned metrics.
The core objective of the measures that will be used in the Colorado SIM minimum dataset is to leverage and consolidate existing measures that are agreed upon by public health experts, providers, and CPCi payers, including Colorado Medicaid. To demonstrate this alignment, the following table details the 12 core population health target areas we will use in SIM and how each maps across other initiatives, including Colorado’s Winnable Battles, USPSTF A & B Recommendations, CDC Recommendations, and CPCi measures:
Table 1. Proposed SIM Population Health Measures (see following page)
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Target Area
SIM Clinical Measures
Colorado Winnable Battles
Hypertension Blood (See also pressure Attachment 6 – 9/8/14)
CDC Recommendatio ns
CPCi Measures
Blood pressure screening – A
Taking HTN medication
Controlling high blood pressure
Obesity screening (adults and children) – B
BMI (adult, youth), exercise, vegetable and fruit consumption, food desert
Weight assessment and counseling for nutrition and physical activity for children and adolescents
Obesity (See also Attachment 7 – 9/8/14)
Weight assessment and management
Tobacco
Tobacco use Substance Tobacco use screening and Use; Tobacco counseling intervention and intervention –A
Use and quit attempts, youth use
Prevention (See also Attachment 8 – 9/8/14)
Breast and colorectal cancer screens; flu shots
Colorectal Breast and screening; colorectal immunization rate cancer screening; flu shots
Asthma
Identify, appropriate prescription
Diabetes
HbA1c, blood pressure, LDLCholesterol
Gestational diabetes screening – b
Ischemic Vascular Disease (See also Attachment 6 - 9/8/14)
Complete lipid panel and control
Aspirin for Cholesterol levels CVD prevention – A; Cholesterol abnormalities – A, B
Complete lipid panel and control, betablocker therapy for LVSD
Safety
Screening for Injury fall risk Prevention
Fall prevention in older adults,
Screening for future fall risk
Colorado SIM
Obesity
USPSTF A&B Recommend ations
Clean air, clean water, safe food
Breast and colorectal cancer screenings – B, A
Use of appropriate medications for asthma Diabetes A1c, foot exam, eye exam
HbA1c poor control, blood pressure management, LDL management
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intimate partner violence – B Depression
PHQ-9 for adolescents and adults, maternal depression screening
Mental health Depression and screening substance use (adults and adolescents) –B
Anxiety
GAD-7
Mental health and substance use
Substance Use
Audit
Mental health Alcohol and misuse – B substance use
Child Development
To be determined
Immunizatio ns (disease prevention), oral health, unintended pregnancy
Dental caries prevention to age 5 – B
Screening for clinical depression and follow-up plan
Immunization rate, low birth rate
As Colorado develops its SIM minimum dataset and quality targets, we will ensure that the targets are consistent with previously-established goals through each of the complementary initiatives listed above, and also consistent with our ongoing inter-agency work.
Policy Advocacy: State and local public health agencies will jointly advance regulatory issues that improve population health and address regulatory barriers in areas such as obesity, behavioral health, tobacco access and pricing, food access, diabetes, and environmental safety and activity measures (See Section 4: Leveraging Regulatory Authority). We will continue existing partnerships that support alignment between private and public payment strategies and
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public health initiatives, allowing for sustainability. We will create a timeline for expanding integration to include oral health and chronic disease self-management training. Ongoing stakeholder engagement will be an important part of Colorado’s success. Our population plan will detail our strategy to tap into a robust dialogue to allow for continual enhancements to meet our goals. (See Section 6: Stakeholder Engagement). Similar to our SIM efforts, Colorado’s Plan for Improving Population Health will build upon the foundation of prior initiatives in order to consolidate and further align statewide efforts. CDPHE will lead the creation of the Plan for Improving Population Health and is an integral partner in our SIM work. Colorado’s Chronic Disease Plan - one of the efforts upon which we will build for our Plan for Improving Population Health - adopted the CDC framework for organizing public health initiatives into five domains: epidemiology and surveillance; policy and environmental change; health systems transformation; community clinical linkages; and media and education. See Attachment 4 (submitted 9/8/2014) for a depiction of Colorado’s work within this framework. Among these five domains, public health’s role in Colorado’s SIM project is most prevalent in three: policy and environmental change; health systems transformation, and community and clinical linkages. CDPHE has identified two particular leverage points with Colorado’s SIM Payment and Service Delivery Model, as follows: ● Colorado’s public health infrastructure, including CDPHE and the Colorado School of Public Health, has been a driver of the development of Colorado’s Health Extension Service (HES). The HES is a central part of our SIM model’s ability to facilitate practice transformation and community coordination statewide and will rely heavily on state and local public health agencies for support.
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● CDPHE is in the process of awarding nearly $40 million to local agencies around initiatives that emphasize health systems change, as well as policy and environmental change, because CDPHE recognizes that the social, cultural, and environmental conditions in which individual choices are made often determine the health of individuals and populations. These funds will address community-driven initiatives around health equity, tobacco use prevention, and prevention of cancer, cardiovascular, and pulmonary disease. Although these funds pre-date the arrival of SIM funding in Colorado, they will provide another building block upon which SIM initiatives can be built. Our state agencies are collaborating to support progress on the social determinants of health. CDPHE, the Department of Human Services (CDHS), and the Department of Health Care Policy and Financing (HCPF) are collaborating to align system infrastructure, integrate health services in Colorado, and work together to address social determinants of health. In order to adequately address the broad context of the social determinants of health, Colorado is taking a “life stages” approach that targets resources, programs, services, and quality measurement based on critical points in life, beginning at pre-conception and progressing to older adulthood. This initiative is based on the Brookings Institute’s “Social Genome Project” framework and crosses social, economic, and cultural contexts to acknowledge the physical, social, and emotional developments throughout the life cycle that affect chronic disease and long-term health risks. In 2013, CDPHE, CDHS, and HCPF began an initiative to assess and align metrics across agencies. The departments assessed existing data with the goal of collecting, comparing, reporting, and trending shared data over time. In addition, they identified complementary initiatives capable of further leveraging limited resources. Through this collaboration, benchmarks and targets will be set that allow these agencies to develop and implement strategic initiatives that tackle existing health disparities, thereby improving future health outcomes. Colorado SIM
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The first joint report, which will be published by October 2014, focuses on behavioral health data and initiatives across the life cycle. We have attached a draft of this report for your reference (Attachment 5 – submitted 9/8/2014). Subsequent reports in this initiative will address child health (nearing completion) and older adults (to be completed in 2015). In order to further align programs that have a demonstrated impact in creating economic opportunities for children and families, this initiative will expand to other state agencies as appropriate, including the Department of Education, the Department of Higher Education, the Department of Labor, the Department of Corrections, the Division of Housing, and the Office of Information Technology. In addition, coordinating with social service agencies is a crucial component of ensuring SIM is successful in integrating community-based social services with clinical care. Colorado's approach to securing firm commitments from local social services agencies is two-fold: First, we are continuing to work with statewide coordinating organizations and agencies to help establish SIM efforts as top priorities for community initiatives in the coming years. Support of many statewide organizations provides us with a strong, statewide backbone for reaching counties as well as local and regional collaboratives that provide social and "wraparound" services to communities. Some of these key backbone entities include:
Colorado Department of Human Services
Colorado Department of Public Health and Environment
Colorado Association of Local Public Health Agencies
Colorado Coalition for the Medically Underserved (which facilitates the 27-member Colorado Network of Health Alliances)
Colorado Coalition for the Homeless
Colorado Boards of Cooperative Educational Services
Colorado Association of School-Based Health Centers
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Second, as we partner with existing and emerging population health transformation collaboratives (PHTCs) across Colorado, we will support them in identifying and engaging local social service organizations most appropriate to leveraging SIM work and connecting with clinical care. This grassroots approach for engaging social services best suits the Colorado environment and our belief that all health is local. 2. Health Care Delivery System Transformation Plan: Colorado’s SIM aims for wide-scale practice transformation in order to reach our goal. At its core, the integrated care envisioned in SIM is intended to help high risk patients with medical and behavioral co-morbidities better manage their conditions, be compliant with treatments, and receive their needed care in more efficient outpatient settings rather than in expensive emergency care or inpatient settings. We will assist more than 400 primary care practices and community mental health centers (CMHCs) statewide as they integrate physical health and behavioral health services. By the full build-out in 2019, we will engage approximately 1,600 primary care providers (PCPs) serving at least four million people, or approximately 80 percent of all Coloradans. This will encompass about one million Medicaid clients, approximately 90,000 Medicare clients, and about three million commercially-insured residents, including state employees. Colorado’s Department of Personnel & Administration (DPA) is in the final stages of reprocurement for our State Employee Plan vendors. The State Employee Plan currently covers roughly 30,000 state employees and dependents, half through a self-funded plan administered by United Healthcare, and half through a fully-insured Kaiser Permanente product. DPA will have the opportunity to review and make changes to the reprocured contracts in July 2016, at which point they intend to include support for SIM-related initiatives, including participation in the SIM minimum dataset, inclusion of state employee data in data aggregation, and consumer engagement tools. Colorado SIM
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In addition, DPA launched a state employee wellness program in July 2013 that is engaging employees through incentivized participation and Personal Health Assessments that are payer agnostic. To-date, over 50 percent of state employees are actively participating in this program. Integrating behavioral health and primary care is the logical evolution of comprehensive primary care and a critical step in defragmenting health care. Evidence suggests integrated care improves individual care, results in better population health and contains costs. Most importantly, integrated care reduces the state’s chronic disease burden. Our health care delivery system transformation plan, called “The Colorado Framework” and outlined in our State Health Innovation Plan, leverages a strong foundation of federal, state and private sector investments in primary care transformation and integrated care (see Section 9: Alignment with State and Federal Innovation). We will knit various important initiatives into long-term, comprehensive innovation. The Colorado Framework envisions three stages of integrated primary care and behavioral health (see Figure 1): Figure 1. The Colorado Framework
Our goal is to help as many practices as possible move to the “Integrated” stage by the end of the grant period. Outcomes measures, as shown in the SIM Minimum Dataset (see Section 7: Quality Measure Alignment), will track our progress for both adult and pediatric populations. Colorado SIM
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Our transformation plan is ambitious and far-reaching. To make it manageable and ensure its success, we will use a phased approach to recruit practices. This will allow for intense support, enabling us to share lessons learned and to conduct meaningful, rapid-cycle evaluation. The initial cohort will be roughly 100 practices that have met key integration milestones, are prepared to adopt reformed payment models, and have demonstrated Stage One Meaningful Use (MU) Electronic Health Record (EHR) capabilities. These pioneering practices will include CPCi participants; participants in grant-funded integrated care pilots as well as partnerships between federally qualified health centers (FQHCs) and CMHCs; and practices that have made significant progress toward comprehensive primary care models, which include many pediatric practices. We will seek diversity in types, sizes, and populations served. We will work with both individual practices and large health care delivery systems. We also recognize that the need for integration is not unique to primary care practices. Bidirectional approaches that bring primary care into behavioral health settings for those with severe and persistent mental illness are a priority. We will also spur integration in long-term services and supports (LTSS), schools and jails. Colorado Health Neighborhoods, Centura Health’s provider network of more than 2,500 physicians statewide, will play a key role in the model test, starting in the first cohort. Across three years, 75 Centura Health practices caring for about one million people will participate. Colorado Health Neighborhoods will tap behavioral health services statewide through a participation agreement a statewide network of behavioral health providers. Similarly, of 74 CPCi practices, 38 have indicated that behavioral health integration is their milestone 2 focus, chosen out of three areas. We anticipate that a high percentage of those 38 practices, with clinical readiness and a willingness to participate in the model, will be in the initial SIM cohort. We aim Colorado SIM
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to balance the number of practices with the number of lives covered (38 CPCi practices referenced here have 159 providers, and cover 233,560 lives), as well as take into account regional and system-level representation. Some Federally Qualified Health Centers that are ready for global payment have also indicated interest in participating in the first cohort. CPCi-style learning collaboratives will serve the first cohort, and we aim to have the remainder of CPCi practices participate in each of the subsequent cohorts as well, in order to share lessons learned from CPCi throughout our SIM participating practices. Selection criteria for subsequent cohorts will be refined to reflect lessons learned and to ensure the longest reach possible. Practices will commit to at least three years of practice transformation facilitation, workforce training, collaborative learning sessions with other practices, ongoing evaluation, and strengthening of their community health networks. Practices will receive tailored transformation assistance based on a baseline Practice Readiness Assessment and ongoing technical assistance. Transformation support can include infrastructure investment, coaching, workforce training for primary care providers, and salary offsets for behavioral health providers (BHPs). Participating practices may be eligible to apply for assistance through the Health Transformation Investment Fund. Colorado will also engage practice facilitators, approximately one for every 12 practices to provide clinic-level technical assistance. They will help practices achieve the core competencies of comprehensive primary care and integrated care, using the practice milestones defined by the CPCi, with additional milestones relating to behavioral health integration aligned with the Agency for Healthcare Research and Quality’s Lexicon for Behavioral Health and Primary Care Integration, which is aligned with SAMSHA/HRSA’s Six Levels of Behavioral Health Integration. A $7.5 million transformation fund is intended to help cover a small portion of the costs Colorado SIM 7 of 68
for practices to participate in the practice transformation activities. SIM practices would align with CPCI practice milestones, but practices would likely “enter” the continuum at different places depending upon their current work and the year of their entry into the program. Assessment would be important to set practices up for appropriate technical assistance and determine where they would fit into the model. The length of requirement to engage would be indefinite – practices would continue to report and participate in learning communities as a core component of their eligibility to participate. We have two possible approaches that we are considering for the transformation fund which is budgeted at $7,500,000: Option 1: $6,000,000 would be based on ongoing participation and progress in the following SIM activities and objectives:
Participation in Learning Collaboratives – a minimum of three participants for each collaborative – $3,000 total
Monthly reporting of core measure set – initial payment for partial reporting, next payment for reporting complete measure set, final payment at the end of the project based on number of monthly reports submitted – $6,000 total
Practice fully participates in the evaluation – initial payment for baseline evaluation assessment and final payment based on participation in ongoing and final evaluation assessments – $6,000 total
An additional $1,500,000 would go toward small grants to practices for upfront costs of transformation based on need and innovation, with preference to practices serving underserved populations. Colorado SIM
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Option 2: $6,000,000 would be based on ongoing participation and progress in the following SIM activities and objectives:
Participation in Learning Collaboratives – a minimum of three participants for each collaborative – $3,000 total
Monthly reporting of core measure set – initial payment for partial reporting, next payment for reporting complete measure set, final payment at the end of the project based on number of monthly reports submitted – $4,000 total
Practice fully participates in the evaluation – initial payment for baseline evaluation assessment and final payment based on participation in ongoing and final evaluation assessments – $4,000 total
Ongoing progress toward accomplishing specific, defined integration milestones – $4,000 total
An additional $1,500,000 would go toward small grants to practices for upfront costs of transformation based on need and innovation, with preference to practices serving underserved populations. We believe the transformation fund is essential to our future success. With CMMI's extensive experience in this arena, we would like to explore which approach would help us reach our objectives. We know there are many lessons learned from the practice support given to practices participating in the Comprehensive Primary Care Initiative and have been discussing this with the Colorado practice facilitators. Community health efforts will be also guided by our Population Health Colorado SIM
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Transformation Collaboratives with Health Extension Agents liaising with practice facilitators, CO-REC IT agents (See Section 5: HIT), Local Public Health Agencies, Early Childhood Mental Health Specialists (See Section 1: Plan for Improving Population Health) and other supports as identified by the community. Health Extension Agents key activities include: • Engaging with practice and organizational leaders, educating them about SIM; • Conducting a readiness assessment with practice leaders, then link practices to needed resources; • Connecting practices with technical support for data linkage, extraction and management (See Section 5: HIT), as well as MU Stage 1 Attestation in concert with the Regional Extension Centers (REC); • Providing practice transformation resources, including facilitation, learning collaboratives, online modules, conference calls, and cross-practice learning networks; • Working with the behavioral health community to help practices determine the integration strategy that works best for them as a starting point; • Connecting BHPs with training resources in the integrated clinical model; • Providing business consultation resources to help plan for integrated delivery systems and outcomes-based payment systems; • Helping to establish patient advisory groups and assist with patient engagement efforts; The competencies will include data-driven quality improvement and practice transformation; team-based care with all practice members, including integrated BHPs, working at the top of licensure; coordination of care across all providers and care settings; identification of high-risk patients for care management; systematic monitoring and adjustment of treatment plans; and engaging patients in their own care and in the overall practice transformation. Colorado SIM
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Each practice will develop a team-based workforce plan, including an HIT technical plan that considers the physical and behavioral health needs of its patient population. The plan will include strategies to engage primary care and specialist clinicians, non-medical staff, and BHPs. Linkages to community resources, with coordinated referrals to public health and community agencies may also feature in the plans. Practice facilitators will help with workforce planning, training and recruitment. A Health Transformation Investment Fund will provide early incentives to both payers and providers as they make the necessary changes toward integrating behavioral health and primary care, both financially and clinically. Finally, we have planned for the sustainability of this important work beyond the SIM funding period. Colorado is committed to exploring a number of sustainability options for our efforts beyond the SIM performance period through collaboration with our partners and stakeholders. Whilee are not currently able to commit to a single sustainability solution that would begin in Calendar Year 2019, which will be beyond the tenure of our current Governor and many of our state legislators, our belief is that SIM will alter the payment and reimbursement structures of insurers, such that the work established in SIM becomes the norm and, put simply, is the “way we do business.” We acknowledge that systemic changes often require long-term commitments of staff who are often state-funded, and we commit to measuring the efficacy and cost-saving potential of SIM with long-term sustainability in mind. Should our efforts prove to be successful, we will identify the means to continue funding beyond the performance period. Some potential options for sustaining our ongoing practice and system transformation efforts include a state-administered fee on participants in the healthcare system; using a shared savings model to recoup avoided costs; and direct program investments by the private, public, and nonprofit sectors. In addition, a Health Transformation Investment Fund may be examined to sustain some practice PMPM payments, both Colorado SIM
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after the conclusion of CPCi and/or SIM to continue moving practices to Phase 3 integration. Through leadership from our foundation partners, we are finalizing a multi-year, multi-stakeholder collective impact strategy and related funding in the area of integrated care. We believe this body of work will support and enhance efforts envisioned in SIM and serve to support ongoing sustainability as well. Colorado proposes to use one-third of actuarially projected savings to support ongoing activities related to the project. We also anticipate that changes in payment models will become permanent and ongoing after the grant period. All of these options and others will be collaboratively evaluated in the first two years of the performance period so that a long-term sustainability plan can be developed in anticipation of continued work. While we are unable to commit to a specific payment model that will sustain the clinical models of integrating care at this time, we do commit to continuing to convene those who are integrating care together to learn and share stories, resources, and ideas. This state led learning community will not only help maintain the momentum of adopting models of care, but will also allow the state to continue to prepare strategies for sustainability. With Colorado’s positioning as a national leader in integrating care, the likelihood that this would have appeal and add value is quite substantial. We believe that these efforts will create a tipping point for integrating Colorado’s health delivery system, achieving a critical mass that will make innovation inevitable. By focusing on whole person care within both the behavioral health and primary care settings, Colorado will achieve the Triple Aim of better care, better population health and lower per capita costs. 3. Payment Delivery Model: Aligning provider payment with financial outcomes (total net reduction in healthcare costs) is a key element of our proposal. Furthermore, payment reform must go hand in hand with health care delivery redesign in order to bring about lasting and sustainable Colorado SIM
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change. As Colorado’s practices progress toward integration, so too will payment. Our goal is that by 2019, the fourth year of the SIM grant, payers serving a majority of Coloradans will reimburse practices for integrated physical health and behavioral health services in shared risk and savings programs. Further, a significant number of integrated practices will receive a global or capitated payment for comprehensive primary care. This objective is reflected in the Governor’s State of Health commitment to support a statewide transition away from paying for volume and toward paying for value. Colorado has received firm commitments from six private payers to: ● Continue care coordination payments; ● Move to shared savings opportunities; ● Move to prospective, non-volume payments; ● Use the SIM minimum data set; and ● Support the aggregation of clinical and claims data.1 These six payers collectively serve 1.6 million Coloradans - 30 percent of our state population - and include: five CPCi payers, four payers with statewide reach, one of our Medicaid RCCOs, and Colorado’s ACA-authorized Consumer Operated and Oriented Plan (CO-OP). Of these, four payers have agreed to move to shared savings models within three years and to prospective, non-volume payments within five years. The remaining private payers who participate in CPCi, as well as Kaiser Permanente, have committed to being active participants in Colorado’s SIM model and submitted letters of support with our July 2014 application.2 Key challenges we are facing in securing stronger commitments from payers include:
1 2
Aetna, Anthem BCBS, Colorado Choice Health Plans, Colorado HealthOp, Humana, and Rocky Mountain Health Plans UnitedHealth Group, Cigna, Colorado Access
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● Colorado is privileged to have a strong and competitive health insurance market. However, this can also present challenges for broad multi-payer initiatives designed to shift market norms. Colorado has roughly 440 health insurers, and the largest 10 carriers only comprise 70 percent of the private market.3 In addition, we have very competitive ASO/TPA services, and many diffuse provider organizations - many of which are at different stages of readiness for integration, making it difficult to reach a critical mass of Coloradans through any single voluntary initiative. ● Colorado has made a strong commitment to full implementation of the Affordable Care Act, through establishing a state-based Exchange (Connect for Health Colorado), expanding Medicaid, and reforming our private insurance market. In order to achieve these objectives and maintain a healthy and competitive marketplace, Colorado payers and our Division of Insurance have been highly sensitive to additional initiatives that may promote insurance market instability. ● Colorado payers maintain a strong commitment to innovation in payment and delivery system reform. However, several large national carriers have expressed concern about differentiating based on unique, state-specific innovations, which compete with their own proprietary national platforms and initiatives. Three payers noted in their letters of support that while they are committed to SIM’s integration of behavioral health and to pursuing innovative payment and delivery models, they must do so while balancing company-driven initiatives and/or multiple partners across the country. For example, while our payers have demonstrated a deep commitment to CPCi and are ready to expand upon that program, two payers have withdrawn from CPCi data aggregation due to concerns over ASO data,
3
Colorado Division of Insurance, “Annual Report of the Commissioner of Insurance to the Colorado General Assembly on 2013 Health Insurance Costs,” July 2014.
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duplicate investments in their own national data portals, or concern with the ROI for investments in data infrastructure. In order to combat these challenges, Colorado will continue to conduct broad outreach to the state’s largest payers, engage the self-funded business community to drive demand for integrated behavioral health in the ASO/TPA market, and use SIM as a leverage point, ensuring Colorado’s premier innovations are complementary to one another, rather than competing. Colorado offers fertile ground for innovative payment reform. For example, Medicaid offers a fee for service (FFS) payment with an enhanced per member per month (PMPM) payment for primary care practices acting as a medical home. Additionally, seventy-three practices and eight payers participate in the CPCi, a multipayer pilot that pays for coordinated care. Collectively, CPCi accounts for care delivered to 465,644 Coloradans, and our SIM work will build on Colorado’s CPCi foundation. By building upon the CPCi foundation, Colorado will leverage private payers’ commitments to migrate toward prospective, non-volume payments, as providers become capable of adopting these new payment models. Recent legislation (HB 12-1281) has opened new frontiers of payment initiatives. One such pilot which coordinates behavioral health and physical health through a complete transfer of risk and budget accountability to community partners, is underway in western Colorado, through a partnership between Colorado Medicaid and Rocky Mountain Health Plans, which serves as both a Medicaid RCCO and as a private payer, with over 250,000 members. More tests are planned in 2015, and as we evaluate the effectiveness of these payment reform models, we plan to scale successful pilots in parallel to SIM through Medicaid. These pilot initiatives will also provide dependable evidence to private payers, enabling them to duplicate these forward-thinking payment models. The evaluation of these models will be essential in understanding which Colorado SIM
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elements should be recommended for scaling, and which elements remain in need of further refinement. Furthermore, the state has committed to integrating primary care across the behavioral health system, as demonstrated in the latest Behavioral Health Organization (BHO) RFP, where organizations were specifically asked to articulate their plans for integration, including care coordination and supportive services just to name a few. Colorado's BHOs already have experience in coordinating with medical health providers and helping individuals to get medical treatment and arrange for supportive services, and the lessons they have learned will inform Colorado’s SIM work. As currently structured, the BHOs are contracted to cover Medicaid clients with a covered diagnoses of major mental illness, and they currently provide services to approximately 10% of the Medicaid-covered population (88,715 in 2012). Medicaid clients served by the RCCOs are also served by BHOs. Under SIM, we want to bring behavioral health into primary care, so all patients seeking primary care have the potential to have any behavioral health issues (not just covered diagnoses) addressed in primary care. BHOs will continue to work with a population that has more severe behavioral health issues, integrating primary care into behavioral health care. The BHOs’ 25 years of experience will inform the process of integration in their care settings. Many providers in BHO networks are already fairly far along the integration continuum, including some that are already providing fully integrated care, and are willing to participate in the first SIM cohort. Coordination of services in support of integration is currently a contract requirement for both BHOs and RCCOs, and future iterations of the RCCOs will enhance requirements for integration of care between the organizations. RCCOs and BHOs strive for ‘whole person care” by focusing on care coordination; bi-directional referrals; screening for major issues that fall under either provider; Colorado SIM
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sharing information to coordinate care; alignment of some quality and performance measures such as reduction of ER visits, hospital readmissions, and increase in follow-up care; and sharing data. Data sharing is mainly achieved through the Statewide Data Analytics Contractor (SDAC), which aggregates FFS claims and BHO encounter data to provide client risk assessments. Based on provider health risk assessments, BHOs and RCCOs will refer to each other to address a client’s primary health needs and coordinate care. Through SIM, the partnership between RCCOs and BHOs will expand beyond major mental illness to address underlying behaviors that negatively impact client health. SIM funding will allow Colorado to scale our efforts and reach more Coloradans, providing infrastructure, operations and administration that will last beyond the four years of funding. Payers in today’s market have a high degree of interest in supporting and paying for integrated care. The challenge is maturing behavioral health and primary care settings so that they can administer, receive and monitor payments that progress beyond FFS. Payers have revealed their willingness to adopt alternative payment methods when practices are able and willing to accept nonFFS payments. For example, Anthem Blue Cross/Blue Shield’s Enhanced Personal Health Care Program assists primary care physicians in becoming more patient-centered by providing data and aligning contract incentives through a PMPM and shared savings model tied to quality benchmarks. This program began in Colorado in 2013 and already has over half of Anthem’s primary care network participating, reaching 200,000 members statewide. This program aligns well with CPCi and SIM and has become a leading-edge model for Anthem, which is expanding the program across its 14 states. Another payer that serves as a Medicaid RCCO and as a private payer, Colorado Access, has used savings through the ACC to develop a Performance Incentive Fund that enables select Colorado SIM
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providers to apply for grant funding to expand integrated behavioral health services in primary care settings. SIM funding will ready the market for this advancement. Private payers will adopt shared savings and prospective, non-volume payment models to support integrated physical and behavioral health, with some variation among payers. The state’s initial threshold for participating payers will be care coordination or practice transformation payments in addition to FFS. In the first year of SIM implementation, we will work with each participating payer to finalize a firm timeline for transitions to more progressive payment models. Generally, payers will adopt shared savings and risk models that support practice transformation and hold providers accountable to SIM metrics by 2017, and by 2019, payers will transition to prospective, non-volume payments for providers able to accept these payment structures. The cornerstone of this payment reform glide path is the readiness and ability of primary care practices to move from a FFS environment. As the practices evolve, payers will begin to employ alternative payment methodologies and move to shared risk models. Our approach contemplates a gradual transition to new payment models that allows for long-term adaptation, rather than an immediate switch that could result in market instability. As an example of private payers playing a leading role in our SIM payment reform initiatives, we have attached a statement from Rocky Mountain Health Plans that underscores their commitment to private payer reform (Attachment 2 – submitted 9/8/2014). These reforms will include:
Expanded primary care capitation rates, including primary physical and behavioral healthcare and care coordination, with potential options to include psychiatric services;
Gain sharing models for non-primary care services, including facility-based services, specialty professional services, and prescription drugs; and
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Risk sharing models for practices that can legally and financially accept such risk sharing structures.
These models will include member attribution models to assign members to primary care practices, and risk adjustment for the specific populations assigned to each practice (for capitation rates and gain/risk sharing targets). Attribution will take into account the preferences and prior visits of individuals and families. Capitation rates will be developed from historical detailed claim experience for each practice’s assigned members, including trends and risk adjustment. Gain/risk sharing will include the projection of utilization and cost targets of non-primary care services (facility-based services, professional specialty services, prescription drugs, etc.) for the attributed populations. Outlier cases will be handled properly to not penalize practices for large claims. Certain claims (e.g. transplants) will also be excluded from these gain/risk sharing mechanisms.
SIM Financial Arrangement Colorado’s SIM most closely resembles the PCMH payment model, rather than the ACO model, and aligns with the CPCi approach to payment reform. While developing our proposal, Colorado worked collaboratively both payers and practices in order to identify a payment methodology that suits both sides. Colorado will develop financial reforms to help achieve the savings projected in the financial analysis. Although these may be implemented at different times for different payers (including Medicaid and CHP+), all reforms will be along our payer glide path, which focuses on getting payers to have prospective, non-volume based payments by the end of our SIM testing period. A fundamental tenet of our proposal is that payers should get “credit” for efforts to promote payment reform, care coordination, and integration that are already under way. Hence, in the initial phases, we will meet payers and practices where they are, and our goal will be to work with them to bring them along the glide path to integration. Colorado SIM
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During the SIM planning phase, we will develop a stakeholder process to put in place an agreement about how any savings would be divided between participating practices and the state. The Colorado SIM model of integrated primary care and behavioral health envisions three phases of integration – coordination, co-location, and integration – that each align with phased payment approaches. The financial arrangement – via PMPM payments from payers to participating practices – will assist practices in becoming “Phase 3” (see below) by the end of the grant period. Practices that are unable to do so due to limitations will still be expected to perform to the highest level of integration practicable, and our practice transformation efforts will help to mitigate against this. The state will also include quality outcome measures in the development of payment reform. Gain/risk sharing payments to provider groups, as well as capitation payments, will have aspects of their payments tied to desired clinical outcomes that tie back to our SIM minimum dataset (CPCI+3). Our trajectory of payment reform parallels practice readiness, beginning with an observation phase and progressing through payments and budgeting for comprehensive primary care and behavioral health. Figure 2. Payment Steps Toward Integrating Behavioral Health and Primary Care
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The cornerstone of this payment reform glide path is the readiness and ability of primary care practices to move from a FFS environment. As the practices evolve, payers will begin to employ alternative payment methodologies and move to shared risk models. Critical to our success will be to continue regular and open discussions with all of Colorado’s payers. Building upon CPCi, Year One will be focused on finalizing specific payer commitments and agreeing to details of the care coordination, shared savings, shared risk and sub-capitated plans. We also will work on aligning administration of the current FFS physical health system with the currently capitated behavioral health system in Medicaid. We acknowledge the work and challenges ahead and have built a trusted stakeholder community that will deliver on this goal. Payers will be asked to support practices with an appropriate payment structure at each phase, supported by a common measure set and shared data. These supports will enable practices to move toward population-based management and the ability to manage care and costs within eventual prospective payment. Phase 1: Coordination (Years 1-2 of SIM for most practices)
How payers would be asked to support this phase: o For SIM cohort participants, provide a care coordination payment at a level appropriate to the risk profile of the patient population. SIM funding will support additional practicelevel infrastructure to leverage payer investments. o Create shared savings opportunity as appropriate. o Use the SIM minimum dataset to assess contracted practices’ performance. o Provide regular quality and cost reports, aggregated with those from other payers, to practices. Colorado SIM
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Phase 2 – Co-location (Years 2-3 of SIM)
How payers would be asked to support this phase: o For SIM cohort participants, provide a care coordination payment at a level appropriate to the risk profile of the patient population. SIM funding will support additional practicelevel infrastructure to leverage your investment. o Create shared savings opportunity as appropriate. o Use the SIM minimum dataset to assess contracted practices’ performance. o Provide regular quality and cost reports, aggregated with those from other payers, to practices.
Phase 3 – Integration (Year 4 of SIM and beyond)
How payers would be asked to support this phase: o For SIM cohort participants capable of assuming risk: annual prospective payment including downside risk. o For SIM cohort participants not ready for prospective payment: enhanced PMPM plus shared savings opportunity. o Use the SIM minimum dataset to assess contracted practices’ performance. o Provide regular quality and cost reports, aggregated with those from other payers, to practices.
Notes on Phases 1-3:
This approach will apply explicitly to SIM cohort participants. However, payers have indicated that as they work to leverage complementary investments, they will also transition payments for practices within their networks that may not be active SIM cohort participants.
Phase 2 differs from Phase 1 in the clinical model being deployed, but financial arrangement remains the same. Colorado SIM
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Scope of Impact We anticipate that 37.05% of Colorado’s non-Medicare revenue will be part of our payment model. More significantly, we anticipate that this shift will impact a substantial portion of the market that is currently excluded from the calculation as Colorado alters the market standard for payers and providers.
We expect the largest healthcare savings will be obtained from the program’s impact on members with co-morbid chronic medical and behavioral conditions while the smallest impact will be with members with neither condition. The membership populations underlying our PMPM claim cost development represent a subset of the Colorado state totals for each eligibility types, representing 100% of the estimated Colorado insured population in 2012. The program will increase the utilization of primary and behavioral healthcare services and improve clinical and financial outcomes for the insured members accessing these services. It is also expected to reduce hospital costs and increase patient adherence to treatment for their medical and behavioral conditions. These savings were developed based on other program results, including the IMPACT, Pathways, Missouri Medicaid CMHC Health Homes, and MDDP programs. Below are the savings expected to be produced under our proposal for Medicare and Medicaid: Medicare savings during 3-year test period = $43.644 million Medicaid savings during 3-year test period = $18.655 million Colorado SIM
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Total Medicare and Medicaid combined = $62.299 million Based on the analysis by our actuarial firm, Milliman, the following are the estimated savings to Medicare, Medicaid and CHIP:
Medicare savings during 3-year test period = $43.644 million
Medicaid/CHIP savings during 3-year test period = $18.655 million
Total Medicare and Medicaid combined = $62.299 million during 3-year test period.
The projected savings in year 4 (after the test period) are $31.8 million for Medicare and $12.3 million for Medicaid/CHIP, for a total of $44.1 million in year 4.
The expected number of Colorado beneficiaries, statewide, that will be a part of the Colorado State Innovation Model (SIM), and their projected pre-program costs, post-program costs and expected program savings per member per month (PMPM) are shown in the following table by Test Year. The savings vary by Test Year due to population mix changes during the years. The PMPM savings times the number of participating beneficiaries, summed across all months of each Test Year equals the total projected savings of the Colorado SIM.
Following are the projected beneficiary counts, per capita costs and per capita savings per beneficiary (member) per month (PMPM) for the Medicare and Medicaid populations.
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We estimate the number of providers participating in our model to be 1,600 based on calculations from the Colorado Health Institute. These include FQHCs and CHCs, private practice physicians, and health system operated physician practices. These providers will be engaged in the following components of our SIM initiative, including:
Practice transformation,
Data quality and technical assistance,
Providers reporting into the data hub, and
Telehealth activities. In some cases, providers will be receiving multiple services described above whereas in
other cases (e.g. telehealth), these will be unique providers. For some components of SIM (e.g. payment reform), we are not currently able to provide the number of unique providers to be engaged. 4. Leveraging Regulatory Authority: Colorado supports a policy and regulatory framework that buttresses the integration of comprehensive primary care and behavioral health services and strengthens public health, smoothing the way for innovation and for reaching our SIM goal of improved population health. The four core areas of “The State of Health,” Colorado’s health care agenda, illustrate this commitment: Promoting Prevention and Wellness: Innovating how we deliver health care in Colorado presents an opportunity for LPHAs and other community-based organizations to provide population-based services with the long-term potential for reimbursement. CDPHE is analyzing its statutory Colorado SIM 25 of 68
authority to act as a pass-through or aggregator organization for reimbursements that are aligned with our payment reform models to support community-based local public health efforts. Improving mental health and reducing substance use disorder – including tobacco, alcohol, marijuana, prescription drugs, and illicit substances – is a top priority. Colorado will work to eliminate limits on the ability of local jurisdictions to regulate tobacco sales and prices. We will build on recent successes with our Colorado Plan to Reduce Prescription Drug Abuse and a regulatory structure for legalized adult-use marijuana that focuses investments in treatment, enforcement, education and research. We are developing a State Plan Amendment (SPA) to expand the role of public health in the lives of over one million Medicaid clients. In addition, we have launched two pilots to integrate core public health functions into our Regional Care Collaborative Organizations (RCCOs). LPHAs and other community partners are providing enrollment support, referrals to clinical and community services, and chronic disease management. Expanding Coverage, Access and Capacity: Our state insurance marketplace and Medicaid expansion jointly expanded coverage to 305,741 Coloradans during 2014 open enrollment. A number of efforts are underway to ensure that all Coloradans, including the newly insured, have access to affordable, quality coverage. Colorado has a number of existing efforts to assess and build an adequate healthcare workforce statewide. Although the overall size of the workforce is appropriate by many measures, rural and frontier regions face ongoing shortages of both primary care and behavioral health providers. 54 of Colorado’s 64 counties qualify as primary care Health Professional Shortage Areas and 50 qualify as Mental Health Professional Shortage Areas. As the ranks of certain health professionals grow in Colorado - including nurses and behavioral health professionals - we are working to ensure these professionals and others choose to Colorado SIM
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work with the state’s underserved populations. With a history of engaging in innovation both inside and outside of the formal health care sector, there is a great deal of expertise, energy and support available to implement new ideas. A sample of our initiatives includes: ● Building Better Data: A multi-agency interdisciplinary workgroup is working to build a statebased data hub for health professional information, using licensure, claims, and other data sources to supplement national information provided through the NPI. This information will provide additional insights on access to care at the community and state levels. ● Promoting the Pipeline: Colorado is continually assessing workforce concerns and developing projects to enhance the provider pipeline. More than 50 workforce pipeline initiatives were underway as of 2010, with programmatic focuses ranging from undergraduates to gradeschoolers.86 For example, the Colorado Area Health Education Center (AHEC) offers a statewide undergraduate summer program designed to introduce students to health profession careers as well as health career exploration programs for kindergarten through eighth-graders. Additional work focuses on consultation, such as telemedicine and health extension services. ● Partnering with Education: Colorado has a robust academic training environment, with two medical schools, a school of public health, two physician assistant programs, seven doctoral psychology programs, four schools offering Master of Social Work degrees, and numerous additional programs in nursing and other professions that add to the capacity of the primary care team across the state. Many schools have already developed special training programs or initiatives to support team-based primary care, behavioral health integration, and interdisciplinary training of health professionals. For example, CUSOM uses a psychologist to teach third-year medical students about behavioral health, and requires all family medicine residencies to have a behavioral health professional on staff; Rocky Vista University College of
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Osteopathic Medicine is graduating over 100 Doctors of Osteopathy each year, over half of whom practice in primary care and have been trained with the principles of whole person care. ● Education’s Commitment to Rural Health: CUSOM established a “rural track” in 2005 to increase the number of physicians practicing in rural Colorado. When Rocky Vista began recruiting students in 2008, one of its first “honors tracks” was in Rural and Wilderness Medicine. Beth-El College of Nursing & Health Sciences in Colorado Springs is working with community colleges to encourage non-traditional educational tracks in order to increase the number of trained, on-the-ground nurses who already call rural Colorado home. ● Supporting Rural Workforce: Colorado is providing incentives for building our health workforce in underserved areas. The state legislature established the Colorado Health Service Corps in 2010 to provide new incentives for health care professionals to practice in underserved rural and urban communities. The program, which provides financial incentives to primary care, behavioral health, and dental professionals, is now recognized nationally for its success in longterm placement of professionals in rural areas. In 2013 and 2014, the legislature increased funding for the Commission on Family Medicine to support residencies in rural and underserved areas of the State and included funding to study Graduate Medical Education programs in Colorado. A shortage of rural residencies has been identified as a key bottleneck in the training of rural physicians by a joint educator-employer taskforce. ● Advancing Telehealth Technology: CUSOM and HCPF are both working to develop alternatives to on-the-ground specialists across the state using extensive audio and video links. Using the model created by Project ECHO at the University of New Mexico, researchers are developing a long distance training and consultation program that will allow specialists in the urban areas of the state to assist patients and practitioners in rural parts of the state without the need for extensive travel or expense. Colorado SIM
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● Enhancing Care Extenders & Lay Providers: A multi-sector partnership with representatives of CDPHE is working to develop standards for patient navigators and community health workers in order to provide more consistency for educators and employers around these crucial lay providers. Other lay professions, such as peer support specialists, are also seeking credentials in order to achieve enhanced credibility. We have a number of initiatives under development or that have been identified for future work to advance health workforce priorities specifically related to SIM, including: ● Conducting a comprehensive review of current Colorado health professional practice acts, statutes regarding provider credentialing and empanelment and related issues. This will help clarify the perceived and real barriers to collaboration among professions and increases in administrative cost. As part of this effort, a Governor-appointed task force is in the final stages of an analysis of requirements for advance practice nurses to obtain prescriptive authority. It is likely they will recommend a statutory change to reduce barriers to entry for this authority. ● Gathering data on the readiness level of Colorado’s practicing behavioral health workforce to be trained to work in an integrated primary care setting in order to inform the scope and level of training efforts undertaken across the state, and help to target efforts. ● Developing a research-based assessment of the behavioral health workforce based on appropriate panel size-to-provider models. Models such as these will help to advance Colorado’s workforce planning, including licensure, scope of practice and efficiently utilizing higher-paid behavioral health staff based on practice populations. ● Assessing the workforce needed for both clinical needs and non-clinical needs, such as IT, administration and billing, discharge planning and health navigator services that may be needed to support the system.
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● Creating learning opportunities for both primary care and behavioral health providers to learn how to best work with one another in both settings. Integrating providers requires addressing cultural elements; as such, we will offer opportunities for providers for team-based training, both in educational and “real world” settings. ● Colorado is one of seven states selected by the National Governors Association to implement a health workforce development plan that will create a centralize data and analytics hub, use data to drive statewide workforce planning that is responsive to local needs and build on Colorado’s nationally recognized loan repayment program to expand recruiting and retraining efforts. The Governor’s Office will work with the Colorado Department of Higher Education, the Community College System, and key health professions’ educators to ensure that team- based, integrated care delivery is a training priority. Colorado is also committed to developing policy and regulatory supports for all providers who can help leverage our primary care workforce. A Governor-appointed, inter-professional task force is currently examining whether existing requirements for advance practice nurses’ prescriptive authority are overly burdensome. Colorado is developing standard, consensus-based criteria for community health workers and patient navigators that will support both professionals and training programs. A health cost study conducted in spring 2014 will inform the work of the legislatively created Colorado Commission on Affordable Health Care, a bipartisan initiative to help reduce health care costs while improving quality and access. Improving Health System Integration and Quality: We have streamlined or eliminated many regulations affecting behavioral health services. We will pursue additional contracting, regulatory or legislative changes as they are identified. Colorado Medicaid will recognize CMHCs and other providers delivering qualified primary care services as Patient-Centered Medical Homes. Colorado SIM
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Colorado will work with stakeholders to develop and apply for an SPA to create Section 2703 health homes and will incentivize contractual and financial alignment between Colorado’s RCCOs and BHOs. Colorado’s Division of Insurance has regulatory authority over Qualified Health Plans and works with our marketplace to ensure regulatory functions are non-duplicative. As a result, reforms and innovations reach all of our individual and small group markets. We acknowledge that some new care delivery and payment models – particularly those involving risk-sharing at the provider or community level – pose a challenge to traditional insurance regulatory models. We commit to evaluating regulatory alternatives that enable innovation while ensuring consumer protection. From a regulatory perspective, our mission is to ensure consumers are shielded from the potential catastrophes of market failure, over-extended risk, and insufficient pooling. However, the high barriers to entering the market as an insurance carrier (e.g., cash reserves, and financial and market regulatory requirements) may inhibit innovation. Colorado has limited experience in the regulation of non-traditional entities and combinations (e.g. limited service limited provider networks) and does not have an integrated and fully developed plan to regulate the emerging models and entities. But the Division of Insurance will facilitate conversations with stakeholders to identify solutions balancing our consumer protection needs with health service payment reform innovation. Enhancing Value and Strengthening Sustainability: Colorado will build on our high rates of EHR and HIE adoption to expand the role of HIT across three key domains that support integrated care through better infrastructure and analytic capacity: state IT systems, clinical and claims systems, and patient engagement tools. The following are completed efforts. (See Section 5: HIT for efforts that are underway or planned.) • State level, standards-based interoperability requirements. Colorado SIM
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• State-driven support and funding for HIT and HIE adoption, including appropriate exchange of behavioral health information to improve care. • Leveraging HIT infrastructure for uses within and beyond the health system, including Colorado’s state marketplace, eligibility services, provider directories, prescription drug monitoring, health condition registries, and other social services and public health programs. In 2011, Colorado’s Health Insurance Exchange, Connect for Health Colorado (C4HC) was the first in the nation to be established through bipartisan state legislation (Senate Bill 11-200). C4HC’s enabling legislation created a very clear division of labor between C4HC, which is primarily identified as a distribution channel for insurance products, and the Division of Insurance, which retains all authority over regulating the insurance industry. C4HC is expressly prohibited from engaging in acts that could be considered “active purchasing,” and it is prohibited from excluding any carrier who is otherwise eligible to conduct business in Colorado. Furthermore, C4HC was created as an independent nonprofit organization that reports to a Board of Directors and a Legislative Implementation Review Committee, but otherwise is not managed by state government. Although these may be viewed as limitations in engaging C4HC in Colorado’s SIM model, C4HC is a crucial partner in connecting consumers to coverage and will, for many consumers, be their first touchpoint for the healthcare system. In its first ten months of operation, C4HC has enrolled 142,747 Coloradans into private coverage, representing nearly 20 percent of the state’s uninsured population. Prior to the coming open enrollment period, C4HC and Colorado Medicaid will debut a new shared eligibility system that will simplify coverage and tax credit determinations for thousands of Coloradans. As its consumer education and engagement tools evolve, C4HC will have the opportunity to Colorado SIM
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educate consumers on varying delivery models, becoming a selling point for unique products attempting to differentiate themselves in an increasingly competitive market. This makes them a key partner for expanding roles in consumer and patient engagement, which will be a critical component of SIM’s success. 5. HIT: Colorado, already a leader in heath IT innovation, plans to expand our infrastructure to support practice transformation, improve population health, develop shared care planning resources, expand telehealth and coordinate public health services. We will build on existing work to realize the creation of a fully integrated electronic health care system with statewide reach, a key component of reaching our SIM goal. Colorado received federal, state and community funding to build and strengthen local HIT infrastructure and test innovations. We won a CPCi grant to foster collaboration between public and private payers and successfully implemented our health insurance exchange. Our innovation plan will extend these investments to the majority of Coloradans. Through our HIT plan: • We will provide technical assistance at the community and practice level to improve quality of data capture and extraction. • The funding request includes amalgamate clinical quality and cost data into a centralized integrated platform that will provide clear and meaningful performance measures, communicate performance to stakeholders, and provide actionable detail. Data will come from a number of clinical sources, core HIE patient and provider data, and the statewide APCD as well as other claims and non-claims datasets. The HIEs provide a hybrid model with connections to physicians, hospitals, clinics, public health, long-term care, laboratories, health plans and patients. The APCD is a secure database that will include claims data from commercial health plans as well as Medicare and Medicaid. Colorado will evaluate and track both provider and state level Colorado SIM
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performance as well as create dashboards to share data across providers. See Table 6 for cost detail. However, We do not yet know if we will leverage Colorado Associated Community Health Information Enterprise’s (CACHIE) platform or create a new layer of infrastructure. However, we will explore this issue in greater detail and make a decision early in 2015. • We will connect the clinical data hub to the CPCi administrative data hub for aggregated clinical and cost data information. • We will support telehealth infrastructure and delivery expansion strategies, including a Telehealth Resource Center (TRC). A centralized data repository will aggregate clinical information (building upon the CPCi solution), provide consolidated reporting for providers to public and commercial payers and give population and practice benchmarking information to providers and payers. The Governor’s Office will continue to work with existing data governing authorities on safe and appropriate data sharing practices by supporting policies, operational practices, technical safe guards, and educational resources. The hub will create a platform for shared care planning resources and a non-condition specific repository for state population health evaluation. It will leverage the existing Master Patient Index (MPI), provider directories and other tools. Building on clinical information, the phased approach will link to administrative claims information via the Colorado All-Payer Claims Database (APCD) and other sources as needed, providing a central aggregated clinical and cost data hub. The following work will support our plan: Governance: Overseen by the Governor’s Office, the state SIM office will provide planning and oversight and will manage HIT contracts for tasks, such as the provision of technical assistance to practices, done at the regional level. The state SIM office also will manage the contract for a centralized data hub with the State Designated Entity (SDE), Colorado Regional Health Information Organization (CORHIO). Colorado SIM
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As SDE, CORHIO coordinates with Colorado health entities to lead data sharing policies, provide technical assistance, promote HIE, and build electronic infrastructure allowing data exchange between different health systems. CORHIO works alongside the nonprofit Quality Health Network (QHN), the organization leading the HIE effort on Colorado’s western slope. Together, CORHIO and QHN have been responsible for facilitating the state-wide Colorado HIE Network. The SDE will support the SIM initiative in the following ways: Provide administration support for coordination and oversight of the SIM HIT proposed programs. Facilitate HIT architecture development supporting SIM clinical and cost data hub. Oversee data governance through statewide expert workgroups and committees. Create, distribute, and vendor selection for additional technology investments. Distribute funding to the HIT partners supporting Colorado’s SIM proposal.
Graphic 1. State SIM Office
SDE
CORHIO
QHN
Health Information Partners
APCD
CTN
Others as identified to support SIM HIT proposal
Colorado is in process of reforming the SDE structure to support a long-term, flexible governance model and execute on the grant deliverables and funding distribution with representation from key state agency and stakeholders. The transition from the current model to a bifurcated, independent SDE will expand scope beyond HIE to a broader HIT authority enabling flexibility for additional data sources and evolving technology while supporting statewide interoperability of Colorado SIM
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health information. The intent in creating an independent authority is to eliminate perceived conflicts of interest, increase public trust and accountability, and create core policies and technical standards for current and expanding exchange. The governance restructuring will proceed in phases and align with SIM timelines. The anticipated timeline for the bifurcation is February 2015. Graphic 2 2009 - 2014 HIT/HIE Governance, Policy, and Operations
HIT Advisory Committee and Executive Order designates CORHIO as State Designated Entity for HIE, CORHIO - Develop HIE policies, align HIE strategies, and facilitate statewide HIE implementation
2014 - 2015
2015
SDE for HIE and HIT, CORHIO dba CO eHealth Collaborative with supporting committees - Policy, transparency, and accountability CORHIO and QHN - HIE implementations, operations
CORHIO and QHN - HIE implementations, operations
New SDE organization and committee structure - Oversight, Policy, Strategic planning, accountability, transparency, standards CORHIO, QHN, or other organizations - HIE implementations, operations - HIT implementations, operations
Below are some of the challenges we anticipate:
The current State HIE, CORHIO, has limited ability to provide a robust, central data repository to support a centralized hub. Any current functionality would need to be extended or additional capabilities procured to support a central, state clinical data hub. CORHIO has identified limitations with its current vendor and is investigating extending services with an integration engine capability, such as Mirth or Rhapsody. This extended services purchase and implementation timeline may be a risk to the SIM HIT timeline and measures.
QHN has recently replaced its HIE platform with a more flexible open source solution. QHN current services Western Slope providers with services including query based longitudinal health Colorado SIM
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records, primary care registries, and risk stratification analytics. The new platform and connections to Western Slope providers is a benefit, but the challenge is to connect this “node” to the larger, intended statewide infrastructure.
CACHIE serves as the HIT provider for 13 of the 18 Federally Qualified Health Centers in Colorado. CACHIE currently supports the FQHC’s EHRs as well as data extraction for reporting and benchmarking. The organization is planning a roll out of a central data warehouse providing population health analytics for their providers with similar technology proposed in Colorado’s SIM HIT proposal. Since CACHIE is a subsidiary of Colorado Community Managed Care Network (CCMNC), CCMCN’s Board of Directors must approve expanding the use of its invested technology to support the wider, statewide use.
Colorado has secured funding from the State General Fund to support HIE infrastructure expansion. This serves as the 10 percent match for HITECH 90-10 Federal Financial Participation. The first year of 90-10 FFP is currently being reviewed by CMS. Long-term plans include investment in clinical quality measure reporting tools to support Meaningful Use Clinical Quality measure extraction, calculation, and reporting with guidance from the Technical Authority for Unified Clinical Quality Improvement Framework (TACOMA) and tools, such as popHealth, Cypress, and Bonnie. The challenge with implementing this central reporting capability is the commercial payer contribution to supplement Medicaid’s Fair Share of the cost allocation. CPC and SIM assist with payer participation, but ongoing contributions from payers will be a challenge until value and return on investment is realized.
One main program for Colorado’s 90-10 FFP program -- HIE Maximization -- is leveraging the successful CO-REC program to create an onboarding to the HIE assistance program. The “onboarding” program will increase the number of ambulatory providers using HIE services.
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The onboarding program to SIM must be carefully coordinated to reduce disruptions to the practices while still meeting program milestones and targets.
Colorado’s SIM proposal will leverage the current HIE connections with an enhanced data set for the targeted practices participating in SIM. This includes reviewing current HIE participants, readiness for integrated care, and the size and capability of practice IT support systems. Wide scale practice participation in the proposed SIM HIT solution will be part of a long-term quality plan that will take significant cross payer and stakeholder planning. The SIM HIT proposal will be a “capstone” and experiential learning for a successful statewide quality and cost repository and reporting solution.
Anticipating these challenges, we have the following mitigation strategies in place:
By bifurcating the SDE to an independent structure with appropriate authority, an objective procurement process will solicit the technical vendor, solution, and owner of the SIM HIT proposed technology. The SDE will also support: o An articulated plan and investment to connect all networks within Colorado’s health information infrastructure. o An additional investment in central data repository functionality by extending one of the current platforms and technical capabilities. o Integration with the CPC cross-payer, central claims of RISE health, aggregating selfinsured payer feeds, and Colorado’s All Payers Claims Database (APCD) aggregating Colorado’s insured data. o New technical solutions for cross-payer benchmark clinical and cost quality reporting.
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Ideally, the state’s shared HIE services will include the central data repository required to support the long-term solution and will support a “network of networks” that leverages Western Slope connections and platform, CACHIE’s connections to FQHCs and data warehouse, and CORHIO’s Front Range connections and platform.
If the health information entities around Colorado align and partner to propose a solution, then the objective procurement process will support funding and accountability for all partners. The partners have been collaborative with the proposal details and definitions work to date.
The objective procurement process will also assist in further defining the shared services needed for long-term, statewide interoperability as well as the selection of a long-term organizational “home” for the proposed central clinical hub.
Timeline: Governance related tasks Task Timeline Status Bifurcation of SDE from July 2014 – Sept 2014 In process CORHIO to transitional phase of a separate Doing Business As (DBA) entity using the CORHIO Financial Committee for independent financial oversight Interim SDE stage Oct 2014 – Feb 2015 Planning
New SDE Advisory group planning activities: Establish and maintain communication plan Establish governance structure and align with SIM advisory group structure Identify and implement supporting tasks to establish legal structure Colorado SIM
Oct 2014 – Feb 2015
Planning
Dependency Stakeholder input and decisions by Health Cabinet
Set up DBA and financial structure Communication Plan Oversight and administration ID SDE Advisory Group State recommended governance structure
Oct 2014 Oct 2014 Oct 2014 – Dec 2014
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Complete new Executive Order for HIT and HIE Designated Entity Align HIT SDE governance structure (decision board, workgroups, and advisory committees) with SIM governance structure Align HIT SDE governance structure (decision board, workgroups, and advisory committees) with overall state governance structure
Task Convene SIM HIT workgroup convening to confirm technical architecture including but not limited to transport standards, platform requirements, identifier requirements Recommend data extraction methods, clinical measure reporting approach, requirements for clinical data hub Document public health IT architecture requirements and solution options Integrate with Quality Metrics workgroup to review clinical quality data set requirements to be considered and accounted for Provide recommended list of connected, practices that may be priority for SIM participation Align with other SIM current workstreams (system delivery/practice transformation, payment reform, consumer engagement) and planned workstreams (evaluation and workforce) SIM Health Transformation Working Summit to confirm roadmap and inter-workgroup dependent activities Colorado SIM
December 2014
Planning
Jan 2015 – March 2015
Planning
Jan 2015 – June 2015 and ongoing alignment
Planning
SIM related tasks Timeline Status Aug 2014 – Oct 2014 In process
Sept 2014 – Oct 2014
In process
Sept 2014
Completed
Sept 2014 – Oct 2014
In process
Oct 2014
In process
Oct 2014 – Nov 2014
Planned
November 20, 2014
Planning
Dependency
SIM workgroup roadmaps confirmed and documented
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Develop RFP for SIM HIT technical solution Solicit RFP proposals Evaluate RFP proposals Select SIM HIT organization and vendor selection leveraging current network Align with other Colorado SIM workstream activities
Dec 2014
Not started
Jan 2014 Feb 2014 Mar 2014
Not started Not started Not started
Jan – Mar 2015
Not started
Dependent upon notification of SIM Round 2 Test award
Phase 1 – HIT Technical Assistance: The practice transformation teams and health extension agents will provide technical assistance based on community and practice HIT assessments using a common Practice Transformation Tool targeting appropriate levels of assistance. Technical assistance will support improved quality of data, workflow assistance, and use of adopted HIT tools to promote quality care. Colorado’s SIM Practice Transformation effort will engage 400 practices, starting with practices that have already taken steps toward integration and taking steps to achieve a diverse group of practice types. Further, technical assistance will be targeted to Behavioral Health practices and non-Meaningful Use Incentive-eligible practices to leverage Colorado’s Medicaid expansion funding. The practices will be assessed and evaluated with the assistance of practice assessment tools monitoring practice assessment progress. By supporting effective use of HIT tools in the clinical workflow, practice transformation and technical assistance will have wide reaching impacts beyond SIM, including but not limited to attesting to Meaningful Use, connecting to the statewide HIE network, and improved data integration across public and private resources. This tool will provide a baseline assessment to create an itinerary for practice support. The HIT technical assistance will ensure that data is driving improved clinical outcomes. Technical assistance will be targeted to behavioral health practices and non-MU Incentive-eligible practices. By supporting effective use of HIT tools in the clinical workflow, we will make improvements beyond SIM, attesting to MU, connecting to the HIE network and improving data Colorado SIM
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integration across public and private resources.
Evaluate current tools: The SIM HIT workgroup will evaluate current tools in the state to determine if the tool can meet the needs for community and practice HIT assessments.
Other uses: This tool may also be used for SIM clinical practice transformation assessment. This tool may also assist with HIE Onboarding program.
Current option identified: A practice assessment tool was used to support Regional Extension Center programs facilitating 3,000 eligible professionals to adopt, implement, and upgrade an EHR and attest to Meaningful Use Stage 1. This tool is currently owned and developed by a CO-REC partner, Health Team Works.
Investment: SIM funding would extend this product or add additional licenses for use at more practices. If evaluation may determine the current product is not scalable, then a proprietary product may be procured and adminstered through SDE procurement process.
Sustainability: The current product is owned by a current health information entity, Health Team Works, which will remain the sole owner of the product which supports HTW’s operational structure. If a proprietary option is pursued, then the SDE would retain ownership for use by health partners. If used by HIE Onboarding program funded, the 10% State General Funds and 90% Federal match for HIE APD may support the initial investment and the HIEs would provide sustainability funds for the additional use of the Practice Assessment Tool. Phase 2 - Central clinical quality improvement and cost data hub: The Colorado SIM
HIT proposal will consolidate provider health information with the initial SIM simplified measure set scaling to comprehensive clinical quality data repository. Building on the Technical Assistance plan to improve data quality and extraction of information, a centralized data repository will aggregate clinical information, provide consolidated reporting for providers to public and Colorado SIM
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commercial payers, and present population and practice benchmarking information via user interfaces and reports for providers and payers. In addition, the centralized hub will create a noncondition specific repository for state public health population health evaluation and a platform for shared care planning resources. The central quality improvement data hub will leverage existing MPI, provider directories, and other tools across the state’s health information infrastructure. Additional expansion of health infrastructure through network interfaces, translation, and mapping tools will be assessed. Building on the clinical information, the phased approach will link to administrative claims information via the APCD providing a central aggregated clinical and cost data hub. Consolidate clinical quality data reporting to create a centralized hub with user interfaces, benchmarking, and dashboards allowing real-time monitoring of population metrics at the community, practice and patient level; Part 1: Data Extraction from practice EHRs
Evaluate current tools: The SIM HIT workgroup will identify current technology options at the HIEs and health partners.
Current option identified: Current tools in use at the HIEs and health partners include manual extraction and third party vendor deduplicating and parsing CCDs will not support quality measure data extraction. CACHIE has current connections with FQHCs in Colorado, and this function will be assessed for extendibility to the SIM practices.
Investment: If a proprietary technical solution will be procured to support data extraction from EHRs at medical settings, the current HIE infrastructure and core functions will be a key part of the architecture. This investment may also support consent management functionality and/or data normalization capability.
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Sustainability: The solution will be a primary function for data extraction. Funding sustainability may be supported through HIE product subscription fees and cross payer contribution. This investment may also be supported by private payers and specific state HIT projects that may leverage this in the future. Examples include Medicaid reporting, public health reporting, and human services interoperability. The additional uses cases must be developed to support these sustainability options. This data extraction from electronic systems will be an additional product or value add service for participants of the HIE or Colorado Health IT Ecosystem and pricing for this service may be part of a bundled solution package.
Other uses: The data extraction from practice electronic health records (EHRs) will also support other clinical quality measure efforts, including and not limited to Meaningful Use eCQMs, PQRS, CMS, and payer specific quality measures. This functionality will contribute to a long-term quality measure extraction, reporting, and evaluation strategy. This functionality could also assist with future attestation to future stages of Meaningful Use. Additionally, the data extraction methodology can be scaled for use by practices, hospitals, community mental health centers, and long-term care facilities by using industry standards and recommended implementation plans.This infrastructure supports activities at the federal and state level aligning quality measures and assessments. DHS CCAR and DaCODS reporting can also use this infrastructure to ease provider reporting for state and federal mental health and substance use assessments. This supports a longterm vision for DHS interoperability. Part 2: Clinical Quality Data Warehouse
Evaluate current tools: The clinical quality data hub or warehouse may leverage developing data warehouse capability currently maintained by CACHIE, the health IT
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service provider for 13 of the 18 FQs in Colorado. CACHIE is a subsidiary of CCMCN, a managed care network for FQHCs. If the current data warehouse at CACHIE will not support a wider use and participant pool beyond FQHCs, then a proprietary solution may be procured to work in conjunction with CACHIe.
Investment: If expansion of CACHIE’s data warehouse infrastructure is not possible, proprietary solutions will be investigated to build onto the HIE infrastructure leveraging existing participants’, interfaces, and core competencies, such as MPI and Provider Directory.
Sustainability: The central data warehouse may be supported through HIE/HIT product subscription fees and cross payer contribution as an additional value added product. This investment may also be supported by specific state HIT projects that may leverage this in the future. Examples include Medicaid reporting, public health reporting, and human services interoperability. The additional uses cases must be developed to support these sustainability options.
Other uses: The central quality hub will also benefit payers by providing a central reporting mechanism for quality metrics. The eligibility file may provide additional patient identification and matching to support the required scrubbing and data normalization process. If the payers are participating with the central clinical hub, then the files may also be leveraged for use of HIE products such as alerting/notification of ER visits or hospital admissions.
Part 3 - User Interfaces and Benchmarking Reports
Evaluate Current Tools: The SIM HIT workgroup will evaluate current functionality, such as the CPCi solution, but a proprietary solution providing user interface providing benchmarking reporting may be pursued.
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Sustainability: The user interface for benchmarking reports may be supported through HIE/HIT product subscription fees and cross payer contribution as an additional value added product. This investment may also be supported by cross payer support and/or specific state HIT projects that may leverage this in the future. Examples include population health, Medicaid RCCOs, and public health use. The additional uses cases must be developed to support these sustainability options. Long-term, these can also be used for patient reporting quality data that may be collected and shared via planned consumer engagement technology investment.
Part 4 - Clinical and Claims Integration
Evaluate Current Tools: To support clinical and cost data integration phase with the central hub and All Payers Claims Database (APCD), Colorado looks to federal guidance on the data integration standards and implementation guidelines to merge the claims and clinical quality data.
Investment: The data normalization and integration functionality will be procured.
Sustainability: The long-term sustainability of the integrated data solution will be realized through the user interfaces and benchmarking reports demonstrating quality improvement and cost savings. This could be support by cross-payer participation
Phase 3 Telehealth Infrastructure and Delivery Expansion: The Colorado Telehealth Network (CTN) will leverage the Healthcare Connect Fund to reach underserved urban and rural health care facilities. The state will leverage CTN’s 195-site network to increase and expedite access to care across physical and mental health providers. The SIM HIT plan supports expansion for an additional 300 telehealth sites for rural and underserved communities. These sites are separate from the 400 practices targeted for behavioral health integration, although there may be some overlap. A telehealth planning grant will develop an implementation and evaluation plan aimed at incorporating Colorado SIM
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telehealth tools into medical settings. CTN is currently funded by FCC grants and is reliant upon additional grant funding for operations. SIM funding will support Telehealth Broadband expansion that current grant and operational funds cannot support. The telehealth planning grant would be a one time expense, and the telehealth technology tool procurement will be supported by provider subscription fees and potential public and provide investment. Use cases and return on investment analysis will be developed as part of the telehealth implementation plan and recommendation. Telehealth resource centers will be initiated through potential HRSA funding, supplemented by SIM funding, and sustained through an integrated practice transformation services collaborative sustainability plan. Finally, the SDE will work through Colorado’s two HIEs, Quality Health Network (QHN) and Colorado Regional Health Information Organization (CORHIO) and other HIT partners. To address conflicts over data ownership, the SDE’s HIE Policy Committee has a stakeholder process, as well as a scalable, flexible policy model. We will incorporate new data owners into data governance policies and use agreements. Policy: Colorado has worked to align state health policy, including creation of the APCD, which is aggregating claims between 2009 and 2012 by more than three million patients. A policy is in process to include payers in the governance and sustainability of HIE. The SIM office will advance new policies to disseminate up-to-date federal IT standards, evaluate and promote the use of telehealth, share information, and support the central data hub. In the planning stage are policies removing real and perceived barriers to exchange through clear privacy and security policies; requiring HIT tools to adhere to federally endorsed standards; and ending policies that inhibit telehealth. Colorado aligned the sharing of mental health data with HIPAA in 2011, enabling organizations to share such data through the state’s HIE networks, with the exclusion of 42CFR Part 2 data. Colorado SIM
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HIT Infrastructure: Colorado’s two HIEs have developed products for hospitals and ambulatory providers. They supply reporting to public health agencies and allow providers to access clinical data, alerts, direct secure messaging, longitudinal patient histories and transitions of care solutions. TABLE 2. Current Rate of HIT Adoption. Measure Providers meeting MU in EHR incentive programs
Percentage 92% hospitals, 48.3% professionals, 72% registered Unique patients in the HIE 72.5% Providers using the HIE 28.4% Users of HIE 58.4% Long-term post-acute care facilities connected to HIE 50% Acute care hospitals with over 100 beds connected to HIE 93% Colorado will implement its technology plan in phases, building first on the work of advanced clinical practices to establish a data quality, sharing and reporting infrastructure. We will improve data quality at the point of care with the SIM measure set, scaling to a comprehensive clinical data set. Through the creation of user interface and reporting tools, public health entities will be able to uncover issues at a state level. Colorado’s SIM technology plan will leverage planned HIT architecture expansion for uses within and beyond the health care system, connecting health data across the Medicaid enterprise and state systems. HCPF plans to leverage 90-10 Federal Financial Participation (FFP) funding to re-use data from the HIE network and services with the new MMIS system (Colorado InterChange). Additional activities connecting the network with eligibility and enrollment systems (CBMS/PEAK) and human service systems are being discussed and planned. Technical Assistance: The practice transformation teams and health extension agents will provide technical assistance to ensure that data is driving improved clinical outcomes. Technical Colorado SIM
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assistance will be targeted to behavioral health practices and non-MU Incentive-eligible practices to leverage Colorado’s Medicaid expansion funding. By supporting effective use of HIT tools in the clinical workflow, we will make improvements beyond SIM, attesting to MU, connecting to the HIE network and improving data integration across public and private resources. Telehealth Infrastructure and Delivery Expansion: The Colorado Telehealth Network (CTN) will leverage the Healthcare Connect Fund to reach underserved urban and rural health care facilities. The state will leverage CTN’s 195-site network to increase and expedite access to care across physical and mental health providers. The SIM HIT plan supports expansion for an additional 300 telehealth sites for rural and underserved communities. These sites are separate from the 400 practices targeted for behavioral health integration, although there may be some overlap. A telehealth planning grant will develop an implementation and evaluation plan aimed at incorporating telehealth tools into medical settings. 6.Stakeholder Engagement: Colorado’s plan to engage a wide array of SIM stakeholders builds on a rich history of collaboration in our state. Under the leadership of Governor John Hickenlooper, we are framing our SIM outreach strategy to maximize the involvement, insight and expertise of statewide partners to reach our health care transformation goal. Stakeholder engagement will be the cornerstone of our success, and our outreach efforts will ensure participation of a wide array of individuals and organizations. A detailed committee structure will serve as the foundation of our strategic engagement plan. SIM Oversight Board: This highly visible board will be comprised of Colorado’s health leaders and visionaries, who will heighten awareness and provide momentum around Colorado’s SIM initiative. The group will be further charged with ensuring that the linkage between primary care and population health is a primary focus of SIM implementation. It will monitor Colorado’s Colorado SIM 49 of 68
progress on all aspects of the model. Members will include representatives from behavioral health representatives, patients, payers, providers and technology experts. The board will meet regularly to provide direction to the SIM project director and staff, to ensure coordination among state agencies, and to keep the project on target to meet its milestones, which are detailed in the operational plan. A Large Advisory Committee will meet twice a year with a broad, diverse membership of more than 150 people from more than 90 organizations. It functions as a communications vehicle, engaging its members in ambassadorship and program knowledge and engendering a solid understanding of their roles and responsibilities as participants in the SIM. Representation in this committee includes patients, behavioral health providers, payers, advocates, foundations and many others. A Patient Committee will ensure that the voices of patients and consumers are not only heard but that the systems of care that SIM builds are focused on the needs of individuals. Patient-centered, integrated care must first and foremost serve the needs of patients. A key focus of the committee will be that systems – both financial and clinical – are designed in ways that allow for consumer engagement and full participation. A Provider Committee will examine various models of integration and determine how, when and why primary care practices can and will integrate care. A chief goal of the committee will be to ensure that the transformation expected at the practice level – from cultural changes, to HIT to financial changes – be well articulated and well supported. The committee will also examine how to scale best practices to all willing practices in Colorado. This committee will also work in partnership with the payer and population health committees to support critical linkages and collaborative efforts that will accelerate the Triple Aim. A Payer Committee will examine how payment changes can provide incentives for care Colorado SIM
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integration to achieve the Triple Aim. This committee will actively explore how the state will migrate from FFS models to shared savings and ultimately risk based models of integrated care. It will work closely with the provider committee to ensure that practices demonstrate appropriate readiness to assume non-FFS based models. A Population Health Committee will align SIM with the state’s overall health improvement plans and explore ways to leverage LPHAs to help achieve the SIM goals. The committee also will address how SIM can help specific populations, including American Indian tribes and the homeless. A cornerstone of the Colorado SIM is the critical linkages between primary care practices and community based population health services. This committee will focus on how to strengthen these linkages in communities throughout the state. Strategically, our stakeholder engagement will work on two levels – targeted when needed and more broadly expansive when appropriate. Actively involved stakeholders who have participated in various committees include companies representing the majority of Colorado’s insurance market, United Healthcare, Rocky Mountain Health Plans, Kaiser Permanente, CIGNA, Anthem and Aetna; representatives of major providers, including the Colorado Hospital Association, Denver Health, and Centura Health; the state’s insurance marketplace, Connect for Health Colorado; and foundations and nonprofits, including the Colorado Health Foundation, The Colorado Trust, the Caring for Colorado Foundation, and the Colorado Consumer Health Initiative. For a full listing of stakeholder organizations and other information disseminated through our project to date, please see www.coloradosim.org. Colorado’s SIM application benefits from a history of meaningful stakeholder involvement in health care transformation under the past three governors, including Governor John Hickenlooper. Former Governor Bill Owens, a Republican, helped to create the Blue Ribbon Colorado SIM
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Commission on Health Care Reform in 2006. His successor, former Governor Bill Ritter, a Democrat, embraced the commission and worked closely with its members. The group brought together health care consumers, providers, payers, and policymakers to recommend a comprehensive set of reforms, many of which have been enacted into law. Its focus on affordable care, improved access and better health outcomes served as an early precursor to the Triple Aim and the Affordable Care Act. 7.Quality Measure Alignment: Measuring and evaluating what is being done, to whom, how effectively, and at what cost, will be central to our plan to transform health care in Colorado. We have restricted our proposed candidate measures to those that are most aligned with where practices are and what payers have committed to in Colorado. Understanding the diversity of constituents who will provide and use the data, we have selected measures for their ability to serve multiple purposes. This will limit the reporting burden on frontline practices and maximize the impact. That said, Colorado remains open to further refinement of our proposed measures. Because Colorado’s clinical and population-level interventions intend to affect behavioral and physical health outcomes, measures need to include both health components. We started by listing the clinical quality measures currently being used in the field, then created a spreadsheet to reveal which measures would best show the impact of the SIM interventions on quality. From this group, we identified measures with multi-payer support. CPCi has provided a solid foundation on which to build clinical measures for SIM, which allows us to further leverage and expand our CPCi efforts and commitments. The majority of our clinical and quality measures start with the basic CPC measure set. However, Colorado SIM
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since our focus is around behavioral health and primary care, we have added three measures. TABLE 2. Proposed CPC+ Measures Basic CPC Conditions Hypertension* Obesity* Tobacco* Prevention*
Asthma* Diabetes*
Measure Blood pressure Weight assessment and management Screening and intervention Breast cancer screening, colorectal cancer screening, influenza immunization
Citations NQF 0018 NQF 0024 NQF 0028 NQF 0031, NQF 0034, NQF 0041 Identification and appropriate prescription NQF 0036 HbA1c, Blood Pressure, LDL- Cholesterol NQF 0059, NQF 0061, NQF 0064
Ischemic Vascular Disease* Complete lipid panel and control Screening for fall risk Safety * PHQ-9 for adolescents and adults, Depression* maternal depression screening GAD-7 Anxiety* Audit Substance Use* To be determined Child Development*
NQF 0075 NQF 0101 NQF 0418, NQF 1401 SHAPE SHAPE
* These conditions also affect children and can be addressed in pediatric care settings. While current CPCi measures primarily focus on adults, during the first year we will confirm which pediatric measures will be used for certain of these conditions. The 73 practices participating in the multi-payer CPC initiative in Colorado, along with the participating payers, have already initiated these measures. Our proposal leverages the multipayer buy-in to begin measuring the impact of behavioral health integration with three additional measures of behavioral health – depression, anxiety, and substance use. These behavioral health measures are included because of the prevalence of these conditions in primary care specifically and in Colorado generally. While plans have agreed to measures (see additional detail in Section 3 above), we have not yet established a multi-payer baseline. It is our intent to establish a baseline so we can measure improvement in quality targets over 4 years, while being mindful of practices’ ‘measure fatigue.’ Please see the revised detailed operational plan (updated 9/8/2014) for additional detail regarding Colorado SIM 53 of 68
accountability targets and quarterly milestones. Colorado will cooperate with other states and CMMI evaluators to optimize and potentially streamline measurement across the CMMI portfolio. Beginning in January 2015, a group of pediatric mental health leaders, health plans, HCPF and consumers will be convened to work on finalizing the pediatric mental health measures. SIM leadership, in partnership with stakeholders, will be responsible for finalizing the measure set. Alignment with Medicaid: A recently-launched interagency initiative, the Colorado Opportunity Project, is a partnership between CDPHE, Colorado Department of Education, HCPF and CDHS to align measures that target social emotional development in early childhood in order to alleviate poverty. Medicaid pays for annual developmental screens up to age 5, reimburses for annual depression screenings for individuals 11 and older, and reimburses for tobacco cessation programs. It also monitors performance on control of BP, HbA1c, and depression screening. The state is exploring how to feed this information to practices more quickly and more often. Reducing the reporting burden on practices is a major driving factor behind our proposed measurement plan. By focusing on a limited number of measures, we can provide support across programs and add value to clinicians. 8.Monitoring and Evaluation Plan:
Fragmentation in health care drives inefficiency, ineffectiveness, and substantial waste. This fragmentation is particularly evident in the separation of behavioral health (including mental health, substance use, and health behaviors) from physical health. Co-morbid medical and behavioral health issues drive high costs: in a commercial population, patients with a chronic medical condition and a behavioral health diagnosis (either mental health or substance abuse) cost on average $1057 per Colorado SIM
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member per month (PMPM), compared to $340 PMPM for patients without a behavioral health diagnosis. This cost disparity holds for Medicare ($1450 vs. $582 PMPM) and Medicaid ($1301 vs. $382 PMPM) beneficiaries (Milliman, 2014). These high costs are not associated with improved outcomes: a significant body of evidence indicates that co-morbid behavioral health and chronic medical conditions are associated with higher service utilization and poorer outcomes than for patients with a chronic medical condition alone. Integrating behavioral health into the overall fabric of healthcare can combat fragmentation and address these burdensome and costly co-morbidities. The idea of integration is really that of good health care, which leads to the Triple Aim (Berwick, Nolan & Whittington, 2008) through better care with a team-based, collaborative approach; better health by improving the treatment and management of both chronic medical and behavioral health conditions; and lower per capita costs through decreasing unnecessary service utilization of high-cost specialty care and emergency department services. Integrating behavioral health care with primary care has the potential to save the health care system between $26 and $48 billion annually; systematic reviews and meta-analyses have shown that it leads to improved outcomes, particularly for patients with depression in primary care (Kwan et al, 2013). Below we detail some of our prospective assumptions as well as the retrospective research and evidence we relied on to develop our proposed interventions. Colorado has used retrospective studies and pilot programs as well as prospective calculations to shape the types of interventions we are proposing and our projections regarding savings or return on investment. We anticipate that through the SIM performance period, we will be able to demonstrate savings consistent with the estimates and evidence below through our evaluation and measurement efforts. Prospective Estimates: Mr. Steve Melek, a consulting actuary for Milliman, has helped us better understand the cost Colorado SIM
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savings potential for integrating care. In the table below, Mr. Melek highlights the impact of comorbid chronic medical and behavioral conditions in insured populations.
Retrospective Studies & Evidence: There is a large and growing body of evidence to support our proposed approach. Our actuarial projections of reductions in ER and inpatient facility costs, and increases in primary care, behavioral services and prescription drug treatment adherence are based on savings achieved in other programs as described in the medical literature, including the IMPACT, Pathways, Missouri Medicaid CMHC health homes, and MDDP programs. Specific examples are listed below:
Several studies of the IMPACT program have shown positive effects on both clinical outcomes and costs. Patients with co-morbid diabetes and depression receiving care through IMPACT experienced 115 more depression-free days over 24 months when compared to patients in the usual care group. While total outpatient costs were $25 higher, the analysis also showed a net benefit of $1,129 (Katon et al. 2006).
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Another study found that patients receiving care through IMPACT incurred lower mean total health care costs compared to those receiving usual care ($29,422 and $32,785, respectively) over four years (Unutzer et al. 2008).
Intermountain Healthcare’s Mental Health Integration Program integrates behavioral health professionals in the primary care setting while also folding in community resources, care management, and patient/family engagement. In the first 12 months after the initial diagnosis of depression, patients enrolled in the program were 54 percent less likely to have an ER visit, and cost the health plan $667 less than patients in the control group; and one-half of the enrollees were in remission as measured by their PHQ-9 depression scores (Reiss-Brennan et al., 2010).
Group Health Cooperative of Puget Sound’s Pathways model of coordinating care for patients with diabetes and comorbid major depression reduced five-year mean total medical costs by approximately $3,900 compared to usual primary care.9-11
In the Advancing Care Together project (ACT) in Colorado, rather than simply provide financial support to practices to better integrate behavioral health and primary care, ACT observed what happens when practices in communities put forward their best idea to address integration without someone telling them how it must be done. Across participating practices, ACT identified three main problems faced around integration. Practices had to: 1) make changes in their organization and interpersonal relationships; 2) address challenges from creating new workflows for behavioral health and how to access these services; and 3) utilize data to improve patient health and practice process. Practices used various strategies to address these problems, all of which were developed by the practices themselves (Davis et al., 2013). The cost savings from these data are forthcoming, but at initial glance appear
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promising. Combining community-generated integration strategies with potential funding will likely have an even greater effect.
One Colorado carrier, which invests heavily in practice transformation support, HIT and non-volume payments for integrated care for a substantial portion of its membership, reported that the total cost of care for patients attributed to advanced primary care practices is 5.7% lower (on an HCC risk adjusted basis) over the past 15 months. "Top tier" exemplar providers are performing even better, producing downward trends in inpatient admissions and re-admissions, emergency department utilization and other key performance indicators.
The state’s Medicaid ACC program has also demonstrated cost savings. In the FY 20122013 year, the program experienced a $44 million gross savings or cost avoidance and a $6 million net reduction in the total cost of care. In addition, there was: o 15-20% reduction for hospital readmissions and 25% reduction in high cost imaging services relative to a comparison population prior to program implementation; o 22% reduction in hospital admissions among ACC members with COPD who have been enrolled in the program six months or more, compared to those not enrolled; o Lower rates of exacerbated chronic health conditions such as hypertension (5%) and diabetes (9%) relative to clients not enrolled in the ACC Program; and, o Emergency room utilization by ACC enrollees increased 0.9 percentage points less than utilization by those not enrolled in the ACC program, or an increase of (1.9%) for ACC enrollees compared to an increase of (2.8%) for those not enrolled.
There is also evidence to support our proposed Health Extension System and Population Health Transformation Collaboratives. For decades, we recognized that “all health is local”: that communities often have solutions to problems that incorporate their unique attributes and assets. Colorado SIM
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When we think about integrating care, we often assume care is only delivered at bricks-and-mortar primary care practices. In fact, integration can be organized around a primary care practice but occur in a distributed way throughout the community. The community can facilitate and support functions of the primary care practice during the 5000+ waking hours12 that patients live with their chronic conditions outside of their clinic visits and face-to-face time with medical providers. They can do this by providing continuous supportive care beyond the clinic encounter, navigating community support systems, and engaging family and relationship support systems. The most successful and comprehensive integration approaches go beyond primary care and bring integrated community resources to support patients and recognize that communities have assets and solutions that far exceed some of the best ideas of our health care leaders. With this research as a basis for our proposed interventions, Colorado will have a strong focus on evaluation. We will develop and implement a self-monitoring plan in conjunction with an internal evaluation that incorporates a formative component, an outcome/impact component with a return on investment (ROI) analysis, and a rapid-cycle component that will inform ongoing model adjustments. The specific plan will be developed with CMMI to align with the national evaluation, provide required data, and minimize duplicative efforts and stakeholder burden. We will select an independent organization to finalize the design and conduct the activities. This will enhance our in-state evaluation expertise and ensure evaluation efforts continue after model funding has ended. The self-monitoring plan and evaluation will assess our progress in achieving the overall project goal of increasing access to comprehensive primary care, including integrated behavioral health, that improves our population’s health and experiences with care while containing, if not lowering, costs through value-based payment models for integrated primary care. Colorado SIM
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We will focus on measuring population health, both overall and for key population subgroups; transformation of the health care delivery system, including quality of care and alternative payment models; and the costs of care, including per-capita total health care spending statewide, across regions and among population subgroups. Some measures will be calculated monthly or quarterly while others will be determined annually. Specific measures will be selected with CMMI, the CMMI evaluator, and our stakeholders. We also will identify selected measures for our rapid-cycle evaluation to guide continuous quality improvement, identify unanticipated challenges and detect unintended consequences. In addition, the Population Health Transformation Collaboratives will provide a Community Scorecard demonstrating progress toward Triple Aim. The RE-AIM framework (Reach Effectiveness-Adoption, Implementation, Maintenance) will guide the development and implementation of our self-monitoring plan and internal evaluation. We will use a mixed-methods approach developed in collaboration with CMS and its evaluator guided by the RE-AIM framework in all three evaluation components (formative, impact, rapid-cycle) to examine the overall impact of our model, the effectiveness of policy and regulatory levers, and determine what program characteristics, implementation approaches or adaptations, and contextual factors are associated with better outcomes. A mixed-methods approach will allow us to examine the overall impact of our model, the effectiveness of policy and regulatory levers, and those program characteristics, implementation approaches or adaptations, and contextual factors associated with better outcomes. This is a high-level description of our proposed approach: The formative component will apply quantitative and qualitative methods to evaluate the reach element of the framework and provide critical contextual information on the adoption, implementation and maintenance elements. Colorado SIM
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We will examine reach among different groups of stakeholders, including patients, providers, payers, and purchasers. For example, we will use multiple approaches to measure the percentage of patients with access to integrated primary care and behavioral health in the patient's medical home. These approaches could include supplementing existing population surveys such as Behavioral Risk Factor Surveillance System (BRFSS) and the Youth Risk Behavior Surveillance System (YRBSS) with questions on access to behavioral health for statewide measures and/or aggregating the number of patients in practices with integrated behavioral health services for estimates of reach statewide and for county-based regions. We will track the integration of behavioral health and the proportion of patient panels under alternative payment methods at baseline and throughout the project. We will measure whether integration of behavioral health in primary care affects contracting and purchasing decisions and use of value-based payment models. To develop a deeper understanding we will also collect information through site visits, focus groups, and key informant interviews with stakeholders representing the same groups surveyed, as well as state and local government agencies, tribal communities, consumer and patient advocacy groups, and public health organizations. Additional information to inform our formative evaluation will be gathered from model documents, including practice transformation facilitator notes. Qualitative methods will allow us to understand how the model was implemented in practices and communities, explain what may have contributed to variation in reach, effectiveness, and maintenance, and describe stakeholder engagement. We will use a prospective, quasi-experimental design for our impact evaluation. We expect that the phased roll-out of practices will provide in-state comparison groups for difference-in-differences and interrupted time series designs to help control for as many Colorado SIM
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confounding factors as possible. Outcome measures will encompass all three focus areas. Population health measures obtained from surveys and surveillance data will include prevalence of, and disparities in, tobacco use, diabetes, and obesity. Delivery system transformation outcome measures will include patient care experiences and provider and staff satisfaction obtained from surveys such as Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Quality of care measures will be developed from HIE data, claims data and payer quality reporting systems. Cost of care and utilization measures will be developed from the APCD and other claims databases, applying methods to assess total cost of care and other cost and utilization measures. A key component of our outcome/impact evaluation will be an ROI analysis for various groups that measures programmatic costs combined with changes in cost and utilization of care. The programmatic cost analyses will obtain startup and ongoing costs from multiple perspectives, including providers, private payers, government payers, purchasers and other government agencies. Combining the programmatic cost information with the changes in cost and utilization of care derived from our data analysis will allow us to examine the business case and sustainability of the model from the perspectives of providers, private payers, purchasers, and federal and state government. Rapid-cycle evaluation results will be reported quarterly to promote continuous program improvement. We will apply the concepts of community-based participatory research to ensure that these findings are actionable and inform real-time decisions. As part of the state’s bidding and procurement process, the selected external evaluator will be required to coordinate as needed with the CMMI evaluator on all aspects of the evaluation, including but not limited to the specific measures. As this is a cooperative agreement, it is expected that the external evaluator and the CMMI evaluator discuss alignment of measures and other Colorado SIM
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opportunities to coordinate as appropriate. Specifically, the external evaluator will immediately engage the CMMI evaluator and propose a schedule for planning calls to maintain constant communication. The state’s evaluation agent will work in collaboration with state agencies to develop and implement the program self-monitoring efforts. The goal of this collaboration is to establish the capability and infrastructure the state to enable the state to sustain rigorous outcome measure driven program self-monitoring beyond the period of the cooperative agreement. Evaluator Access to Data In order to provide identifiable Medicaid claims data to the federal evaluator, we – and other applicants – would need to identify a HIPAA exception that permits us to do so. Our legal analysis suggests that there are only two HIPAA exceptions permitting the disclosure of PHI to our evaluator or to CMMI: through individual client authorizations, or through the “required by law” exception. Absent re-consenting each Medicaid client, we would be able to provide the requested Medicaid data if directed to do so in writing by CMS/Innovation Center. Colorado will fully cooperate after receiving the required directive from CMS and promulgating the appropriate rule(s). Colorado will allow CMS to review and comment on methods and results from the state evaluation before publication of results. In addition to HIPAA, the confidentiality requirements of 42 CFR Part 2 may inhibit our ability to share records relating to alcohol and drug abuse. 42 CFR prohibits these being shared absent a client release. Assuming full compliance with HIPAA and other state and federal privacy law, the only firm barrier to disclosure of data relevant to SIM is federal law (42 CFR Part 2). 42 CFR Part 2 prohibits release of substance use data, employing a more stringent standard than HIPAA. As this federal regulation are currently under review, a number of Colorado organizations submitted comments during the recent public comment period, including through national membership organizations, including HCPF, which requested a change to 42 CFR to allow sharing Colorado SIM
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of behavioral health information for integration of mental and physical health in the RCCOs for the ACC; such a chance would also apply to SIM, for integration of physical and behavioral health care. Once the referenced rule is passed, it would provide a safe harbor authorizing the data requested under the grant. Colorado’s All Payer Claims Database (APCD) is the primary source of commercial and Medicaid medical and pharmacy claims data for Colorado. The CO APCD was established by statute in 2010 under the oversight of the Colorado Dept. of Health Care Policy and Financing (HCPF); HCPF appointed the nonprofit Center for Improving Value in Health Care (CIVHC) as administrator of the APCD. Colorado’s All Payer Claims Database is authorized by state statute to cooperate with private and public sector initiatives at the state and federal level. Commercial health plans with more than 1,000 covered lives in Colorado are required to submit claims for their fully-insured lives to the APCD; Medicaid is also required to submit claims data. Currently, 19 commercial payers submit data to the APCD. As of this writing, the APCD hold claims for over 50 percent of all covered lives in Colorado (commercial and Medicaid). In order to facilitate the evaluation, it may be necessary to execute multi-party business associate agreements (BAAs) between the federal evaluators and key cost and claims data sources, including the CO APCD and CIVHC. Those BAAs are not currently in place but the state is willing to execute and manage them if necessary. Importantly, there is currently no statutory mandate to submit self-insured claims to the CO APCD. While significant efforts have been made to secure voluntary submissions from these payers and their administrators, it has proven difficult to accomplish this in light of ERISA concerns and in the absence of any state regulation of third-party administrators. As a result, this important segment – approximately one-half of the commercial market in the state – is not reflected in the APCD.
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If the evaluators need claims data at the patient identifiable level, the CO APCD can provide it subject to the limitations of HIPAA, HITECH, and other applicable privacy and security laws. 42 CFR 2.1 et seq. which essentially requires client authorizations in order to disclose substance abuse treatment data, even if necessary for payment. Colorado has successfully operationalized client authorizations for its Medicaid program – obtaining a 97% success rate in gaining client written consent to allow for care coordination and data exchange in its Accountable Care Collaborative. We do not believe that operationalizing the client authorization will present a barrier to providing the required data to the federal evaluator/CMS. Any remaining HIPAA issues can be resolved through the passage of an administrative rule authorizing the Colorado All Payer Claims Database to disclose the requested information to the federal evaluator/CMS for the purposes of the SIM grant. The Colorado APCD authorizing statute and enabling regulations specify the terms under which claims information, at various levels of detail, may be released for non-public use. Under the CO APCD established data release policies, the federal evaluator/CMS can submit a written data request for CO APCD data that meets the requirement. As an alternative, the Department of Health Care Policy and Financing, which is the state agency responsible for contracting out the APCD, can issue a rule requiring the APCD to provide individual-level commercial claims data to the federal evaluator/CMS if such data is a written requirement of the grant performance contract, subject to HIPAA privacy and security restrictions. Colorado would make the necessary written commitments to be bound by the data requirements. Current state statute states: “Cooperation among health care payors, including both private sector entities and federal and stateadministered health care programs, has the potential to eliminate needless and costly complexity in the administration of the programs and to benefit patients, payors, and the government. Further, alignment of financial incentives among private and public entities may accelerate and reinforce improvements in health care quality and patient outcomes. … The executive director may promulgate rules relating to the collaborative process set forth in this section. (The executive director of the Colorado Department of Health Care Policy and Financing alone votes on whether to Colorado SIM 65 of 68
pass such rules.) Colorado Revised Statutes 25.5-1-205. This rulemaking authority is specifically tailored to allow for the data exchange with the federal /CMS evaluator. Colorado believes it can quickly put into place rules to allow for the disclosure of data from the APCD to the federal evaluator/CMS. The rule only requires a public hearing after which the executive director of the Colorado Department of Health Care Policy and Financing makes the sole determination to adopt the rule. This would represent approximately half the covered lives in Colorado due to preemption requirements in ERISA preventing the collection of claims data from employee-sponsored plans. This is still a very substantial data source and will represent approximately 4.2 million lives by 2015. Colorado’s All Payer Claims Database receives Medicare fee-for-service claims through a state agency agreement with the Centers for Medicare and Medicaid Services. This is facilitated through the state’s public health authority, and also through CIVHC’s designation as a Medicare qualified entity. However, Medicare claims received by the APCD have a multi-year delay: the most recent Medicare data available is claim year 2011, which may present challenges for timely identified Medicare data for SIM evaluators. In addition, the HIEs may collect Medicare identifiers from some hospitals and facilities, but this is not a consistent data field. This may provide an opportunity for data standardization in the future. Functional reporting to CMS would be part of the SIM HIT proposal at a later phase. Hence, we also plan on convening a Data Policy Workgroup to determine policy and operational impacts to the proposed rule. The workgroup will provide a recommendation on the data source(s) for the minimum data set to fulfill the evaluation requirements. A list of preliminary information and follow up tasks are noted below.
Evaluate current data sharing policy landscape with SIM stakeholders.
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Add Medicare and Medicare identifiers from all participating payers to the agreed upon data set for CMS evaluation.
Determine and identify recommended data sources for reporting to CMS:
Possible sources systems include but are not limited to: MMIS; APCD; HIEs; CPCi RISE solution; and/or a hybrid solution.
Identify current data sources, gaps, barriers, and policies for sharing identifiers to support the federal evaluation.
Evaluate operational impact of requiring data field for all participating practices and other stakeholders for SIM participation.
Provide recommendations for federal evaluation.
9. Alignment with State and Federal Innovation: Colorado’s SIM builds on, and aligns with, numerous CMMI, Department of Health and Human Services (HHS) and state initiatives that support high-performing primary care and integrated behavioral health. SIM funding will enable practices engaged in these initiatives to add new services, or to extend programs beyond their current grant funding, without duplicating or supplanting current funding. Projects include: • CMS State Financial Alignment Model to integrate care for Medicare-Medicaid beneficiaries within a managed FFS model (awarded July 2014); • The Accountable Care Collaborative; • CMMI Comprehensive Primary Care Initiative; • CMMI Advanced Primary Care Practice Demonstration; • Five CMMI Health Care Innovation Challenge projects for behavioral health integration; • Two SAMHSA/HRSA funded integrated care initiatives; • Medicaid global payment pilot for integrated care; Colorado SIM
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• Numerous private grant-funded and payer-specific integrated care initiatives. Federally supported initiatives that align with Colorado SIM’s population health improvement focus include the CMMI Community-based Care Transitions Program and CDCfunded programs in chronic disease management, tobacco prevention, health screenings, immunization and sexually transmitted infections. Programs like the full federal match through 2016 to expand Medicaid eligibility, the TEFT grant for community-based long-term services and supports, and the Colorado Regional Extension Centers will support the expansion of HIT/HIE into all care settings, encourage evidence-based medicine and give technical support through the integration process.
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