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3M Health Policy Executive Summit

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  • Improving member safety: The hidden costs of elective procedures
    • (SPEECH) Good afternoon, and welcome to the 2023 Health Policy Executive Summit. We're excited that you're all here and appreciate you attending. We have a great three day agenda, so we are kicking off day one from 12:00 to 2:00 today. If you were not able to join or not registered for the upcoming days, within your resources section, that link is there. Before we get started, I do just want to go over a couple of housekeeping items. We are utilizing the ON24 webinar platform, which is a web-based platform. So we recommend you using Google Chrome, closing out a VPN or multiple tabs, that will help with your bandwidth. Because this is a web-based platform, we do not have a dial in number. So if you are having audio issues, check your speaker settings. Or if you want to do a quick refresh, that usually helps with any audio issues. You can see within the ON24 platform, we have a lot of engagement tools. We have the media player that if you would like to make that larger or smaller, you can. We also have closed captioning available. Same with the presentation area, you can make that larger or smaller. And all of the engagement tools you can minimize or make larger if you would like to. With the engagement tools, we have the resources section. So within there, we have the agenda. We have all of our bios for our speakers with some other resources as well. And again, that link for registration if you do want to attend the other days, you can get that there as well. And then lastly, we encourage a lot of Q&A. So in that Q&A box, put as many questions as you want. We'll get to as many as we can. And we also have the attendee chat on. And for that is for attendees to chat with each other if they would like to talk about the content. But we do ask that if you have questions about the content to put that in the Q&A box, it's just easier for our presenters to see. So again, we welcome you and let's go ahead and get started. I'm going to pass this over to Megan Carr, who's going to introduce our first session and go over the agenda. Megan? Thanks, Lisa. Hello, and welcome to day one of our 3M Health Information Systems 2023, Health Policy Executive Summit. I'm Megan Carr, vice president of regulatory and payer solutions here at 3M. And it's my pleasure to welcome you, share some organizational details-- (DESCRIPTION) Megan's audio cuts out. (SPEECH) about this-- to your summit. And let me start with a quick overview of our great agenda for this week. We've heard from many of you that you like the format we used last year with just two hours each day over three days. So we're glad to repeat that again for you. So today from 12:00 to 2:00 Eastern, we'll have two great sessions focused on quality outcomes in the ambulatory health care space. And I'll come back to that in a minute for more on our panelists. Tomorrow from 12:00 to 2:00 Eastern, we'll focus on a critical issue facing our country, and something about which I'm personally very passionate, and that's safeguarding maternal health. My colleague Flora Cohen will be joined by two wonderful panelists. Representative Ruth Richardson of the Minnesota House of Representatives and Dr. Steve Calvin of the Minnesota Birth Center, to discuss challenges and strategies to address maternal health. They'll be followed by a session on maternal health bundles that can help surface potentially preventable complications from antepartum through postpartum encounters. Then on Wednesday, again, from 12:00 to 2:00 Eastern, we will briefly look back at the last 40 years of prospective payment for some key thoughts on what we've learned over those many years, and then look ahead at the very timely topic of state directed payments, which could be subject to future changes by CMS. We are very excited to be joined by Amir Bassiri, Medicaid director for New York, Victoria Grady, director of provider finance for the Texas HHS Commission, And Jamie Snyder, former Medicaid director from Arizona and Texas, as they discuss the good, the bad, and the ugly of state directed payments, and what to expect on the horizon for potentially changing policy on that topic. So I'm sure you can see why I'm very excited about this week. (DESCRIPTION) A slide reads "Your participation is encouraged!" (SPEECH) I know you hear from us often as we continue to ask how we at 3M can support your goals to drive quality and efficiency, as well as improve patient outcomes and health care delivery system performance. It is our great privilege to bring together these experts this week from across the health care space to dive into important issues and look for solutions together. Over these next three days, as Lisa said, we want to hear from you. We hope the sessions are engaging and full of discussion. So please do use your chat feature often, ask questions, submit comments, or even just cheer on a comment made by a presenter. We want to hear from you. And make sure you get the information you're seeking out of these sessions. So now that we've covered some housekeeping, let's turn to our first session. I'm pleased to introduce Dr. Sandeep Wadhwa, our global chief medical officer here at 3M to lead the session on improving member safety, the hidden costs of elective procedures. Dr. Wadhwa will be joined by Greg Kamas, director of Medicare quality improvement and stars program, senior health solutions at Mutual of Omaha. And Dr. Yichen Zhang, lead health economist and manager of the 3M clinical and economic research group Dr. Wadhwa is our-- as I said, our chief global medical officer here at 3M. He's a physician executive with a particular interest in payment and care delivery reform to advance population health for vulnerable populations. He previously served as a state Medicaid director for Colorado, and led the effort to create the Accountable Care Collaborative. He guided the widespread Medicare payer adoption of the Diabetes Prevention Program while at Solera Health Dr. Wadhwa previously oversaw population care management at McKesson, including 10 state Medicaid programs. He is currently serving on the board of directors of one of the nation's largest nonprofit banks, the Reinvestment Fund, devoted to revitalizing low income communities. Dr. Wadhwa is board certified in internal medicine and geriatrics. He earned his BA from Wesleyan, his M.D. From Cornell, and his MBA from Wharton. And he has been volunteer faculty at the seniors clinic at the University of Colorado for over 20 years. Greg Kamas is currently the director of Medicare quality and stars program for Mutual of Omaha and the senior health solutions division. He was previously the director of quality improvement accreditation and population health for the Denver Health Medical Plan, a subsidiary of Denver Health and Hospital Authority for Medicare, and Medicaid, CHP plus or CHP plus health care exchange and commercial lines of business. In addition to quality improvement and managed care, Mr. Kamas says leadership experience in a TPA and health management company as chief health officer in the broker consultant area as a creator and national practice leader for health management and as the director of care management for an IPA physician management group. He resides in Colorado where he reports that his daughter and his money are attending University of Colorado Boulder. Dr. Yichen Zhang works on State Medicaid Research Projects and develops the episode payment methodology at 3M HIS. Before joining 3M, Dr. Zhang was a senior research health economist in RTI health care financing and payment program. And prior to that, she worked at Harvard Medical School Dana-Farber Cancer Institute. Thank you for joining us, Sandeep. Let me hand it off to you. Megan, thank you for the very kind introduction and thank you for your participation, and I appreciate the introduction. So I can jump right into our presentation. Let me just get that. (DESCRIPTION) They search for the correct slide. (SPEECH) Great. There we go. Thank you. We can-- I thought maybe we could begin our session just with a little pop quiz here. That would be super interested. There's a good number of folks on the call. If you can go ahead and click right on your screen. If you or a family member has had a complication after a outpatient procedure, an elective procedure, whether that was surgical, or medical, super curious if we can-- to see. We'll anonymously share the group results here. So please go ahead and let's spend a second and click. (DESCRIPTION) The quiz reads "Have you or a family member experienced a complication after an outpatient procedure?" (SPEECH) I'll give it another 10 seconds here, and we can take a look. (DESCRIPTION) "Yes" and "No" appear as response options, above a button marked "Submit." (SPEECH) I'll give it five more seconds. Let's see. Great. They're still coming in. If you've had a complication-- All right. Let's take a look and see what that looks like. Look at that. Almost 50%. (DESCRIPTION) The responses read 53% no and 47% yes. (SPEECH) And I think that-- and that was also my experience too. And I think that is really the Genesis of what-- one of the key things that we were really interested in addressing at 3M was looking at the frequency, and prevalence, and trying to bring some structure for decision makers on where we are doing well and where there's more opportunities around patient safety in an outpatient setting. So we'll use that 50% of our own personal experience as a backdrop here for this conversation. And we'll cover these three main bullets for our agenda over the next 45 minutes (DESCRIPTION) He reads the bullet points: (SPEECH) understanding the current challenges and opportunities related to patient safety and outpatient settings. Greg will really share with us some insights on developing a roadmap from his perspective as a leader at one of the biggest Medicare supplement plans in the country. And we'll also share some news from US News and World Report that speaks to. They're looking at outpatient safety as a emerging opportunity for both improving patient experience, patient safety, but also looking at that as an area where we can look for efficiency and excess costs. So let me begin by having Greg talk a little bit about Mutual of Omaha, and then we'll come back and talk about patient safety and outpatient settings. Greg? Thanks, Sandeep. Good morning to you all. I'm grateful to be included in a panel of two doctors and some guy from Omaha. I actually do live in Denver and the joke for years was about Nebraska having born and raised in Nebraska was I lived there 28 years and found out you could leave. However, I now work for Mutual of Omaha and actually I'm thrilled to do so. A little bit of background, I'm not sure how familiar you are with Medicare supplement products in general. But Medicare supplement products in general as a contrast to an MA plan that assumes the total cost of care and the risk. Med plans really supplement what Medicare doesn't pay or cover, and can also offer some value added programs in that equation. So your Medicare supplement policy would pay its share-- you would pay its share of Medicare, and then it would pay the share based on the plan type which are standardized. No waiting period, choice of your doctor that accepts Medicare, coast to coast coverage. We are 1.3, 1.8-- sorry, 1.385-ish million members policy owners. It's a mutual. It's not a nonprofit. It's a mutual. And our mission is to help seniors feel confident and empowered to live their healthiest lives. And protecting people's assets and making that difference is the noble purpose. And so with 64 million Medicare beneficiaries with 14 million 22%-ish of using a Medicare supplement, insurers continue to improve and diversify products, look for opportunities for improvement, and ways to further the triple aim, which is the context of my participation today. So by way of background, I joined Mutual of Omaha about a year and a half ago from what I would call a connected payer and health care delivery system on its way to an integrated care system. And even in a connected system, there were challenges for care across the continuum of care, and within transitions of care, and certainly for how quality instances may be isolated or siloed. So imagine even in a connected care system, it was a challenge. It's more even a challenge, I think, for those that don't have that system available to them. We started a project with 3M, a research project where we wanted to add to their database the Medicare Supplement data, which wasn't-- I don't think was reflected in their data set originally. And so we wanted to add that for a three year period. And in return, then a chance to explore some 3M tools that really aggregate, gave us a benchmark, really layered some data, gave us some ways to peel the onion or to do further analysis. And we'll talk about that model in just a second. And what we really wanted to do was looking at the levers as a Med sub plan, different than a fee for service plan or different than an MA plan, was to look at what levers we had and what opportunities there were that corresponded using these 3M tools. And what I would tell you before even looking at data was that we were both-- I was amazed at the level of detail and the quality of the drill down that we got to be able to help us identify opportunities, as well as some of the data that went with that. I was also pleased as we performed better than the fee for service or the Medicare benchmark average. I think that complications are a bona fide piece of that patient safety puzzle. And with half of you all, me included, having a complication based on an outpatient surgery. Mine, a rotator cuff surgery. I think that it's not quite Six Sigma, is it? 50%, is that one sigma or not even sigma? I'm not even sure. Yeah. But I think that what we're talking about is pursuing the quadruple aim of access, and cost, and quality, and then also the member experience piece as part of our obligation, and really in fulfillment from a Mutual of Omaha's perspective of their noble purpose. (DESCRIPTION) The slide changes from "Project Background" to "Why do we care?" (SPEECH) The question would be, why do you care? And so I think that it's a rising costs and more complications as more visits. More visits are more costs and less healthy members. And that makes more visits and it's a whole spiral that starts. And so how do you interrupt the spiral? It is ultimately about patient safety and members quality of care. It's about empowering the provider partners and systems with information, complete information that they may not see that might be scattered across their system that would make a difference in patient quality. It might be the basis for incentives or partners. It certainly will help us get to a specific areas of improvement or focus, and then it may be the basis for some cost bundling. And we'll just reference that a little bit later as well. (DESCRIPTION) A new slide appears, titled "Safety incident impact for elective procedures." (SPEECH) Sandy, is this-- I think you. Thanks, Greg. And I'll also just build on Greg's comments that the chief medical officer at Mutual of Omaha, Dr. Manoj Pawar and I go back to our Medicaid days when he was the chief medical officer at one of our biggest health systems. And we stayed in touch over the past decade and we were having a conversation almost a year and a half ago. And I was just talking to him about cost drivers and Medicaid. And I was sharing with him that personal care services inside of the HCBS programs for the Medicaid folks on the call. That was the area that we used to see with really rapid growth, and then also outpatient facility. And again, some of that was talking to an Osha about it was some of it struck me as very appropriate and some of it didn't know. And I saw that outpatient facility line growing 10%, 15% a year, and Manoj's response was that's interesting as a Medicare sub plan, that part B part of Medicare is growing in a faster than expected and its sustainability is of concern. And that there was a real interest in trying to unpack the part B expenses for Medicare. And thought about it from a Medicaid expense that this was something that was of interest from my former Medicaid days. And I think we both started to talk about outpatient facility and recognized that there was a patient safety quality gap. That when it came to the inpatient side, we have a lot of measurements for hospital acquired conditions, and inpatient safety, and readmissions. But we were just talking about how the volume is shifting to the outpatient side and what are the-- how are we measuring safety there? We have such a robust inpatient safety system from the payer perspective, and I'd even say from the provider perspective. We've built an infrastructure that is looking at safety and quality, and we were both just recognizing that the volume has shifted. That when you look at just to pick on orthopedics, it's turned into an outpatient profession. This was a profession that was largely inpatient up until practically five years ago. And do we have a quality oversight system for the shift where we move from inpatient to not just outpatient facility, but even to ambulatory surgical centers. And part of-- and this all dovetailed with some work that 3M had been doing, because we've been very interested in this issue of building a more robust measurement system for evaluating elective procedures. And part of the challenge is it's hard to track, or you have a procedure and then you go home. And how you connect the data from-- when you're an inpatient, you can just keep-- there's eyes on the patient and you chart every day and you're treating every day what's going on. But we send the patient home and so there's a challenge in terms of the follow-up events. There's also a challenge in terms of defining complications. And so we took that seriously on our side to develop a system that looks at the starting point being the elective procedure and the next 30 days and analyzing the patterns of care over the next 30 days by procedure, by specialty, and that's what Gregg and I will share a little bit more in terms of what were the insights we saw when we looked at over a million members, owners of the Mutual product. And part of the other complexity that we were dealing with was that patients often assume that if it's an outpatient procedure that it's got to be safe. If it wasn't that, we'd be doing it in an inpatient setting. And so there may be some patient opportunities for education. They may underestimate what's going on until things can get very severe. And so there's opportunities here for patient awareness, patient empowerment, and I think really an interest in trying to bring some systematic tools. What we saw at the beginning with the survey of 50%, we should be able to put it into a framework that says, where did it occur? What was the nature of the complication? And what can we do to make care better? And so we were very motivated by a patient safety, patient experience perspective, but I also think we recognize that right now, I'm just going to be kind of blunt here-- complications, pain, that the follow-up care from a complication is not-- other than within 72 hours that gets bundled into if you're directly admitted post your procedure that gets bundled into the inpatient rate, but after that, these get treated as separate events. And so there's an opportunity here to look at excess costs and efficiency and variation and bring to outpatient procedures I think some of the lessons we've learned around readmissions and inpatient complications. We've been able through combined focus in this country to bring down the readmission rate and normalize that curve and shift it to the left. And I think there's a real important opportunity here to do something similar with outpatient procedures. So we will show you some more details of that system. Let me describe it in a little bit more detail, but in advance of that, I did want to share some breaking news that US News & World Report is using this system that Gregg and I will be talking about as part of best hospital rankings next week. And so they announced earlier this month that they'd been very interested. And we've also been talking to US News about hospital rankings, feeling like they very much weigh the inpatient experience when so much of the care is delivered in an outpatient setting. And I think that resonated and was aligned with what they were thinking about in terms of wanting to look at safety in outpatient settings. And so they announced the use of our software, the software we'll be talking about that we've been working with Mutual of Omaha for orthopedics and urology in next week's release, and looking at ortho and urology procedures and an outpatient facility setting. And they also shared that they'll be looking to evaluate expansion to ENT, OB/GYN, and ophthalmology. These are specialties that are largely outpatient. It's the rare inpatient opto case. And if US News is interested in helping inform consumers around performance and safety, having a tool that looks at complication events for dominantly outpatient specialties adds a lot of power to their system. So we're very excited to collaborate with them as well as with Gregg and Mutual of Omaha. Let me spend a few minutes just describing the system and then let Gregg share the findings and next steps that Mutual of Omaha has been embarking upon. But we defined potentially preventable complications of care as being events that occurred after an ambulatory procedure, after an elective procedure that results from a process of care or treatment, not from the natural progression of the condition. And we recognize that some of these conditions are inevitable, that every procedure has risks, every medication has risks. And so what we're interested in is if there's higher than expected event rates, or if there's lower than expected event rates, what can we learn from them? And so you'll see some averages here and some distributions. We did think it was important to risk adjust. And most importantly, we are risk-adjusting around the complexity of the procedure. A hip replacement is a much more complex and risky procedure than an arthroscopy when you're looking and cleaning versus when you're replacing. And so we designed the system to be reflective and separate into different risk categories by procedure complexity so that we can really compare apples to apples. A simple cataract procedure has a complication rate of about 2 in 1,000, but a complex cataract rate has doubled that event rate, almost 4 in 1,000. And so we made sure that we were risk adjusting by the complexity of the procedure, by people's age. Oncology turns out to really increase the risk of procedure complications. And so we have an adjustment for oncology as does dual eligible status. And so if patients are both eligible in the Medicare and Medicaid programs, we did see a higher complication rate, and we made an adjustment for that so that both payers and providers aren't penalizing performance evaluation for people who are duly eligible. And we looked at complication events in four settings. The most important for this conversation are follow-up care with an inpatient or an admission-- I mean, emergency room or admission, but we're also looking at office visits and the 72-hour direct admit. And so those are the key settings of care, how we risk adjust. And I want to emphasize that we are looking at almost 3,000 procedures in this system that we've categorized anatomically into 93 procedure groups. And so this system is looking at more than surgical procedures. If there's an insertion or a puncture, whether that is an endoscopy or interventional radiology, we've taken a very expanded view of procedures so we can look broadly at complication events. And so certainly, the surgical specialties, general surgery, orthopedics, urology, OB/GYN are included. But I really want to emphasize that we're looking broadly at all procedures across these 3,000 and across sites of care. The software looks at hospital outpatient that can also look at ambulatory surgical center or even office visits. And so it starts to give-- and we've got both payers and providers on the call today, a view of performance that we can look 30 days after the procedure and start to assess how we're performing. We are defining 35 different complication groups that you can track. And we'll be showing you what that data looks like by these different complication groups. But to give an idea, they span infections, sepsis. Bleeding is very common after a procedure that can even lead into anemia visits. But we also see mechanical failures or surgical site wound dehiscence. And so we're able to track, not just the procedure, but tie it to a complication type so that we can aggregate it, but also so we can help support performance improvement by the health systems around what they can do differently to improve performance. And for many of you, this is not unfamiliar to how we attacked inpatient complications, whether it's catheter-associated UTIs or surgical site infections. And so we're somewhat bringing that familiar model for measurement and action to an outpatient environment. As I mentioned, we are looking at complications in these four settings. Did the patient end up in the ER? Did they end up as an inpatient, or was there an office visit with a complication, or direct admit, or 72-hour admission? That gets the procedure gets bundled in with the inpatient event, but we were able to develop some logic to look at those events, too. We do have benchmarks that allow payers and providers to see how they're-- and that's what Gregg's going to show in a second how the plan or state or system is performing against either Medicare or national benchmark. There are a couple of states that have started to seed our national benchmark with their blinded state Medicaid performance. So we're able to get a couple of views of what performance looks like. I'll note that we were somewhat surprised that the rates of complications were very similar when we looked at Medicare and the national data sets. (DESCRIPTION) A new slide: Risk Adjustment at Procedure Level. (SPEECH) And I had mentioned, but I just think it's important to mention again that we're risk adjusting. We're risk adjusting by age, by dual eligible status, by procedure complexity, oncology. And we didn't overfit the model with a lot of risk adjustment. These are elective procedures. And so we did some research to look at comorbidities on the day of admission and these were the ones that stood out. It's still an area of active research for us, but we felt that these are elective procedures. Procedure complexity captures we think the most important risk adjustment which is the procedure itself and that allows us to do some apples-to-apples comparisons. Last slide before I let Gregg share with us some of the findings and just to give another visual on the samples of complications. These are some of the more common categories. Many times after a procedure, particularly when there's anesthesia for a whole host of reasons, we see pneumonias, aspiration pneumonias. We also see pulmonary emboli occur. The frequency of pulmonary emboli and venous thrombo-like clots is surprisingly high after outpatient procedures. And when those are occurring higher than expected, we think there's opportunities for prevention, that there are interventions and care bundles. But first, you have to know if you have an issue. Bleeding and hematoma is another big category for complications. Infections are part of a commonly seen post-procedure, and then mechanical complications. When you're inserting a foreign body into a human body, there's all sorts of risks in terms of function, performance, or other kinds of categories. So we've got 35 different ways of measuring complications. And so that's a little bit about the system. Gregg, do you want to talk about when we ran the software against your data what you saw? Yeah, absolutely. So given the sophistication and the complexity of the model that really accommodated and accounted for so many things in its analysis, we were really encouraged to see-- and I'm going to put this chart up for just a minute and let you orient yourself. We were encouraged to see the Medicare Supplement performance compared to the overall benchmark. And so that is the far column to the right, which is the difference rate between the expected, which would be the benchmark, and our observed. However, there are some opportunities that are very close to the bubble and some that you'd pay attention to just by sheer volume. And the sheer volume example is the gastroenterology. And so-- I'm sorry, at the very start of the table, there is OA, which is original admit; O1, which is the original-- which would be the presentation to the EDO2 at inpatient, and it gives you a combined total. And you can see we're running three quarters of a percentage point below the national benchmark, which is highly encouraging. When I look at the table below that, you see gastroenterology which has over 200,000 procedures. And so when you start to go down the analysis slope, you can look at the highest or lowest-performing measures. You could also look at some high-volume procedures and have a sense of the scale of this where the opportunities might live. And so what we started to do in this process was starting with where we performed overall and maybe looking at gastroenterology, and Sandeep mentioned the GI bleeds or hematomas and sepsis and infections being a really high risk across the board, we also saw that. But this gave us a way to sort by service line our complications overall, which was I thought a fascinating look. And we chose-- let me give you a couple of examples. We'll do gastroenterology. Maybe we can jump to-- Sandeep also mentioned orthopedic surgery, where our rate of complications was 1.8%. Still below the national benchmark of 2.05, but higher than we'd like it to see, and so many moving parts. So let me give you a couple of examples of how we've approached this. What we really-- If I could just make one quick comment. I also would invite the audience to just absorb the complication rates we're showing here. The average event rate was 2% overall. So one out of every 50 people are coming back to either the ED or being admitted. And you see those rates with interventional radiology in 6%, urology 5%. These are practically comparable to the inpatient complication rates. And so we're seeing I think this-- our sense is underappreciated burden. And you saw that over our lifetime we see up to 50% of us on the call have had an event. And these are common procedures with different event rates that-- and so we really invite people on the call to think about running a baseline report and understanding your variation. But I just thought, Gregg, that these event rates I think have always struck us as being a bit surprising, that we think of elective procedures and you think of-- 2% overall starts to get doctors' attentions about and I think policymakers and trying to understand if you've got providers that are double that rate or half that rate as you think about networks or you think about incenting safety opportunity to play with. Sorry, Gregg. Just a quick thought on that. No, that's awesome. Thanks, Sandeep. And I mean, one of the things I was taken by was just the sheer scope of it when you look at a quarter of a million people at risk on an annual basis, it's just a tremendous amount, and the context of inpatient. Thank you. I appreciate that very much. So we started to go-- how do I make sense of this? And we started to look at a couple of different models to go from the wide end of the funnel to the narrow end of the funnel and to see if there wasn't something that was actionable given our dynamic of levers that we might have. For you if you're an MA plan or you're a provider system or you're a facility, you might be starting to think about-- how would I peel this onion? What would be the sequence of steps I would go down? Let me give you a couple of examples using gastro and using maybe orthopedic and see if some of those might not resonate for you and you'll start to see what maybe we saw as well. So whether you start with all complications, maybe you switch then, where are they geographically? Maybe it's inside a geography. It's a hospital or a facility. Maybe that's nationwide and you could make a line in the sand there. It could be more specifically by service line, which might even be more instructive, or service lines with the most complications or the most volume, which is why I was starting with GI as a place to start. And then by procedures, by volume. And then by procedure by complication, and you start to see that. And maybe there's a best practice in there. And then finally to have a quick look at maybe there's some value-based contracting or reimbursement models that might be affected that you might be able to leverage if that was one of your levers. And then maybe a more of a global population view and zooming out for a second as well. So let me show you some of those examples. So when we started down this road we said, we have a total list, let's look at where those distributions are and their occurrences and their accounts. And from there, maybe to the middle box where we're looking at the provider components, providers and facilities, or systems. And that was maybe even more instructive as you look at ACOs or partners nationally, or if you're maintaining your own network maybe this is even more relevant for you. And then some more value-based cares where we're looking at specific service lines with performance differences from expected. It may be putting the cost piece in there. My bias for our conversation today would be to really use the utilization as the way to help, share our data with you. But I think maybe we should look nationally at cost to give you some sense of that. And maybe that would either affect shared cost calculation, or it could be the basis of a shared savings program innovation. And with Med Supp performing better than the rest of Medicare book of business, then maybe there's even opportunities for some kind of see my kind of activities. (DESCRIPTION) A pie chart appears. (SPEECH) All right. This is all complications. And what are those complications? And you can see its distribution-- UTIs and septicemia and infections being right in there, pulmonary complications, and then GI bleeds complications. And so fully more than half at the first three kind of the Pareto concept right there. This was based on Mutual of Omaha's data. We also looked at how it might be distributed geographically in a heat map version. One of the original versions of this was red and green and I'm a little color-challenge. Given the garanimals dressing style that I've chosen, you might have assumed that, but you can see. And in the live slide, you can mouse over these and it will pop up the actual rates to give you that expected versus actual portion. And then the circle being the volume. And so this was a really data visualization forward version of that. If that didn't resonate for you, there's also maybe a tabular version where you can see. And this is sorted by volume, but then you see expected versus actual and leaders in practice and who might have an opportunity with 1.0 being that normative level of actual and expected being the same. And so you could be able to-- and these are actual hospitals in our system. MPI numbers were redacted and A through O were put in for your viewing pleasure. But I really think that you start to say, I cannot only see what the complications are, I can see where they are, I can see who they're by. And at this point, then you start to get down to something that might be really more useful and helpful. I think you could do it simply by volume and try it by just facility. And in this case, the line in the sand being that 1.0, that you can see that these range from 1.0 to 1.36, and our top 50 facilities. For the sake of spreadsheet management, we did top 50. You might do that as well as you consider how you'd use this. (DESCRIPTION) A bar graph shows analytics by service lines. (SPEECH) The other thing that we looked at was that we looked at GI stuff because of its high volume, and it's a little bit above what we would have liked as expected. But I think you could also look at high risk where there's also above-the-standard performance like orthopedic surgeries. And Sandeep mentioned hip and knee replacements as a key candidate there. And in a senior population that's particularly relevant, I think. So let me give you a couple of different slices, one doing GI, and then one may be doing ortho as well. So this was Medicare Fee-For-Service data. I just wanted before we did that to give you the context. We talked about the utilization numbers, but I want to give you the context of the cost. And you can see for the gastroenterology a $7 million at risk here in Alabama and Georgia. It's a tremendous amount of money in the system for a preventable complication. And when you start to think about how to build contracts or how to manage care, these things become really relevant. It's real money. I don't know where else you live where that's not, but that's a tremendous amount of money. So I wanted to give you just that context from a Medicare Fee-For-Service perspective what that looked like. We'll come back to that as we just talk about the volume of those things. This was for that GI endoscopy procedure where we were looking at the procedure subgroups soon. But the procedure complications were highly bleed-oriented followed by pulmonary and followed by anemia and hemorrhage, and finally, then septicemia or infections. So not a surprising list, but the distribution was really quite striking. (DESCRIPTION) A new slide shows orthopedic complication rates: (SPEECH) I want to jump to-- so look at GI and you look at what kind of things we are or we go down the funnel a little bit and we can tell you where they are, who they're by, and what sub-service line they go to, and then specifically what those complications are. The orthopedics is also a great example. And in this case, our rate was 1.8, which was still below the national average but above where we'd like to be for what is I considered to be a high-risk procedure or service. And in this case, knee replacements having a complication rate that was significantly higher than the others. And that there are-- you'd ask what kinds of complications went with this specific service, which was that root cause. How do I get to the specifics of this particular kind of service? And what you get to is then for knee arthroplasties, you get to a full third being anemia and bleeds. And so really a remarkable level. But the question is, well, who are they, where are they, what's going on, what do you do? And so the good news is that there are-- NIH is a tool kit for post-hemorrhagic anemia/acute anemia best practices-- pre-op, during the operation, and post-op. And so let's say a managed care organization where you can insert a pre-op requirement for anticoagulation management, or you can look at nutrition and you can make sure that home care is all setup or follow-up care set up before the procedure. You could also then insist or if you were a care system then you might go, oh, what do I need to do differently to manage mine? If I knew what mine was, what would I do differently? And we can help you know what yours is and help you drive towards those interventions that might reduce your risk as an ambulatory surgery center, as another outpatient surgery or services, as well as then for follow-up care. And so the good news-- the bad news is there's lots of them. The good news is there are bonafide and established best practices by organizations like NIH and others that would lead to that. And so this is one example of how that funnel led us to anemia and how it led directly to a best practice solution that would be partnerships with your providers, care systems, delivery systems to improve care for our members, quality of care, and the patient experience. I wanted to give you a slightly different slice. I'm being time-sensitive, so I'm zooming-- is to think about looking at a slightly different way, where you might look geographically and you might look at the top number here being the complication rate or the rate above 1.0, as well as the volume. And so you could look at-- in this case, I was surprised to learn that our Western states are in the middle of our volume at the top of our complication rates. And so this is a different way to look at that, that you might be able to examine your population distribution a little bit more globally. I think that the other piece of this was that with millions of dollars involved in the actual procedure costs, there was almost a correspondingly equal portion-- actually, a little bit greater, in complication costs. So when you think about quality of care and you think about patient experience and you think about cost, a full half of these are represented by complication costs. So on the left-hand side, the network potential savings for this-- what is the procedure subgroups, not primary subgroups. I'm sorry, I apologize for that. And you look at the lower GI procedures at $7.3 million and you look at the savings where they live in UTI prevention and septicemia and infection management, as well as certainly other infections and then pulmonary complications. And so when you think about how you would set up contracts or how you might incent facilities or partners, you might be looking at your highest performers to provide them a differential reimbursement. You might be trying to drive all your low performers into opportunities for improvement as part of the puzzle for you to manage, not only the patient experience but ultimately the cost, no mission without margin. And so it's the business of health care for sure and we see it right here. (DESCRIPTION) A summary slide fades in. (SPEECH) All right. So we looked at ambulatory settings. We went down the procedure subgroup inside, a really sophisticated risk-adjustment model, and that our use cases were looking at national averages for complications in comparative analysis. We looked at providers, distinguishing providers, and the network profile. We looked at regional variations. We fed in our side both the business intelligence and the machine learning models that might help us set rates more effectively or partner with our providers more effectively and ultimately improve that quadruple aim in our noble purpose. And then I think as time evolves and maybe you see this in your system more than you see this in a Med sub-system, where there might be some value-based care or contract agreements for quality improvements, whether that's care bundling or whether that's differential reimbursement based on complication rates above or below a benchmark, that might give you some opportunities to take that funnel approach using your data to find your opportunities. Your levers may be different than mine. All right. I ran us almost to the end of time. There may be a couple of questions. I want to offer that if there's questions after I'm glad to follow up with you through the 3M team. Thanks. Thank you, Gregg. There's so much to say about what you just presented. I think for me, it just is, I think, such a testimony to your organization that we're seeing this leadership from a Med Supp plan. I think you're helping to kind of disabuse this thinking that Med Supp is a passive product and it's just a pleasure to see how you are thinking about both the efficiency and the trust fund as well as the patient safety experience. A couple of questions come in. I'll address those before I wrap us up here in two minutes. There is a question about how my patients learn more about these kinds of results. I think in part of that, I think US News has the same idea, at least for those two specialties, but there's such a history of public reporting. And I applaud those efforts by states that have scorecards and other managed care plans of their health systems and I think this all-payer claims databases. So I think that this kind of insight around complications against a benchmark feed very naturally into APCD and public reporting efforts that payers-- I know there's a lot of Medicaid listeners on the phone/ and I also think health systems can now start to use that to talk about how they differentiate and how they focus on safety for this really important part of their service offering. There is another question about hospital-at-home. It's such a great question about this system. We've been thinking about hospital-at-home and using our-- hospital-at-home is such an emerging trend. It is a hospital but it's not institutionalized. And so we've been very interested in running our potentially preventable complication system through hospital-at-home patients and beginning to look at complication rates between those sites that care. This particular system I think is much more procedure-oriented, but there is a analogous system that I think would be really useful. So a PI may follow up with you on that front. Megan's back on. You can see the next steps here. We really invite collaboration. We've started to share these results with providers. They want to validate, dig under. We want to be transparent in the measurement. And so I think there's a lot of interest by providers in measuring outpatient safety. It's been an area where we haven't had as much of a risk-adjusted tool ability. So more to come on that front, more to follow in the next session. So let me turn it back over to Megan Thank you. (DESCRIPTION) A placeholder slide reading "Health Policy Executive Summit" appears. (SPEECH) Thank you again, Dr. Wadhwa and Mr. Kamas.

      A webinar presentation slide with presenters showing on the side.
      • Elective surgical and medical procedures are one of the fastest growing areas in health care expenditures. A new 3M solution identifies and quantifies post procedure complications and excess utilization. This session will take an in-depth look at orthopedic, cardiac, urology, pediatric, and gastroenterology elective procedure complication results. Dr. Wadhwa and our panel also describes how the solution can be incorporated into value-based care arrangements, network selection and evaluation, public reporting, and physician and facility payment penalties/incentives to reduce avoidable costs and measurably improve member experience and safety.
      • Speakers:
        Gregg Kamas, director of Medicare quality and the PDP stars program, Mutual of Omaha
        Yichen Zhang, lead health economist, clinical and economic research, 3M HIS
        Dr. Sandeep Wadhwa, global CMO, 3M HIS
      • View presentation (PDF, 1.6 MB)
    • (DESCRIPTION) Presentation. Improving the value of outpatient care by understanding the healthcare continuum, increasing value and reducing total cost. Three video feeds in the upper left-hand corner with the speakers. Logo, 3M science applied to life. Image, a female health practitioner writes on a whiteboard in a hospital hallway. (SPEECH) Thank you very much, Lisa. So (DESCRIPTION) Slide, improving the value of outpatient care. Analyzing the continuum of care. Three profile pictures of the speakers. (SPEECH) for the next hour, my colleague, Gina Perna, who's regional manager for our 3M HIS state team. She's going to moderate two great sessions. The first is with Lisa Lanier, a methodology consultant and true subject matter expert, who will provide insights on how to understand complication rates across the continuum of care using the ambulatory potentially preventable complication or AM-PPC tool, that you just heard about. Following Lisa, Gina will introduce you to Alyson Schuster, deputy director of quality methodologies for Maryland's HSCRC for state's perspective on reducing patient complications. So with that, Gina, let me turn it over to you. Thank you, Megan. Hi, everyone. Good afternoon. We are so excited to start this session with everyone today. And thank you for joining our policy summit this afternoon. (DESCRIPTION) Slide, 3M trademark ambulatory potentially preventable complications, AM – PPC's grouping software. (SPEECH) Like Megan said, my name is Gina Perna. I'm one of the state regional managers for the northeast portion of the US, located outside of Albany, New York. I am passionate about improving health outcomes, and patient safety, and a huge proponent of the 3M methodologies that are so very valuable in this space. It's a pleasure to be your moderator for the rest of today. In this session, we are going to focus on the ambulatory potentially preventable complication methodology to extend our understanding of complications across the health care continuum-- addressing quality and reducing total cost of care in a holistic manner. When we think about measuring quality procedures in an ambulatory or outpatient setting, there can be many complexities-- the intricacy of tracking patients across a multitude of settings and encounters on top of the complexity that arises from the need to differentiate between not only the procedure that identify the complication of care versus those that cause them. So we will review this perspective with an understanding of how the ambulatory PPC methodology links services-- a patient may have following an outpatient or ambulatory procedure across multiple settings. And Lisa Lanier will help us to walk through that detail. At 1:30, like Megan said, we will transition over to hear from Alyson Schuster, who is joining us from the Maryland Health Care Commission, about their journey and focusing on addressing inpatient quality and their vision for extending quality of care measurement into the outpatient hospital setting. So this will help to provide a concrete customer perspective on how other states have used the tool to address cost and quality in the past and for future considerations. (DESCRIPTION) Slide, current opportunities and challenges. Image, three health practitioners down below have a conversation over clipboards and tablets and shake hands. (SPEECH) As we have been discussing throughout the session and in the past several years, measuring ambulatory care has been a market trend primarily because ambulatory care is one of the fastest growing market segments within the health care industry. With more than 70% of procedures now being performed in the outpatient setting, with limited outcome and quality measurement systems, the impact on patient safety and potential complications that can arise from these procedures can have downstream impacts across the health care ecosystem-- from patient safety, experience, to cost. (DESCRIPTION) Slide, 3M approach to facility programs. Diagram, a circle split into three equal parts labeled as follows, clinically based, risk-adjusted, meaningful measurement. There is a clockwise arrow that outlines this circle. (SPEECH) It's important to understand that the 3M approach to quality and cost is consistent throughout our methodologies. And across the last several decades, facility quality programs should be focused on adverse outcomes that are potentially preventable, meaningful to the patient, and expensive for the health care system. As with all of our methodologies, rooted in clinical and economic research, this latest methodology extends quality across the health care continuum from inpatient facility programs to outpatient and ambulatory settings. To understand this approach, let's go back to 1999 when 3M began its approach to facility programs. At that time, the Institute of Medicine issued its now famous report "To err is human" with its estimate of 44 to 98,000 preventable deaths a year in American hospitals. At the same time, 3M researchers began work on what became the 3M inpatient potentially preventable complication methodology which was released in 2007. Since then, many states have adopted inpatient PPCs. And more solutions were built by 3M to close the gaps in inpatient and outpatient quality, including potentially preventable readmissions, admissions, ED visits, and services. With this ever-growing shift in services, CMS also implemented the hospital outpatient quality reporting program in 2009 and the Ambulatory Surgical Center or ASC reporting program in 2012. 3M researchers began initial research on AM-PPCs back in 2015. And much has evolved since the initial hypothesis, all which has led to the commercial release of the tool in November of 2022. Tracking quality in the outpatient setting lags behind that of care delivered in an inpatient setting, and Sandeep touched on this a bit earlier, for a variety of reasons. While the patient journey within the inpatient hospital setting can be clearly tracked through documentation in a single electronic medical record, once the patient transitioned or is discharged from the hospital into other care settings, you can have disparate EMR systems. And the continuation is disrupted in the ambulatory setting. And so therefore, there can be disparate EMR systems. And tracking across the longitudinal care can be an issue. (DESCRIPTION) Slide, understanding the methodology. (SPEECH) For the rest of the session, we will dive into the logistics of the methodology with Lisa Lanier to understand how it transcends the patient health care continuum and service sites. Lisa has over 25 years of experience in health care information. She joined 3M HIS in 2002 and currently works as a principal methodology consultant in our payer solutions team, where her duties include educating payers-- both private and government entities and provider clients on the effective implementation of 3M patient classification methodology. Lisa, it's a pleasure to hear more about this important tool. How's it going there in Florida today? Thank you, Gina. It's hot down here, but I don't think I'm alone with these hot temperatures around the US lately. Thank you for having me here today to talk about AM-PPCs. (DESCRIPTION) Slide, ambulatory potentially preventable complications, AM-PPCs. Definition. Risk adjustment. Examples. (SPEECH) And so far, speakers have discussed the clinical side of identifying complications resulting from ambulatory surgeries. So now, I'd like to walk through a little bit more about the technical details of AM-PPCs. Like Dr. Wadhwa and Greg were talking about before, a little bit of this is going to be repetition. But take it from me as somebody who has recently learned all about AM-PPCs, repetition is good. So again, the definition of an AM-PPC is a complication of care that develops after an elective ambulatory procedure and may result from processes of care rather than from the natural progression of the underlying disease or illness. And examples of that include post-op infections like pneumonia or sepsis. And as with inpatient PPC logic, we've included a wide range of potentially preventable complications. But it's important to realize that these should be understood as a rate comparison of actual to expected, where high rates of provider complications compared to a benchmark serve as a trigger for review or basis for performance improvement incentives. Keep in mind, there's never an expectation to avoid all complications even under the very best standards of care. So AM-PPCs are identified by comparing an initial outpatient procedure encounter to a subsequent encounter that is reporting a related and credible complication within a designated timing window. The software includes a total of 93 procedure subgroups. We call them PSGs. With 3M, we always have acronyms for everything. And those are used to determine which ambulatory encounters are at risk of being followed by one or more of the 35 available AM-PPC groups. Here are a couple of examples. So patient A has an elective laparoscopic cholecystectomy. Wait, Lisa. Lisa? What is a cholecystectomy? Did I even say that right? Yeah, you did. No, you did. You did. Sorry, that's a medical coder in me. That's my background. And sometimes I use overly technical clinical terminology. So a cholecystectomy is a gallbladder removal. OK, so a gallbladder removal is performed within a hospital outpatient department. And within 30 days, this same patient was admitted as an inpatient with sepsis. And that was indicated as being present on admission. The software identifies the setting of the complication, whether it's inpatient, emergency department, physician's office, or clinic. That helps identify trends within the patient's post-procedural management period and can be used to improve the quality of care and reduce health care costs. (DESCRIPTION) Slide, input and output, AM-PPCs. Input, AM-PPC grouper, output, input pearls, output pearls. Bullet point lists. (SPEECH) The data that's required to perform an AM-PPC analysis comes from commonly available fields-- from either a clinical data warehouse, or from the UB-04, or 837I or P billing forms. Those are routinely submitted by hospitals, health systems, or from payer claims. For those of you familiar with 3M methodologies, the data fields for AM-PPC are similar to those of APCs, EAPGs, MSDOGs, or APRDOGs. See what I mean about our acronyms? And includes principal and secondary diagnoses, HCPCS or CPT procedure codes, with service dates for outpatient and professional claims, and applicable revenue codes for ED encounters, and printed on admission-- an ICD-10 PCS procedure codes with service dates for inpatient claims. For AM-PPC analysis, it's especially important to have a consistent and unique patient identification number over the analysis period, which is typically at least one year. So patient records with multiple claims or encounters are input into the AM-PPC software module. And this module is available within several 3M products, including core grouping software and our cloud platform grouper plus content services. For every patient, the AM-PPC output includes the list of events identified and used within the analysis. This includes a unique event ID, an event type classification, such as emergency room, inpatient, outpatient, along with applicable event chain IDs that link at risk procedures to related subsequent encounters. And all of which are classified using the event status, the procedure subgroups, and the AM-PPCs assigned. The event status is the primary indicator describing how the software used and classified all claim counters supplied in the input. (DESCRIPTION) Slide, identifies locates and quantifies procedural complications. Three columns with bullet point lists labeled procedure groups, complication groups AM-PPCs, and complication setting. (SPEECH) So as I previously said, the logic compares an initial outpatient procedure encounter to a subsequent encounter that contains a related, incredible complication within a designated timing window. So seen here on the left, there are 93 procedure subgroups. These are ambulatory procedure groups that we have considered to be at risk of being followed by a complication. Those complications are categorized into 35 groups that are seen in the middle. And on the right, are the settings or the sites of service where the patient presents with those complications. (DESCRIPTION) Slide, samples of complications. Bullet point lists for lung issues, bleeding hematoma, infection sepsis, and mechanical complications. (SPEECH) And I'm sure you'll recognize this from the first session. Here are a few examples of some postprocedural complications-- so lung complications like pneumonia or other kinds of infections, and then pulmonary embolisms. Bleeding issues like anemia, hematomas, and thrombosis. Infections like urinary tract infections sepsis, and infections of the surgical site. And mechanical complications of devices, implants, or grafts. (DESCRIPTION) Slide, examples of type one through three complications. A table with four columns labeled sample patient type, clinical scenario, day, comment. (SPEECH) So now, let's walk through three examples of complications following an outpatient procedure. And these will show how the methodology looks across the health care continuum and links the complication back with the initial outpatient surgical encounter. That has been missing-- that has been the missing piece up to this point. We know that there are complications after surgeries, but there was no way to link the subsequent visits with the initial one. So patient 1 comes in on day 1 for a bronchoscopy. And that's a scope of the respiratory system. So this procedure is on the list of at-risk procedures. And then on day 4, the patient presents to the emergency department with pneumonia. The emergency department visit is classified as a complication. And this reassigns the bronchoscopy, the initial bronchoscopy encounter to an at-risk with a type 1 ED complication. For patient 2, they undergo a hip arthroplasty, a hip repair or maybe a replacement. And then on day 5, the patient presents to the ED, but their reason for that visit is not related to the hip procedure. That encounter is classified as an emergency department non-event. The event chain continues to look for complications within that timing window, which is usually 30 days. And inpatient admission occurs on day 15. And the complication is present on admission and is related to the initial procedure. And it meets the timing requirement. The inpatient admission is classified as a complication. And the surgical encounter is reclassified to at-risk with a type 2 inpatient complication. And then patient 3 has an outpatient procedure that is considered at-risk and four days later, has an outpatient visit with a related complication that meets the timing requirement. The outpatient visit is classified as a complication. And the initial encounter is reclassified as at-risk with a type 3 outpatient visit complication. And then on day 22, the patient had an ED visit, but it was not related, but is still reported in the chain for tracking and analytic purposes. Lisa, thank you so much for describing these procedures. For those of us who are not clinical, that was very helpful, thank you. What about when a patient has an outpatient surgery but subsequently gets admitted as an inpatient within 72 hours, and I think Sandeep mentioned this in his session as well? I sometimes hear patients asking about the three-day rule. Can you speak a bit about that? Yeah, that's a good question, Gina. Medicare does have that rule. Sometimes people refer to it as a three-day rule, but as Dr. Wadhwa said, it actually is called the 72-hour rule. And that's the next type of complication that the methodology addresses. (DESCRIPTION) Slide, example of type four complication. A table with the same four columns as the previous. (SPEECH) So it's called a type 4 complication. So the patient comes in for an outpatient arthroscopy of the shoulder and elbow. So they're doing a scope and they're also doing a repair, but within 72 hours or three days of that procedure, the patient was admitted to inpatient. So the outpatient charges are merged with the inpatient admission. The procedure precedes the admission date and a complication is noted to be present on admission. The inpatient admission is initially classified as a potential type 4 complication and grouped using inpatient APR DRGs. A complication is identified and meets the timing requirements. So the inpatient admission is reclassified as a type 4 complication with an inpatient admission. OK, so these examples really do help to understand the various complication types and how the grouper really crosses service sites and impacts payment. Now that we've walked through some of these real life examples of the procedures that can lead to complications and where those complications can occur, for those who may be a bit more technical, can you speak about how the tool actually accomplishes this a bit? (DESCRIPTION) Slide, AM-PPC, clinical logic. Five phases of processing. A flowchart with five sections, one for each phase. (SPEECH) Yes, I sure can. So here are the five phases of how AM-PPCs process the medical information, identify pertinent events within the specified time period, and determine applicable complications. So in phase 1, the encounter is analyzed to determine if it's even pertinent. So phase 2 identifies applicable procedures and exclusions. And the hierarchy classifies the encounters. Phase 3 sets the event window and reviews events to establish the chain and determine the final classification of the procedures. Phase 4 looks at inpatient admissions for any type 4 complications involving the 72-hour or the three-day rule. And finally, phase 5 sets the lookback window to identify if any events occurred prior to at-risk procedure. I see. Thank you, Lisa. So seeing the process flow of how the grouper works really helps to frame the different scenarios that the grouper can identify and address. I know if I or any of the family members I have go for an outpatient procedure, and Dr. Wadhwa mentioned this as well, is that I instinctively think that it's an outpatient. So what are the risks, right? It's a low-risk procedure. So we signed that disclaimer without much thought. And even as the poll revealed, almost 50% of the folks on the call have experienced a complication in that setting. So this is really helpful to understand the details and underneath the hood a bit, so to speak. Can you walk us through some more of the timing and the steps of how the clinical logic works? (DESCRIPTION) Slide, how does 3M identify procedures resulting in AM-PPCs? Diagram, a flowchart labeled event window 30 days with labeled rectangles and arrows. (SPEECH) Yeah, of course, I can. Yeah, maybe this next slide will help a little bit because when I was first learning about AM-PPCs, it really helped me understand the flow and how it all works. So this is a diagram of the flow of the logic used to identify and link back the initial procedures with follow-up visits within that event timing window to identify complications. So as you can see at the top, the event window is 30 days. So the patient on day 1 has a laparoscopic cholecystectomy, a gallbladder removal that is considered at-risk. So this starts the event chain. Then on day 7, this patient presents to the emergency department with sepsis that is considered a type I complication because it's happening in the emergency department. The initial encounter converts from an at-risk to an at-risk with a type 1 complication because the complication occurred during the 30-day event window. Gina, does that help to explain a little better how the logic works? Yes, Lisa, thank you. So if I had my gallbladder removed and I get the post-op instructions telling me what to do if there's any concerns, this software is really tracking all of those visits. And it's specifically looking at the duration of time to understand if it's related to the gallbladder. So this is great. Thank you. But have you looked at some actual data to see what kind of complications might be the most prevalent? Yes. (DESCRIPTION) Slide, procedure subgroups, PSGs. A table of data with six columns labeled PSG, description, at risk procedures, E.D. complications, IP complications, AM-PPC rate. (SPEECH) Yes, we have. And this next slide shows the top volume of procedures performed on a Medicare population. So the group before, we were talking about the Mutual of Omaha data. Here are the top 20 procedure subgroups by volume for Medicare population. You can see that the top volume is lower gastrointestinal endoscopy like colonoscopies. Number two are spinal injections. And number three are coronary angiography procedures. Those are your cardiac caths, things like that. And you can see the number of those procedures performed and then the number of emergency department and inpatient complications with the overall AM-PPC rate. (DESCRIPTION) Slide, potentially preventable complication groups, AM-PPCs. A table with data where six rows are highlighted in red. (SPEECH) And here are two list of the top AM-PPC groups by volume. So on the list on the left, you can see, when looking at only inpatient admissions and emergency department visits, that more severe complications like sepsis occur more often. But on the right, with outpatient and physician office visits also included, a lower level infection like a urinary tract infection is most frequent. Oh, wow. That's a big difference when outpatient is added to inpatient and ED. You could, yeah, look at the rates. That's huge. So this is, really, seems like it would be important to know all the various settings a patient may land after an outpatient procedure across the health care ecosystem that might really impact the patient's care, the cost, not to mention quality of life if you're in and out-- trying to get outpatient care. Looking across the longitudinal settings and the continuum of care that follow the person seems really important. Putting the person at the center of you really can help payers and state agencies to understand the best practices and challenges across the entire system. That's exactly right. And we split it out that way because the complication that is addressed in a physician's office, logically, isn't as severe as one where the patient had to go to the emergency department or get admitted as an inpatient. It's important to look at the numbers with a different slant. Right, right. This is fantastic. I wonder if this information might also be helpful for even the provider office staff to have insight into future requests for sick-day appointments following an outpatient procedure, maybe there could be some additional services put in place, like a nurse's line to call if the patient has symptoms, or follow-up calls, telehealth visits for post-op concerns. Even though the professional visits are lower acuity, obviously, any access to care limitations or reduction in resources in one end of the ecosystem could impact other areas of the health care system. We don't want those to end up as potentially preventable ED visits, or some other type of higher utilization, or higher cost service. So my other question is about joint replacements. There's been a lot of discussion. And Dr. Wadhwa mentioned this in the prior session as well. What about knee replacements as an outpatient, are there complications with knee replacements as well? (DESCRIPTION) Slide, data by procedure group PSG 13 primary total knee. A bar graph with subgroups along the vertical axis and numbers from 0 to 1600 along the horizontal axis. There are two arrows that point to urinary tract infection and post hemorrhagic acute anemia which have the highest numbers. (SPEECH) Yes, Gina. And here's an example slide about that. I think this is an interesting way of looking at the data. And this is similar to the previous slide with the Mutual of Omaha data. But this is looking at the procedure subgroup for a total knee replacement. But now, we're looking at the volume of different types of complications that occurred. And on the left, it shows the number of cases that were in the ED or were inpatient. So from this, it looks like anemia and urinary tract infections were the top two complications related to total knee replacements, just like it was with the Mutual of Omaha data. (DESCRIPTION) Slide, financial analysis of potential associated savings. A bar graph with providers along the vertical axis and money along the horizontal axis. Each of the providers is subdivided into inpatient, E.D., and ambulatory. (SPEECH) So here is an example breakdown to understand where the patients are presenting after the outpatient surgery. In this example, it looks like most are showing up in the emergency department, but it's a good way to compare providers or facilities to see the total financial impact of these complications. (DESCRIPTION) Slide, network scorecards. A table of data with six columns labeled facility, inpatient, E.D., ambulatory, at risk cases, observed and expected. Provider seven is highlighted in red. (SPEECH) And this is a good comparison of different providers and their observed versus expected complication rates. So the goal is to resolve these complications in the lowest intensity setting, preferably outpatient and physician office. Post-op follow-up timing may impact whether patients present to the ED or their complications intensify and that requires an inpatient stay. So AM-PPCs identified the outpatient surgery that is the source of the subsequent complication, as well as the setting where the patient presents. (DESCRIPTION) Slide, The value of AM-PPCs, providing an analysis into postoperative complications. Image, a female health practitioner examines data on a tablet. (SPEECH) Well, Gina, that's all I have today to share on AM-PPCs. Thank you again for having me. Do you have any additional questions? Thank you, Lisa, for joining us today and sharing so much detail about this new methodology. And the insight into the tool for this growing market is so valuable, In summary, today, we reviewed the importance of measuring outpatient procedures, and the ability to track services, and complications across to provide payers and policymakers insight into this important segment. So thank you very much, Lisa. Are there any questions before we shift the discussion to Alyson and hear more about the journey that Maryland is on. (DESCRIPTION) Slide, questions. (SPEECH) There are not, but this was a really great presentation, I think. Lisa, just your presentation style is fantastic. So we thank you very, very much. (DESCRIPTION) Slide, for more information. For more information. Gina Perna, MHA, PMP State regional manager, Northeast Regulatory and payment solutions. 3M Health Information Systems Division, 518-698-3854, gperna@mmm.com. Lisa A. Lanier, BS, CCS Principal methodology consultant. Population and payment solutions. 3M Health Information Systems Division. lalanier@mmm.com. https://www.3M.com/3M/en_US/health-information-systems-us/drive-value-based-care/patient-classification-methodologies/am-ppcs/ (SPEECH) If you do have more questions, you have our contact information here.

      A webinar presentation slide with the presenter showing on the side.
      • Industry leaders and subject matter experts take a look at improving outcomes by reducing complications, creating actionable data for providers, payers, hospitals, and researchers, and informing collaboration efforts amongst the healthcare industry, highlights high-performing providers. 3M™ Ambulatory Potentially Preventable Complications (AM-PPCs) provide insight into understanding complication rates across the continuum of care, inpatient and ED complication rates across facilities, and national averages of complication rates for comparative analysis.
      • Speakers:
        Gina Perna, regional manager, 3M HIS
        Lisa Lanier, methodology consultant, 3M HIS
      • View presentation (PDF, 1.3 MB)
    • (DESCRIPTION) Video chatting from her office, Flora Coan appears in the top left of the screen. A slide show appears on the screen beside her, featuring an image of the National Mall at sunset. The red 3M logo appears at the top left of the slide, beside text: "Science. Applied to Life." White text appears center-left on the slide: "Maternal health bundles. 3M Severe Maternal Morbitity solution. 3M Health Policy Executive Summit. July 25, 2023. (SPEECH) Well, good morning and good afternoon again. And welcome to the second session of the second day of our annual Health Policy Executive Summit. I am happy, excited, and thankful to see all of you here. My name is Flora Coan, and I'm delighted to moderate this session titled Maternal Health Bundles, 3M Health Information Systems, Severe Maternal Morbidity Solution. (DESCRIPTION) Flora switches to the next slide, which is titled, "Agenda." A list of black text appears over white beside a QR Code: "1. What is severe maternal morbidity (SMM). 2. Tracking and understanding patterns of SMM. 3. Why 3M Severe Maternal Morbidity? 4. Episodes and maternity care. 5. Moving the needle. (SPEECH) Earlier today, we discussed the topic of maternal health from a legislative/policy approach and from a program delivery approach. In this session, we will take a deeper dive into maternal health. We will discuss how 3M's Severe Maternal Morbidity tool and integrated solutions can help your organization identify and trend for risk-adjusted maternal outcomes. Finally, we will open it up to questions and comments. So it is my pleasure to welcome and introduce my guest speakers. (DESCRIPTION) Images of the two guest speakers appear on a new slide. (SPEECH) So Shannon Garrison, Lead Health Care Policy Analyst for 3M HIS Clinic and Economic Research Group, has been with 3M Information Systems since 2011. She holds an MBA and a master's in healthcare law and has been in the healthcare industry for 20 years, in providers, payer, and government environment. At 3M, she has worked across many commercial and government payers as well as providers and excels in developing strategies to support policy compliance, market growth, and cost and quality target. Shannon has experience in leading the implementation and ongoing support of strategic initiatives, including 3M potentially preventable events, accountable care model, and value-based care initiatives. Jamie McCarthy is a healthcare executive with over a dozen years of experience partnering with payers and large health systems to develop, implement, and scale value-based care solutions for Medicare Advantage, managed Medicaid, and commercial populations. His expertise ranges from pay-for-performance program, to fully capitated risk models, and include all aspects of population health management, including network development, provider contracting, performance reporting, and product development. Jamie is currently a principal strategic consultant with 3M HIS population and payment solutions. Jamie has a bachelor in science in business administration from the University of Vermont and a masters of business administration from Rensselaer Polytechnic Institute. We have a lot to cover in this session. So without further ado, I'll turn it over to Shannon. (DESCRIPTION) Shannon's video appears in the top left, speaking from her office. A title headlines a new slide, "What is severe maternal morbidity." A quote follows from the Centers for Disease Control and Prevention: "SMM is a range of serious pregnancy complications that result in significant short-term or long-term consequence to a woman's health." Text runs beneath the quote: "Tracking and understanding patterns of SMM, along with developing and carrying out interventions to improve the quality of maternal care are essential to reducing SMM." (SPEECH) Thank you, Flora. So we usually spend a bit of the beginning of this presentation really describing the need for what it is we've developed and the analytics suite that we've pulled together, so that we can view a really nice lens to try and get at the problem of severe maternal morbidity. But if you were in the last session, I don't know that I could even come close to doing a better job than Dr. Calvin or Representative Richardson did on forming what the issues really are and really how severe the problem is across the world, but in the US specifically. But what we did do is try and pull in the definition of severe maternal morbidity, just for the sake of making sure that our analytics had a target and that we were driving towards the same area that was understandable. And so we used the CDC's definition, which is a range of serious pregnancy complications that result in significant short-term or long-term consequences to a woman's health. And as you'll see we went a bit beyond the list that they have when we were looking. (DESCRIPTION) A title headlines a new slide, "Scope of issue." Text runs below this: "A greater health system and policy focus on maternal health before, during and after childbirth is needed to prevent serious pregnancy complications and address access to care." Shannon describes a graphic and list of statistics that appear on the slide. (SPEECH) But we did want to stick with that definition. So you can see here that maternal morbidity-- maternal mortality is a major issue, as we discussed in the last session. It actually has risen in more recent statistics from about 800 deaths a year in the US to closer to rising above the 1,200 mark, which is really a frightening fact, that those statistics are getting higher. And also, that is the worst complication that can come out of childbirth. But it's still a small enough number that it becomes sort of hard to track and to see where your focus should be and find where that volume is and where we can come up with the root cause. So the CDC said we shouldn't just stop at mortality, we really want to look at these severe morbidity episodes because it's a problem. It's low-value care. And it causes complications going forward. And you can see that according to the CDC, we were at (DESCRIPTION) Shannon's audio temporarily cuts out, and her video freezes. (SPEECH) about 50,000 [AUDIO OUT] a year, despite efforts to try and curb the growth. And as it shows on the left-hand side of your screen, it's not simply an issue of Medicaid and those mothers that are insured by Medicaid, but also those that are commercially insured as well, which Dr. Calvin spoke to as well. It's 1 in 6 mothers in Medicaid are experiencing one of these severe maternal morbidity events. But it's still 1 in 7 in the commercially insured as well. So having that commercial backing and those dollars is not meaning that these events are not occurring. 75% of those severe maternal morbidity cases were actually identified within the first two weeks of postpartum. So what that means is while we do want to look to that year out-- and unfortunately, not only morbidity but mortality is occurring up to a year out from delivery-- but the majority of them are actually occurring right in that window where we truly should be monitoring these mothers. And the value gets even worse when you start to look at the dollars. So births with severe maternal morbidity cost about 40% more than the births that do not have one of those complications. And much of the extra cost is really at that delivery or shortly thereafter, within those first 30 days. (DESCRIPTION) Shannon switches to a new slde. White text centers a grey background:"How do 3M preventable solutions help address maternal morbidity?" (SPEECH) So how did we at 3M decide that we could use a lens to look at these solutions and help address the maternal morbidity issues? (DESCRIPTION) A value statement appears on a new slide: "Not only do the tools correspond with SMMcomplications defined by the CDC, but 3M Severe Maternal Morbidity further identifies preventable patterns of additional complications, readmissions and emergency department visits throughout pregnancy and postpartum. This solution enables performance monitoring by MCO, facility, health plan or provider group, and identifies sites of care for performance learning, or improvement. Further text appears on the left of the slide: "The CDC lists 21 SMMindicators including blood transfusions, embolism shock, sepsis, renal failure, MI and hysterectomy. This is only a starting point to improving maternal care and patient outcomes. 3M Potentially Preventable Complications (PPCs) have a complication measure for 18 of those indicators, plus many more maternal related PPCS. 3M Potentially Preventable Admissions (PPAs) and 3M Potentially Preventable Readmissions (PPRs) cover the rest plus more related c omplications. 3M Potentially Preventable Clinically related visits to the ED after delivery discharge (PPR-ED) highlight further opportunity to improvement. (SPEECH) We started with that CDC list. And it's got 21 severe maternal morbidity indicators. However, we really wanted to go beyond that and speak to more complications that are occurring. So when we look at our potentially preventable complication suite, we can pick up more complications that are occurring to the mother. And they're a bit more specific and clinically driven with their language. So while the CDC in their 21 indicators has some that are a bit more general, we actually try, with our complications, to be more specific, so that we can get to the analyses a bit more detailed. We also looked at potentially preventable admissions for things like preeclampsia, and potentially preventable readmissions and revisits back to the ED for clinically related reasons to that delivery. So when we pull that in, we're really seeing not just what's occurring during the visit and the delivery at the hospital, but also what's occurring for 30 days out, and those conditions that are severe enough and creating an experience that they need to come back to the hospital for something. (DESCRIPTION) Shannon switches to a new slide. On a graphic, a green arrow points to PPCs and Delivery. (SPEECH) By looking at those numbers, what we've done is we're saying that we're creating a volume large enough that it's beyond that 50,000, that it's going to show us trend in these outcome measures and allow us to look at volume as well as where there's variance, so we can really start to find that opportunity. In this case, we're starting, as we said, with those potentially preventable complications and then going into looking at our potentially preventable readmissions and readmissions to the emergency department, so that we can start to get those first 30 days, those really severe complications. And then we can go back and say, this is the poor outcomes. What was possibly the cause of some of these? (DESCRIPTION) A bar graph comparing the PPC rate at ten hospitals, inclusing both the potentially preventable complications and expected rate of complications, appears on a new slide. (SPEECH) To do that properly, and to do it in a way that we're really trying to find that opportunity, we wanted to look at it in a way that we're comparing a risk-adjusted rate. So you can see, if you look at this chart, that when you look at hospital E, for example, that left bar is a potentially preventable complication rate per 10,000 deliveries. (DESCRIPTION) It reads 148 per 10,000 deliveries. (SPEECH) And while that looks very daunting, (DESCRIPTION) The expected rate reads 190 per 10,000 deliveries. (SPEECH) when you look at the expected rate that's next to it, your experienced rate is actually lower than the expected, which means that that hospital is actually taking on higher acuity mothers and mothers that possibly have comorbidities and a more severe-- that you might actually expect some complications to happen during the delivery. When you look at hospital A, however, though they're experiencing a lower rate of actual potentially preventable complications per 10,000 deliveries, it's actually much higher than what we would expect, meaning they're taking on healthier mothers and still experiencing a high rate of complications and problems. (DESCRIPTION) Hospital A shows a rate of 104 per 10,000 deliveries versus an expected rate of 80 per 10,000 deliveries. (SPEECH) So it's a good place to start to dig in. And it's allowing us to say, instead of looking at every complication, we can focus in on where we can take some action and where there may be some opportunity. (DESCRIPTION) A graph titled "Maternity Actual v Expected PPR ED per 10,000" appears on a new slide. (SPEECH) Similarly, when we look at the potentially preventable readmissions, we can see this "expected to actual." And when we look at just coming back to the emergency department as opposed to truly getting readmitted, even though they're both for clinically related issues to the delivery, we start to then make sure we see even higher volume. So they're about three times more likely to come back to just the ED and not be severe enough to be admitted. However, it's a severe enough complication that they do have to come back. So we want to make sure we track those. In this case-- and these are just example reports of an entire suite of reporting that we've put together to view through a lens that's similar to this-- but in this case, we also wanted to highlight the fact that it may not just be in, perhaps, comparing hospitals, or even comparing regions, but it could be in within a hospital for the type of delivery. In this case, we're looking at, as you can see, you can see the difference between vaginal delivery or cesarean delivery as well as some other breakouts. These are based on our APR-DRGs. (DESCRIPTION) Vaginal Delivery reads 130 expected versus 201 Actual. Cesarean Delivery reads 84 expected versus 133 actual. A new slide is titled, "Ability to dive deep to understand root cauase. Antepartum care." Shannon reviews a Deep Dive Example outlined on a spreadsheet. (SPEECH) So once we've looked at these outcome measures-- and the outcome measures can be used for either an analysis after the fact to see if programs are working, or perhaps programs haven't been put in place yet, or need to be tweaked. So looking at the outcome can then send us back to where that variation is and where there's that opportunity for improvement. And then we can start to dig into those mothers specifically, allowing us to do-- perhaps where there's some root cause. So in this case, we're actually looking at some mothers that have experienced potentially preventable complications as well as potentially preventable readmissions. And we've pulled them together to say, well, what could possibly be the problem? This is all mass data, of course. But when you look at it, we're looking at, in this case, potentially preventable admissions and potentially preventable visits. And when we dig into the admissions and visits prior to delivery, or even prior to pregnancy, it really can show where there maybe isn't an access to care issue or poor quality primary care. And a lot of times it shows that they may have-- either they had a chronic illness prior to pregnancy that wasn't being taken care of because they didn't have that access, or they were going to the wrong side of service because they didn't have that access. So this is really just an example of some of the things that we've examined in these root cause analyses. But there's other-- just to find that area for action-- so some other things that we've looked at, for example, are violence in the background of the mother, which can actually be determined through diagnoses codes and where that diagnoses code has actually come to fruition. So what sort of setting? Did their primary care recognize it? did it get recognized in an inpatient setting? So that not only can we perhaps find the cause, but it can point us towards potential solutions potential programs. It may be that you want to look at, to see if the mothers have smoking in their background or preexisting comorbidities. Or perhaps it's to look and see are they in a region that has put in a program that has doulas or midwives or, for that matter, a rural region that does not have either of these options at their fingertips. (DESCRIPTION) A title on a new slide reads, "3M solutions can serve as the foundation to address health equity." Shannon discusses the text on the slide, which appears beside an animated picture of a multi-racial group putting their hands in the center of a circle. (SPEECH) One of the other things that we've looked at and can be overlaid in this comparison, is to truly start to dig in to race and ethnicity and some of those other SDOH factors. So when we look at our methodologies, they are clinically based. They're all on that clinical level and do not bring things like race and ethnicity into the analyses. And that's purposeful, because then when we overlay some of these factors, we can see where the differences are. And we can see where some of these outcomes and poor outcomes are occurring. And that is really the dividing factor. (DESCRIPTION) A title on a new slide reads, "Quality measurements are risk-adjusted, but what about cohorts?" Shannon discusses the text on the slide, which appears beside an animation of three women. (SPEECH) So while 3M potentially preventable complications, potentially preventable readmissions, as well as those potentially preventable admissions and ED visits are risk adjusted-- and other factors can also be viewed by the occurrence and dig into the root cause and complications-- a cohort can also be very helpful for the analyses to pull it together. And once we have a cohort, we can do things like Dr. Calvin suggested and look across an entire episode, not only prior to the delivery but post delivery as well. And our patient-focused episodes can really create those risk-adjusted cohorts and can do it based on deliveries. And we can do that and use that again for even more use cases, as well as bundled payments. So I am actually going to hand things over, now, to Jamie to get much deeper into our patient-focused episodes and how we would use those for maternal morbidity and maternal care in general in a focus on that. And then come back for questions after. Thank you. Great. Thanks, Shannon. (DESCRIPTION) A white title centers a grey slide: "Patient Focused Episodes (PFE)." Jamie's video feed appears in the top left, speaking from his office. (SPEECH) Thanks for passing over. I'm excited for this opportunity to speak with this group. Before we get into the specifics of maternal care episodes, I want to create a baseline understanding and really walk through what are episodes, why are they important, and really talk about what's unique about 3M's approach to episodes. So what's an episode? A single comprehensive unit of service for the treatment of a condition or medical event. So these are services that are rendered across multiple settings, multiple providers, and within a prescribed window of time. So what's interesting that I think about this is consumers intuitively understand this. This is how we consume healthcare. Something comes up. You go see your doctor. You may see some specialists, get some testing. And by the end of it, you hope to be back better-- back to where you were before. The healthcare system kind of sees these things as separate and distinct interactions that are all managed, coded, and paid for individually and discretely. So the approach works well as a payment mechanism. It doesn't do a great job in incenting high quality, longitudinal, coordinated care. (DESCRIPTION) Jamie reads the text on a new slide, titled "Why are episodes important?" (SPEECH) So why are they important? So they're important for a number of reasons. They're a critical tool that we use to identify and measure sources of variation-- impact cost, quality, and outcome. So really understanding that variation and how it impacts other parts of the episode are key. And it really promotes transparency and communication. So understanding, for each piece in the episode, what's happening outside of each provider's four walls. Provider performance improvement. So what is one doctor doing different than others in the network certainly coordinating whole person care. And I think this was highlighted in the last session, really focusing on the better patient experience I think any sort of healthcare innovation, if it doesn't improve that patient experience, I don't think it's going to be a success long term. So really focusing on that experience of the patient going through. (DESCRIPTION) Jamie switches to a new slide and reads the bullet points. (SPEECH) So what makes our approach to episodes different? So there's really five main things. We're patient-, not disease-focused. We utilize some well-established systems in the market. We're comprehensive. We do a configurable implementation. And the key to all of it, really, is our risk adjustment and our clinical model. So let me go into to each of those points in some more detail. So disease-based approach-- this is kind of the traditional approach to episodes. It generally only includes related events. So you see a lot of time and effort spent on what's part of this episode, and what's part of another disease? So lots of times, trying to figure out which codes should be included or excluded. There's lots of comorbidity exclusion. So some of these can be around age. Some of these can be on other conditions, where they say, these patients are too complex. We're just going to put them off to the side. And really, by doing that, it requires an episode-by-episode customization. At the end of it you're kind of left with this homogeneous, not very complex population that doesn't-- it's not really the people that are driving utilization and cost. It becomes a scaling issue, that, due to these customizations, not only do you have to define these codes, but then you have to update them every year. And then, at the end of the day, you're still managing services, not people. That's, fundamentally, our approach is a patient-based approach. We believe you've got to treat the whole person, just not the sum of their conditions. So we go through and we include all the claims within a specified time period. We do some configuration that allows different markets, different use cases, to meet those use case needs. And we do no comorbidity exclusions. We kind of deal with it with risk adjustment, which I'll show in a bit. So really two fundamentally different approaches. (DESCRIPTION) On a new slide, three maps of the United States outline states that have implimented or commited to All Patient Refined DRGs, Enhanced Ambulatory Patient Groups, and Population Health and Risk Groupers. (SPEECH) The next thing is utilizing well-established systems. So PFEs are really based on APR-DRGs or All Patient Refined DRGs for inpatient episodes. Our outpatient episodes use EAPGs or Enhanced Ambulatory Patient Groupings. And then we use CRGs-- Clinical Risk Groups-- to really focus on the patient disease burden. So these are widely used throughout the country. And really the advantage of using PFE is, for any of the states or plans that have made an investment in APRs or EAPGs or CRGs, you're able to more fully leverage that investment. So when we look at PFEs, it's going to be the same service definition. You're not going to have a debate on what is a COPD versus an asthma admission, right? It's already coded for. Aside from the service definitions, we use a similar weight development and risk-adjustment process and [? perspectives. ?] And really, what this does is it creates the same clinical language that can be used by both clinicians and administrators to really describe what's happening in the market. So for anyone in the crowd, any of the states that have invested in this PFE can help leverage that investment you've already made. (DESCRIPTION) A new slide defines two main types of episodes in 3M's PFE grouper. (SPEECH) Our episodes are very comprehensive. So we have two types of episodes. We have an event episode, which is initiated by a specific health care event. In this case, a delivery would be an episode event. We have actually seven different delivery episodes within the event episode. But outside of just deliveries, we actually have 330 event episodes that we can put together, which is fairly comprehensive from what you see in the market. We also have cohort episodes. So this is all the enrollees within a specific condition over a specified time period. So while the event episode is based on a delivery, cohort episode would be around pregnancy. So we have six different pregnancy cohorts within the episode group, but overall, 123. So we spent a lot of time on making sure that we have a very robust set of episodes, so it's just not a handful of services that we can use. (DESCRIPTION) Jamie switches to a new slide, titled "Configurable implementation." On the left, a list provides options for services, icluding institutional services, outpatient hospital services, profession services, and other services. On the right, a graph details "Services used to Assign CRG," "Post-Event Services," and various "Windows" within these services based on "Time." Below the slide, options for version 2.0 PFE Specification are shown. (SPEECH) The next big thing is our configurable implementation. And I'm not going to go through this slide in a ton of detail. I just want to point out a couple of. Things we allow lots of different options to make sure that we develop episodes that meet specific use cases and market needs. So there's 19 different service buckets, claim buckets, that can be included within an episode. Users can decide which of those 19 buckets they want to include. We have a number of different options for-- in this case, we're looking at an event episode leading window-- so the number of days before the actual event happens, trailing windows a number of days after the event happens. We have lots of options for outliers, readmissions, truncation, the number of days used for the CRG assignment-- all to meet user needs. So while it's not customizable, you can configure it. And really, for each episode that's in here, you literally can do thousands and thousands of different types of iterations. I wouldn't necessarily recommend that. We have-- can kind of walk you through what our recommendations would be. But the point here is, there's lots of things that we can do to make it useful for specific markets. (DESCRIPTION) Jamie discusses a Risky-adjusted clinical model titled "Episodes include risk adjustment for." Columns included are, "APR-DRG," "SOI," "Acute Inpatient Weight," "CRG Health Status," and "Post Acute Weight, CRG Severeity of Illness Level." (SPEECH) And then the coup de grace here is really our risk-adjustment clinical model. So we-- by including all of those comorbidities, you have to have a way to risk adjust to make sure you're doing apples-to-apples comparison. So on the episode acuity, we're looking at APRs for inpatient episodes, EAPGs for outpatient episodes. And then we're layering in the chronic disease burden. We can use up to 12 months of CRG data to really look at that member acuity post utilization-- or, post-discharge utilization that occurs. So the key point here is, I want to make a couple of things. Is one, is really highlight the clinical distinction. So we have within this, four different severities of illness on the actual episode acuity. You've got a number of different health statuses that someone could be put into, as well as different severities within that health status. And so a very comprehensive approach. There are other approaches out there that are not as granular. There are approaches that say, take the total number of episodes, take the total cost, divide one by the other, and there's your average. And maybe we'll do an adjustment on age, maybe on gender, maybe on complications. But really, from our standpoint, this is a problem. It's like describing and saying, the average American has two and a half kids. It's mathematically accurate. But it describes no one. And so this creates a situation where you create an opportunity where people may want to avoid the sickest patients, if you're not of accounting for the differences there. And then, certainly, if you're not avoiding the sickest patients, you have to have enough of the lower acuity patients to make up for some of the higher, severe ones. So our approach we just try and capture and account for the differences and sort of the resulting utilization. The other key thing that I point out here is the obvious, is-- there's weights. There's standardized, national data set weights that are included in PFEs. And this is particularly important when you get into some episodes. And the other side of having this clinical distinction is you can get into small cell sizes. But by having this national data set, by being able to look at small cell sizes and still get expected values, it's a really powerful, powerful way to look at the data. (DESCRIPTION) A new slide uses this model to compare "Practice A,"and "Practice B." Under the "Average Allowed," Practice A has $19,567, while Practice B has $23,827. Under "Percent Difference," Practice A is 10.1%, and Practice B is -7.0%."A greater health system and policy focus on maternal health before, during and after childbirth is needed to prevent serious pregnancy complications and address access to care." (SPEECH) So how does this look in the real world? So by using the risk-adjusted model, we're able to do an apples-to-apples comparison between providers that accounts for the difference in risk. So if you were just looking at practice A and practice B and say this is a set of episodes. It could be anything-- knees, hips. If you just looked at average allowed, you might walk away saying, you know what, practice A is actually looking better than practice B, given that they're $4,000 and change less costly than practice B. But when you account for that acuity, both on the episode and the chronic disease burden of the patients, and account for it in expected values, it actually turns out that practice A is performing over expected. And practice B is actually doing pretty well. And so not only are we able to identify that, but because we've created the episodes, we can dig in and say, OK, for practice A, what's really driving their cost? Utilization. So, obviously, there's a lot of cost in the hospital portion. But you can go within the different components of the trigger event, different components of the trailing window, and really see what's driving their costs. And then compare it to their peers and say, you know what, the reason or at least what seems to be driving that higher than expected cost is what's happening with the inpatient hospital and a little bit on the skilled nursing side as well. So you can start to just-- other than just saying, hey, something's high or low, and you can start to dig down and see really what's driving it. (DESCRIPTION) A white title on a grey slide reads, "Episodes and maternal health." (SPEECH) So we've talked about a background of episodes. I want to talk, now that we have a baseline understanding, it's really, how we're using them to address maternal health? (DESCRIPTION) A new slide, titled "Episodes in practice - maternal health," shows graphics for three moments in care: Antepartum care, Delivery, and Postpartum care. Various services and events appear beneath each time frame, (SPEECH) So, as you know, maternity care has been covered by health plans since 2014. And the benefits vary from plan to plan. But they generally include a number of [? differences. ?] So on the prenatal side, there's prenatal physical exams, labs, and screenings. Coordination Of Care is what the COC stands for. On the delivery side, that covers the actual delivery and associated services, the hospitalization, the specialists, can include lactation consultant-- is the LC here. And then, certainly, in the antepartum-- or, I'm sorry, in the postpartum care, the same idea-- the labs, consultations, et cetera. So a lot of these services are already bundled and paid for through either a global payment or a facility DRG payment. But the payments don't include other related events that are outside the standard of maternity care. So there could be things like potentially preventable events during the pregnancy-- PPAs, PPVs. These could be things such as eclampsia. It could be a respiratory infection that happens in antepartum care, a migraine, an abdominal pain that someone goes to the ED for. There's certain complications that occur during the delivery that may not be covered. And then, certainly, in the postpartum care-- could be cardiovascular issues, hemorrhage, sepsis, a whole smattering of things that could be there. So that's outside the bundle. But it's certainly-- all of these impact the pregnancy. They impact the delivery. They impact the wellness of our mother and child throughout the process. So being able to account for them is important. And really, the issue is that the care delivery across the settings still remains, despite having the global payment very siloed and fragmented throughout the pregnancy and after the delivery. And really, our goal is really to take PFE episodes and go beyond payment and understand longitudinally the difference that different providers, services, systems, settings, communities, have on maternal care. (DESCRIPTION) A series of questions appear on a new slide. (SPEECH) So when we do this-- when we connect disparate, discrete, events within an episode-- you identify many different facets of the patient journey. And as you do that, questions come up. So as you look at it, and you start to create this longitudinal view, you start to say questions like, well, what hospitals are providing the highest quality care, most efficient care? From a physician standpoint, what physicians are providing the best care? And how do we document that? We can look at discharge protocols. How are those discharge protocols impacting outcomes? Or the flip side of that is, maybe it's not the discharge protocols. Is it adherence to those protocols from the patient? And it also includes other things that-- nonclinical So what kind of support do you have at home? Are you by yourself? Do you have a family that can help you out? And certainly, characteristics of the community-- so do you have access to a pharmacy? Can you get to your follow-up appointments? All of which makes a huge impact on outcomes in maternal care. And the reality is, there's not a silver-bullet solution. It's never just one thing. What this enables is to ID the areas that we're doing successfully, ID opportunities for incremental improvement, and really inform how we want to prioritize our investments and our activities moving forward. (DESCRIPTION) Jamie reads through the text on a new slide. (SPEECH) So there's really many practical uses for episodes. We can look at referral management-- who's providing the best, most efficient care? We look at outmigration analysis-- what's staying in the network? And I always find interesting is, is what's staying in the network actually performing better or worse than outside of the network-- is always an interesting look at things. From a network-management side, lots of people are looking at narrow networks. Episodes can be used to help inform that. We've been using episodes to inform looking at linking specialty care to some of the primary-care-based models, ACOs, medical homes. Certainly bundled payment is out there, has been a focus of the market, but generally is one of the most difficult to implement. And then certainly on the health equity side, really starting to use this to identify those hidden inequities in care delivery that we may not even be aware of. But all of it really starts with a bedrock of reporting. So all these things I mentioned here, you cannot do unless you have good, solid reporting. And when I say solid reporting, I mean really understanding where does the variation exist. You'll hear me say that a number of times. It's really understanding where that's coming from. And the other key thing is identifying what kind of behavior you want to incent. We had some discussion on that in the prior session. Then going through and defining how we want to inform, engage the people we need to work with. And ultimately, I think, episode reporting comes down to asking better questions. If we ask better questions, we dig a little deeper, we're going to find out more and more information. And so that gets us to a maternal health case study that we've started. We're really just in the beginning of it as we start to combine some of these pieces. But I wanted to share just anecdotally what some of the things we've started to do. So (DESCRIPTION) A new slide includes a grey line that extends from Antepartum care, to delivery, to Postpartum Care. A line labelled "PFE cohort" extends from antepartum care to delivery, and a line labelled "PFE Event" extends from delivery to postpartum care. Text reads, "3M PFE captures a holistic patient-centered view across the entire continuum of maternal care." (SPEECH) we have looked at maternal care. And what we've done is actually look and say, all right, well, let's take the PFE cohort output, which actually goes from the first instance of the pregnancy EDC up to delivery. And then also let's look at the PFE event that takes the delivery and can go out to 90 days. And let's put that together. And while it's not the full 365 days that a lot of states are moving to, at least it'll start to say, what kind of value can we see as we go forward with it? So we put that together as kind of a proof of concept, and really wanted to start at the ground floor and say, at the 10,000-foot view, let's do something common, looking at normal deliveries and C-section deliveries. So (DESCRIPTION) Graphs on a new slide compare vaginal delivery and C-sections between a "Network Average," "ACO 1," "ACO 2,"and "ACO 3." Text reads, "ACO 3 has the highest c-section rate compared to peers in the same market." (SPEECH) what we have here is-- this is actual data from a client. We have three ACOs within the same market. So same market conditions-- they're not at different parts of the state or whatnot. And we wanted to just see what are some of the C-section rates. And what we found was, there was one ACO, ACO number 3 here, that had a significantly higher C-section rate compared to its peers. So up at over 40%, when the network average was at 30%. And then the other two within the market were just over 30%. And so this analysis is not knew. People do this. You don't need episodes to do this. But typically, the question is, well, why is it higher? And then you have a question of, well, my patients are sicker or have more needs. (DESCRIPTION) A new graph outlines the C-sections by Risk Cohort and compares ACO 1, 2 and 3. Text to the right of the graph reads, "But the fewest number of c-sections that are from high-risk prenancies." Jamie discusses the percentages found in a breakdown of ACO 3. (SPEECH) And it doesn't really progress much further than that. And so we wanted to say, OK, well, now that we see this can, we dig a little deeper and see if we can find other interesting information? So we tried to test that. And so what we have here is along the x-axis ACO 1, 2, and 3. And what we did was take all their pregnancies and using the PFE cohort, grouped them into a normal pregnancy with delivery, which is the light blue, and intermediate risk, which is in navy, and high-risk pregnancy, which is in kind of this royal blue. And at least as defined by the PFE grouper, ACO 3 actually had the highest number of normal pregnancies compared to their peers. They had the lowest number of high-risk pregnancies. And they had the fewest number of C-sections coming from those high-risk pregnancies. So the idea that it's just sicker patients, at least by this measure, didn't seem to hold water. So that's a little bit more information. But we wanted to dig a little bit deeper and say, OK, well since we're seeing this variance, what other kind of variants are we potentially seeing? So we said, well, let's look at what's happening prior to delivery. Maybe there's something there. (DESCRIPTION) On a new slide, the dollar-cost for ACO 3 are outlined in red on a bar graph for three conditions: normal pregnancy with delivery, intermediate risk pregnancy with delivery, and high risk pregnancy with delivery. In each case, the dollar amount is higher than that of ACO 1 and ACO 2. (SPEECH) And so what you see here, along the x-axis, is-- now I've got the cohorts-- so normal pregnancy, normal risk, intermediate risk, and high risk. And then the bars are ACO 1, 2 and 3. So ACO 3 is this royal blue. And in each instance, ACO 3 had the highest average antepartum allowed, across all risk cohorts and delivery times. So across the board, they were higher-- in some cases significantly higher-- than their peers. Again, I want to reiterate, within the same market. So again, this gives us a little bit more information. But you answer one question, you get half a dozen more that you want to answer. So we went down and said, well, what's driving that cost? And so, within ACO 3, we found that the high utilization was in radiology, office, and lab, across all risk cohorts. So this was across the board. And so we dug deeper. And anecdotally, the radiology was not necessarily what was being done. It was where it was being done. So a lot of hospital-based services here. With the professional lab, one of the things that jumped out was, there was a lot of genetic testing that was being done here. And so, you start putting these pieces together. And so, now we've got ACO 3 that we can say has a higher C-section rate, lower patient acuity as measured by PFC episodes, higher antepartum costs and utilization. And something we didn't show here but we looked into, there was no discernible impact on better post-acute outcomes than anyone else in the market-- nothing at all. And so, we have to be careful not to be pejorative when we look at this, but really, just note variation and try and understand the why. And so it's not to say that something bad's happened, but to say, ask better questions. Not only are we seeing higher C-section rates, but we're seeing all this. Help us understand why your needs are different than others in the same market. And it becomes a much richer conversation than just arguing about the C-section rate and the "my patient is sicker" conversation. And so we've just started this. But there's layers that we're looking to go into. So there's additional analysis drilled down into other components of maternal episodes-- so different regions, different provider groups, different individual providers we can go down to. So one of the questions is, when you see something like that is, is it systemic? Is it everyone in that particular ACO that's driving it? Or is it a couple of providers or a couple of groups that are really causing that? Anecdotally, in that instance, it was something that we started to go into. But you can start to dig into. But beyond that, you can do member subpopulations. So are there different products that may be driving it? Maybe it's the benefit design that's driving some of these differences-- different geographies, demographics, nonclinical attributes that are impacting performance. And really, as you're looking at this, is really trying to understand all those different pieces. And I like to think of it as almost like a giant Rubik's cube. You can keep shuffling and moving depending on your perspective to find that key point that may drive some insight. So that's one of the things you're doing is that drill down, looking at adding social-determinant data, nonclinical data, again, seeing how that impacts performance. And I think the thing that we're most excited about-- or at least, speak for myself that I'm excited about-- is that idea of version 2.2 of PFE coming out by the end of the year. So this includes updated versions of APRs, EAPGs, and CRGs, updated weights and expected values. And probably most exciting is the inclusion of a pregnancy postpartum option for 365 days. And so this is kind of a game changer with some of these enhancements that we'll be getting by the end of the year. So we're excited to work with that. That being said, I would say, as people are interested, if they're interested, not to wait for 2.2. There's definitely a learning curve with all of this. And so if some of this is of interest, definitely reach out. There's a lot that we can tell now, even without some of these updates. (DESCRIPTION) A title headlines a new slide: "Create a solid quality program for maternal health that is efficient, effective and equitable." Below this, Five squares containing text appear along an arrow. Jamie discusses the text in each square. (SPEECH) So really, what we're trying to get at is, we've got a lot of different coals in the fire, so to speak, that can really help move the needle depending on where people are at, and really focus on trying to meet our clients with where they're at. And so, whether it's the maternal morbidity solution that Shannon discussed earlier, whether it's looking at some of the episodes, whether it's a combination of those two or something different, we can really help along that way. And so our goal is to create that solid quality program for maternal health that's efficient, effective, and equitable. And really, there's really five steps. So it is defining maternal care holistically. The second part is risk adjusting, really making sure we're making those fair comparisons. That overlay of nonclinical data-- race, gender, SDOH, and really with a focus on areas of interventions. And, I can't stress enough, identifying what do we want to incent? If we can define that, we're going to be in good shape to really come up with interventions that will have an impact and take action. I think with all of this, there's only so much you can do until you get out there and you try something. And we learn, get better, and improve. So it's kind of that cycle over time. So that's everything I had. I think, Flora, passing it back to you. (DESCRIPTION) Flora re-appears on the video screen and speaks from her office. (SPEECH) Thank you, Jamie. Great, great information. I mean, great presentation. Lots and lots of information, wealth of information provided here. So while you were presenting, we received a few questions. And I hope that we can get through all of them. But just for the audience, in case that we don't get to all of them, we'll follow up with email. So, the first question is, "Is there any consistency in the steps of commercial health plans are taking to address SMM, or are the efforts all over the place?" (DESCRIPTION) Shannon: (SPEECH) So, I can take that one, Flora. I think all over the place is probably closer to the facts. And it's not just commercial. It's states. It's really across the board. And I think because there's an urgency to get going and get started. And there's really nothing wrong with that because a lot of-- I think what will be found is that there's definitely going to be impact from what's being done. But that's what we're trying to do in part as well, by looking at these outcome measures because it may be that just something needs to be tweaked. So there's process measures that are being put in place. There's an increase in doulas in some places, or a higher reimbursement for it. There's home visits postpartum. And there's other places and other commercial plans that are just saying, let's just look at everybody who-- every mother who has a comorbidity going into the delivery. And which are, none of those are bad things. They'll improve. But-- and I think that's where we're looking to. Where can you prioritize? How can you really, even if you're going to use the same program, are there certain aspects of that mother's background or maybe just, then, in the case of what Jamie just showed, maybe there's an accountable care organization that we can look back and say, hey, let's grab some best practice and really start to hold this ACO truly accountable for what's happening with those mothers, so that it could just be a tweak. Or it could be a prioritization in the list. There's only so many people that can do this work effectively. So what we want to do is make sure that we can prioritize where they are. And hopefully looking at those outcome measures and looking back in the retrospective way, we can stop-- prospectively stop it from happening again-- stop some of these maternal morbidity and maternal mortality statistics from even occurring, because we intervened ahead of time with the right mothers. (DESCRIPTION) Jamie: (SPEECH) And just to jump in there, too, Shannon, I think it's important-- everyone's interested. We can't boil the ocean. And so, what we really try and do is be thoughtful in our engagement, meet people where they're at, and really come up with a strategic plan to say, OK, based on where you're at, we recommend you start here. And we start here. But that doesn't mean we finish there. We're going to learn some stuff. And as we expand, we can decide to stay there, if that's where we think we need to be. If we need to grow into something more, we can do that but let's leverage what we did prior. And so I do think it's important that our clients and that 3M, that we're thoughtful in that approach to making sure that we don't run everyone ragged, try and do everything and nothing really gets done in a cohesive manner. So we're very careful to make sure that we of meet our clients where they're at. And kind of build that plan that makes sense for them. (DESCRIPTION) Shannon: (SPEECH) And for that matter, to build on that, Jamie, too, and meet the providers where they're at. So a lot of our outcome measures, they're an outcome that they don't specifically say, this is what you need to do differently. What they do is allow us to say, hey, something needs to change, here. And we can discuss different options that can change. And the provider can fit in what works best for them. (DESCRIPTION) Flora: (SPEECH) Great, Thank you both. The next question is, "What are approaches to using these tools in developing value-based programs? Please describe examples of how we can use the tools to help hold facilities and providers accountable." (DESCRIPTION) Shannon: (SPEECH) It's a great question. So I think when we speak of value-based programs, I think it's really important to realize the true meaning of that value. So it's not just lower dollars spent. So, yes, we all want the healthcare system to be less expensive. We all want to be able to use those dollars in other parts of the healthcare system. However, really making sure that that quality level stays at a high level or improves, I think is very important when creating a value-based care program, any value-based care program. So when we look at, and these outcome measures are that 3M has are a very good measuring stick to how it's occurring. Because, again, they don't say how you necessarily have to do it. They're just saying what is happening on a clinical basis that is creating these, that is an actual adverse outcome. And when you layer in-- and Jamie can speak a little bit more to the episode grouper-- but it's a way to pull things together as well, as well as with some of our other tools like our clinical-risk groups, to say that not only are we looking at your quality, but we can look at your dollars comparatively. And we're comparing that apples to apples that Jamie spoke of, not pitting, you know, should you be selecting these people based on the healthier. We don't want anyone to select the healthier mothers because they're not being judged on that risk-adjusted basis. (DESCRIPTION) Jamie: (SPEECH) And just to piggyback on what you said, Shannon, I've worked in network management prior. And it really comes down to relationships. And some relationships can be adversarial. Some are not. But I think part of it, as we get closer and closer, the days of pitting one against the other, really, in that example where we looked at ACO 3, my guess would be that they had no idea that they were doing things higher or to the degree they were being higher. The other side is there could be legitimate reasons for those things. So it just enables a better, richer conversation to say, hey, this is what we're noticing. Help me explain it. It may be they look at it and were like, well, gee, maybe we can pare some of that back. Maybe we are kind of over ordering some of the lab tests. Or it may be, actually there's a legitimate reason why we're doing that, and here's why. And so, it just, at the end of the day, with any of these arrangements, it's going to come down to relationships. I know it's kind of cliche, but this gives a tool to just say, all right, let's look at it. If there's questions about the methodology-- it's one of the great things I love about our stuff is we can get into such detail of how you got put into this risk category, blah, blah, blah, that it kind of takes the defensive away from everyone. And then you're just actually trying to solve health problems. (DESCRIPTION) Shannon: (SPEECH) I do think that this-- that some of these episodes as well, can come into play when identifying these cohorts and looking at it in that respect for existing value-based programs. So I think that's something to be thought through as well. We're talking to some payers that are saying, well, I have an existing value-based program. But do I hold my primary care doctor accountable for these women who are really seeing their OB-GYN, but they're not part of my group. And I lose contact with them. So is there a way to use some of these tools as well to either make some of those decisions on what's included in your value-based programs, what's a separate value-based program, or how can you complement that program by enabling those conversations to occur. Because now you can see where some of that opportunity lies for perhaps just better communication. (DESCRIPTION) Flora: (SPEECH) Thank you. Maybe one of you have used an acronym. We believe in and don't we love acronyms? So a question was, "What is EDC?" (DESCRIPTION) Jamie: (SPEECH) It's Episode Diagnostic Category. And so it's part of the CRG output that, if there's more information-- there's a whole roll up of things that happen in CRG. And I apologize for letting one slip through there. But if that person has additional questions on that, if they reach out, we can give you the gory details. (DESCRIPTION) Flora: (SPEECH) Thank you, Jamie. The next question says, "We want to use the tool for SMM. How do we get started?" I think I'm going to take that question. So, great opportunity-- we recognize that your agency might be managing competing priorities. So for that reason, what we are doing at 3M is offering an opportunity to collaborate with your agency in using the SMM solution. Your agency might already have some or all of those methodologies that we discussed today. If they do, great. Then, what we are offering is what we call the early adopter proposal. So that we want to work with your organization in starting the process. Like Jamie and Shannon mentioned, we want to meet you where you are. And see what we can do to help you move that needle. So if you are interested, feel free to contact me, or contact your specific regional manager or any contact at 3M. Somehow that information will get back to us. And we'll be happy to collaborate with your organization in helping you implement 3M SMM solution. Next question. It's more like a comment. So it says, "This is great. Thank you. This is more of a comment versus a question. So in the situation where the patient, or in the case of Serena Williams, where the patient had a blood clot in her maternity episode, a state or health plan or an ACO who clearly analyze complication in their episode connected to blood clot, potentially an adjustment-- potentially an opportunity for patient education on these symptoms or telehealth visit post-discharge for higher risk patient to assess a symptoms that may point to blood clot, like shortness of breath, et cetera." Any thought on that? (DESCRIPTION) A new slide reads, "Closing remarks." Shannon responds to the question: (SPEECH) Yeah, so I think that's a good point. Our methodologies, what's really great about them, is-- and Jamie made the point earlier-- when you see a complication, it's not just, here's the complication. There's the clinical reasoning behind the complication. And then you can dig down deeper into the grouper on why that was actually flagged as a complication, what could have been-- it can tell you possible driving reasons for that complication. And then you could dig further and say, OK, well is that complication occurring a lot in that hospital? Is this something that is occurring based in that region? Is there something in her background that maybe-- maybe those are mothers that need more education, if we find something in her background. It's Serena Williams, so I'm assuming she's not a smoker. But, as an example, maybe if you found that sort of a blood clot you would find that. Or perhaps she has a family history of blood clots in other surgeries. And that's something that if you were to discover that, you could go back and say, OK, these are mothers that when we see this in their background, we want to flag that because we want to have that conversation with them and their doctor. (DESCRIPTION) A blonde woman speaks from her office: (SPEECH) Thanks, Shannon. And, thank you, again, everyone, for joining us today. Thank you to our great speakers-- Mr. Calvin, Representative Richardson, Jamie, Shannon, and Flora. I'm sure you all agree, we had great information today to talk about this important challenge. Please join us again tomorrow for our final day with two more great sessions to look back on lessons learned. And then looking ahead to critical issues related to payment policies and systems. Thank you so much for your time. And have a wonderful rest of your day.

      A webinar presentation slide with the presenter showing on the side.
      • This panel discusses how 3M™ Severe Maternal Morbidity solution addresses not only the CDC’s 21 severe maternal morbidity (SMM) indicators but also a consortium of preventable complications from antepartum through postpartum encounters. Our subject matter experts will address how to pinpoint and solve SMM complications efficiently and effectively.
      • Speakers:
        Jamie McCarthy, principal strategy consultant, 3M HIS
        Shannon Garrison, lead healthcare policy analyst, 3M HIS
      • View presentation (PDF, 1.7 MB)
    • (SPEECH) And (DESCRIPTION) Presentation. Text, on 24 for a better webinar experience. Screenshot, a webinar interface with different boxes labeled slides, speaker bio, survey, live stream, resources, Q&A. Logo, 3M, science, applied to life. A video feed with a speaker along the left side of the screen. (SPEECH) welcome to our final day of the 2023 3M Health Policy Executive Summit. We (DESCRIPTION) Slide, 2023 3M H.P.E.S., Welcome. Health policy executive Summit 2023, solve problems. Establish strategy. Logo, 3M, science applied to life. (SPEECH) appreciate you being here. If you were not here the first two days, we will be posting the presentations that we can share on our website in the next couple of weeks. So if you would like to listen in to those after or if you'd like to listen to a presentation again, those will be there. Before (DESCRIPTION) Slide, housekeeping. A bullet point list. (SPEECH) I hand things off over to Megan to get things started, I'm just going to go over those housekeeping items again. We are utilizing the ON24 platform. So if you are experiencing any issues, check your VPN settings, make sure you're using Chrome. And if you are having any audio issues, we do recommend doing a quick refresh. That usually helps any of those issues. You do have the ability to move your engagement tools around. So if you want to make the slides bigger or the media player larger or if you do want to minimize any of those engagement tools, you certainly can. Within that media player, we do have closed captioning available, if you do need that. We do encourage as many questions, and we'll get to as many as we can at the end. In the Engagement tools, you'll see a Q&A box. Put your questions in there. That'll just help our moderators and presenters see questions easier. And then you also have the chat feature as well. So if you do want to chat with attendees on the content, you certainly can. But again, if you can put questions in that Q&A, that will certainly help us out. In the Resources section, we do have the agenda as well as our speaker bios and presentation slides. So make sure you download those, if you're interested. And then lastly, at the end of the presentation today, we will be having a survey. So please let us know how we did. That'll definitely help us in the future. So let's go ahead and get things started. I'm going to pass things over to Megan to introduce our speakers and sessions today. Megan. (DESCRIPTION) Slide, Welcome day three, July 26, 2023, payment and finance policies. Health policy executive Summit 2023, solve problems. Establish strategy. Logo, 3M, science applied to life. (SPEECH) Thanks so much, Lisa. Welcome, everybody to day 3 of our 2023 Health Policy Executive Summit. We're glad you're here today as we dive into health care payment and funding policies. Probably one of the single largest and most influential changes of how we pay for health care was the adoption of the Medicare inpatient prospective payment system about 40 years ago. It will adopt-- I would say adopt, excuse me, to address Medicare financial needs and the lack of uniformity across the country on how hospitals are reimbursed. Today, CMS is looking closely at policies around state-directed payment programs, which are integral strategies for states to finance their Medicaid programs reportedly to the tune of about $70 billion. CMS is proposing ways to improve oversight and transparency as well and ensure the programs align with value-based payment and quality, and our panel today will share their thoughts on those state-directed payments in the proposed rule. So (DESCRIPTION) Slide, your participation is encouraged and appreciated. Three icons, information between three figures in a text bubble, a question between two figures in a text bubble, and a megaphone. (SPEECH) just as Lisa said, a gentle reminder, we really want to hear from you today. So please use that chat feature to share your thoughts and comments. And remember to use the Q&A section for questions today. As I shared before, these sessions are being recorded and-- or as Lisa shared, these sessions are being recorded and will be shared after the summit. (DESCRIPTION) Slide, prospective payment, what we have learned in 40 years. A profile picture of the speaker. Text, State directed payments, the good the bad and the ugly. Four profile pictures of the speakers. (SPEECH) It is my great pleasure to introduce, for our first presentation today, is Rich Averill. Rich is an international authority on the development of classification case mix, quality utilization review, and reimbursement methodologies. He is a principal at the Hesperian Group today, but all of us three members know him from his years of leading our 3M Clinical and Economic Research team and managing the work the team does for the Centers for Medicare and Medicaid Services, or CMS, on diagnosis-related groups, DRGs, outpatient prospective payment, ICD-10 procedures, and so much more. Rich has worked with the World Health Organization, the State of New Jersey, State of New York, Department of Health, the National Association of Children's Hospitals, and many other organizations through the years. Rich has been a leader in driving the language of value for over three decades, one of the original developers of DRGs to tackle hospital cost variation back in 1980s. Rich will discuss today what he's learned over those 40 years and provide some recommendations on what additional steps may be warranted today for our payment system. After Rich is done speaking, he will hand it over to the moderator for our last session of this year's summit, and that's Matt Ferrara. Matt is a regional manager with our state team and former director of quality oversight for Texas Medicaid. Matt will introduce his wonderful panel of speakers on the topic of state-directed payments, the good, the bad, and the ugly. The session comes on the heels of the deadline for submitting comments to CMS on their Medicaid proposed rule, looking at quality transparency, including those state-directed payments. I expect this will be a lively discussion then. So Rich, let me turn it over to you. Thanks so much for being with us today. Thank you, Megan. (DESCRIPTION) Slide, prospective payment after 40 years, what we've learned and can apply forward presentation. Image, a female health worker writes on a whiteboard in a hospital hallway. (SPEECH) Well, 40 years later. 40 years goes by pretty fast. And I dare say everybody on the phone has only known hospital payment under DRGs. So what I wanted to do was give you a little history of how it came to be, and then talk a little bit about what we might do next. (DESCRIPTION) Slide, original research objective, to develop a new approach to hospital management. (SPEECH) Well, this little quote here is from the very first article that the group of us at Yale wrote about DRGs and what we intended to do. And you can see the language was very much industrial, quality control. We talked about customers who consume similar resources and for whom the production process follows a statistically predictable path. We were totally thinking about creating a management system. We had absolutely no conception or idea that this would ever become a reimbursement system. (DESCRIPTION) Slide, casemix cost accounting. (SPEECH) So we spent about five years creating the DRGs themselves. And then we realized that we had to develop a new cost accounting system. So we developed a method of essentially accounting for and giving a financial picture of the cost of treating individual patients grouped into what we ultimately call DRGs so we could understand the amount and type of resources that they were using. So first, we built the DRGs, then we built a financial accounting system. (DESCRIPTION) Slide, D.R.G. 131, arrhythmia and slowed conduction with insertion of heart device. A table with four columns labeled 1975, 1976, difference, and percent. Another table with five columns labeled cost center, unit cost, unit cost, difference, and percent change. (SPEECH) Now, what I'm showing you right here is actually the first ever essentially management report using DRGs. We were using Yale New Haven Hospital data from 1975 and 1976. We put this together. We met with all the leadership of Yale New Haven Hospital. Thought we had done a great thing. This is essentially pacemaker insertions. And if you look at the med surg supply line, you could see that the cost of pacemakers between '75 and '76 had gone up 66%. So we thought that was an important thing to know. The reality was we were met with polite disinterest, don't call us, we'll call you. And so there was basically just disinterest in this kind of information. We came to realize, which actually should have been obvious, that Medicare was paying costs at that time. So if you became more efficient and you managed patients better, you got less revenue. So there is absolutely no incentive for hospitals to take a look at this kind of management information. (DESCRIPTION) Slide, realization. A light bulb icon. (SPEECH) And so we had a realization that look, if we're going to actually have people interested in what we did and what we were doing, we realized we're going to have to use the DRGs as a payment tool. So that was a realization that we could set goals based on DRGs that are balanced to reflect the interests of both the public and the industry. And so we set out on a multi-year journey again to move into the payment space. So our first project was with the State of New Jersey who wanted to do an all payer DRG-based prospective payment system. So we spent three years, almost four years doing that, getting that operational, looking at the benefits of that. During that whole time, working closely within the Health Care Financing Administration in terms of what we're doing. (DESCRIPTION) Slide, In 1983, Medicare proposed a D.R.G. based PPS. 1982 Health and Human Services department, report to Congress. (SPEECH) And at that point in time, early '80s going into '82, the hospital Medicare Trust Fund was on the verge of bankruptcy. And so the then HCFA in Congress was at a state where they really said, we have to do something fundamentally different. So after a big review, the decision was made to essentially say that we're going to switch from cost-based payment for hospitals to a prospective DRG-based payment system. This is an actual quote from the report to Congress that proposed the DRGs. And it's succinctly summarized what was about to be done in the thing that I have in italics, that what they were trying to do was set a reasonable price for a known product. So basically, move from cost-based to a product with a price type system. And (DESCRIPTION) Slide, Dramatic reduction in cost of hospital care. (SPEECH) so that got implemented in October of '83, and it was a dramatic success, far exceeded anyone's expectations. Got to remember, when this was implemented, it was budget neutral. So there were no baked in savings from the system. This was a great New England Journal article that summarized what actually happened. And so expenditures from the hospital trust fund for 1990 are expected to be $18 billion less in 1990 dollars than was expected shortly before prospective payment went into effect. That was an equivalent of lowering the cost to Medicare of paying for hospital care of roughly 20%. So it was an astounding success. That $18 billion in today's dollars would be more like $35 billion to give you an order of magnitude. It literally changed everything. And so we had a tremendous success there. (DESCRIPTION) Slide, why the D.R.G. based IPPS was effective. Federal Register. (SPEECH) And CMS, at one point, around 2000, stepped back and said, well, why was this so successful? And this first line here said, "The success of any payment system that is predicated on providing incentives for cost control is almost totally dependent on the effectiveness with which the incentives are communicated." Stated another way, how you paid was also a management tool. So simultaneously, it was a means of paying hospitals, but it was also a means of hospitals managing different. So essentially, what happened with the new management tool, the behavior change, that behavior change was substantive. And ultimately, it proved to be sustainable. That went on for many, many years. So the basic lesson was that, look, if you're going to have an incentive-based system, it can't just be a payment system. It also needs to be a management system for those people who are being regulated by the system. (DESCRIPTION) Slide, evolution of IPPS. The Medicare IPPS 40 years later. (SPEECH) So over the past 40 years, there's been a gradual evolution of IPPS. But for the most part, the 80%, 75% of what we put into effect in '83 has pretty much been there. So although the IPPS savings have been permanently incorporated into the underlying cost of hospital care, those savings largely occurred during the initial decades. And so yes, we got the 20% and future increases were off an amount that was 20% lower. And that certainly sustained the program. But in terms of new savings, CMS really hasn't achieved really new savings over the past decades or so from IPPS. (DESCRIPTION) Slide, expanding the services in the IPPS payment bundle to a hospital episode of care. (SPEECH) So how do you do that? What would you do? If you want more savings out of IPPS, what are some things you could think about? Well, certainly, one of the things that one can think about is essentially, well, making the DRG payment bundle bigger. So let's include post-acute care, let's include readmissions, let's include anything that happens to say 30-day post discharge. Well, CMS is dabbled with that. It's put up a number of programs, but none of those programs have really led to substantial savings. One of the problems is that as you put in very expensive items into the base cost like readmissions, payment accuracy decreases, provider risk goes up. And so while that, I think, in the long-term is potentially an avenue CMS can go down, I think there might be a better alternative to think about. (DESCRIPTION) Slide, expanding the aspects of performance used to determine IPPS payment. (SPEECH) And the alternative is to say, instead of adding more dollars into the DRG bundle, what we should maybe do is adjust the DRG payment for more aspects of care. So yes, we're looking at the basic cost of providing care that's in the DRG price. But we should also start adjusting that price for a larger and larger series of aspects of what we would like to see hospitals do. And so what it suggests here, in an article we wrote back in 2016, is to focus on a few outcomes that have a large financial impact and shift payment policy, IPPS payment policy towards getting value instead of increasingly complex attempt to measure value. And so what we want to roll into IPPS is adjustments for a broad range of things related to inpatient care. (DESCRIPTION) Slide, adjusting IPPS payment for quality and delivery system performance can create the equivalent of a hospital episode. (SPEECH) So as listed on this slide, the suggestion is, well, let's look at complications. Let's look at readmissions. Let's look at post discharge ED visits. Let's look at surgical mortality. Let's look at post discharge PAC facility admissions. Let's look at a wide range of different-- [AUDIO OUT] (DESCRIPTION) Video of the speaker freezes temporarily. (SPEECH) --measures of performance that are related to hospital care through norms like the DRG price, but what's national surgical mortality rate for bypass surgery, for example? Let's look at those things. Let's set national expectations. Let's look at performance relative to that, and then let's develop a payment adjustment to the DRG rate that reflects performance on those. Essentially, what this would do is create a pseudo episode because it's adjusting for the various things that would normally affect episode cost, but not have to get into the whole problem of coming up with a comprehensive single dollar amount that includes all of those. So (DESCRIPTION) Slide, criteria for selecting quality measures. A numbered list. (SPEECH) if one wanted to do that-- we've done a lot of experiments over the years with payment systems for Medicaid and commercial insurers, and these nine points are the things that we think are really important. If we're going to add other factors in there, which should be a substantial financial impact. Those things should be outcome-based, focus on outcomes of care, and not processes. It should be comprehensive. If we're going to look at complications, look at them all. Always remember, we're trying to change behavior, we're trying to have cultural changes in terms of how hospitals are managed. And so anything that we're going to look at should be comprehensive. What we include should be actionable. It should be realistically that the hospital could do something about it. We should have a risk adjustment for any of those quality type measures that is DRG like, so it's based on categories of patients. So we could set a norm. Payment adjustment should be proportional to the financial harm that's done. And then some administrative things like no additional administrative burden. And it could be scalable to all payers. And of course, it should be transparent so there'd be no black boxes. So these are the kinds of things or the kind of criteria we would want to have. So (DESCRIPTION) Slide, summary. A bullet point list. (SPEECH) in summary, what I've gone over is what IPPS did was set a clinically credible performance standard, the DRG price by type of patient to DRG, with variation from the DRG price resulting in a profit or loss that was directly proportional to a hospital's performance relative to the DRG price. So truly a product with a price. |PPS was successful because it was based on a hospital management tool that revolutionized how hospitals were actually managed. It was more than just the payment system. So the next phase of the evolution of IPPS should adjust IPPS payments for quality and delivery system performance to create the equivalent of a hospital episode of care. So that's a quick journey down, how IPPS came to be, and some suggestions of what we might think about in the future for IPPS.

      A webinar presentation slide with the presenter showing on the side.
      • With the 40-year anniversary of the Medicare Inpatient Prospective Payment System (IPPS) approaching, there have been many lessons learned and key takeaways that can be applied to expand the scope of IPPS moving forward. Please join former 3M Director of Public Policy, Rich Averill, as he takes a look at some of the most important takeaways from the past 40 years of IPPS, and what to expect as the program continues to expand hospital incentives to reduce costs and improve quality of care.
      • Speaker:
        Richard F. Averill, principal, The Hesperium Group
      • View presentation (PDF, 1.1 MB)
    • (DESCRIPTION) Video chatting from his home office, Matt Ferrara appears in the top left of the presentation screen. A slide show appears on the screen beside him, featuring an image of the National Mall at sunset. The red 3M logo appears at the top left of the slide, beside text: "State directed payments and the CMS proposed rules. The good, the bad, and the ugly. A conversation with Medicaid leaders on challenges and opportunities. Health Policy Executive Summit 2023. Solve problems. Establish strategy." (SPEECH) Thanks. So welcome, everybody, and thanks for being here for the third day of our Health Policy Executive Summit. Really interesting couple of days. I hope we can be as interesting as the previous two. I want to thank all of our panelists here today but also the ones for the first two days and also my colleagues at 3M who moderated the sessions. Great content and really stimulating discussion. I hope we can continue to stimulate your brains with today's session. My name is Matt Ferrara, and I'm a regional manager here with 3M Health Information Systems Regulatory and Payment Solutions Group. Like all of my colleagues here at 3M, I think I safely say that we're passionate about seeking and promoting ways to maximize the value of healthcare and the value of our healthcare system. We want to help agencies, health plans, and providers be aligned toward that effort. I felt this way in my previous career at HHSC, Texas Medicaid. Worked there for about 21 years in various agencies and in the Medicaid program. And I feel that way now. I really feel that's why I'm here. My guess is my fellow panelists, being where they're are and working where they are, will feel that way as well as well as you in the audience. Everybody has aligned interests here. The really excellent day one and day two sessions provided some really great information on ambulatory care, and patient safety, and maternal care, and how our solutions can help target and help develop interventions for those issues. Today's session, I would say, is a bit more esoteric. It involves this thing called state-directed payments, which have become a very critical financing mechanism for Medicaid programs to preserve access, achieve quality, and ensure health equity. This issue reinforces to me the really incredible complexity of Medicaid. There's a glue holding it together. But each individual state Medicaid program is different. They all operate in different states with different geographic challenges and political environments and sometimes are very divergent in how they look, but they're all held together through a common framework. We'll dig into the topic of state-directed payments in a bit. But first, let me introduce our panelists for today's discussion. (DESCRIPTION) Matt switches to the next slide, titled, "Meet the speakers." Images of three panelists appear above their names and job titles. (SPEECH) Amir Bassiri. Amir is the director of the New York State Department of Health. He joined the department in 2019 as the Chief of Staff to the Medicaid Director and recently served as the Deputy Medicaid Director overseeing the operation and performance of nine Medicaid divisions. Collectively, these nine divisions are comprised of more than 750 staff, over 500 contracted staff, and management over 300 contracts, including some of the state's largest technology, actuarial, and financial audit contracts, along with the health plan contracts. Prior to his work with the department, he worked as a senior policy advisor for health in the governor's office under Deputy Secretary of Health and Human Services. Amir earned his BA in both economics and psychology from the University of California Davis before earning a master's degree in social work from Columbia University. Thank you, Amir. Victoria Grady. Victoria Grady is the Director of Provider Finance in the Chief Financial Officer division of the Texas Health and Human Services Commission. Victoria oversees the development and implementation of reimbursement methodologies and rates for Medicaid and certain non-Medicaid services, supplemental and directed payment programs for hospital services, long-term services and supports, and acute care services. Victoria began her career at HHSC in 2014 in governmental relations as the legislative liaison for financial services, procurement and contracting services, and transformation and policy in performance divisions. She was promoted to senior advisor to the director of rate analysis before being promoted to deputy director and then director in 2018. Prior to joining HHSC, Victoria worked at the Texas Senate Research Center and as Chief of Staff for former state representative, Jim Pitts. Victoria earned a bachelor's degree in English literature from the University of Southern California. Thank you, Victoria. Jami Snyder is the President and Chief Executive Officer of JSM Strategies LLC where she provides health-related consulting services to a range of public and private sector clients. Previously, Jami was the Arizona cabinet member charged with overseeing the state's Medicaid program. During her tenure, Jami spearheaded efforts to stabilize the state's healthcare delivery system during the public health emergency to advance the agency's whole-person care initiative. Jami has also served as the Medicaid Director in Texas and as President of the National Association of Medicaid Directors. In April of 2023, she was appointed to the Medicaid and CHIP Payment and Access Commission, MACPAC. Jami holds a master's degree in political science from Arizona State University. And thank you for being here, Jami. (DESCRIPTION) An agenda is outlined on a new slide, and Matt reviews the bullet points. (SPEECH) Pretty broad agenda here, pretty simple agenda. We're going to talk a little bit and define state-directed payments for the benefit of everyone in attendance, their origins, and how they've evolved over time, which have led to some of the CMS concerns and other concerns which stimulated the proposed rule development. I'll look to the panelists to give an overview of the existing array of state-directed payments, the goals, the evolution, their financing, what kind of providers they're targeting, and the estimated dollar value of those state-directed payments. And then we'll have a panel discussion of the CMS proposed rules and, in line with the theme here, what's good, what's bad, or potentially ugly in those rules, knowing that a lot of those proposed rules, we don't know what they're going to finally look like as they are today. And they don't fall neatly into one of each-- one of those categories. They could be all three, in fact. And I'll talk a little bit about some of the 3M tools and how they can be used to help support state-directed payments and measuring the value proposition of state-directed payments. And then we'll leave some time for questions and answers. (DESCRIPTION) Matt switches to a slide titled State Directed Payments. Text on the slide reads, "State Directed Payments (SDP) are an integral strategy for Medicaid programs to ensure accessible and high-quality services for populations enrolled in managed care. While the Centers for Medicare and Medicaid Services (CMS) recognize SDP's role in Medicaid financing, federal concerns have grown since the adoption of 2016 Managed Care Rule, mainly around: The lack of transparency and trackability of SDP expenditures, the interaction with capitated, rish-based managed care, and the value proposition of SDPs. The proliferation of SDPs since the 2016 rule adoption and the relative magnitude of SDPs in terms of funding have stimulated these proposed rules, which signal CMS' intent to put parameters around and better understand the impacts of SDPs. (SPEECH) So state-directed payments. Before we get into this, I want to just give some statistics to put this all into context. Doing some research, Medicaid is about a fifth of the overall national healthcare spend. The overall healthcare spend is approaching one fifth of the US GDP around $4 trillion. So one fifth of one fifth. And as we know, in Medicaid, the most vulnerable people are served by the system. And in many ways, I really believe that Medicaid is a trailblazer in value-based care that is moving from volume to value. I think it's a case of necessity being the mother of invention. I think Medicaid is always one of the biggest state budget line items. It's always under scrutiny. Where are the dollars going? What are you getting for those dollars? What value are you bringing to enrollees and their care? And what value are you bringing to the taxpayer? So it's under the microscope. It's forced to do things that I think other systems may not be forced to do because it's under such scrutiny. And that's the prism through which I look at the Medicaid program. And in my career, working in Medicaid, how can you get the most value? Where do we have deficits? Where do we have opportunities for improvement? So that's the prism I look at healthcare, and Medicaid, and this issue of state-directed payments as well. But, Jami, I was wondering if you could give folks a little history lesson and take a little time to talk about what state-directed payments are and the kinds of directed payments there are, their origins in the 2016 rule, and then the impetus behind the proposed CMS rules. (DESCRIPTION) Jami speaks from her home office. (SPEECH) Certainly. I'd be happy to do so, Matt. Apologies. My camera doesn't seem to be functioning properly. So I'll just leave this frozen image of myself up on the screen here. Yeah. We just wanted to start by providing an overview of state-directed payments. SDPs are really one of the most powerful tools that Medicaid programs have in their toolbox to ensure access to high-quality care and services. There are a few different ways in which SDPs can benefit states. They can assist states in achieving their overall objectives for delivery system and payment reform. They can ensure that states maintain an adequate provider network. And as we all know, CMS's eyes are on a state's performance in terms of maintaining an adequate network. SDPs also allow states to require that MCOs increase the use of value-based purchasing models, which, as we shift from volume to value, this is a great tool to have in advancing value-based care. SDPs also provide states with more control over the rates and methods used by MCOs to pay network providers. And they really allow states to direct managed care organizations to use methods that advance specific state goals. So they're an incredible tool again for Medicaid programs. In recent years, CMS has begun to take a closer look at states' implementation and employment of SDPs for good reason, as Megan mentioned earlier. The annual SDP spending now sits around $70 billion up from $48 billion in March of 2022. So we've seen dramatic increases in particular in recent years in terms of the use of SDPs and that overall SDP spend. So in the recent rule package released by CMS, they really focused on a handful of areas in order to get their hands around what's occurring at the state level in terms of the employment of state-directed payments. In the draft rule that was released, comments were due on the third of this month. They spoke to concerns around transparency and a lack of transparency and trackability of state-directed payment expenditures, so trying to create more transparency with a set of proposed regulations. They also spoke to regulations that really shed light on the interaction between a capitated payment system, a risk-based managed care system, and state-directed payments. And then finally, they talked about the value of-- the value proposition of SDPs and specifically really raising the bar in terms of expectations around quality when states implement directed payments. As I mentioned, we've seen dramatic increase in the overall annual spend related to SDPs in recent years. So it's no surprise that CMS wanted to update its original framework around state-directed payments with the draft regulation that was issued just a couple of months ago. And, again, commentary on the draft regulation was due on the 3rd of July. And we've had the good fortune to take a look at many of the states' input specific to some of the proposed regulations related to state-directed payments. We want to go to the next slide. Sure. Jami, what do you think was attributed-- whoops. I'm sorry. There you go. (DESCRIPTION) Matt switches to the next slide titled, "Some Basic Stats on SDPs." Two pie chart depict the Directed Payment Types and Projected Payment Amounts in 2023. To the right, a spreadsheet lists Directed Payment Characteristics and their associated fee schedules, uniform rate increases, and VBP's. (SPEECH) What is attributed to the growth, do you think? Is it just the number of state-directed payments? Is it the pegging them to the average commercial rate and more and more states doing that? Is it just states becoming aware of this option and utilizing it more for policy objectives? (DESCRIPTION) Jami: (SPEECH) I think it's all of those things. I definitely think, again, it is a really powerful tool that the state can employ if they know their concerns around access to care. And so allowing the state or granting the state the ability to direct that payment is pretty important because, as I mentioned earlier, not only can it ensure access to care where we know there are gaps. It can also allow states to really advance specific state goals, whether those be around value-based purchasing or ensuring that certain provider types are properly compensated so that we can or the state can ensure that there's an adequate network. So this slide really speaks to the different types of state-directed payments. And just to level-set, there are really three different types. There's a minimum or maximum fee schedule directed payment construct, which allows states to set parameters for the base payment rates that managed care plans can pay for specified services. There's what's called a uniform rate increase, which requires managed care organizations to pay a uniform dollar or percentage increase in payment above negotiated base payment rates. And then there's the value-based purchasing bucket, which requires managed care organizations to implement value-based purchasing models, maybe shared savings arrangements, pay for performance incentives, or other alternative payment models, but, again, allowing the state to really advance their work in the BBP space and direct that work specifically in their partnership with managed care organizations that they contract with. So you can see that both in terms of the number of approved directed payments and the overall projected spending, uniform rate increases are the most common form of state-directed payment. And of note, 39% or the largest share of uniform rate increases benefits hospitals. So hospitals are a big player in this space. And most often when we're talking about uniform rate increases involving hospitals, the state share, again, is funded through IGT arrangements oftentimes. It's not entirely the case. But more often than not, minimum and maximum fee schedule arrangements, our directed payments have benefited behavioral health providers. And VBP-directed payments have tended to focus more on physicians and practitioners. So just important to note some of the distinctions between the three different types of arrangement as well as the overall spending and number of approved directed payment arrangements. Clearly, the bulk of those SDPs are in the uniform rate increase bucket. Matt, do you want to hit on this last slide? (DESCRIPTION) Matt switches to a new slide titled, "Additional Stats." He discusses a list of bullet points on the slide. (SPEECH) So yeah, some additional stats here. And some of it was reflected on the previous slide. But minimum and maximum fee schedules were often targeted to behavioral health providers. Uniform rate increases and VBP arrangements were most often targeted at hospitals. Minimum and maximum fee schedules and VBP arrangements were often financed with state general revenue funds. And as Jami alluded to, the most uniform rate increases were financed by providers themselves through provider taxes or IGTs. About 76% of the dollars in 2023, according to MACPAC, were for uniform rate increases. 72% were for uniform rate increases, and 4% were for VBP arrangements. And by my calculation, it seems like about 3/4 of the dollars in SDPs are targeted to hospitals for inpatient payment increases or outpatient payment increases. There's another statistic here. And I think this might be something where CMS-- the concerns originated and thus the proposed rules. But it looks like about 18% of MCO premium payments, the capitated payments, are in SDP dollars. So basically, 18% of the dollars that are built into the capitation payments, the state is directing those health plans to pay providers in certain ways. And so I think that that's where CMS probably has some concerns related to the integrity of managed care because it's becoming quite large. I don't know what the point is where managed care loses its oomph in terms of the risk and things. But 18% seems like quite a bit at last count. And then you can see the increases there, the state-directed payment dollars. These are estimates, the $25 billion in 2020, $48 million in 2022, and then that last data point about $69 million in 2023. So about 176% increase if my math is correct. And so that's another area where CMS is looking at and, maybe a little surprised on what was unleashed, and trying to put some parameters around it. And, like was mentioned earlier, hospitals typically finance the non-federal share for hospital SDPs. It's around 40%, varies from state to state, but that's the generally average non-federal share. And then another piece of information because we'll talk a little bit about it down the road here. But the average commercial rate, which is-- a lot of these SDPs are benchmarking off the average commercial rate. Commercial prices for hospital services, according to MACPAC, about 223% of Medicare on average. Now, 223%, I suppose you have to deduct that they are putting up the non-federal share. So that has to be deducted from that. But still, it seems like quite a large percentage over what Medicare pays. And then, again, that same statistic, Medicaid, about one fifth of the overall US healthcare spend. And then the overall healthcare spend approaching one fifth of the GDP. And so in my mind, it's always a good thing to demand value for those dollars. These are real dollars here, not in state-directed payments, but in Medicaid and in healthcare. And so I think demanding value is an incredibly important thing. (DESCRIPTION) A new slide is titled, "Summary of New York State Directed Payments (Continued)." A spreadsheet includes the following columns: "Preprint Number, Program, State Funding, Proposal Name, Brief Description, Anticipated Effective Date, Type, and Preprint Status." (SPEECH) So I want to hear from our panelists. And we'll start with Amir to talk about what's going on in your state regarding SDPs, how they evolved, what are they trying to achieve, or what are you trying to achieve with these SDPs, their purpose in the overall Medicaid program, how they're financed in terms of the non-federal share, and what kind of providers you're targeting. And, Amir, if you could start off with what's going on in New York, that would be great. (DESCRIPTION) Amir Bassiri speaks on video from his home office. (SPEECH) Absolutely. And thanks for the table setting, Matt and Jami. A lot of what you shared resonates very much with our experience in New York and our increasing use of state-directed payments. I do want to talk about how we got here. But just so you understand what you're looking at on the screen, this is a summary of the approved state-directed payments that we currently have in New York and the rates. These state-directed payments are primarily focused on hospitals and increasing reimbursement to designated, specific, financially distressed hospitals in New York. Most are voluntary. In New York, we don't have for-profit hospitals . So most are specific to not-for-profit hospitals. There is one with the largest public hospital system in New York City, which is funded through IGT. But the others are primarily through just a general revenue. So we don't utilize IGTs to finance the hospital state-directed payments as many other states do. But outside of hospital payments, which do comprise close to 80% or 90% of our state-directed payments in terms of funding, we do have some others that we recently got approved in relation to the ARPA investments under the American Rescue Plan Act. One recently in maternal health, and that's our only value-based payment state-directed payment. And on the next slide, which I'll talk about later, there is a set of fee schedule changes for behavioral health. We have a managed care product called HARP. It is for behavioral health. And a lot of those are just tied to fee-for-service fee schedules. They're government-mandated rates. So those are less complicated, but there's a high volume of them. And we have a lot of state-directed payments. We have plans for a lot more with our upcoming 1115 waiver. And so we're generally pretty excited about some of the changes in the CMS proposed rule. There is the need for more clarification. And as Matt said earlier, we're not sure what will be in the final rule. But we do intend to leverage the value-based payment framework for state-directed payments under our 1115 waiver pretty heavily. And I can talk about that too. But how did we get here? It really goes back to the 2016 final rule, the mega rule. And New York at that time, we had a very high volume of pass-through payments in managed care that we needed to bring into compliance under the rule. And then the COVID pandemic came. New York was hit pretty hard pretty early. And so that was pretty disruptive. And the challenge we faced was, how do we translate the pass-through payments we had specifically for financially distressed hospitals into and under this new managed care payment authority that is based on utilization? The pass-through payments previously were not always service-based. They were quality incentives in some instances. But translating that into a utilization-based payment when facilities are recovering from pandemic-related changes in volume was very challenging. And we started with probably the hardest one, that being the financially distressed hospitals. And it ended up being a very complex, long negotiation with CMS that lasted almost two years given some of the complexities with volume tiers, given the range of needs at different provider types, and also just the magnitude of the payment. I think CMS was initially a little concerned and threw a lot of discussion. We were able to get to a reasonable place given some of the criteria. We had a very strict criteria for the hospitals that would be eligible for some of these payments based on inpatient and outpatient Medicaid payer mix. So it is very much targeted. But once we were able to get through the very difficult one, the others came into place. We have something specifically for sole community hospitals, critical access hospitals, and one of our public hospital systems, as I mentioned. And what we have seen in one of the things we've changed in recent years from where we started with state-directed payments is use of what is called separate payment terms, which, in effect, further limit the health plan's ability and removes any incentive to deny or question encounters that are submitted by hospitals. So we and, I think, many other states have been experiencing providers very concerned with plan denials. And so we wanted to get in front of that to fulfill the intent of the state-directed payment. And so we pursued a separate payment term. We do have that in place today. It is very, very complex operationally to implement. It requires a lot of data reconciliation on a recurring basis, in our instance, quarterly. And there's a lot of education we've had to provide to our health plans and providers to really see this play out as intended. And to Matt's earlier point, one concern we have while we're certainly using this authority quite regularly given the needs of the provider community and providers in New York is that you are-- how far does this go in terms of its use in managed care? Because we're effectively, in many instances, replicating fee-for-service in managed care in a far higher administrative expense given the number of health plans we have. So we want to move more towards the value-based payment pathway of state-directed payments so that we shift to quality. Some of the changes that are in the proposed rule are helpful in that regard. And so we are trying to move more towards using these for quality improvement as opposed to minimum payment. And it's going to take time, but that's really our focus. And the 1115 will be the impetus to do that at scale. The next slide is really just a list of all of our behavioral health mandated payment rates. Again, the behavioral health community is very concerned with managed care utilization review and management. And these are just straight fee schedule increases. They're relatively easy to implement. They've been seamless. We don't have many uniform increases. The pathway Jamie mentioned earlier, it was too difficult with the variation in reimbursement from plan to plan, provider to provider. And we weren't clear as to what the benefit would be from the providers. And so we've been more prescriptive with some of the minimum fee schedule changes and tying to fee-for-service. The new rule does really provide a lot of other opportunities, including benchmarking to Medicare. And the changes to ACR are very, very much appreciated. So we intend to incorporate those into some of these existing approved SDPs but really want to pursue more on the value-based payment side. (DESCRIPTION) Matt Fererra: (SPEECH) What do health plans-- what's their reaction to the growing share of what they're supposed to be managing and being state-directed? (DESCRIPTION) Amir Bassiri (SPEECH) It's been relatively mixed, but I would say the health plans don't like this. We are telling them how to manage the plan. They are skeptical on some of the premium changes that are being made. And I think they're hesitant. Some of that is driven by other rate development policy decisions we've made, including paying at the bottom of the actuarial rate range. So I just think they're very hesitant to go forward with some of the SDPs. And they have pushed back pretty extensively. It has led us to explore enforcement opportunities to ensure they're in compliance with the model contract. But thus far, nothing too problematic. I would just say the separate payment term, while we thought it was going to be very-- it would facilitate and comfort the health plans because we're effectively-- the separate payment term means, in essence, that we are only going to pay the health plan what the health plan pays out to the provider. So there's no incentive for the health plan or need to manage risk to the degree they normally do such that we were hoping payments would flow more seamlessly. It has actually created a lot of complexity with implementation given some of the way the health plan adjudication systems are set up and the system changes needed to effectuate those payments. So it's been mixed, Matt, but the health plans don't love these. (DESCRIPTION) Matt: (SPEECH) Yeah. It seems like their public comments on this were, build it into the rates. Let us handle it. And so there's a degree of trust with verify, I guess. But I was just wondering that-- seems like the-- I guess you're verifying that the health plans are probably not super thrilled with this. They accept it as part of their contract with the state, but they'd rather be the manager at all. (DESCRIPTION) Amir: (SPEECH) Yes. And exactly right. I mean, for certain state-directed payments, our actuary does require us to incorporate a plan admin given some of the system requirements and things they will have to do. So it's not as though there's nothing in it for the health plans. But generally, it is somewhat counter to the idea of managed care, which New York has a long history with. So it is a little bit of a sea change in that regard. (DESCRIPTION) Matt: (SPEECH) And has there been any issues with hospitals or other providers that are getting state-directed payment dollars understanding if they were accurately paid? (DESCRIPTION) Amir nods. (SPEECH) So there have been issues. On the inpatient side, it was relatively easy just given the way the health plan is benchmarked to our fee-for-service fee schedule on the acute inpatient rates. We've been very interested in incorporating changes specific to outpatient services, which has been difficult to operationalize given the various payment methodologies health plans use. Some are using Medicare PPS. Some are benchmarking as a percentage of Medicaid and using the APGs. So that has been definitely challenging. And what we've heard from the hospitals is that health plans aren't complying with what we have required. There's a little bit of confusion. So what we've done to get in front of this is to provide very specific definitions and encounter data specification documents for the health plans and the hospitals so that everybody understands what service lines, what encounters are eligible for the add-on payments that we've established by provider, which has helped a little bit. But there have been difficulties with the hospitals. And I will also say one thing that this proposed rule from CMS does not address that is top of my mind is how all these payments will intersect with federal DSH limits and facility-specific DSH caps. We are nearing that point where we can see there will be issues in a couple of years when we true up on the DSH audits. And so I don't know that CMS has fully contemplated that, but there is a potential, if these payments continue to increase, that we would have to recoup that funding from the provider at a later date, which is not anything we are interested in doing. So we will need to talk to CMS more about that. And I'm sure other states are also struggling with that as well. (DESCRIPTION) Matt: (SPEECH) Well, that's an excellent overview. So the VBP option given the rule changes related to the VBP, we'll talk about a little later. That seems to have stimulated some interest for how you want to do this in the future. Absolutely. All right. (DESCRIPTION) Matt pauses to change the slide. (SPEECH) It was dancing here. Oops. (DESCRIPTION) A new slide, titled "Summary of Texas State Directed Payments" appears. Bullet points read, "Comprehensive Hospital Increase Reimbursement Program (CHIRP), Quality Incentive Payment Program (QIPP), Texas Incentives for Physicians and Professional Services (TIPPS), Rural Access to Primary and Preventive Services (RAPPS), Directed Payment Pr ogram for Behavioral Health Services (DP BHS), and Network Access Improvement Program (NAIP) (pass thru)." (SPEECH) Oh. OK. Can everybody see the-- is the Texas state-directed payments up? (DESCRIPTION) Victoria Grady: (SPEECH) That's what I see. OK. Great. I'm having a little trouble navigating the system. So, Tori, why don't you give us an overview of the array of state-directed payments? And same kind of thing. What's their purpose? How did they evolve? And who do they intended to benefit? Yeah. So I'm Victoria Grady. I'm the director of provider finance for Texas. And if I was a Game of Thrones fan, I could say I was the mother of CHIRP, and QIPP, and TIPPS, and all those things. But I think our directed payment programs, we have done five directed payment programs that are additional funding. And then we have a couple of minimum fee schedules, one for rural hospitals, one for nursing facility services, and then for community attendance services as well. I'm going to focus mainly on the five that are related to increasing payment rates for providers. We operate all of our programs either as a uniform rate increase or in part as a uniform rate increase. And one of our programs is also in part a value-based payment structure. So the CHIRP program pays for both inpatient and outpatient hospital rate increases. This past year, it was just about $6 billion in additional payments. Next year is projected to be about $6.5 billion. QIPP is our nursing facility quality incentive program. It has an estimated annual value of right around $1.1 billion. And then TIPPS, which is our physicians and professional services incentive program, is right around $700 million-ish. And RAPPS is our focus for rural health clinics. It is one of our smaller programs but no less important at about $32 million. And then the Directed Payment Program for Behavioral Health Services is focused on incentivizing the CCBHC model of care. And this past year was right around $238 million. And then finally, we're in the process of phasing out our NAIP program, which was determined to be a pass-through. And so we have already end-dated the health-related institution program portion. And then we'll be working in the next couple of years to end-date our hospital portion of that program before the regulatory required sunset date in 2027. So I think, as you can see, in Texas, we go big. We do things big in Texas. So while we may not have the volume of programs that exist in other states, our programs are high-value. They constituted about, I want to say, 28% of our managed care reimbursement. So it's quite a lot of our reimbursement model. Our programs have really been born out of a place of transformation. So everything that we have was predominantly preceded by a different type of program. And when we were in a fee-for-service environment or after we transitioned into more of a managed care environment, we were operating on payment pools like the Delivery System Reform Incentive Payment program, or DSRIP, or the uncompensated care program. So in the case of QIPP, our nursing facilities had a nursing facility upper payment limit program when we were in a fee-for-service environment. When we transitioned to managed care, we were no longer able to continue that program. And so we had created a program that, at that time, was MPAP, which was the Minimum Payment Amount Program. That was determined to be a pass-through. And so we were not able to continue that program. And so we replaced it with QIPP. QIPP is structured as a hybrid between a uniform rate increase and a value-based payment. And what we did is we have four components of the program. And the first component of the program, which has about 45% of the program funding, and it is a uniform rate increase. And then the other three components of the program are value-based payment models, the first of which is focused on recruitment and retention of workforce and specifically increasing the number of RN coverage hours. The second component is a pay for performance on certain long-term care MDS measures or long-stay measures. And then our fourth component is focused on infection control, which we know is a huge indicator of client outcomes. I think one of the biggest challenges that I have identified in operating these programs since 2016 to now is that I think getting a uniform rate increase through the preprint approval process is, in full candor, a lot easier than a value-based payment model. With a uniform rate increase, it's really a lot more of an algebraic formula for lack of a better way to put it. You're looking at here's my base payment, here's my increase, here's my total amount of spend, and whether that is reasonable and appropriate. In the early years, the evaluations were not even required to be written and submitted. And that has evolved as CMS has sought to strengthen that tie to advancing equality goal or strategy. In terms of value-based payments, I think one of the things that's really challenging is that because it needs to be tied to utilization, it's been really difficult to get sufficient quality data timely enough to be able to key the payments off of basically real-time performance data. And so that has been a real challenge. I think it's even a challenge in doing the evaluations because the data needs time to mature. I think the other thing that's really challenging is getting from a place of baseline to improvement. Because the programs are renewed annually, it's very challenging because, in some cases, you're still collecting data or analyzing data for months or even years after the program period has actually ended to be able to see is what you were doing working. And because of the time frames, you end up in this cycle where you're going to ask for renewal of a program potentially midway through the prior year's program. And you don't even have data yet to know is it working or not working. And so I think that that's, in my experience, part of why we lean more heavily on a uniform rate increase because it doesn't require as much pressure on the real-time data collection and evaluation. We get to take a little bit more time and really use that data only for evaluation purposes. I think my perspective on the rules is that I understand where they're going with some of those things that they're putting in there, but I think we felt that the rules were a little bit prescriptive and maybe pigeonholed people into a certain situation without allowing for flexibility for each state who might have a unique circumstance to find a creative solution and work with CMS to advance it. And so an example of that would be, I think, our rural hospitals. Texas has the largest number of rural hospitals in the country. And our rural hospitals, in general, as a class, are not usually sophisticated negotiators with commercial health plans. And so making a regulatory requirement that their payments can't exceed average commercial, we think, is potentially problematic because it's not necessarily indicative that it would be an inappropriate reimbursement as much as it might be an indicator that they don't have a lot of commercial business. And so negotiating those rates is not as important or that they're too small to negotiate as effectively with a large health plan. And so that's where we're at. Also, in the proposed rules, there was a large section about the way that local funding can be used, specifically local jurisdiction provider taxes or other provider taxes. And that particular interpretation of the law or legal theory is a current topic of dispute in an ongoing lawsuit between Texas and CMS. It was filed as Texas v. Brooks-LaSure in the Texas Eastern District Court earlier this spring after the issuance of a bulletin in February that promulgated the same legal theory that was also proposed but not adopted during MFAR in 2019. Texas has received a preliminary injunction order that we requested from the federal court prohibiting CMS from applying that legal theory on any hospital here in Texas. And so that litigation is ongoing and is not a final adjudication. It's just at the preliminary injunction order stage. So I think from that perspective, it's definitely a challenge to make sure that, on some topics, I think we're in great alignment with CMS. We would love to see more clarity and easier tracking of what payments are being made through directed payments and being able to identify that report on it, evaluate it, all of those things. And I think that they acknowledged in their preamble some of the concerns that we have around hard and fast limits on reimbursement for those who are not sophisticated negotiators. But I also think that we're a little bit far apart from CMS in the theory of how to leverage value-based payments in a managed care environment in a directed payment program model because of the challenges with real-time data collection and the lag time that it requires to really get that meaningful data. You asked the previous speaker about the way managed care organizations feel about them. And I would say our MCOs are wonderful partners to us, and they're wonderful partners to our providers. But in general, the frustration has been largely around the claiming system changes that are required or the technology changes. And so, for example, with identifying what payments are being made attributable to a directed payment program, right now we're having conversations with our plans about whether they can break it out separately on the explanation of payment to the provider. And for some of our plans, that is not a significant change. For other plans, it will require major reconfiguration of their IT systems. We've tried other types of solutions like asking them to put a flag on the encounter when they report it to the state. So that way, we can at least query and provide that data to the provider upon their request. But compliance with that type of voluntary flag utilization has not always been the best. So it's definitely a challenge that we have. I think the other thing for our plans that is complicated is it puts a lot higher stakes on their ability to control utilization because the payment amount associated with each claim or encounter is higher. And we do not have a separate payment term. Everything is incorporated in their capitation. And so they are at risk if related to these programs. And I think that that's definitely scary. We incorporate an appropriate risk margin and administration to the capitation along with the dollars that are directed or estimated to be needed to support the rate increase. But we definitely don't guarantee our plans that they'll be made whole. And we also don't guarantee providers that they'll end up getting any specific amount. (DESCRIPTION) Matt interjects. (SPEECH) I think-- It seems, in that way-- it seems, in that way, you're in the spirit of what CMS is generally looking for is more prospectively building into the rate structure, having health plans pay it out contemporaneously to providers with the directed payment increase. That's what it sounds to me for the hospital program. (DESCRIPTION) Victoria nods. (SPEECH) Yeah. So we definitely are in that regard. But I also think that one of the things we are not able to do is to move away from a fee-for-service model as well in terms of we're still paying for volume over value, which is part of the spirit of managed care is, can you move away from a-- I'm going to pay you X amount per adjudicated claim every time you see a client, and moving into truly alternative payment models. And so I think that that's where the tension is. We would love to see that evolution away from the per-claim-based payment into a more value-based payment model, whether it's sub-capitation arrangements, or payment for performance, or things like that. But the approval process on the CMS side and the requirements around real-time data collection to prove up performance during a program year becomes a really hard tension to balance in a managed care environment where you're waiting for data to happen, get reported to the state, get evaluated, especially if that data is coming and being evaluated based off of the claims or some other national reporting system like the MDS measures. I think the other thing that becomes really challenging too is the desire from CMS to see the payments directly attributed to improvements made exclusively for managed care clients. That's an ongoing conversation Texas is having with CMS because rightly so, most providers don't make a change that impacts only one payer type and certainly not only within the Medicaid program managed care clients and not fee-for-service clients. And so they're making a change to improve the care at the provider level and trying to drive quality that then ends up driving it for all of their clients. So that's a really hard thing to be able to tease out, that limited subset of data both for providers, plans, and the state to really tie it so clearly. Yeah. I was talking to another state Medicaid program, and they mentioned that change. Is that something that CMS is pretty firm on that, in terms of measurement, you look at the managed-care-only performance? Yeah. I would say that CMS has been really good partners to us in that they are really firm on wanting to get there. But I think they understand that the data challenges in isolating folks at that level of granularity in your numerator and denominator, in some cases, is just not really possible. And so they've been really good about working with us when we've been able to demonstrate these good-faith efforts to try to get there. And we're continuing to work with them to try to get there. But, for example, with MDS measures, they're the actual recipient of that data. And so we're working with them to try to work with CMS to see if they can even distill it down to that. And at this point, they haven't been able to either. So when I worked in Texas Medicaid-- and I think it does predate the state-directed payment programs. But we had a hospital quality-based payment program where we looked at potentially preventable readmissions and potentially preventable complications. And there were small downward payment adjustments for hospitals that had high rates. And the fee-for-service claims administrator would make those base rate adjustments to the hospitals-- specific to the hospitals. And then in the managed care realm, the actuaries would take the data from the performance for the period that they were looking at to build the rates. And they would build in adjustments to the health plans as well. And those health plans, they received their actuarial document. They saw what the different calculations that were gone into that. And they would always want the list of hospitals that were poor performers because they would do those same adjustments downstream. And this was APR DRGs. And I'm assuming that because Texas adopted APR DRG as the payment method that the health plans, although they're not told to, they probably are paying in that way. And so when the state-directed payments came along, it seemed like those two were still happening where a health plan would get a-- here's your directed payment increases to these hospital classes by region. And then here's your list of hospitals that have poor performance on PPRs or PPCs. And they would do both things. The health plans would adjust the base rates or the claim amount for performance on PPRs or PPCs, whatever that may be. It usually is like 2% to 4% or 4.5% downward adjustment based on whatever their performance was. And then they would add on the directed payment increases. And that way, it struck me as a value-based state-directed payment in that you were still incorporating value into those payments. Yeah, absolutely. And I think-- and that program does still exist, but I think one of the key things is all of those adjustments of PPR and PPC adjustments are made based on prior year performance. And so in a theoretical world, if you tried to incorporate that as a value-based payment modification under the current preprint model, CMS would tell you that's not allowed because you are basing a payment in a program period based on performance in a different program period. And so they would require you to then categorize that as a rate increase or maximum fee schedule or fee adjustment, which means that then when you see the data that I would say Ms. Snyder was presenting before and you see how many are related to a minimum or maximum fee schedule, or uniform rate increase, or fee replacement, it skews the data that way even if the real purpose of the program is to advance a quality or value goal by incorporation of things that just happen to rely on data from a prior period because of the timeline issues with data logs. Yeah. So it was categorized for the CMS purposes as one thing. But, in fact, you were really-- because it's on a cycle every year, and they calculate these metrics, the PPRs and the PPCs, every year, so it's on a cycle. And they're using the same period that they use to set the rates. It seems like it's, while called a uniform rate increase, there really is a very value-based payment component to it. Yeah. You're just calling it a different thing for purposes of getting through an approval process. But I think because of that, it makes it look in a more aggregated way like states are leaning really heavily on uniform rate increases and obscures some of the larger programmatic goals that are being achieved through those same programs. Yeah. And so focusing on the CHIRP program here, you say that the actuaries build these dollars into the rates. So the health plans maintain some risk associated with this. And there's really no guarantee that the hospitals will get those dollars back. Do health plans ever question whether or not-- whether they scrutinize the actuarial work that was done in order to make sure that, hey, did you build the dollars in correctly, fairly? And then downstream, do you get any issues from providers saying, hey, these health plans, you're saying I am entitled to a 14% increase because of my hospital class and where I am? Do you ever get issues from providers confused as whether or not they're getting paid accurately? So I would say yes, and we used to. So our MCOs definitely scrutinize their capitation both related directed payments and the portion of the rates. That's non-directed. And I think that they take an equal level of scrutiny to all parts of the capitation rate development process. And so, to that extent, I think we're used to that and in a rhythm with them of how that process goes. And I would say in terms of with our providers in the early years of having a directed payment program-- and we've been doing a hospital rate increase program since 2018 now-- we definitely got a lot more inquiries is the way I would put it from a provider saying, I'm not sure that I'm getting everything I'm supposed to because I can't tell on my EOP what was part of my base and what was not. And so our plans have worked pretty hard to provide good customer service to providers and help walk them through questions when they have them. And I would say over time, as the providers get more comfortable with the programs and the plans get more comfortable with the programs, we have had fewer and fewer matters that have then come to the state. We always encourage providers to work with their plan first to try to see if they can get the information that they need before the state involves ourself. However, I think those things happen just like they do on base payments today where somebody will say, my contract says the plan is going to pay me X. I'm not sure that that's actually what I'm getting. And so we have the appropriate processes to handle that. I would say one of the things that I think is important is, so in the CHIRP environment, we've had a preceding program that goes back to 2018. In the case of a program like RAPPS, we really brought that program online for the very first time in 2022. And so our providers there were brand new at this. And they have really taken an exponential curve in terms of understanding how the programs are going to work and working with our plans to understand the expectations, and how the money was going to flow, and all of that. And I would say we're really fortunate that our plans, in general, worked really hard to do good provider education with some of the smaller providers who entered into those programs when they were brand new. And so if these dollars are built into the capitation rates, and then there's the precipitous decline in utilization, say, inpatient and outpatient hospital, and those dollars aren't, I guess, expended, is that captured through your experience where you claw back excess profits or some mechanism like that? Yeah. So it would be considered part of our experience rebate. However, we know that some of our plans have used portions of their capitation that have not been fully utilized to create incentive programs of their own to enter into different kinds of things like that that the state's not a part of and aren't part of the directed payment program. And particularly, during the public health emergency related to COVID-19, we experienced a lot of plans seeing profitability that they had not ever experienced before as caseloads increased and things like that. And so I would say we treat these capitation dollars no differently than anything else. But we also know that our plans when they start to experience profitability might do things that are more creative in terms of incentive arrangements, or they might do things like provider retention payments, or bonuses, or things like that in order to keep their networks really strong and secure during the public health emergency. And we're supportive of that, of course. Because they're going to give the money back anyway. So they might want to reinvest it in there. Yeah, especially to make sure that those providers continue to be there to provide care to the clients or particularly when it's an incentive arrangement related to a quality target or improvement. Yeah. Very interesting. There's a lot going on. That's a lot of dollars. So you said 28% of the capitation-- Oh, yes. --is state-directed payments. Sure. Excellent. Well, thank you, Tori. Let's move to Jami and talk a little bit about the Arizona state-directed payments. (DESCRIPTION) A new slide titled, "Summary of Arizona State Directed Payments," appears. Bullet points read, "Access to professional services initiative. Pediatric services initiative. Hospital Enhanced access leading to health improvements initiative (HEALTH!!). Nursing facility enhanced payment program. Other state directed payment programs." With her video feed still frozen, Jami Snyder speaks from her office. (SPEECH) Sure. And I'll just start as a point of comparison by providing the data point that you just referenced, Matt. In Arizona, the state-directed payments-- and there are several of them-- equate to 16% of the state's managed care spend at this point. And I think the state does anticipate that that will increase incrementally over time in the coming years. So, like Texas, Arizona has really focused a lot of energy on a series of uniform rate increases. And those include the access to professional services initiative, the pediatric services initiative, the healthy program, which is focused on SDP for hospitals, and the nursing facility enhanced payment program. I'll provide a brief overview of each of those and then talk about a few other directed payment programs that we've implemented or that Arizona has implemented more recently. So it's probably very clear, but the Access to Professional Services program, APSI, is really about enhancing access to physicians and non-physician professionals. It is a uniform percentage increase of 70% over the contracted rates for qualified practitioners that are associated with teaching hospitals essentially. The pediatric services initiative, again, is a uniform percentage increase and specifically focused on ensuring the financial viability of the state's freestanding children's hospitals. The HEALTHII SDP is, again, a uniform percentage increase for hospitals that offer acute inpatient and ambulatory outpatient services. It's the second of two hospital-directed payment programs, the first of which was focused on providing the state funding or the non-federal share for the expansion population when the state expanded. Medicaid. A nursing facility enhanced payment program, again, not a uniform percentage, but a uniform dollar increase for nursing facilities across the state. All of the programs have been very successful. But I will tell you, interestingly, while I do think, generally, state-directed payment programs shift the balance of power or control to the states, these programs-- APSI, PSI, HEALTHII, and the nursing facility payment program-- were largely implemented as a result of provider advocacy efforts to stand up the program. So we worked really closely in partnership with the various providers or members of the provider community to stand up the programs. They were able to obtain legislative approval for the programs. And then as a state agency, our focus was really on implementing the programs in a manner that was consistent with the overall construct that the provider community had advanced to the agency. The state does have a couple of other state-directed payment programs similar to, I think, New York. We have one tied to the Rescue Plan Act that's focused on directed payments to home and community-based services providers, really helping to support their recruitment and retention efforts given the workforce issues that exist. A targeted investments program, which is our only or the state's only VBP or delivery system reform directed payment program, which is really focused on offering additional funding to providers that meet certain milestones or metrics that demonstrate their progress in integrating care at the point of service, whether that's having an integrated care plan connecting with the health information exchange and the like. And then the differential adjusted payment program is a uniform percentage increase program. It's offered to a whole host of providers, including hospitals, behavioral health outpatient providers, integrated clinics, crisis providers, home and community-based service providers. And there are a series of metrics for each of the respective provider type that the provider must meet in order to qualify for the additional funding, including milestones like connecting with the health information exchange, e-prescribing, for dentists, offering dental sealants, for HCBS providers, compliance with electronic visit verification metrics, and the like. But the rate increase is ranged from a quarter of a percent to 20% depending on the provider type and the associated performance metric. So it's pretty broad-ranging but has been a really, really successful program and instrumental in supporting, in particular, some of the smaller providers outside of hospitals and nursing facilities that really need additional support and holding them accountable, again, to milestones or metrics very clearly established well in advance of the contract year. I will say going back to some of the questions that you've asked, one of the questions that both Amir and Tori answered was related to managed care organizations' opinion or view of directed payments. I would weigh in in a similar vein. I think managed care organizations in Arizona, SDPs present a level of frustration in that it really, again, shifts the control or power more over to the state and assists the state in advancing their goals. So I think there's always some tension there for sure. In terms of the draft rule, I think from Arizona's perspective, using the ACR cap for the individual's directed payment arrangements is a very comfortable place for the state. It's been the test or the benchmark that's been used for several years in their conversations with CMS around the various SDPs. So no question on that front. The state did have a real concern about some language in the preamble of the rule related to the aggregate spend for SDPs, which I think suggested that it may be limited to between 10% and 25% of the managed care spend. As you can imagine, Arizona is at 16%. Texas is quite a bit higher. And there's some real concern around the impact that that could have in terms of the SDP arrangements influencing or impacting in a negative way access to care. One of the other topics discussed extensively in the draft rule was around hold harmless arrangements. Arizona really didn't weigh in on that front because I don't think there's a significant concern. But in reading over many of the other states' commentary on the rule, I think there's a real feeling that CMS is-- the provisions contained in the draft rule, rather, CMS is really extending the responsibility for those hold harmless arrangements to the states holding them accountable for arrangements that occur between providers in the private sector. And there's some question as to whether the current statutory construct really imposes that expectations on the state-- that expectation on the state. And as we know, many of those arrangements happen outside of-- most of them outside of the state's purview between providers in the private sector. So holding states accountable for those types of hold harmless or redistribution arrangements, I think, has been a point of concern for many, many states. The state too also-- I think while Arizona absolutely supports CMS's interest in increased and improved transparency, and enhanced quality, and, again, raising the bar in these SDP arrangements around quality metrics and performance, I think the state, like many states, expressed some concern around the operational lift associated with some of that work and even extending to some of the expectations around the evaluation process. And I think as several parties weighed in on the need to exempt the simpler-- whatever that means-- simpler SDP arrangements from the extensive evaluation process and really focusing on those SDP arrangements which are more significant in terms of overall spend. And I think states generally agree with that. There's a lot of discussion-- and perhaps we get to this in a minute-- around whether states should be able to use their external quality review organization to conduct the evaluations for SDPs. From what I've seen and looking at states' commentary, states, overall, are supportive of using their established egro. Just from, I think, an operational or practical standpoint, it's easier to use an existing vendor rather than having to look for an independent vendor. But I think we can have additional discussion on whether it makes sense to bring in a new set of eyes in terms of that evaluation process. But, overall, I think Arizona, again, supported the philosophical objectives of CMS in their proposed regs around state-directed payments but just had some concerns more on the operational or logistical end of things and, again, that concern around the aggregate cap on SDP spends relative to the managed care spend for the state. Yeah. It just seemed arbitrary as what the general commentary was on that. Yes. Exactly. So I'm monitoring here, and I see some questions come in. And one of them is from one of our audience. And I think it would probably be most appropriate for Amir. The question is, how do you allow for administrative costs relative to the separate payment terms with the managed care plans? How do we allow for it? Yeah. Well, we are allowing for it at reasonable-- so it's a 3% admin assumption. And that is in accordance with other rate-setting activity or rate-setting principles like taxes, admin trend, all of those components. But some of the separate payment term requirements do necessitate health plans to make system changes and system modifications to the claims adjudication system that do-- we believe there is an administrative cost to some of the things we're requiring them to do as compared to how they're managing across other product lines and for other providers. So it has been justified. The actuary does agree that we do need to re-compensate them the minimum amount required. But there is an administrative cost they have to incur to effectuate the payment requirements under the state-directed payment. So we have not encountered any issues with CMS regarding that admin component. And it is only applicable when both the state and the actuary agree that there is some expectation that the plan modify its business practice and operations to fulfill the obligations of the payment. So for something like a benchmark to the fee schedule or benchmark to Medicare, we wouldn't be applying those admin assumptions to the total payment. OK. Excellent. I hope that helps answer the question. Another question here, and I think maybe for Tori. It says, as shown, hospitals typically finance the non-federal share for hospital state-directed payments through IGTs or CPs. Sometimes physicians are only affiliated with those hospitals only through the tax IDs. The state-directed payment is made to the hospitals providing the non-federal share. And the service provider's physicians do not benefit from that payment. How do you address that issue? So I would say payments are not contingent upon IGT. And that is not allowed by a federal law. And so in our program model, we actually have two different programs. So we have our hospitals program, which is paying for the actual hospital claims or for inpatient and outpatient that-- not to get too technical, but the part that's going to come on the UB-04. And then separately, on our TIPPS program, we have participation from community physicians, physicians associated with teaching hospitals, and physicians associated with academic medical health centers or our health-related institutions. And we restrict that to certain taxonomy codes that indicate that it is the professional service. And so those claims typically come in on a Form 1500 which tells us that it's a professional. And so we really have two different programs targeted to two different purposes. And to the extent that somebody is a hospitalist that is employed at the hospital and they're billing on a 1500 but the payment is being remitted back to the billing provider of the hospital or something like that, I would say their payment arrangement is related to their employment contract. I would say the other thing that's really important is we always pay whoever the billing provider is. We don't pay separately to a rendering provider because there isn't a payment arrangement to a rendering provider when they're not also the billing provider. And so that's how we handle it. And it really is not related to who IGTs or who doesn't. In terms of the professional versus the hospital, we just have different programs that target different types of services. OK. And one more question for you, Tori. Does Texas make any specific accommodations for rural hospitals given that their low volume-- their volume is lower than other hospitals? So we do our best. But I would say that's been one of the challenges that we've had with making transitions. So under the delivery system reform incentive program, payment program district, we had payments that were made to rural hospitals, and we had set actually a payment floor of $1 million. And when we made the transition to a directed payment program, we were required to end-date district because they required us to pay and do an analysis of reasonableness of payment relative to the claims and the utilization in the period. We weren't able to make that same type of minimum payment expectation. And so our rural hospitals, in general, saw an overall reduction in reimbursement when we made the transition from district to our directed payment program CHIRP. I will say that that's definitely a point of frustration about how directed payment programs work and some of the differences of what you can do in a directed payment model versus others. Part of the state's response to that situation is by the creation of the RAPPS program. So a number of our rural hospitals also own rural health clinics or operate rural health clinics. And so we created that program to try to provide some additional support in rural communities in that RAPPS is open to both hospital-affiliated RHCs and non-hospital-affiliated RHCs. But I think that that's definitely something that is difficult is finding ways to find solutions that really fit in a rural community. And, again, it goes back to the comments I made about the rules is I think that when you put in place hard and fast limits, it doesn't enable a state to work to come up with a creative solution that really makes sense for the particular circumstances that may be going on with a particular provider type, or class, or even service delivery situation. Excellent. Well, thank you, all, for that overview. I know we peppered you with some questions along the way. (DESCRIPTION) Matt switches to the next slide, titled, "Panel Discussion: SDP Sections of CMS Proposed Rules... Good, Bad or Ugly?" Beneath a subheading that reads "proposed changes," bullet points read, "Grey area payments. Medicare exemption and prior approval. Non-network providers. SDP Submission Timelines. Payment rate thresholds and caps. Hold harmless and attestation. Tying state directed payments to utilization and delivery of services. Value-based payments and delivery system reform initiatives. quality and evaluation requirements. contract terms requirements. rate certifications and seperate payment terms. contract requirements; reporting requirements. State directed payments and medical loss ratio calculations. appeals process. And, effective dates for compliance." (SPEECH) So we'll move to second to the last slide here in terms of-- this is just the layout of the headers of the proposed rules and the different sections. Some of these things are non-controversial and presumably reduce some of the administrative burden. I think, at least in the public comments that I've read, some states indicate that in totality, this is going to increase administrative burden. And some of these are, I wouldn't say, maybe showstoppers but seem to be a big change. So I would turn to Jami. And, Jami, would you-- in the list of these issues, we covered a lot of the-- some of the proposed rules in our discussion in the state-directed payment portion. But could you highlight some of the-- what you're hearing from some of the big sections of the rule that are showstoppers or present serious challenges for states? Sure. And I touched on it earlier. I think the payment rate thresholds, in particular, the aggregate cap that was suggested in the preamble is a real concern for states. Now, again, it was in the preamble of the proposed rule, not in the draft regulation itself. But sometimes that can signal, as we all know, what CMS is thinking about for the future. And so I think it's really important for states to continue to have conversations with CMS and CMCS about the challenges associated with an aggregate cap. Clearly, the hold harmless provision is a big concern for many states. I don't know if I articulated it perfectly in my prior comments. But the current statutory construct prevents states, state entities, from redistributing funds in a way that results in a hold harmless arrangement. What we know is states aren't doing that. They're not redistributing the funding. The redistribution that happens happens down the line between providers. And so the question here, I think, from states is, how can you hold states accountable for activity that's occurring outside of the states' work with the directed payment arrangement and, in particular, the attestation? So there's a suggestion in the draft rule that every provider that's participating in an SDP must attest that they're not participating in any sort of hold harmless arrangement. I think there are real concerns about whether providers would be willing to do that and what the state's responsibility is in that process in terms of monitoring or auditing the degree to which providers are being honest if they attest. And so I think there's some real concern there. And I think Tori knows more than I do certainly on that topic. The value-based payment piece, Amir talked a lot about this. I think there's some really helpful language in the draft rule that would make VBP arrangements under the state-directed payment framework much more attractive to states. So I think that's really exciting because I think, as Amir said, there's a lot of opportunity to move the needle on quality and cost in the VBP buckets where that may not be as much the case with the other types of state-directed payment arrangements. Personally, I think there's just tremendous opportunity on the quality side of things. Rather than focusing on concerns around hold harmless and the like, I think this is an opportunity for CMS and CMCS to weigh in in terms of their expectations around quality and really raise the bar, the expectations of states and providers participating, and really using state-directed payments to move the needle on quality consistent with the states' objectives in the quality improvement arena. And I think those are the main items that I've heard a lot about from states as I've talked with them. But I'd be curious to know Tori and Amir's perspective if I missed anything. Amir, go ahead. I think you hit on the key things for us, Jami, here in New York at least. I completely agree with everything you said on the VBP and moving the needle on quality. Our quality experts aren't thrilled just given that some of the new requirements do necessitate us to change the way we measure quality. But I think we're supportive of the underlying goals and do believe this is a vehicle to move the needle in that area. The only thing I would say that is somewhat unspoken in the final rule relates to how they're going to treat SDP revenue in the context of other federal payment limits. I mean, I think it is a problem and will be a problem. And I don't know that CMS ever intended for SDP revenue to be what it is becoming. And so how they treat that in the context of DSH and UPL limits is going to be interesting. Tori, any thoughts? Yeah. So I will say I know a lot about the hold harmless arrangements that they allege are happening. I think one of the things I want to make clear is that a lot of these arrangements are just that they're alleged. In many cases, states don't even know that they're happening or would have no way to know that they're happening. And I think it's also important to note that it requires an expectation that states are going to be looking at business arrangements with non-Medicaid providers. That might be happening related to, in a theoretical world, a non-Medicaid provider receiving a payment from a nonprofit making a grant. And so we think that there's a lot of problems with that. It is the basis of the lawsuit that we filed and have a preliminary injunction order related to. And so I think that I would tell really any other state, if you have a nonprofit operating in your state, you might be required to comply with investigating their arrangements to make sure that none of this is happening. This is not something that I think they're painting with a very broad brush in a way that the federal statute just, I don't think, was drafted to allow. And I think that people should be very cognizant of the potential challenges to your state. We estimated here in Texas that complying with that provision, not specific to directed payments, but in general, would cost our state as much as $55 million a year because of the level of intensity that would be required to investigate potential payment arrangements at 500 hospitals and any third-party intermediaries, which means anyone that they paid, we'd have to go look to see if that person made a payment to somebody else. And there's no clear distinction in how many degrees of separation away you can say, OK, we no longer need to follow the money. So I think that's a really big deal. I think the other thing that we haven't really talked about much is their proposed appeal process, which is proposed and I think we commented here in Texas on that the other types of processes that are required to go through the dab, all have defined end dates for CMS to act or take a final action and also have a very clear and statutory standard by which they would be basically approved or disapproved whereas in the directed payment program context, while they imposed or proposed requirements related to the submission time frame for a directed payment, they didn't actually put any requirements on themselves to act or not act. And so we saw a lot of potential conflict where you might be in a situation where they leave your preprint in purgatory, never acting on it. But you can't appeal to the dab because there's no final action by the agency. And because of this new appeal requirement that it has to go through the dab, you can't seek judicial review or intervention to force an action approval or disapproval. And so it would really put states in a place where they get stuck. And so we expressed that we didn't feel that it was appropriate for preprints to be exclusively required to go through the departmental appeals board process. But I think that that has some really big implications for states and their potential pathways to get relief if they're not having appropriate success in working with CMS in a collaborative way. Excellent. I think we have just a few minutes left. I wanted to just talk a little bit about some of our tools and how they might be helpful in a value-based care environment. But I really, really appreciate your time here. This was a long session. I was worried that we weren't going to fill it up, but we had no problems. And we could actually use some more time. But let me go to this next slide here. And (DESCRIPTION) Matt switches to a new slide, titled "A possible framework for measuring the value proposition." Text below reads, "Hospital SDPs. There should be an expectation that these additional funds improve care that can be attributed to hospitals. Integrate SDP increases into APRDRG and or EAPG structure. Leverage quality tools that are connected to APR DRGs and EAPGs; Focus on outcomes controllable by hospitals." Three links appear below. The text on the slide continues, "Set expectations; develop a fair, risk adjusted formula for a healthy competition for some of these cost based on relative provider value. SDP's that target hospital avoidance. How is the population health being measured." Four links appear below. The text on the slide continues, "Set expectations; develop a fair, risk adjusted formula for a healthy competition for some of these cost based on relative provider value. SDPs exist within a managed care environment. These same measurement tools are ideal for also measuring managed care (health plan) value. Collectively, we should always demand value. Enrollees win, taxpayers win. Medicade can continue to lead the way in value-based care and innovation. (SPEECH) just wanted to highlight for folks in attendance that we have some tools that really can provide a really good framework for measuring the value proposition of state-directed payments. It's more money. And I think we're really seeking to help states get value from those funds. And so I look at this in two buckets-- hospital state-directed payments and then state-directed payments that target hospital avoidance or high cost care avoidance. And so with the hospital SDPs, I think that there should be an expectation that additional funds improve the care, and that should be monitored. And I'm talking care that can be attributed to the hospitals. The APR DRG or EAPG structure in many states leverage that payment structure for inpatient care and outpatient care can be leveraged for that effect. And then our quality tools for hospital-specific activities can also be leveraged. And they're very good at the risk adjustment. And so you can have these fair comparisons on hospital performance for things that are within their control. And so these are the inpatient complications, the ambulatory complications that we talked about on Monday, and then the potentially preventable readmissions. And I really feel like setting expectations and developing a real fair risk-adjusted formula for a healthy competition for some of these dollars is a good thing. I think there should be an expectation that there should be some value attached to these dollars. And so in my mind, I find these tools to be really, really useful in this environment. And then for those SDPs that target providers that are seeking to keep people in the community to avoid hospitalizations or nursing facility care, we have our population-focused preventable [INAUDIBLE], emergency department visits, hospital admissions and readmissions. Those are things that are population-health-focused and can really measure provider performance for those provider types. And same thing, set expectations, and you can really move the needle forward in terms of having a healthy competition for some of these dollars. And then just to sum up the state-directed payments, they exist within managed care environment. And these same measurement tools are ideal for measuring the managed care or the health plan performance. And so there are ideal at that level. And I think collectively-- I don't want to sound too preachy, but collectively, I think we should always demand value. Enrollees win, taxpayers win. These are big bucks here. And I think really, Medicaid-- Thanks, Matt. Yes. (DESCRIPTION) White text appears on a grey slide, "Thank you. Amir Bassiri, Victoria Grady, Jami Snyder, Richard F. Averill, Matthew Ferrara." (SPEECH) Thanks, Matt. I know we're at time and going over. So I just wanted to thank you, thank everyone for joining us today for this last day of our summit. Thank you to our speakers Amir, Tori, Jami, Rich, and Matt. I hope you found these sessions these three days to be informative. I know I sure did. (DESCRIPTION) A new slide, titled "Driving health equity through certification and accreditation: what does it mean for health care delivery?" appears. Text on the slide reads, "Thursday, August 3, 2023, 1 to 2 pm, eastern time. Moderator: Melissa Clarke, MD, chief population health officer, 3M HIS. Speakers: Bryan O Buckly, DrPH, MPH, MBA, director, health equity initiatives, national committee for quality assurance (NCQA). Jamye Chapman, senior program officer, center for health care strategies (CHCS)." Photos of the moderator and panelists appear at the bottom of the slide. (SPEECH) Please know as you tackle these and many other issues facing your programs, 3M HIS is here to support your goals. As you know, we provide these kind of webinars throughout the year. So just want to-- you can see up here on the screen we have another webinar coming up quickly on August 3 with Dr. Melissa Clark of our team. She'll moderate a session looking at driving health equity through certifications and accreditation, what does that mean for healthcare delivery. She'll be joined by speakers from NCQA and Center for Health Care Strategies. So please join us for that. Let me just close again by saying thank you. Have a wonderful rest of your day. (DESCRIPTION) A new slide reads, "Get in touch!" followed by the names, titles, and emails of 3M employees. A final slide reads, "Thank You!"

      A webinar presentation slide with the presenters showing on the side.
      • State directed payments (SDPs) are a topic of increasing interest among federal regulatory officials and state Medicaid leaders. This panel discussion will offer insight into the role SDPs can play in advancing delivery system reform efforts as well as strategic initiatives aimed at enhancing access to care and improving the quality of care offered to Medicaid members. The panel will also explore recent draft regulations issued by federal authorities, seeking to further define the parameters guiding the establishment and maintenance of SDPs. Drawing on the insight of current and former Medicaid directors, the panel will shed light on the challenges state officials face in administering SDP programs as well as the ways in which 3M’s tools can support states in adhering to the current and proposed regulatory framework and in furthering key program improvement initiatives.
      • Speakers:
        Matthew Ferrara, regional manager, 3M HIS
        Amir Bassiri, Medicaid director, New York State, Department of Health
        Victoria Grady, director of provider finance, Texas Health and Human Services Commission
        Jami Snyder, JSN Strategies LLC and former Medicaid director, Arizona Health Care Cost Containment System
      • View the presentation (PDF, 791 KB)

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