Transcript Document

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Emerging Mega-Trends in Healthcare and
Implications for Providers of Services to Persons with
Developmental Disabilities in New York State
New York State Association of
Community and Residential Agencies
James W. Lytle
Manatt Phelps & Phillips
December 4, 2014
Agenda
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Overview of megatrends in larger health and human
services environment
Impact of megatrends on New York State policy
development
Discussion of implications for the developmental
disability field in New York and beyond
Healthcare Megatrends
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More with Less, Volume to Value
Consumers Take Charge
Employers Recalibrate
Mega-Health Systems
Healthcare Everywhere
Value Through Data
Predict, Prevent, Personalize
The New Aging
The Centrality of States
The Globalization of Healthcare
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Megatrend 1: More with Less, Volume to Value
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Supporting higher-quality outcomes and greater satisfaction, while reducing costs
Innovative payment
mechanisms and
value-based
purchasing (vs.
traditional fee-forservice) to ↑ quality
and ↓ cost
Re-pricing of
physician specialty
services; emphasis on
re-balancing primary
care; more targeted
use of specialty
services
Satisfying provider
supply through:
expanded role and
scope of practice for
non-MDs; new
models of mid-level
providers and teambased care
New York: The Cost and Value Proposition
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Payment/Delivery System Reform & Scope of Practice
NY is remarkably
slow and cautious
on scope of
practice issues
for an allegedly
progressive State
RRecent progress
on NPs,
pharmacists and
extending
exemptions from
Nurse Practice
Act
Decades of
increasing
reliance on
managed care for
Medicaid newly
focused on DD
Field
DISCO
Persistent
experimentation in
payment
methodologies:
Rate Rationalization
and DSRIP valuebased payments
$8 Billion in New Federal Funding
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Planning Grants,
$70 million allocated,
$21.6M awarded
Other MRT Purposes,
$1.08 billion
Interim Access
Assurance Fund,
$500 million
DSRIP,
$6.42 billion
Overall pot to be
allocated,
depending on
application
valuation, into
Public Hospital
and Safety Net
Funds
10% of each fund
set-aside for high
performance
payments in years
2 through 5
State Program
Administration,
$300 million
Performance
Payments,
$6.048 billion
Potential
Reductions in
Federal Funding
for Failure to
Meet Statewide
Metrics,
$381 million
Overview of DSRIP
New York State (NYS) received federal approval to implement a Delivery System
Reform Incentive Payment (DSRIP) program that will provide funding for public
and safety net providers to transform the NYS health care delivery system.
Goals:
(1) Transform the safety net system
(2) Reduce avoidable hospital use by 25% and improve other health
measures
(3) Ensure delivery system transformation continues beyond the waiver
period through managed care payment reform
Key Program Components:
 Statewide funding initiative for public hospitals and safety net providers
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Only coalitions of community/regional health providers are eligible
DSRIP projects based on a menu of interventions approved by CMS
and NYS
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Payments to providers based on their performance in meeting
outcome milestones and state achieving statewide metrics
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DSRIP Projects Menu & Domains
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Each DSRIP “Performing Provider System” selects at least 5 projects (and no
more than 10 projects) from the following menu:
Domain 2: System Transformation Projects (must include at least two projects)
• Create integrated delivery systems (required)
• Implementation of care coordination and transitional care programs
• Connecting Settings
• Patient and community activation
Domain 1:
Overall
Project
Progress
Domain 3: Clinical Improvement Projects (must include at least two projects)
• Behavioral health (required)
• HIV
• Cardiovascular health
• Perinatal
• Diabetes Care
• Palliative Care
• Asthma
• Renal Care
Domain 4: Population-Wide Prevention Projects (must include at least one project)
• Promote mental health and prevent substance abuse
• Prevent chronic diseases
• Prevent HIV and STDs
• Promote Healthy Women, Infants and Children
Value-Based Payments
• Movement to coordinated care did not alter fee for service
status quo
• Goal: At least 90 percent of plan payments are required
to be value-based by 2019
• Value-based payments involves Plan to individual PPS
provider, Plan to PPS and Plan-PPS-Provider
arrangements
• Examples may include:
 Bonuses or penalties based on quality
 Shared savings
 Upside/downside risk sharing
 Bundled payments with outcome-based component
 Capitation with outcome-based component
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Megatrend 2: Consumers Take Charge
Increasing role of the consumer in healthcare decision making
Consumers become
“active shoppers,”
able to compare and
select products,
utilizing data made
available on smart
phones and in social
media
Consumers bear
more risk, particularly
through higher cost
sharing and high
deductible health
plans
Individuals and
communities increase
focus on the impact
of personal behavior,
including diet,
exercise and homebased self-care
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NYS: Consumers & System Transformation
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OPWDD and Consumer-Direction
Consumer-direction has
become a key element of
residential, employment and
related reforms throughout
OPWDD System
Transformation
Megatrend 3: Employers Recalibrate
The employer-sponsored insurance landscape is shifting
Employers moving toward dropping
coverage for retiree beneficiaries and
shifting individuals to the
Marketplace, and/or using a voucher
system for current beneficiaries to
purchase insurance on private/public
Marketplaces
As landscape for employers as
purchasers becomes more complex
and regulated, employers may pool
interests and purchasing power
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NYSACRA Members as Employers
Employee health benefits in ACA environment
Skinny networks,
greater cost-sharing,
limits on out of
network access,
prescription drug
concerns
Coverage for
Associations and the
self-employed under
the ACA: Freelancers
dilemma and new
ERISA standards
State intervention to
protect against
surprise bills and
limits on out of
network limitations
and costs—and
premium review
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Megatrend 4: Mega-Health Systems
Mergers & Acquisitions
Merging of payers,
providers results in
mega-healthcare
systems managed by
giant organizational
entities
Roles of providers and
payers shift to
increase focus on
delivering the “right
care, at the right
place, at the right
time” via joint
ventures and
partnerships
Increase in payers’
use of utilization
controls and narrow
networks creates
concern A
regarding
limited consumer
choice
ACCESS
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New York State: Mergers/ACOs/PPSs
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Mergers & Acquisitions
Consolidation of
payors and providers
present new
competitive concerns
with legal/regulatory
implications
Mergers and other
affiliations of
providers becoming
more common as
strategy to address
current fiscal and
operational
challenges
Accountable Care
Organizations and
PPSs—providerbased, collaborative,
non-MCO models—
pose challenges to
plans, smaller
providers
Megatrend 5: Healthcare Everywhere
Shifting from care delivered in healthcare facilities to home and communities
Tools (e.g., smartphones, social
media, sensors, text messaging)
empower consumers and physicians
with more options for where and
how to treat, particularly remotely
and from home
Care may move from acute to
ambulatory settings, where
consumers spend their time
(e.g., retail clinics, homes) and
where care can be delivered by
lower-cost providers
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New York: Convenient & coordinated care
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Shifting from institutional-based care to home and communities
Transformation of
home and
community-based
services for the
elderly and persons
with disabilities
through
coordinated care.
Patient care
monitoring
technology, new
diagnostic and
treatment
modalities present
new opportunities
and new
challenges.
Telehealth
technologies offer
new
opportunities,
challenge statebased licensing
quality oversight
Expanding ambulatory,
urgent care,
freestanding
emergency room and
retail care options—
and implications for
more traditional
providers
Megatrend 6: Value Through Data
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Increasing demand for ability to access and analyze huge amounts of data
Insurers and providers will
begin to create and analyze
giant data sets to support
quality improvement, planning,
population health
management and cost
effectiveness
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Integration of clinical,
molecular and demographic
data will drive new R&D for
the pharmaceutical and
medical
device arenas
New York: Data-focused health policy
Data-driven health policy and new privacy concerns
MRT focus on
data, reliance on
real-time allpayor claims
information and
analytics
Electronic
prescribing: new
challenges for
healthcare
practitioners in
digital age
The SHIN-NY,
RHIOs and the
health
information
technology
revolution—and
privacy concerns
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Megatrend 7: Predict, Prevent, Personalize
Medical care personalized at an individual-by-individual level
Genomics brings
personalized
medicine and
predictive diagnostics
Emergence of
cybernetics, cloning
and regenerative
medicine
Rise of ethical
concerns related to
scientific advances
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New York: Bioethical Challenges
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The New York Experience with Key Ethical Issues in Medicine
NY has (slowly)
reached consensus
on a host of difficult
issues, including
surrogate decisionmaking, genetics,
FHCDA
21st century may
promise new genetic
interventions to predict
& prevent
developmental
disabilities—and new
ethical quandaries as a
result.
Megatrend 8: The New Aging
Impact of the population becoming proportionally older
Enhanced focus on selfcare, connected care, and
monitoring/assistance that
allows individuals to
receive care at home
longer; enhanced focus on
managing chronic disease
Increased role for family
care giving; increased
impact on health of family
care givers; increased need
for end-of-life care
planning
Continued shift in
Medicare to managed care
organizations; increased
focus in states on dual
eligibles
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Aging caregivers and workforce
Significance of aging on caregivers, professionals and volunteer workforce
Implications of aging
caregivers on loved ones
with developmental
disabilities, leading to new
and desperate concerns for
services
Health care workforce
shortages compounded by
pending retirements of
direct service professionals
and other caregivers,
leaving NYers without care.
Demands on workforce to
undertake family caregiving
responsibilities impacts on
healthcare professionals
and volunteers
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Megatrend 9: Centrality of States
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Expansion of Medicaid and reforms of state programs
Medicaid
expansion brings
the program
squarely into health
insurance market;
concerns regarding
sustainability of
growing program
surface
Alignment of public
coverage with
private insurance
New focus on
delivering
integrated services
for medical care,
behavioral care,
public health
Increased use of
managed care,
including for
populations that
have been last to
transition
Why Advocacy in New York is so important
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New York plays extensive role in overseeing health care issues
State’s vigorous
healthcare and
nonprofit regulatory
role makes NYS of
central importance
Historic and
longstanding
constitutionallybased role of
state in serving
persons with
His
mental
disabilities
While federal role in
overseeing
healthcare has
grown, State’s
responsibility for
Medicaid and new
FIDA initiative
makes NYS key
player for public
programs
Prolonged and
persistent
dysfunction in
D.C.—and relative
success in
governance at NYSlevel—underscores
importance of statedriven public policy
Challenges and opportunities: Tale of Two Cities
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• Workforce
 COLA implementation
 Credentialing Progress
 Justice Center and background checks
 Continuing recruitment/retention challenges
• Fiscal Support
 State budget status
 CMS takeback
• Pace and scope of change
 Well-intended and progressive vision
 Overtaxed state resources/personnel
 Overwhelmed field
Challenges and opportunities: Tale of Two Cities
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• Federal-state relationship
 Continued support in Obama Administration
 Presidential prospects for Hillary Clinton
 Diminished role for NY in Congress
 Congressman Issa and CMS view of NYS
Medicaid
• Complicated political environment
 Strong support in legislature for field
 Committed and capable leadership
 Recent vetoes of legislation to reform front
door and related planning bills
Prognosis
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James Lytle
Partner
[email protected]
Manatt Phelps & Phillips, LLP
30 South Pearl Street
Suite 1200
Albany, NY 12207
(518)431-6704