Hazel
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Presentation by Health and Human Resources Secretary William A. "Bill" Hazel Jr.
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Hazel
- 1. Virginia Rural Health Association 2015 Conference The Honorable William A. Hazel, Jr., M.D. Virginia Secretary of Health and Human Resources
- 2. Program and Services Map VA Health and Human Resources Secretariat SSA DOL AOA NIH ACL ACF FNS CDC SAMHSA EPA CMS DARS DBHDS DHP DMAS VDSS OCS VBPD VDBVI VDDHH VDH VFHY • Vocational Rehabilitation • Disability Determination • Community Rehabilitation for Disabled • Aging Services • Adult Protective Services • Developmental Disability Services • Mental Health Services • Substance Abuse Treatment Services • Behavioral Health Emergency Response Services • Provider Licensing • Licensing and Health Profession Regulation • Prescription Monitoring Program (PMP) • Health Practitioners Data Center • Medicaid • Family Access to Medical Insurance Security (FAMIS) • Medicaid Analytics and Reform • Supplemental Nutrition Assistance Program • Temporary Assistance for Needy Families • Child Care • Energy and Cooling Assistance • Eligibility Determination • Foster Care and Adoption Services • Child Support Enforcement • Child and Adult Protective Services • Licensure • Community Policy and Management Teams (CPMT) • Family Assessment and Planning Teams (FAPT) • At-Risk Youth and Families • Policy Setting • Grants for Innovation • Leadership and Advocacy Training Programs • Disability Services Assessment • Vocational Rehabilitation • Randolph- Sheppard Vending Program (RSVP) • Virginia Industries for the Blind • General Library Services and Education Services • Technology Assistance Program (TAP) • Virginia Relay • Outreach and Community Services • Interpreter Services • Family Health Services • Emergency Preparedness and Response • Environmental Health Services • Licensure and Certification • Epidemiology • Virginia Certificate of Public Need (COPN) • Minority Health and Equity • Drinking Water • Youth Programs • Youth Tobacco Use Prevention • Youth Obesity Prevention IRS A Focus on Value What do we do? How well do we do it? How much does it cost?
- 3. Policy, funding, workflow, people Silos come in many forms...
- 4. The Virginia Health and Human Resources Secretariat is focused on six strategic issues. Virginia Health and Human Resources Virginia Health and Human Resources Secretariat Healthy and Productive Virginians Eliminating Intergenerational Poverty Thriving Children and Families An Aging and Diverse Population Integrating Individuals with Disabilities in the Community Supporting and Valuing Our Veterans and Volunteers Financial Sustainability Performance Management Customer- Centric Data Aware Promoting Pathways to the 21st Century Economy for All Virginians While Maximizing the Value of Commonwealth Resources Cultural Competence Trauma Informed Systems of Care
- 5. An interaction in one domain may only be measured by impact in another domain. Coalition Partners Fiscal Impact Data Outcome Measures Data Citizen Census Data Population Health Data Specific At-Risk Population Data Social Program Data Health Care Data DMAS DSS, OCS DBHDS, DHCD, DOC, DJJ VDH DMV, Elections Education, DOC, DJJ, State Police Tax, DPB, Trade & Commerce
- 6. Virginia is shifting from a ‘program-focused’ model to a more ‘Customer-Centric Coordinated Care’ model. ‘Customer-Centric Coordinated Care’ Model Agency Traditional Program-Focused Model ‘Customer-Centric Coordinated Care’ Model Agency Agency Agency Agency Service Delivery Partner Service Delivery Partner Agency Agency Agency Services driven by individual, family, or community needs Agencies recognize and consider the full range of services provided by other agencies, partners and organizations Services are considered more broadly factoring in role of social determinants
- 10. System Transformation, Excellence and Performance (STEP Virginia) – The Path to a Healthy Virginia • Establishes Certified Community Behavioral Health Clinics (CCBHCs) • There are two phases: • Phase 1: Virginia granted $982,000 for 1-year planning grant for CCBHC • Phase 2: Up to 8 CCBHC Planning Grant states will be selected to participate in the demonstration program. • This grant opportunity from SAMHSA arose from the Excellence in Mental Health Act. CCBHCs
- 11. Other recent grants • With help from the Center for Health Care Innovation, VHQC recently received a $5.7 million grant from CMS as a Practice Transformation Network. Only such grant awarded in Virginia. • In May, VCU received a $10 million grant to establish a statewide consortium to help small-to-medium-sized primary care practices in Virginia.
- 12. METRICS ALONE ARE INSUFFICIENT • We also require: • Vision – Where we want to be • Process – How to get there • Accountability – Who does what and by when • Will – A commitment to move forward • Much of the above will be addressed as we collectively create Virginia’s Plan for Well- Being
- 13. What is DSRIP? • Medicaid waiver to access federal dollars to invest in transformation of the Medicaid delivery system • CMS has approved seven DSRIP programs to date (CA, NM, TX, KS, NJ, MA, NY) • Helping states move from Fee-for-Service to Value-Based Reimbursement
- 14. DSRIP program is an opportunity for transformation • The future is a Medicaid delivery system that reimburses based on high-value care • Ensure that even the most medically complex enrollees with significantly behavioral, physical, and developmental disabilities can live safely and thrive in the community • To accomplish either of these, significant investment in data infrastructure at the provider and state level is imperative
- 15. DSRIP program is an opportunity for Virginia to transform The future is a Medicaid delivery system that reimburses based on high-value care Ensure that even the most medically complex enrollees with significantly behavioral, physical, and developmental disabilities can live safely and thrive in the community To accomplish either of these, significant investment in data infrastructure at the provider and state level is imperative
- 16. Certificate of Public Need • Study group required by 2015 legislation • Evaluating whether Virginia’s COPN process, needs, and relationship with charity care • Has met 3 times, has 2 more meetings; next is Oct. 27 • Final report due Dec. 1, 2015 • http://www.vdh.state.va.us/Administration/COPN. htm
- 17. Provider Assessment • Workgroup mandated by 2015 legislation • Will analyze options for creating a provider assessment program • Prompted in part because of struggles of rural hospitals, about half of which are operating in the red • Group has met twice – next meeting Oct. 28 • http://www.dmas.virginia.gov/Content_pgs/paw g.aspx
- 18. Intersection of SIM and DSRIP 27 SIM projects from 8 workgroups and three subgroups 1) Population Health, Quality, Payment, HIT 2) Care Transitions 3) Workforce 4) Medicaid Innovation 5) VBID/Choosing, Wisely 6) Telehealth 7) Integrated Care (Behavioral Health, Oral Health, Complex Care) Possible SIM project funding via DSRIP
- 19. Rates of Opioid Overdose Deaths, Sales, and Treatment Admissions, United States, 1999–2010 0 1 2 3 4 5 6 7 8 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Rate Year Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000 CDC. MMWR 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e1101a1.htm?s_cid=mm60e1101a1_w. Updated with 2009 mortality and 2010 treatment admission data. Rates of Opioid Overdose Deaths, Sales, and Treatment Admissions, United States, 1999–2010
- 20. 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Motor Vehicles 1037 1035 1052 1070 1124 928 841 823 878 877 831 Guns 799 824 884 812 838 818 843 868 863 830 848 Drug/Poisons 595 498 545 669 721 735 713 690 819 799 912 0 200 400 600 800 1000 1200 NumberofFatalities OCME's Top 3 Methods of Death by Number and Year of Death, 2003-2013
- 21. Deaths from Heroin and Rx Opiates in Virginia 0 4 19 100 89 107 48 100 135 213 210 0 50 100 150 200 250 NumberofDeaths Year Number of Fatal Heroin Overdoses by Year, 2004-2014* 1 Fatal heroin overdoses may have one or more drug or poisons contributing to death. 2 The number of fatal heroin overdoses in 2014 is estimated based upon data for January 1, 2014 to June 30, 2014. 389 422 398 415 487 414 468 508 0 100 200 300 400 500 600 2007 2008 2009 2010 2011 2012 2013 2014 NumberofDeaths Year Number of Fatal Prescription Opioid Overdoses by Year, 2007-2014* 1 Heroin and prescription drug deaths are tallied separately. Where heroin and prescription opioids caused or contributed to death, decedents will be counted twice. 2 Prescription opioid deaths are drug/poison deaths where one or more prescription opioids caused or contributed to death. 3 The number of fatal heroin overdoses in 2014 is estimated based upon data for January 1, 2014 to June 30, 2014.
- 22. The systems of care are constantly evolving due to some key challenges in Virginia. Key Challenges in Health and Human Services Delivery Population demographic changes including aging and ethnicity Key Challenges Keeping pace with technological and political shifts Developing and retaining a skilled health and human services workforce Balancing the requirement for specialization with need for integration Addressing the role of social determinants of health Coordinating with complex federal, state and private structures and requirements Managing funding instability and inflexibility
- 23. An interaction in one domain may only be measured by impact in another domain. Coalition Partners Fiscal Impact Data Outcome Measures Data Citizen Census Data Population Health Data Specific At-Risk Population Data Social Program Data Health Care Data DMAS DSS, OCS DBHDS, DHCD, DOC, DJJ VDH DMV, Elections Education, DOC, DJJ, State Police Tax, DPB, Trade & Commerce
- 24. The illustration below provides spending overlaps of individuals served by Medicaid, SNAP, and TANF in Virginia. Program Overlaps – Spending NOTE: Costs for each program have been derived by using population overlap data from SFY 2014 and program spending from SFY 2013 SOURCES: SFY 2014 VDSS Clients Served Annually , SFY 2013 VDSS Annual Statistical Reports • Majority of the state and federal HHR spending focuses on individuals receiving Medicaid only followed by individuals receiving both Medicaid and SNAP benefits • Spending on individuals receiving TANF is accompanied by Medicaid and SNAP spending as well Program Annual Program Spending (in Millions) Annual Per- Capita Spending Medicai d $7,600 $6,138 SNAP $1,625 $1,251 TANF $105 $655 Medicaid Only $5,100 M Medicaid & SNAP $2,100 M Medicaid, SNAP & TANF $997 M SNAP Only $572 M TANF Only $0.88 M Medicaid & TANF $36 M SNAP & TANF $30 M
Editor's Notes
- DSRIP proposals in Virginia are currently just that – proposals, not done deals. DMAS is in the stakeholder public comment process, DMAS has put together a framework/ strawman and is on the road describing the proposal and gathering feedback from stakeholders.
- Virginia Health Information database of fiscal 2013 financial results for the hospitals. It lists 36 rural hospitals, 17 of which had a negative operating margin. That comes to 47 percent. In this database, the hospitals were allowed to determine for themselves whether they should be classified as rural or urban. In a second batch of data, hospitals were sorted as rural or urban based on definitions from the federal Centers for Medicare & Medicaid Services. This grouping listed 25 rural hospitals in 2013, 16 of which ran in the red. That comes to 64 percent. By comparison, of the 60 urban hospitals in Virginia under the federal definition, 13 had operating losses. That means nearly 22 percent of urban hospitals in the commonwealth had an operating loss in 2013.
- A clear genesis of the abuse and overdose epidemics. Important to note that often these addictions begin with legitimate prescriptions. A primary contributor to the increase in opioid overdose deaths is an abundance of supply of these very powerful drugs. A recent analysis by CDC looked at the relationship between the sales of opioids and the number of deaths from them. What the study found was alarming: As the amount of opioids sold increased, so did the number of deaths. In fact, the supply of opioid pain relievers is larger than ever. The quantity sold in 2010 was four times that sold in 1999. Enough opioids were sold in 2010 to give every American adult a 5mg Vicodin tablet every 4 hours for a month. When you look at substance abuse treatment admissions for opioids and emergency department visits related to their misuse or abuse, you also see increases consistent with the increases in sales of these drugs.
- Of the 912 poisoning deaths in 2013, 468 of those involved prescriptions opioids and 213 involved heroin. The street value of oxycontin is about $1/milligram (5-120mg available). Heroin is about $10 a dose (1/10 gram). An active heroin user may spend about $100 daily, much cheaper than the same amount of pills it would take to get high. New 2014 numbers, not out as graphics yet, separate out opioid and heroin deaths, and show that in 2014, 728 Virginians died from heroin and prescription drug overdoses, up from 661 in 2013. In the last five years, fatal overdoses have increased by 57% and nearly 3,000 Virginians have lost their lives.
- There is no reason to assume that these numbers will reverse course without significant, coordinated efforts.
- Funding Stability and Flexibility Flat federal funding and limited state funds for ongoing programs High dependency of certain programs and agencies on federal grants/one-time grants and silo-ed funding approach Workforce Development and Retention Specialization vs Integration Focusing on specialized issues sometimes results in siloes Gaps in services due to inconsistent eligibility requirements Complex Federal Structure and Interaction Significant and wide-ranging federal oversight Complicated regulations and requirements Requirements not always current with modern service delivery Addressing Social Determinants in Health Limited usage of social determinants in designing, measuring and implementing policies and programs Limited infrastructure to support social determinants in health Legislative and Political Direction Changes