Health Services Cost Review Commission · 9/9/2015  · The final rule will increase rates by 0.9% after accounting for inflation and other adjustments required by law. This increase - [PDF Document] (2024)

John M. Colmers Chairman

Herbert S. Wong, Ph.D.

Vice-Chairman

George H. Bone, M.D.

Stephen F. Jencks,

M.D., M.P.H.

Jack C. Keane

Bernadette C. Loftus, M.D.

Thomas R. Mullen

Donna Kinzer

Executive Director

Stephen Ports Principal Deputy Director

Policy and Operations

David Romans Director

Payment Reform and Innovation

Gerard J. Schmith Deputy Director

Hospital Rate Setting

Sule Calikoglu, Ph.D. Deputy Director

Research and Methodology

Health Services Cost Review Commission 4160 Patterson Avenue, Baltimore, Maryland 21215

Phone: 410-764-2605 · Fax: 410-358-6217 Toll Free: 1-888-287-3229

hscrc.maryland.gov

State of Maryland Department of Health and Mental Hygiene

522nd MEETING OF THE HEALTH SERVICES COST REVIEW COMMISSION September 9, 2015

EXECUTIVE SESSION

12:00 p.m. (The Commission will begin in public session at 12:00 p.m. for the purpose of, upon motion and approval,

adjourning into closed session. The open session will resume at 1PM.)

1. Update on Contract and Modeling of the All-payer Model vis-a-vis the All-Payer Model Contract – Authority General Provisions Article, §3-104, and 3-305(b)(7)

PUBLIC SESSION OF THE HEALTH SERVICES COST REVIEW COMMISSION

1:00 p.m.

1. Review of the Minutes from the Public Meeting and Executive Session on August 12, 2015

2. Executive Director’s Report

3. New Model Monitoring 4. Docket Status – Cases Closed

2298A – MedStar Health 2299A – MedStar Health 2301R – Holy Cross Hospital 2302A – University of Maryland Medical Center 2305A – University of Maryland Medical Center

5. Docket Status – Cases Open 2300R – Washington Adventist Hospital 2303R – Frederick Memorial Hospital

2304N – UM St. Joseph Medical Center 2306A- University of Maryland Medical Center

6. Summary of the Certificate of Need Related Capital Adjustment Process

7. Draft Recommendations on Revisions to the Quality Based Reimbursem*nt Program for Rate Year 2018

8. Market Shift Update

9. Overview of the Health Employment Program Proposal

10. Report of the Consumer Engagement Task Force

11. Report of the Consumer Outreach Task Force

12. Summary of FY 2014 Community Benefits Report

13. Hearing and Meeting Schedule

Closed Session Minutes

of the Health Services Cost Review Commission

August 12, 2015

Upon motion made in public session, Chairman Colmers call for adjournment into closed session to discuss the following items:

1. Update on Contract and Modeling of the All-Payer Model vis-à-vis the All-Payer Model Contract;

2. Consultation with Legal Counsel on Contested Case Implications; The Closed Session was called to order at 12:09 p.m. and held under authority of -§§ 3-104 and 3-305(b) (7) of the General Provisions Article. In attendance, in addition to Chairman Colmers, were Commissioners Bone, Jencks, Keane, and Mullen. In attendance representing Staff were Donna Kinzer, David Romans, Steve Ports, and Dennis Phelps. Also attending was Stan Lustman, Commission Counsel.

Item One David Romans, Director-Payment Reform and Innovation, presented and the Commission discussed an updated analysis of Medicare per beneficiary data. Authority: General Provisions Article, § 3-104.

Item Two Stan Lustman, Commission Counsel, outlined and reviewed and the Commission discussed the legal process associated with Contested Cases. Authority: General Provisions Article, § 3-305(b) (7).

Item Three Donna Kinzer, Executive Director, advised the Commission on the need for strategic planning moving forward with the Model. Authority: General Provisions Article, § 3-104. The Closed Session was adjourned at 1:08 p.m.

MINUTES OF THE 521th MEETING OF THE

HEALTH SERVICES COST REVIEW COMMISSION

August 12, 2015 Chairman John Colmers called the public meeting to order at 12:09 pm. Commissioners George H. Bone, M.D, Stephen F. Jencks, M.D., MPH, Jack C. Keane, and Thomas Mullen were also in attendance. Herbert S. Wong, Ph.D., joined the meeting via telephone. Upon motion made by Commissioner Jencks and seconded by Commissioner Mullen, the meeting was moved to Executive Session. Chairman reconvened the public meeting at 1:15 pm.

REPORT OF THE AUGUST 12, 2015 EXECUTIVE SESSION

Dennis Phelps, Associate Director-Audit & Compliance, summarized the minutes of the August 12, 2015 Executive Session.

ITEM I

REVIEW OF THE MINUTES FROM JUNE 10, 2015 EXECUTIVE SESSION AND PUBLIC MEETING

The Commission voted unanimously to approve the minutes of the June 10, 2015 Executive Session and Public Meeting.

ITEM II EXECUTIVE DIRECTOR’S REPORT

Ms. Donna Kinzer, Executive Director, stated that the Centers for Medicare and Medicaid Services (CMS) issued its hospital inpatient prospective payment system (IPPS) final rule for fiscal year 2016 beginning October 1, 2015. The final rule will increase rates by 0.9% after accounting for inflation and other adjustments required by law. This increase is approximately .2% lower than the staff preliminary estimate noted in its June recommendation. After accounting for a Disproportionate Share reduction of 1.0%, the inpatient update would be expected to be less than a 0.1% increase. Ms. Kinzer noted that staff estimated an outpatient hospital increase for Medicare of approximately 1.9%. Under the proposed rule for CY 2016 for the hospital outpatient prospective payment system (OPPS), there would be a net decrease in OPPS payments of 0.2%. The net decrease largely results from a proposed 2.0 percentage point cut intended to account for CMS overestimation of the amount of packaged laboratory payments under OPPS, which caused an overpayment for hospital outpatient payments in 2014. Ms. Kinzer noted that the Office of the Actuary has released updates to the estimates of hospital revenue increases per beneficiary in connection with the update of the Trustees Annual Report. Staff used the estimates from the President’s Budget estimates.

Ms. Kinzer noted that while the rate increases for Medicare are lower than initial estimates used by staff, the per beneficiary figures are in line with staff estimates. Ms. Kinzer discussed two changes emerging from CMS relative to provider payment direction, which will affect us in Maryland as we move forward in working with partners outside as well as inside the hospital. The first change was that in April 2015, the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) was signed into law. This law permanently eliminated the use of the Sustainable Growth Rate formula, a mechanism originally created to control spending on Medicare physician services. MACRA revised Medicare physician payments using a new quality driven payment system to move from volume based payments to value based payments. Physicians will be able to receive additional payment updates for participating in alternative payment models. HSCRC and other stakeholders will explore how Maryland’s transformation strategies affect Medicare physician payments in order to align hospital and physician incentives. The second change was that on July 14, 2015, CMS released a proposed payment rule for the Medicare Comprehensive Care for Joint Replacement (CCJR) model. This is a bundled payment model for major lower extremity joint replacements (LEJR). In this 5 year demonstration program, hospitals would be responsible for the LEJR episodes of care of Medicare fee for service beneficiaries, with the episode covering hospitalization through recovery, defined as 90 days post discharge. Hospitals in 75 Metropolitan Statistical Areas (MSAs) would be required to participate in the model. If the model program is adopted as final, it would be effective for discharges on or after January 1, 2016 unless otherwise noted. Staff will work with stakeholders to craft comments on the proposed payment rule and request data to evaluate opportunities for Maryland patients. Staff will also requests to have access to the same tools offered in the demonstration program, while considering how this proposed rule fits into a broader picture for improving health in the State. Ms. Kinzer noted that in the last several months, staff has worked diligently with stakeholders to develop a transformation plan built on four pillars of activities for clinical improvement: statewide infrastructure, alignment, care coordination and integration, and consumer engagement. To build further momentum with the Model, the HSCRC will work with stakeholders to move forward with key alignment issues. In order to implement the Model fully, Maryland will need some waivers relative to such things as fraud and abuse that are typically granted to ACOs across the country. The Center of Medicare and Medicaid Innovation (CMMI) has agreed to work with us in determining how to put these waivers in place with our current Al-Payer Model. Staff is providing CMMI with additional information to support waivers in four areas that focus on being able to develop and implement: Pay for Performance programs, gainsharing programs, care coordination activities among physicians, hospitals, and nursing homes, and to provide for access to Medicare abuse and care coordination data similar to the data available to ACOs.

Ms. Kinzer next reported on the status of the planning and implementation of care coordination and alignment activities. Ms. Kinzer noted that at the May 2015 Commission meeting staff reported on the availability of Budget Reconciliation and Financing Act (BRFA) funds to support the success of the All-Payer Model. Of these funds $11.5 million will be provided to the Chesapeake Regional Information System for our Patients (CRISP) to fund expanded IT and analytic infrastructure as well as consulting support for implementation of care coordination and alignment activities. In addition, staff reported that budgets of $495,000, $1.08 million, and $0.9 million for state-level infrastructure planning, the regional transformation process, and the development of alignment strategies were reviewed and approved by staffs of DHMH, HSCRC, and MHCC. A third budget of $6.2 million, supporting the development of a statewide integrated care and care coordination infrastructure, has been approved by the Executive Committee of CRISP. Ms. Kinzer noted that Staff and consultants are focused on transformation support activities relative to regional planning grants and infrastructure planning and implementation activities. These include: Learning Collaboratives, Webinars, Shared site for resources and Individual Consultation. Ms. Kinzer stated that Staff has finalized the calculations for the market shift adjustments for all inpatient and outpatient services, except for radiation therapy, infusion and chemotherapy for inclusion in the rate year 2016 global budget. The revenue shifted under this calculation is approximately $28 million. Staff is in the process of reviewing a preliminary calculation completed for cancer services. Staff hopes to finalize a market shift calculation for these services by September. The market shift calculation, exclusive of oncology services, is being incorporated into FY 2016 rate orders. Dr. Sule Gerovich will report to the Commission on the final details at the September Commission meeting. Ms. Kinzer reported that the Board of Dimensions’ Healthcare System announced that it agreed to an innovative approach to enhance the health of the population served by Laurel Regional Hospital. The System will be reducing the scope and complexity of inpatient services, while simultaneously constructing a comprehensive ambulatory medical facility dedicated to preventative care that reduces avoidable healthcare. The new facility will cost approximately $24 million, which will include emergency services, outpatient surgery and comprehensive diagnostic imaging. The new hospital will be built on the existing hospital campus by 2018. Ms. Kinzer noted that Staff is currently focused on the following activities:

• Completing the rate orders for rate year 2016 • Continuing the focus on waivers, alignment models, and state level, regional and hospital

transformation planning and implementation. • Reviewing Certificate of Need (CON) and rate application that have been filed. • Beginning work on updates to value-based performance measures, including efficiency

measures. • Staff will released an RFP for support of the Phase 2 development and application

process with CMMI, which will focus on transitioning the All-Payer Model to a greater focus on the total cost of care.

ITEM III

CHESAPEAKE REGIONAL HEALTH SYSTEM FOR OUR PATIENTS (CRISP) REPORT ON INTEGRATED CARE NETWORK INFRASTRUCTURE

Dr. Mark Kelemen, Senior Vice President and Chief Medical Information Officer at the University of Maryland Medical School, and Mr. David Horrocks, CRISP President and CEO updated the Commission on the CRISP work plan (See “ICN Infrastructure Tools and Services Update on Progress” on the HSCRC website). Mr. Horrocks characterized the work plan to develop the integrated care network infrastructure as expanding the scope and capabilities of current operations and extending the access to services to additional providers. To oversee the development and implementation of the work plan, CRISP established a steering committee, chaired by Dr. Kelemen, and including hospital organization representatives with responsibilities in clinical integration/population health management and information technology from Johns Hopkins HealthCare LLC, Anne Arundel Health System, Advanced Health Collaborative, MedStar Health System and the Maryland Hospital Association. Other members of the steering committee include representatives from the Prince George’s County Department of Health, Columbia Medical Practice, Erickson Living, the Advisory Board Company, and the Maryland Health Care Commission. The steering committee has organized the work plan into seven project activities;

• Ambulatory Connectivity- The project aims to achieve bi-directional connectivity with ambulatory practices, long-term care, and other health providers.

• Data Router- enables sending relevant patient level data to the health care organizations by normalizing health records, determine whether a patent/provider relationship exists, and verifying patient consent.

• Clinical Portal Enhancements- Enhancing existing clinical portal with new elements, including care profile, a link to a provider directory, and information on other known patient/provider relationships and patient risk scores.

• Notification and Alerting- New tools integrated within existing work flows to alert providers to relevant care events

• Reporting and Analytics- Expands existing reporting capabilities to support many more case managers and ambulatory practices.

• Basic Care Management Software- Current scope is planning only, as advisors help determine an appropriate path.

• Practice Transformation- Current scope is planning only, as advisors help determine an appropriate path.

Mr. Horrocks and Dr. Kelemen also shared timelines and goals with the Commission and will periodically update the Commission on work plan progress

ITEM IV

NEW MODEL MONITORING

Mr. David Romans, Director Payment Reform and Innovation, stated that Monitoring Maryland Performance (MMP) for the new All-Payer Model for the month of June will focus on fiscal year (July 1 through June 30) as well as calendar year results. Mr. Romans reported that for the twelve months ended June 30, 2015, All-Payer total gross revenue increased by 2.00% over the same period in FY 2014. All-Payer total gross revenue for Maryland residents increased by 2.51%; this translates to a per capita growth of 1.85%. All-Payer gross revenue for non-Maryland residents decreased by 2.96%. Mr. Romans reported that for the six months of the calendar year ended June 30, 2015, All-Payer total gross revenue increased by 2.19% over the same period in FY 2014. All-Payer total gross revenue for Maryland residents increased by 2.63%; this translates to a per capita growth of 2.06%. All-Payer gross revenue for non-Maryland residents decreased by 2.28%. Mr. Romans reported that for the twelve months ended June 30, 2015, Medicare Fee-For-Service gross revenue increased by 2.92% over the same period in FY 2014. Medicare Fee-For-Service for Maryland residents increased by 3.70%; this translates to a per capita growth of 0.44%. Maryland Fee-For-Service gross revenue for non-residents decreased by 5.39%. Mr. Romans reported that for the six months of the calendar year ended June 30, 2015, Medicare Fee-For-Service gross revenue increased by 3.83%. Medicare Fee-For-Service for Maryland residents increased by 4.61%; this translates to a per capita growth of 1.25 %. Maryland Fee-For-Service gross revenue for non-residents decreased by 4.75%. According to Mr. Romans, for the twelve months of the fiscal year ended June 30, 2015, unaudited average operating profit for acute hospitals was 3.19%. The median hospital profit was 4.36%, with a distribution of 1.89% in the 25th percentile and 6.89% in the 75th

percentile. Rate Regulated profits were 5.86%. Dr. Alyson Schuster, Associate Director Performance Measurement, presented a quality report update on the Maryland Hospital Acquired Conditions program based upon Potentially Preventable Complications (PPCs) data and discharges through March 2015 and readmission data on discharges through May 2015. Readmissions

• The All-Payer risk adjusted readmission rate was 12.89 % for the period of January 2014 to May 2015. This is a cumulative decrease of 6.46% from the January 2013 risk adjusted readmission rate.

• The Medicare Fee for Service risk adjusted readmission rate was 13.73% for the period January 2014 to May 2015 YTD. This is an accumulated decrease of 5.60% from the January 2013 risk adjusted readmission rate.

• Based on the New-Payer Model, hospitals must reduce Maryland’s readmission rate to or below the national Medicare readmission rate by 2018. The Readmission Reduction incentive program has set the goals for hospitals to reduce their risk adjusted readmission rate by 9.3% during CY2015 compared to CY2013. Currently, only 14 out of 46 hospitals have reduced their risk adjusted rate by more than 9.3%. Potentially Preventable Complications

• The All-Payer risk adjusted PPC rate was 0.85 for March 2015 YTD. This is a decrease of 14.42% from the March 2014 YTD risk adjusted PPC rate.

• The Medicare Fee for Service risk adjusted PPC rate was 0.99 for March 2015 YTD. This is a decrease of 11.96% from the August 2014 YTD risk adjusted PPC rate.

ITEM V

DOCKET STATUS CASES CLOSED

NONE

ITEM VI DOCKET STATUS- OPEN CASES

2298A- MedStar Health

MedStar Health filed an application on June 2, 2015 on behalf of Union Memorial Hospital and Good Samaritan Hospital (the “Hospitals”) requesting approval to continue to participate in a global rate arrangement for orthopedic services with MAMSI for one year beginning September 1, 2015. Staff recommends that the Commission approve the Hospitals’ application for an alternative method of rate determination for orthopedic services for one year beginning September 1, 2015, and that the approval be contingent upon the execution of the standard Memorandum of Understanding. The Commission voted unanimously to approve staff’s recommendation.

2299A- MedStar Health MedStar Health filed an application on June 2, 2015 on behalf of Union Memorial Hospital (the “Hospital”) requesting approval to continue to participate in a global rate arrangement for cardiovascular services with Kaiser Foundation Health Plan of the Mid-Atlantic Inc. for one year beginning August 1, 2015.

Staff recommends that the Commission approve the Hospital’s application for an alternative method of rate determination for cardiovascular services for one year beginning August 1, 2015, and that the approval be contingent upon the execution of the standard Memorandum of Understanding. The Commission voted unanimously to approve staff’s recommendation.

2302A- University of Maryland Medical Center

The University of Maryland Medical Center (the “Hospital) filed an application on June 18, 2015 requesting approval to continue to participate in a global rate arrangement for solid organ and blood and bone marrow transplant services with Maryland Physicians Care for one year beginning August 23, 2015. Staff recommends that the Commission approve the Hospital’s application for an alternative method of rate determination for solid organ and blood and bone marrow transplant services services for one year beginning August 23, 2015, and that the approval be contingent upon the execution of the standard Memorandum of Understanding. The Commission voted unanimously to approve staff’s recommendation.

2305A- University of Maryland Medical Center The University of Maryland Medical Center (the “Hospital) filed an application on July 30, 2015 requesting approval to continue to participate in a global rate arrangement for solid organ and blood and bone marrow transplant services with Interlink Health Services for one year beginning November 1, 2015. Staff recommends that the Commission approve the Hospital’s application for an alternative method of rate determination for solid organ and blood and bone marrow transplant services services for one year beginning November 1, 2015, and that the approval be contingent upon the execution of the standard Memorandum of Understanding. The Commission voted unanimously to approve staff’s recommendation.

2301R- Holy Cross Hospital On June 12, 2015 Holy Cross (the “Hospital”) submitted a partial rate application to the Commission requesting that the Hospital’s Medical Surgical Intensive Care (MIS) and Coronary Care (CCU) approved rates be combined effective July 1, 2015 utilizing FY 2016 approved volumes and revenues. After reviewing the Hospital application, Staff recommended the following:

• That the Hospital be allowed to collapse its CCU rate into its MIS rate effective July 1,

2015; • That FY 2016 approved volume and revenue will be utilized to calculate the combined

rate; and • That no change be made to the Hospital’s Global Budget Revenue.

The Commission voted unanimously to approve staff’s recommendation.

ITEM VII

REPORT OF THE COMSUMER ENGAGEMENT TASK FORCE Ms. Hillery Tsumba, Primary Care Coalition of Montgomery County, presented an update to the Commission on the activities of the HSCRC Consumer Engagement Taskforce (CETF) (See “HSCRC Consumer Engagement Taskforce Preliminary Report- Promoting Patient – Centered Approaches in the New All Payer Model” on the HSCRC website). Ms. Tsumba outlined the goals of the CETF. They are as follows:

• Establish a consumer centered health care delivery system with an ongoing role for consumers to participate in the design and implementation of policies and procedures at all levels.

• Engage, educate, and activate people who use or are potential users of health services for their own health care to promote efficient and effective use of the health care system.

Ms. Tsumba also reviewed the communications strategy of the CETF and the development of materials for implementation from a consumer centered approach. The next steps of the CETF are to:

• Identify and Address Gaps in Information or Learnings • Finalize Communication Strategy • Finalize and Submit Report to Commission

CETF will finalize and submit the report to the Commission at the September public meeting

ITEM VIII

MARYLAND HEALTH CARE COMMISSION ON STATUS OF CERTIFICATE OF NEED APPLICATIONS

Mr. Paul Parker, Director Center for Health Care Facilities Planning and Development for the Maryland Health Care Commission (MHCC) presented an update on pending hospital projects before the MHCC ( See “ Proposed Hospital Capital Projects: 2012 -2015” on the HSCRC website).

ITEM IX LEGAL REPORT

Regulations Final Action Notification of Certain Financial Transactions – COMAR 10.37.01.08 The purpose of this action is to conform to the requirements set forth in Ch. 263, Acts of 2014, effective July 1, 2014, that require hospitals to notify the Commission, in writing, within 30 days before executing any financial transaction, contract, or other agreement that would result in more than 50 percent of all corporate voting rights or governance reserve powers being transferred to or assumed by another person or entity. This proposed regulatory change appeared in the May 1, 2015 issue of the Maryland Register (42:9 Md. R. 651) The Commission voted unanimously to approve the final adoption of the proposed regulation. Proposed Action Update to Accounting and Budget Manual – COMAR 10.37.01.02 The purpose of this action is to update the Commission’s Accounting and Budget Manual with Supplement 23, which has been incorporated by reference. The Commission voted unanimously to forward the proposed regulation to the AELR Committee for review and publication in the Maryland Register. Rate Application and Approval Procedures- COMAR 10.37.10.07-1 The purpose of this action is to conform to legislation passed in the 2015 General Assembly, which establishes that outpatient services associated with the federal 340B Program and that meet certain criteria shall be considered provided “at the hospital” and, therefore. subject to HSCRC rate jurisdiction. The Commission voted unanimously to forward the proposed regulation to the AELR Committee for review and publication in the Maryland Register. Rate Application and Approved Procedures- COMAR 10.37.10 The purpose of this action is to assure that rate applications are submitted in easily readable formats. The Commission voted unanimously to forward the proposed regulation to the AELR Committee for review and publication in the Maryland Register.

ITEM X

HEARING AND MEETING SCHEDULE September 9, 2015 Times to be determined, 4160 Patterson Avenue HSCRC Conference Room October 14, 2015 Times to be determined, 4160 Patterson Avenue HSCRC Conference Room There being no further business, the meeting was adjourned at 3:35 pm.

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Executive Director's Report

Health Services Cost Review Commission

September 9, 2015

All-Payer Model Implementation Embarking on Year 2 of Model implementation, the HSCRC has worked closely with stakeholders to develop strategies on four key pillars of activity for clinical improvement: statewide infrastructure, alignment, care coordination and integration, and consumer engagement.

Last month, we heard from CRISP regarding statewide infrastructure activities. We also heard from one of the consumer task forces. This month, we will hear from consumer task forces for a second time and receive a status report on regional partnership activities.

The HSCRC staff has released the RFP for Competitive Implementation Plans, after gaining stakeholder input, relative to the .25% that the Commission approved for FY 2016. This amount will be added to rates based on a review of applications to be submitted. Competitive transformation implementation awards are intended to support investments and activities related to partnerships, strategies, progress, and vision for care coordination and provider alignment in the State. Competitive transformation implementation awards will be available to any Maryland acute care or specialty hospital that submits a successful bid. Applicants will need to show current readiness to implement as well as a short term impact on reducing avoidable utilization, improving quality, improving coordination of care, and achieving a return on investment. The aggregate amount available for these awards is up to 0.25% of statewide revenue. More information can be found at:

http://www.hscrc.maryland.gov/rfp-implement.cfm

Staff has also released to hospitals and stakeholders the reporting requirements for the Strategic Hospital Transformation Plans (STP) that are due on December 7, 2015. These plans will describe each hospital’s short-term and long-term strategy to support the goals of the all-payer model, particularly as they related to care coordination, care transitions and alignment.

http://www.hscrc.maryland.gov/documents/HSCRC_PolicyDocumentsReports/PolicyClarification/2015/20150828-Strategic-Plan-Final-memo-v1.pdf

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I want to thank Steve Ports for his tremendous efforts in working with the transformation support process and getting this RFP to completion.

Analytics Progress HSCRC staff, CRISP, the St. Paul Group (HSCRC’s case mix data vendor), and SSS (HSCRC’s Medicare data vendor) have been working together to develop and execute strategies to make analytic information more readily available for care coordination and monitoring.

• CRISP has been working on patient level reporting, including the production of analytic data with flags of Potentially Avoidable Utilization. These data should be available in a “trial” format in October. This effort is focused on bringing analytics and information to support care coordination enhancements. This allows for leveraging analytic information that is used for both regulatory purposes by HSCRC and for care coordination and monitoring purposes by providers and payers.

• St. Paul will develop preliminary and final quarterly reports of market shift. These will be provided to all hospitals. We will release a timeline for this process in the near term.

• HSCRC staff has been working on utilization trend analysis that combines data from hospitals’ case-mix data, and includes analytic information added to the case-mix data by CRISP, The St. Paul’s Group, and HSCRC staff. Staff will begin presenting some of this data to the Commission today.

• HSCRC staff and SSS have been working on reconciling the Medicare claims and enrollment data used to support the Medicare savings calculation requirement under the All Payer Model. We are pleased to report that the reconciliation process is now complete. We expect that CMMI will release results in the near term.

The HSCRC staff, CRISP, and our vendors have made significant progress in advancing analytics to support implementation of the Model. The HSCRC staff strategy is to engage CRISP and vendor support for executing these data and monitoring reports so that we can meet the needs of providers and payers as well as our regulatory needs. We look forward to receiving feedback on this process and needs from the stakeholders.

Many of our staff as well as stakeholders have been involved in this effort, which has required a great deal of coordination and teamwork. I want to especially thank Sule Gerovich and David Romans for their efforts in moving this process forward. It is now HSCRC staff’s intention to focus analytic efforts on the Total Cost of Care, Cost and Utilization Per Capita, Episode costs, advancing outcomes, performance and efficiency measures, and improving current models. In executing this effort, we will need to work closely with MHCC (the APCD data sets), DHMH-Medicaid, and Medicare data. Progress in these areas is needed for measuring success under

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the existing All Payer Model as well as preparing for increased focus on total cost of care, comprehensive outcomes, and opportunities for improvement outside of hospitals.

Performance and Efficiency Measurement As indicated above, HSCRC staff is preparing to work with stakeholders on evaluation and development of performance measures. These will include HSCRC’s quality programs, risk adjustment approaches for attainment measures for readmissions and other PAUs, and appropriate efficiency and productivity measures for the new All Payer Model.

HSCRC has awarded a multi-year contract for professional services support of these efforts. The organization process for this work has begun, and we are in the process of fleshing out a work plan for this effort.

ICD-10 ICD-10 implementation is due to take place beginning October 1, 2015. Hospitals and payers have been busily preparing for implementation. HSCRC staff has interacted with MHA work groups and has discussed implementation readiness with the Maryland Insurance Administration. While hospitals and payers have made strides in readiness, there is concern that physicians are not uniformly well prepared for implementation. Also, HFMA reported in August that CMS Results for the final round of preparedness testing for the ICD-10 code set switch showed stagnant acceptance rates below the Medicare average.

The third round of end-to-end Medicare claims testing achieved an 87 percent acceptance rate, which was similar to the 88 percent rate achieved in the second round of testing, reported in June. However, the results continued to lag behind the average 95 percent to 98 percent standard fee-for-service Medicare claim acceptance rates.

HSCRC staff will stay in close contact with MHA and the Maryland Insurance Administration during implementation. If we become aware of situations where claims are not being processed, we will take appropriate steps in conjunction with the MIA.

The performance measures consultant recently engaged by HSCRC will work with us to evaluate the impact of ICD-10 on our data. It is possible that we will experience increased data resubmission or data lags resulting from the conversion.

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Planning and Implementation of Integrated Care Network (ICN) Activities Funding Administration Staff and CRISP have executed addenda to the prior MOU that detailed the initial 90-day planning process for state level ICN infrastructure and support. These addenda are temporary so that work may begin and vendors may be obtained to continue the progress that has been made thus far. Staff will continue to work with CRISP to help in the development of the products or deliverables, timelines, benchmarks, and dashboards for continued transparency and accountability related to the ICN infrastructure and support, initially budgeted at $6.2 million.

Staff Focus HSCRC staff is currently focused on the following activities:

• Completing the rate orders for rate year 2016. Many rate orders have been issued. All hospitals have received files with draft revenue and rate calculations. Several rate orders have not been issued because we are still awaiting some adjustments that require data from hospitals. There will be a final reconciliation of GBR/TPR and rate compliance, QBR performance, and the oncology market shift adjustment. We will update the budgets and rate orders as needed once these calculations are finalized.

• Reviewing radiation therapy, infusion and chemotherapy market shift adjustments with stakeholders.

• Continuing the focus on waivers, alignment models, and state level, regional and hospital transformation planning and implementation.

• Reviewing Certificate of Need (CON) and rate applications that have been filed. • Moving forward on updates to value-based performance measures, including efficiency

measures. • Turning to focus on per capita costs and total cost of care, for purposes of monitoring

and also to progress toward a focus on outcomes and cost across the health care system.

• As previously reported, staff has released an RFP for support of the Phase 2 application development and application process with CMMI, which will be focused on transitioning the All-Payer Model to a greater focus on the total cost of care.

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Summary of Interim Reports of the Regional Transformation Planning Grants Nancy Jaeckels Kamp and Deborah Gracey of Health Management Associates will summarize the interim reports of the Regional Transformation Planning Grants.

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Maryland Health Services Cost Review Commission

Interim Reports SummaryRegional Partnerships for Transformation

September 9, 2015

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Regional Partnerships Overview The 8 Regional Partnerships have each been given 60 hours of individual

consulting time. Each RP has a “Point of Contact” who serves as a guide and resource to help RPs identify areas of need for use of their 60 hours and to bring in subject matter experts as needed. Each RP also has a point of contact assigned from CRISP.

In addition to individual TA, the Regional Partnerships and all hospitals have been invited to participate in a series of bi-weekly, topic-specific webinars and an interactive Learning Collaborative. Six webinars have been given so far specific to the framework for transformation: Kick-off to the framework needed for transformational change Understanding data resources and performance metrics and electronic tools for

coordination (three individual webinars around these topics) Governance structures Care coordination

Regional Partnerships have also been invited to participate in a three-part, in-person Learning Collaborative hosted at MHA. Two have already been held in June and August.

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Highlights from the TA Points of Contact The Points of Contact have helped with relationship building

and served in a general communication role, aiding regional partnerships with connectivity, understanding and the building of their plan as driven by the HSCRC and DHMH planning process grant

Most common technical assistance needed from RPs: Governance structure development Aid in strategic initiatives and infrastructure development Research and summaries of best practices, i.e., care

coordination models, BHI models, transitions of care Financial and incentive modeling Providing other specific resources of information

Interim Report Themes

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Number and Type of Meetings Held The organization and structures vary among Regional

Partnerships. Number and types of meetings depend on complexity of planning structure.

Common elements include: Core Project Team to manage and drive the planning

process, at least bi-weekly meetings Advisory or Steering Committee, at least bi-monthly

meetings Additional meetings (depending on RP):

Board meetings: 3-7 meetings Topic-specific Task Forces or Subcommittees: 2-6 meetings.

Topics include care coordination, data, community and provider engagement, model design, pharmacy, behavioral health, sustainability

Provider Focus Groups Planning Retreats

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Organizations and Person Involved in Planning Process

Hospital Partners – generally leading the planning process

County Representatives - Health Departments, LHIC, Social Services, Office on Aging and Disability Services

Provider groups – MedChi, Emergency Medicine reps

Community partners are frequently engaged in planning activities, with representation on Advisory Committee and/or sub-committees.

Consultants – data analysis, project management, payment modeling

State Technical Assistance – CRISP, HMA

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Data Reviewed to Help in Decision-Making Process

Community Health Needs Assessment - Disease prevalence and burden within region

CRISP and Hospital systems - High-utilizer data, population and patient level data.

Additional Data Sources: Qualitative data from clinicians through focus

groups, MedChi and Medical Society surveys, EMS Medicare data from VHQC, MSSPs, and other

sources Office on Aging and Disability case load and trend

data SHIP

8

Briefly Describe the Planning Process Thus Far

Building the culture and working relationships needed for a true regional partnership to function – working together to first align multiple hospitals and build trust, then community partner expansion

Identifying fundamental aspects of shared work, overlap and efficiencies

Creating organizational committee structures for planning process and for long-term

9

List of Decisions Made Related to Delivery and Financing Model

Create strategy for physician engagement in first phase and implementation of physician alignment through initiatives and incentives

Need marketing plan for care management model to patients

Clear method to track saving generated and use part for sustainable program funding

Identification of vendors for care coordination or build yourself and use of CCM process and payment- understanding the relationships and connectivity

10

What Gaps/Barriers Have Been Identified, if Any

Sharing patient level data across hospitals and other partners Compliance with HIPPA, creating DUAs, BAAs Access and timeliness of data Obtaining data from non-hospital partners

Timeline for building new partnerships and resources needed to ensure effective collaboration and completion of plans due

Ability to achieve financial and practice alignment across partners, especially with PCP and other physicians

11

Next Steps – RPs Plans for Implementation Explore and formalize governance structures Include and expand coalition to new partners

Develop and implement operational plans addressing staff resources and needed infrastructure

Modify existing care management models in place or secure care management vendors

Seek additional revenue and funding streams that will support RP and service lines

Future plans for RPs to engage: Patients and family care-givers Additional community physicians and county social

service agencies

12

Next Steps – Ongoing Technical Assistance

Routine communications, ongoing guidance and technical assistance continues to be offered for the regional partnerships as needed.

Five more topic specific webinars coming over the next few months. Upcoming webinar schedule: Consumer Education and Outreach: September 10 Behavioral Health Integration Models: September 24 Physician Alignment: October 8 October 22 and November 12: Topics TBD

The last Learning Collaborative is scheduled for Nov. 5.

Appendix: Additional Detail from Interim Reports

14

Key Stakeholders/Community Partners

• The Coordinating Center• Provider Groups – EMS, Assisted Living Facilities, SNFs,

CHCs/FQHCs, Community physicians, home health care, behavioral health

• County Service and Transit• Partnership for Children, Youth, and Families• CBOs – Esperanza Center, Health Care for the Homeless,

Sisters Together Reaching• NGO/Faith-based organizations

Additional Detail from Interim Reports

15

Additional Detail from Interim ReportsProgress and Decisions Made Thus Far for

Planning

•Understanding and working with CRISP on areas to help with data and tools

•Identifying overlap of provision of services and efficiencies

•Building trust and expanding coalition•Defined clear scope of work and SMART goals•Decision on structural governance needed•Changes in interventions and approach based

on realizations of shared patients across hospitals and need for collaboration

•Best practices and spread models identified•CRISP as the engine for new levels of

communication•Data and incorporating social determinants of

health•Physician focus groups to test interventions•More clearly defined target high utilizer

population

List of Decisions Made Related to Delivery and Financing Model

• Development of transition and chronic disease clinic

• Care management bonus based on enrolling and follow-up management of patients and ultimately outcomes (reducing readmissions)

• Engage ED and community-based physicians to decrease PAUs

• Expanded use of CRISP• Use of CCM code/fee and creating the

infrastructure to perform• Use of Behavioral health as part of care

management strategy

16

Additional Detail from Interim ReportsWhat Gaps/Barriers Have Been

Identified, if Any

• Physician engagement – PCP, ED physicians and specialty providers

• Data capabilities• Alignment with and across EMRs• Risk assessment and care plans• Identification of providers working

with specific patients• Lack of coordination and leveraging

of existing care management/coordination across partners

• Timeframe challenging particularly in light of evolving information and data capabilities

Plans for Implementation

• Continue regular meeting schedule in place during planning process to review cases, metrics, report cards and identify opportunities for expansion across partners

• Focus on provider and physician engagement

• Invest in behavioral health expansion and capacity

• Seek consultation and TA as needed• Continue to identify and problem-solve

regarding gaps and barriers• Standardize processes and workflows

across partners• Maintain current decision making advisory

committee structures in place• Include any new partners identified in

existing structures

1

Monitoring Maryland Performance Financial Data

Year to Date thru July 2015

2

Gross All Payer Revenue GrowthYear to Date (thru July 2015) Compared to Same Period in Prior Year

3.40%

2.44%

3.71%

2.85%

0.31%

-1.70%

-4.00%

-3.00%

-2.00%

-1.00%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

FY 2016 CY 2015

All-Payer Year-to-Date Gross Revenue Growth

AllRevenue In State

Out of State

All Revenue

In State

Out of State

3

Per Capita Growth RatesFiscal Year 2016 and Calendar Year 2015

Calendar and Fiscal Year trends to date are below All-Payer Model Guardrail for per capita growth.

3.13%

2.28%

-4.00%

-2.00%

0.00%

2.00%

4.00%

6.00%

All-Payer In-State Fiscal Year YTD Medicare FFS In-State FY YTD All-Payer In-State Calendar YearYTD

Medicare FFS In-State CY YTD

Population Data from Estimates Prepared by Maryland Department of Planning FFS = Fee-for-Service

Fiscal Year Calendar Year

Data Delayed Due to Submission Errors

Date Delayed Due to Submission Errors

4

Per Capita Growth – Actual and Underlying GrowthCY 2015 Year to Date Compared to Same Period in Base Year (2013)

Two year per capita growth rate is well below maximum allowable growth rate of 7.29% (growth of 3.58% per year)

Underlying growth reflects adjustment for FY 15 & FY 16 revenue decreases that were budget neutral for hospitals. 1.09% revenue decrease offset by reduction in MHIP assessment and hospital bad debts in FY 15. Additional 1.41% adjustment in FY 16 due to further reductions to hospital bad debts and elimination of MHIP assessment.

3.98%

5.26%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

Per Capita - All Payer Per Capita - Medicare

Net Growth Growth Before FY 15 UCC/MHIP Adjustments

Data Delayed Due to Submission Errors

5

Operating Profits: Fiscal 2016 Year to Date (July) Compared to Same Period in FY 2015

Year to date FY 2016 unaudited hospital operating profits improved compared to the same period in FY 2015.

3.35%

2.56%

3.72%

8.07%

6.09%

4.44%

1.39%

4.94%

7.35%

8.21%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

All Operating 25th Percentile Median 75th Percentile Rate Regulated Only

FY 2015 FY 2016

6

Operating Profits by HospitalFiscal 2016 Year to Date (July)

-50.00%

-40.00%

-30.00%

-20.00%

-10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

7

Purpose of Monitoring Maryland PerformanceEvaluate Maryland’s performance against All-Payer Modelrequirements:

All-Payer total hospital per capita revenue growth ceilingfor Maryland residents tied to long term state economic growth(GSP) per capita 3.58% annual growth rate

Medicare payment savings for Maryland beneficiaries comparedto dynamic national trend. Minimum of $330 million in savings over5 years

Patient and population centered-measures and targets topromote population health improvement Medicare readmission reductions to national average 30% reduction in preventable conditions under Maryland’s Hospital Acquired

Condition program (MHAC) over a 5 year period Many other quality improvement targets

8

Data Caveats Data revisions are expected. For financial data if residency is unknown, hospitals report this

as a Maryland resident. As more data becomes available, theremay be shifts from Maryland to out-of-state.

Many hospitals are converting revenue systems along withimplementation of Electronic Health Records. This may causesome instability in the accuracy of reported data. As a result,HSCRC staff will monitor total revenue as well as the split ofin state and out of state revenues.

All-payer per capita calculations for Calendar Year 2015 andFiscal 2016 rely on Maryland Department of Planningprojections of population growth of .56% for FY 16 and .56%for CY 15. Medicare per capita calculations use actual trendsin Maryland Medicare beneficiary counts as reported monthlyto the HSCRC by CMMI.

1

Monitoring Maryland Performance Preliminary Utilization Analytics

FY2013-FY2015

2

Utilization Analytics Utilization as measured by Equivalent Case-mix Adjusted

Discharges (ECMAD) 1 ECMAD Inpatient discharge=1 ECMAD OutpatientVisit

Observation stays with more than 23 hour are includedin the inpatient counts IP=IP + Observation cases >23 hrs. OP=OP - Observation cases >23 hrs.

Preliminary data, not yet reconciled with financial data Careful review of outpatient service line trends is needed TableauVisualization Tools

3

All-Payer Inpatient(IP) and Outpatient (OP) ECMAD Trend

740,581

418,278

724,508

422,910

721,431

431,227

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

IP OP

FY2013 FY2014 FY2015

4

Medicare All-Payer Inpatient(IP) and Outpatient (OP) ECMAD Trend

314,054

120,604

309,763

124,771

313,866

128,189

50,000

100,000

150,000

200,000

250,000

300,000

350,000

IP OP

FY2013 FY2014 FY2015

5

Annual Percent Growth Rate-Total ECMAD

-0.99%

-0.03%

0.46%

1.73%

-1.50%

-1.00%

-0.50%

0.00%

0.50%

1.00%

1.50%

2.00%

All-Payer Medicare

FY2014 FY2015

6

Case-mix Index Trends by Payer

1.000.96

1.181.10

1.01 0.98

1.191.10

1.01 0.98

1.201.11

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

All Payer- IP All Payer -OP Medicare- IP Medicare- OP

FY2013 FY2014 FY2015

7

All-Payer ECMAD Trends by Resident Status

682,599

383,936

57,98234,342

664,849

388,558

59,66034,352

663,712

397,120

57,71934,107

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

Resident-IP Resident-OP NonResident-IP NonResident-OPFY2013 FY2014 FY2015

8

Medicare ECMAD Trends by Resident Status

292,079

110,532

21,97510,072

286,995

114,306

22,768 10,465

291,684

118,004

22,18210,185

50,000

100,000

150,000

200,000

250,000

300,000

350,000

Resident-IP Resident-OP NonResident-IP NonResident-OPFY2013 FY2014 FY2015

9

Service Line Definitions Inpatient service lines: APR DRG to service line mapping Readmissions and PQIs are top level service lines (include

different service lines)

Outpatient service lines: Highest EAPG to service line mapping Hierarchical classifications (ED, major surgery etc)

Market Shift technical documentation

All Payer MD Resident Inpatient Service Line Distribution

Rank Service LineFY2015 ECMAD % Total ECMAD

1 Readmission 90,377 8%2 Orthopedic Surgery 89,403 8%3 General Surgery 55,793 5%4 PQI 51,112 4%5 Obstetrics/Delivery 43,783 4%6 Infectious Disease 36,593 3%7 Gastroenterology 31,628 3%8 Neurology 24,922 2%9 Pulmonary 24,192 2%10 Cardiothoracic Surgery 21,311 2%11 Cardiology 18,642 2%12 Psychiatry_IP 18,150 2%13 Neonatology 16,908 1%14 Ventilator Support 14,918 1%15 Invasive Cardiology 14,015 1%16 Categorical Exclusions_IP 13,263 1%17 Neurological Surgery 11,655 1%18 Rehabilitation 11,176 1%19 Oncology_IP 11,101 1%20 Newborn 9,607 1%

Inpatient Service Lines-ContinuedRank Service Line FY2015 ECMAD % Total ECMAD21 Vascular Surgery 9,492 1%22 Nephrology 9,075 1%23 General Medicine 9,050 1%24 Spinal Surgery 8,967 1%25 Urological Surgery 6,632 1%26 Gynecological Surgery 5,664 0%27 Hematology 5,606 0%28 Endocrinology Surgery 5,417 0%29 Thoracic Surgery 5,242 0%30 Trauma 5,218 0%31 Orthopedics 5,013 0%32 Endocrinology 4,360 0%33 Myocardial Infarction 3,713 0%34 Rheumatology 3,647 0%35 EP/Chronic Rhythm Mgmt 3,434 0%36 Substance Abuse 3,296 0%37 Otolaryngology 3,234 0%38 ENT Surgery 3,177 0%39 HIV 2,385 0%40 Other Obstetrics 2,180 0%41 Injuries/complic. of prior care 2,046 0%42 Dermatology 1,934 0%43 Urology 1,513 0%44 Gynecology 725 0%45 Unassigned_IP 493 0%46 Dental 427 0%47 Diabetes 402 0%48 Ophthalmology 381 0%49 Ophthalmologic Surg 148 0%

All Payer MD Resident Outpatient Service Line Distribution

Rank Service Line FY2015 ECMAD % Total ECMAD

1 ED 101,018 9%2 Rad/Inf/Chemo 85,694 7%3 Major Surgery 73,774 6%4 Clinic 41,033 4%5 Cardiovascular 27,943 2%6 Radiology 26,419 2%7 Minor Surgery 24,473 2%8 Other 13,884 1%9 CT/MRI/PET 10,894 1%10 Psychiatry 8,637 1%11 Rehab & Therapy 7,835 1%12 Lab 4,806 0%13 Drugs 2,228 0%14 Unassigned 1,522 0%15 Pathology 1,067 0%

13

All-Payer MD Resident Largest 10 Service Line Trends

0 20,000 40,000 60,000 80,000 100,000 120,000

ED

Readmission_IP

OrthopedicSurgery_IP

Oncology_OP

Major Surgery_OP

General Surgery_IP

PQI_IP

Obstetrics/Delivery_IP

Clinic_OP

InfectiousDisease_IP

FY2013 FY2014 FY2015

14

Medicare MD Resident Largest 10 Service Line Trends

0 10,000 20,000 30,000 40,000 50,000 60,000

Readmission_IP

Orthopedic Surgery_IP

Oncology_OP

PQI_IP

General Surgery_IP

Infectious Disease_IP

Major Surgery_OP

ED_OP

Cardiovascular_OP

Gastroenterology_IP

FY2013 FY2014 FY2015

15

All-Payer MD Resident Service Lines with Largest Net Changes FY15 vs FY13

-6,000 -4,000 -2,000 0 2,000 4,000 6,000

Oncology_OPOrthopedic Surgery_IP

Major Surgery_OPInfectious Disease_IP

Cardiovascular_OPClinic_OP

Categorical Exclusions_IPED

Rehab & Therapy_OPPulmonary_IPRadiology_OP

Spinal Surgery_IPInvasive Cardiology_IP

Oncology_IPGynecological Surg_IP

Cardiology_IPGeneral Surgery_IP

Readmission_IP

FY2014 FY2015

16

Medicare MD Resident Service Lines with Largest Net Changes FY15 vs FY13

-3,000 -2,000 -1,000 0 1,000 2,000 3,000

Orthopedic Surgery_IPOncology_OP

EDInfectious Disease_IP

Cardiovascular_OPMajor Surgery_OP

PQI_IPCategorical Exclusions_IP

Clinic_OPEP/Chronic Rhythm Mgmt_IP

Invasive Cardiology_IPRehabilitation_IP

Oncology_IPCardiology_IP

General Surgery_IPReadmission_IP

FY2014 FY2015

Cases Closed

The closed cases from last month are listed in the agenda

H.S.C.R.C's CURRENT LEGAL DOCKET STATUS (OPEN)

AS OF SEPTEMBER 2, 2015

A: PENDING LEGAL ACTION : NONEB: AWAITING FURTHER COMMISSION ACTION: NONEC: CURRENT CASES:

Rate OrderDocket Hospital Date Decision Must be Analyst's FileNumber Name Docketed Required by: Issued by: Purpose Initials Status

2300R Washington Adventist Hospital 6/8/2015 9/8/2015 11/5/2015 Capital GS OPEN

2303R Frederick Memorial Hospital 7/10/2015 9/8/2015 12/7/2015 FULL JS OPEN

2304N UM St. Joseph Medical Center 7/17/2015 9/8/2015 12/14/2015 CCU/DEF CK OPEN

2306A University of Maryland Medical Center 8/28/2015 N/A N/A ARM DNP OPEN

2307A Maryland Physician Care 8/31/2015 N/A N/A ARM SP OPEN

PROCEEDINGS REQUIRING COMMISSION ACTION - NOT ON OPEN DOCKET

IN RE: THE APPLICATION FOR * BEFORE THE MARYLAND HEALTH

ALTERNATIVE METHOD OF RATE * SERVICES COST REVIEW

DETERMINATION * COMMISSION

UNIVERSITY OF MARYLAND * DOCKET: 2015

MEDICAL CENTER * FOLIO: 2116

BALTIMORE, MARYLAND * PROCEEDING: 2306A

Staff Recommendation

September 9, 2015

I. INTRODUCTION

University of Maryland Medical Center (“Hospital”) filed an application with the

HSCRC on August 28, 2015 for an alternative method of rate determination pursuant to

COMAR 10.37.10.06. The Hospital requests approval from the HSCRC for continued

participation in global rates for solid organ transplant and blood and bone marrow transplants for

one year with Aetna Health, Inc. beginning October 1, 2015.

II. OVERVIEW OF THE APPLICATION

The contract will be continue to be held and administered by University Physicians, Inc.

("UPI"), which is a subsidiary of the University of Maryland Medical System. UPI will manage

all financial transactions related to the global price contract including payments to the Hospital

and bear all risk relating to services associated with the contract.

III. FEE DEVELOPMENT

The hospital portion of the global rates was developed by calculating recent historical

charges for patients receiving the procedures for which global rates are to be paid. The

remainder of the global rate is comprised of physician service costs. Additional per diem

payments were calculated for cases that exceed a specific length of stay outlier threshold.

IV. IDENTIFICATION AND ASSESSMENT OF RISK

The Hospital will continue to submit bills to UPI for all contracted and covered services.

UPI is responsible for billing the payer, collecting payments, disbursing payments to the

Hospital at its full HSCRC approved rates, and reimbursing the physicians. The Hospital

contends that the arrangement between UPI and the Hospital holds the Hospital harmless from

any shortfalls in payment from the global price contract.

V. STAFF EVALUATION

Staff reviewed the experience under this arrangement and found it to be favorable. Staff

believes that the Hospital can continue to achieve favorable performance under this arrangement.

VI. STAFF RECOMMENDATION

Based on the Hospital’s favorable performance, staff recommends that the Commission

approve the Hospital’s application for an alternative method of rate determination for solid organ

transplant, and blood and bone marrow transplant services, for a one year period beginning

October 1, 2015. The Hospital will need to file a renewal application to be considered for

continued participation.

Consistent with its policy paper regarding applications for alternative methods of rate

determination, the staff recommends that this approval be contingent upon the execution of the

standard Memorandum of Understanding ("MOU") with the Hospital for the approved contract.

This document would formalize the understanding between the Commission and the Hospital,

and would include provisions for such things as payments of HSCRC-approved rates, treatment

of losses that may be attributed to the contract, quarterly and annual reporting, and

confidentiality of data submitted, penalties for noncompliance, project termination and/or

alteration, on-going monitoring, and other issues specific to the proposed contract. The MOU

will also stipulate that operating losses under the contract cannot be used to justify future

requests for rate increases.

Partial Rate Application for Capital

September 9, 2015

2

Partial Rate Application for Capital

What it does: Allows a hospital that is undertaking a major capital project to

request an increase to rates to finance a portion of the project

Who is eligible? Any hospital that has filed a Certificate of Need (CON)

request with the Maryland Health Care Commission (MHCC) The project must be a major renovation or relocation, defined as

having a total project cost that is at least 50% of the hospital’s total approved revenue for the year

3

Partial Rate Application for Capital

Why is it allowed? As part of the CON process, the HSCRC must comment on

the financial feasibility of the project The feasibility may be dependent on the HSCRC’s approval of rate

increases at the time of the project’s completion Allows HSCRC to review and approve future increases so that the

feasibility may be better estimated

4

Partial Rate Application for Capital

What is used? Blended Reasonableness of Charges (ROC) Methodology,

adopted June 2010, with modifications Incorporates outpatient charge per visit (CPV) with inpatient charge

per case Hospitals are divided into peer groups: Urban Non-urban teaching hospitals Suburban and rural non-teaching hospitals Special Hopkins & University Group

5

Partial Rate Application for Capital Adjustments included in the Modified ROC: Compares the hospital with its peer group standard, comprehensive

charge target (CCT) adjusted for the following: Mark-up: Commission approved markups over costs that reflect the

payer differential and uncompensated care built into each hospital’s rate structure

Direct Strips (Direct Medical Education, Nurse Education, and Trauma): Remove partial costs of resident salaries, nurse education costs and incremental costs of trauma services of hospitals with trauma centers

Labor Market: Adjustment for differing labor costs in various markets Case Mix: Adjustment accounts for differences in average patient acuity

across hospitals Capital: Costs for a hospital are partially recognized Indirect Medical Education: Adjustment for inefficiencies and

unmeasured patient acuity associated with teaching programs Disproportionate Share: Adjustment for differences in hospital costs

for treating relatively high number of poor and indigent patients

6

Partial Rate Application for Capital

Normal adjustments to convert to the Inter-hospital Cost Comparison (ICC) Remove regulated profit percent Remove additional 2% productivity adjustment (not done as

part of the Partial Rate Application for Capital) Peer group average becomes the standard

7

Partial Rate Application for Capital

Adjustments to the standard Same as those made for each hospital when developing

standards Disproportionate Share Indirect Medical Education Capital Case Mix Labor Market Direct Strips Mark-Ups

8

Partial Rate Application for Capital

If the adjusted standard is less than the current approved: The percentage difference is offset to the future capital

adjustment

If adjusted standard is more than the current approved: No additional amount is added to the calculation of future

capital adjustment

9

Partial Rate Application for Capital

Future adjustment allowed for capital: 50% of the hospital’s depreciation and interest (D&I) as a

percentage of total cost (after addition of project D&I) 50% of the peer group’s average depreciation and interest as a

percentage of total cost

10

Partial Rate Application for Capital

Example:

$7,000,000 $100,000,000 7.00%

Total Cost

Hospital’s current depreciation and interest

Hospital’s project depreciation and interest $6,000,000 $6,000,000

$13,000,000 $106,000,000 12.26%

Peer group depreciation and interest as a percentage of total cost

9%

Allowed % for Capital 50% x 12.26% = 6.13%

50% x 9.00% = 4.50%10.63%

D&I % D&I

11

Partial Rate Application for Capital

Example: Final adjustment Allowed Capital % 10.63% Current Capital % - 7.00%

Difference 3.63% Adjustment from ICC (minus only) 0% Final Capital % 3.63%

Approved revenue for current period $115,000,000 Additional capital adjustment $4,174,500

This amount will be added to rates when the project is completed and the hospital begins to record additional depreciation and

interest

12

Future Issues Volume Growth Previously reimbursed actual volume growth at 85% Variable

Cost Factor (VCF)

Current policy only provides 50% VCF on market shift and population/demographic growth

Other Avenues for Financing Major Capital Projects Cash from operations (prior, future)

Philanthropy

Sale of bonds- how much and how do we finance?

13

Future Issues Efficiency of Prices Previous ROC and ICC adjusted for only differences in prices,

which were considered reasonable or necessary to compare one hospital to another

Efficiency Bands Around Prices, which should consider: Quality measures

Per capita efficiency levels

Potentially Avoidable Utilization

Draft Recommendation for Updating the Quality-Based Reimbursem*nt Program

for FY 2018

September 9, 2015

Health Services Cost Review Commission 4160 Patterson Avenue

Baltimore, Maryland 21215 (410) 764-2605

FAX: (410) 358-6217

This document contains the draft staff recommendations for updating the Quality-Based Reimbursem*nt (QBR) Program for FY 2018 for consideration at the September 9, 2019 Public Commission Meeting. Public comments should be sent to Dianne Feeney at the above address or by e-mail at [emailprotected]. For full consideration, comments must be received by October 1, 2015.

Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

1

A. INTRODUCTION

The Health Services Cost Review Commission (HSCRC) quality-based measurement initiatives, including the scaling methodologies and magnitudes of revenue “at risk” for these programs, are important policy tools for providing strong incentives for hospitals to improve their quality performance over time. HSCRC implemented the first hospital payment adjustments for the Quality-Based Reimbursem*nt (QBR) Program performance in July 2009. Current Commission policy calls for measurement of hospital performance scores across clinical process of care, outcome and patient experience of care domains, and scaling of hospital performance results in allocating rewards and penalties based on performance.

“Scaling” for QBR refers to the differential allocation of a pre-determined portion of base-regulated hospital inpatient revenue based on assessment of the quality of hospital performance. The rewards (positive scaled amounts) or penalties (negative scaled amounts) are then applied to each hospital’s update factor for the rate year; these scaled amounts are applied on a “one-time” basis (and are not considered permanent revenue).

For fiscal year (FY) 2018, HSCRC staff draft recommendations include adjusting the weights and updating the measurement domains to be as consistent as possible with the CMS Value-Based Purchasing (VBP) Program and holding steady the amount of total hospital revenue at risk for scaling for the QBR Program.

B. BACKGROUND

1. Centers for Medicare & Medicaid Services (CMS) VBP Program

The Patient Protection and Affordable Care Act of 2010 requires CMS to fund the aggregate Hospital VBP incentive payments by reducing the base operating diagnosis-related group (DRG) payment amounts that determine the Medicare payment for each hospital inpatient discharge. The law set the reduction at 1 percent in FY 2013 and mandates it to rise incrementally to 2 percent by FY 2017.

CMS implemented the VBP Program with hospital payment adjustments beginning in October 2013. For the federal fiscal year (FFY) 2017 (October 1, 2016 to September 30, 2017) Hospital VBP Program, CMS measures include the following four domains of hospital performance with 2 percent of Medicare hospital payments “at risk”:

• Clinical care: process of care weighted at 5 percent and outcomes weighted at 25 percent • Patient experience of care (HCAHPS survey measure) weighted at 25 percent • Efficiency/Medicare spending per beneficiary weighted at 25 percent • Safety weighted at 20 percent

HSCRC staff note that, for the VBP Program for FY 2017, CMS has added Health Safety Network (“CDC-NHSN”) Clostridium Difficile and Methicillin-Resistant Staphylococcus Aureus measures, as well as the Elective Delivery Prior to 39 Completed Weeks Gestation measure.

Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

2

2. QBR Measures, Domain Weighting, and Magnitude at Risk to Date

For the QBR Program for state FY 2017 rates, as approved, the HSCRC will: weight the clinical process measures at 5 percent of the final score, the outcomes and safety domains more heavily at 50 percent combined, and the patient experience of care measures at 45 percent; as well as scale a maximum penalty of 2 percent of approved base hospital inpatient revenue. The program uses the CMS/Joint Commission core process measures also used for the VBP Program, clinical outcome measures, “patient experience of care” Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and safety measures. The weighting for each domain compared with the CMS VBP program are illustrated below in Figure 1.

Figure 1. Final Measure Domain Weights for the CMS Hospital VBP and Maryland QBR Programs for FY 2017

Clinical

• Outcomes (Mortality)

• Process

Patient Experience

Safety Efficiency

CMS VBP • 25 percent • 5 percent

25% 20% 25%

Maryland QBR • 15 percent • 5 percent

45% 35% N/A

HSCRC staff have worked with stakeholders over the last three years to align the QBR measures with the VBP Program where feasible, and to align the list of process of care measures, threshold and benchmark values, and time lag periods with those used by CMS,1 allowing HSCRC to use the data submitted directly to CMS. This alignment has also occurred with the magnitude of revenue “at risk” for the two programs. Maryland has not yet developed and implemented an efficiency measure as part of the QBR Program, but it does apply a Potentially Avoidable Utilization adjustment to hospital global budgets, as well as a shared savings adjustment based on hospitals’ readmission rates. HSCRC staff will also work with stakeholders to develop a new efficiency measure that incorporates population-based cost outcomes.

3. Value-Based Purchasing Exemption Provisions

Under the previous waiver, VBP exemptions had been requested and granted for FYs 2013, 2014, and 2015.

The CMS FY 2015 Inpatient Prospective Payment stated that, although the exemption from the Hospital VBP Program no longer applies, Maryland hospitals will not be participating in the

1 HSCRC has used core measures data submitted to the Maryland Health Care Commission (MHCC) and applied state-based benchmarks and thresholds to calculate hospitals’ QBR scores up to the period used for state FY 2015 performance.

Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

3

Hospital VBP Program because §1886(o) of the Act and its implementing regulations have been waived for purposes of the model, subject to the terms of the agreement.

The section of Maryland All-Payer Model Agreement between CMS and the state addressing the VBP program is excerpted below.

…4. Medicare Payment Waivers. Under the Model, CMS will waive the requirements of the following provisions of the Act as applied solely to Regulated Maryland Hospitals:

…e. Medicare Hospital Value Based Purchasing. Section 1886(o) of the Act, and implementing regulations at 42 CFR 412.160 - 412.167, only insofar as the State submits an annual report to the Secretary that provides satisfactory evidence that a similar program in the State for Regulated Maryland Hospitals achieves or surpasses the measured results in terms of patient health outcomes and cost savings established under 1886(o) of the Act….

For FY 2016 under the new All-Payer Model, HSCRC staff submitted an exemption request and received approval on August 27, 2015 from the CMS Center for Medicare and Medicaid Innovation (see Appendix I).

C. ASSESSMENT

1. FY 2016 Performance Results

Staff analyzed changes in performance on the QBR and VBP measures used for FY 2016 performance for Maryland versus the United States for October 2013 through September 2014 compared with the base period. Figure 2 below lists each of the measures used for the VBP and QBR Programs. As the data indicate, Maryland has performed and continues to perform similarly to the nation on the clinical process of care measures but better than the nation on the 30-day condition-specific mortality measures. For the Safety infection measures, Maryland has performed and continues to perform better than the nation on the CLABSI measure; for the other infection measures, Maryland appears to perform worse than the nation, and this may be in part due to limited hospital participation in reporting the data for these measures as hospitals were continuing to align their reporting with Medicare requirements. With exception of the “Discharge Information” measure—for which Maryland is on par with the nation—Maryland has lagged and continues to lag behind the nation on the HCAHPS measures. Final QBR payment scaling for FY 2016 rate year is provided in Appendix II.

Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

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Figure 2. QBR Measures Change for Maryland versus U.S.

2. FY 2018 VBP and QBR Measures, Performance Standards, and Domain Weighting

HSCRC staff examined measures finalized for the CMS VBP Program for FY 2018 in the 2016 CMS Inpatient Prospective Payment System (IPPS) Final Rule, as well as those in the potential pool for the QBR Program for 2018. Appendix III details the measures by domain and the available published performance standards for each measure. It also indicates the measures that will be included in the VBP and QBR Programs. Staff note that one process of care measure remains—PC-01 Elective Delivery Before 39 Weeks Gestation—and is now part of the Safety domain that also comprises the CDC NHSN measures.

Maryland Base

Maryland Current

Difference US Base US Current DifferenceMD-US

Difference in Base

MD-US Difference in Current

CLINICAL PROCESS OF CAREAMI 7a Fibrinolytic agent received w/in 30’ of hospital arrival NA NA NA 61% 60% -1 NA NAPN 6 Initial antibiotic selection for CAP immunocompetent pt 96% 98% 2% 95% 96% 1% 1% 2%SCIP 2 Received prophylactic Abx consistent with recommendations

98% 99% 1% 100% 99% -1% -2% 0%

SCIP 3 Prophylactic Abx discontinued w/in 24 hrs of surgery end time or 48 hrs for cardiac surgery

98% 98% 0% 98% 98% 0% 0% 0%

SCIP 9 Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2

96% 99% 3% 100% 98% -2% -4% 1%

SCIP-Card 2 Pre-admission beta-blocker and perioperative period beta blocker

97% 98% 1% 100% 98% -2% -3% 0%

SCIP VTE2 Received VTE prophylaxis within 24 hrs prior to or after surgery

98% 99% 1% 98% 99% 1% 0% 0%

IMM-2 Influenza Immunization 93% 96% 3% 88% 93% 5% 5% 3%OUTCOMESMortality Observed Mortality Inpatient All Cause (Maryland All Payer) 3.45% 2.50% -0.95% NA NA NA NA NA30-day mortality, AMI (Medicare)* 14.75% 14.50% -0.25% 15.20% 14.90% -0.30% -0.45% -0.40%30-day mortality, heart failure (Medicare)* 10.79% 10.90% 0.11% 11.70% 11.90% 0.20% -0.91% -1.00%30-day mortality, pneumonia (Medicare)* 10.81% 10.85% 0.04% 11.90% 11.90% 0.00% -1.09% -1.05%Safety/ComplicationsAHRQ PSI composite (Maryland All Payer) 0.862 0.647 NA NA NA NA NA NACLABSI 0.532 0.527 NA 1 1 NA -46.8% -47.30%CAUTI 2.327 1.659 NA 1 1 NA 132.7% 65.90%SSI Colon 0.768 1.055 NA 1 1 NA -23.2% 5.50%SSI Abdominal Hysterectomy 1.751 1.281 NA 1 1 NA 75.1% 28.10%MRSA NA 1.344 NA NA 1 NA NA 34.40%C.diff. NA 1.15 NA NA 1 NA NA 15.00%PATIENT EXPERIENCE OF CARE - HCAHPS

Communication with nurses 75% 76% 1% 78% 79% 1% -3% -3%Communication with doctors 78% 78% 0% 81% 82% 1% -3% -4%Responsiveness of hospital staff 60% 60% 0% 67% 68% 1% -7% -8%Pain management 68% 67% -1% 71% 71% 0% -3% -4%Communication about medications 60% 60% 0% 64% 65% 1% -4% -5%Cleanliness and quietness 61.0% 61.5% 0.5% 66.5% 68.0% 1.5% -5.5% -6.5%Discharge information 84% 86% 2% 85% 86% 1% -1% 0%Overall rating of hospital 65% 65% 0% 70% 71% 1% -5% -6%

Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

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In proposing updated measure domain weights based on the VBP measure domain weights published in the CMS IPPS Final Rule, staff considered the following:

• The measures and domains available for adoption in the QBR rate year FY 2018 • Maryland’s continued need to improve on the HCAHPS measures, and addition of the

Care Transition (CTM-3) measure, an area of critical importance to the All-Payer Model success

• Number of measures in each domain, for example the Clinical Care domain comprising only the inpatient all-cause mortality measure, different number of measures for each hospital in Safety domain due to low cell sizes for some of the measures

Figure 4 below illustrates the CMS VBP final domain weights for FY 2018 and the QBR proposed domain weights for FY 2018 compared to the domain weights from FY 2017.

Figure 3. Final Measure Domain Weights for the CMS Hospital VBP Program and Proposed Domain Weights for the QBR Program, FY 2018

Staff circulated the draft recommendation via e-mail to the members of the QBR Subgroup of the Performance Measurement Workgroup and had a discussion about the draft at the in-person meeting on August 24, 2015. Hospital representatives and Maryland Hospital Association (MHA) staff voiced their concerns that 50 percent weighting of the Patient Experience/Care Coordination domain was too high, and that this area has proved difficult to improve upon. In their correspondence of August 27, 2015, approving the FY 2016 VBP Exemption (Appendix I), the Innovation Center notes Maryland’s significantly lagged performance on HCAHPS and supports increasing the weighting by 5 percent. Hospital representatives and MHA staff also noted that it would be useful to analyze to what extent small sizes impacted the number of measures that may be used for QBR on a hospital-specific basis in the Safety domain. Staff modeled FY 2016 performance data in their analysis and found that the vast majority of hospitals had data for 7 or 8 measures out of 8 in the Safety domain (See Appendix IV). Staff will use CMS rules for minimum measure requirements for scoring a domain and for readjusting domain weighting if a measurement domain is missing for a hospital. Staff will also score hospitals on attainment only for any measures obtained from the CMS Hospital Compare website where only performance period data is available (i.e., base period data is missing such that improvement cannot be assessed). Furthermore, hospitals that are missing both base period and performance period data on Hospital Compare will receive a score of zero for that measure. Hospitals are strongly encouraged to review and contact CMS with any concerns related to preview data or issues with posting data to Hospital Compare, and to alert HSCRC staff in a timely manner if issues cannot be resolved. Hospitals will be required to have scores on at least 2 out of 3 of the QBR Domains to be included in the program.

QBR FY 201715% (1 measure- mortality)

5% (clinical process measures)45% (8 measures- HCAHPS) 35% (3 infection measures, PSI) PAU

Proposed QBR FY 2018 15% (1 measure- mortality) 50% (9 measures- HCAHPS + CTM)35% (8 measures- Infection, PSI,

PC -01)PAU

CMS VBP FY 2018 25% (3 measures- condition

specific mortality25% (9 measures- HCAHPS + CTM)

25% (8 measures- Infection, PSI, PC -01)

25%

Clinical CarePatient experience of Care/ Care

CoordinationSafety Efficiency

Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

6

Staff note again that the established revenue “at risk” magnitude for the CMS VBP Program is set at 2 percent for 2017.

A memo summarizing the updates to the QBR methodology, base period data, and preset revenue adjustment scale will be sent to the hospitals shortly after CY 2014 data is available on Hospital Compare (estimated release mid-October 2015).

D. RECOMMENDATIONS

For the QBR Program, staff provide the following draft recommendations:

1. Continue to allocate 2 percent of hospital-approved inpatient revenue for QBR performance in FY 2018 to be finalized by the Aggregate Revenue “at risk” recommendation.

2. Adjust measurement domain weights to include: 50 percent for Patient Experience/Care Transition, 35 percent for Safety, and 15 percent for Clinical Care.

Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

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APPENDIX I. CMS INNOVATION CENTER CORRESPONDENCE APPROVING THE FY 2016 VBP EXEMPTION REQUEST

Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

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Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

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APPENDIX II. FINAL QBR PROGRAM PAYMENT SCALING FOR RY 2016

HOSPITAL ID

HOSPITAL NAME FY 2015 PERMANENT INPATIENT REVENUE*

QBR FINAL POINTS

SCALING BASIS REVENUE IMPACT OF SCALING

REVENUE NEUTRAL ADJUSTED

REVENUE IMPACT OF SCALING

REVENUE NEUTRAL ADJUSTED PERCENT

A B C D E F = C*E G H=(C+G)/C-1210003 PRINCE GEORGE $176,633,176.79 0.204 -1.000% -$1,766,332 -$1,766,332 -1.000%210024 UNION MEMORIAL $239,732,514.10 0.236 -0.848% -$2,032,700 -$2,032,700 -0.848%210013 BON SECOURS $75,937,921.77 0.237 -0.842% -$639,466 -$639,466 -0.842%210017 GARRETT COUNTY $18,608,187.37 0.243 -0.811% -$150,839 -$150,839 -0.811%210061 ATLANTIC GENERAL $38,616,312.78 0.262 -0.721% -$278,422 -$278,422 -0.721%210010 DORCHESTER $23,804,066.20 0.300 -0.536% -$127,696 -$127,696 -0.536%210062 SOUTHERN MARYLAND $161,253,765.94 0.306 -0.506% -$815,828 -$815,828 -0.506%210056 GOOD SAMARITAN $178,635,337.98 0.316 -0.457% -$817,238 -$817,238 -0.457%210023 ANNE ARUNDEL $308,739,340.58 0.324 -0.420% -$1,297,299 -$1,297,299 -0.420%210034 HARBOR $122,412,281.84 0.337 -0.355% -$434,912 -$434,912 -0.355%210015 FRANKLIN SQUARE $282,129,811.54 0.338 -0.351% -$990,065 -$990,065 -0.351%210004 HOLY CROSS $319,832,140.30 0.347 -0.309% -$989,139 -$989,139 -0.309%210057 SHADY GROVE $231,030,091.92 0.366 -0.215% -$497,403 -$497,403 -0.215%210055 LAUREL REGIONAL $77,138,956.35 0.369 -0.203% -$156,364 -$156,364 -0.203%210038 UMMC MIDTOWN $137,603,928.30 0.370 -0.199% -$273,596 -$273,596 -0.199%210060 FT. WASHINGTON $17,901,765.04 0.373 -0.183% -$32,819 -$32,819 -0.183%210016 WASHINGTON ADVENTIST $160,049,372.87 0.379 -0.153% -$245,350 -$245,350 -0.153%210018 MONTGOMERY GENERAL $87,866,457.56 0.387 -0.117% -$102,775 -$102,775 -0.117%210011 ST. AGNES $238,960,906.16 0.390 -0.099% -$236,680 -$236,680 -0.099%210022 SUBURBAN $182,880,097.32 0.391 -0.095% -$174,048 -$174,048 -0.095%210002 UNIVERSITY OF MARYLAND $869,783,533.93 0.392 -0.089% -$777,220 -$777,220 -0.089%210035 CHARLES REGIONAL $76,417,733.97 0.399 -0.057% -$43,855 -$43,855 -0.057%210001 MERITUS $188,367,775.67 0.415 0.020% $37,886 $23,050 0.012%210037 EASTON $95,655,306.19 0.420 0.045% $42,869 $26,081 0.027%210019 PENINSULA REGIONAL $232,896,407.52 0.439 0.139% $323,230 $196,651 0.084%210040 NORTHWEST $141,883,177.42 0.446 0.169% $240,213 $146,144 0.103%210051 DOCTORS COMMUNITY $136,010,793.59 0.446 0.169% $230,271 $140,095 0.103%210039 CALVERT $67,061,372.88 0.447 0.174% $116,461 $70,854 0.106%210005 FREDERICK MEMORIAL $190,475,900.63 0.455 0.216% $411,978 $250,644 0.132%210029 HOPKINS BAYVIEW MED CTR $354,237,613.19 0.460 0.239% $845,105 $514,157 0.145%210006 HARFORD $46,774,506.17 0.461 0.245% $114,535 $69,683 0.149%210030 CHESTERTOWN $29,287,619.34 0.462 0.250% $73,134 $44,494 0.152%210048 HOWARD COUNTY $167,430,726.52 0.476 0.318% $531,634 $323,443 0.193%210044 G.B.M.C. $200,727,664.89 0.478 0.327% $656,806 $399,596 0.199%210032 UNION HOSPITAL OF CECIL COUNT $67,638,499.19 0.488 0.375% $253,429 $154,185 0.228%210008 MERCY $232,326,849.10 0.504 0.453% $1,052,795 $640,513 0.276%210012 SINAI $428,400,532.05 0.505 0.456% $1,953,758 $1,188,653 0.277%210009 JOHNS HOPKINS $1,303,085,115.22 0.512 0.490% $6,390,980 $3,888,230 0.298%210033 CARROLL COUNTY $136,537,812.51 0.516 0.510% $696,104 $423,505 0.310%210028 ST. MARY $69,990,405.25 0.525 0.554% $387,680 $235,862 0.337%210049 UPPER CHESAPEAKE HEALTH $153,131,633.20 0.531 0.583% $892,707 $543,117 0.355%

210043 BALTIMORE WASHINGTON MEDICAL CENTER $224,082,797.59 0.552 0.684% $1,533,183 $932,778 0.416%210063 UM ST. JOSEPH $230,010,193.37 0.609 0.961% $2,209,908 $1,344,493 0.585%210027 WESTERN MARYLAND HEALTH SYSTEM $182,494,313.32 0.657 1.192% $2,175,921 $1,323,816 0.725%

$8,904,474,715 $8,290,541 $0 0.000%

Rewards 21,170,587 0.608Average Score 41.07% Penalties -12,880,046

Statewide*FY 2015 Permanent IP Revenue = FY 2015 Total GBR Revenue + out of state and other non-GBR revenue x percent inpatient revenue from FY 2013

ratio of rewards/penalties

Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

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APPENDIX III FY2018 VBP AND QBR MEASURES AND PERFORMANCE BENCHMARKS AND THRESHOLDS

Measure ID Description Achievement threshold Benchmark

Safety

CAUTI National Healthcare Safety Network Catheter- associated Urinary Tract Infection Outcome Measure.

0.906 0

CLABSI National Healthcare Safety Network Central Line-associated Bloodstream Infection Out- come Measure.

0.369 0

CDI (new QBR FY 2018) National Healthcare Safety Network Facility- wide Inpatient Hospital-onset Clostridium difficile Infection Outcome Measure.

0.794 0.002

MRSA bacteremia (new QBR FY2018)

National Healthcare Safety Network Facility- wide Inpatient Hospital-onset Methicillin-re- sistant Staphylococcus aureus Bacteremia Outcome Measure.

0.767 0

PSI–90 (VBP) Patient safety for selected indicators (com- posite). 0.577321 0.397051

American College of Surgeons—Centers for Disease Control and Prevention Har- monized Procedure Specific Surgical Site Infection Outcome Measure.

PSI-90 (QBR) All-Payer TBD TBDColon and Abdominal • Colon • 0.824 • 0.000

Hysterectomy SSI • Abdominal Hysterectomy • 0.710 • 0.000

PC–01 Elective Delivery before 39 weeks 0.020408 0

Clinical Care Measures

MORT–30–AMIHospital 30-Day, All-Cause, Risk-Standard- ized Mortality Rate Following Acute Myo- cardial Infarction Hospitalization *.

0.851458 0.871669

MORT–30–HF Hospital 30-Day, All-Cause, Risk-Standard- ized Mortality Rate Following Heart Fail- ure *.

0.881794 0.903985

MORT–30–PN Hospital 30-Day, All-Cause, Risk-Standard- ized Mortality Rate Following Pneumonia Hospitalization *.

0.882986 0.908124

(VBP Only, condition specificmeasures not in QBR)

Mortality TBD(MARYLAND)

Efficiency and Cost Reduction Measure

Floor

(percent) Benchmark

(percent)

Communication with Nurses 55.27 78.52 86.68

Communication with Doctors 57.39 80.44 88.51

Responsiveness of Hospital Staff 38.4 65.08 80.35

Pain Management 52.19 70.2 78.46

Communication about Medicines 43.43 63.37 73.66

Hospital Cleanliness & Quietness 40.05 65.6 79

Discharge Information 62.25 86.6 91.63

3-Item Care Transition 25.21 51.45 62.44

Overall Rating of Hospital 37.67 70.23 84.58

Patient and Caregiver-Centered Experience of Care/Care Coordination

Achievement threshold (percent)

Inpatient All-Payer, All Cause TBD

MSPB–1 (not included in QBR)Payment-Standardized Medicare Spending per Beneficiary

Median Medicare Spending per Beneficiary ratio across all hospitals during the performance period.

Mean of the lowest decile Medicare Spending per Beneficiary ratios across all hospitals during the performance period.

Draft Recommendation for Updating the Quality-Based Reimbursem*nt (QBR) Program

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APPENDIX IV. HOSPITAL SPECIFIC COUNTS OF SAFETY DOMAIN MEASURES MODELED USING FY 2016 PERFORMANCE DATA

Hosp ID Hospital Name CLABSI CAUTI SSI-ColonSSI-

Hysterectomy*MRSA C. diff PC -01 PSI-90 (CY14)

Count of Measures

210001 MERITUS MEDICAL CENTER 0.586 1.057 0 0 0.939 1.196 Not Available 0.399 7

210002 UNIVERSITY OF MARYLAND MEDICAL CENTER 0.54 2.353 2.437 0 2.191 1.274 1 0.722 8

210003 PRINCE GEORGES HOSPITAL CENTER 0.236 0.06 1.599 <1 predicted 2.004 0.549 20 0.733 7

210004 HOLY CROSS HOSPITAL 0.888 1.407 0.112 1.787 0.604 1.127 1 0.779 8

210005 FREDERICK MEMORIAL HOSPITAL 1.037 0.854 1.914 0.988 3.174 0.724 4 0.920 8

210006 UNIVERSITY OF MARYLAND HARFORD MEMORIAL HOSPITAL <1 predicted 1.696 <1 predicted Not Applicable <1 predicted 0.441

shorter/no cases met criteria 0.800 3

210008 MERCY MEDICAL CENTER INC 0.431 1.654 1.029 1.93 1.445 1.086 8 0.917 8

210009 JOHNS HOPKINS HOSPITAL, THE 0.628 1.179 1.642 2.944 1.598 1.06 0 0.819 8

210011 SAINT AGNES HOSPITAL 0.678 1.64 0 0 0.216 1.759 0 0.646 8

210012 SINAI HOSPITAL OF BALTIMORE 0.855 4.465 1.418 3.088 1.382 1.071 Not Available 0.660 7

210013 BON SECOURS HOSPITAL 0.455 2.508 <1 predicted Not Applicable 0.896 0.943 Not Available 0.656 5

210015 MEDSTAR FRANKLIN SQUARE MEDICAL CENTER 0.524 2.648 0.422 0.519 1.012 1.315 0 0.653 8

210016 ADVENTIST HEALTHCARE WASHINGTON ADVENTIST HOSPITAL 0.164 0.679 1.869 0.707 0.422 1.695 6 0.768 8

210017 GARRETT COUNTY MEMORIAL HOSPITAL <1 predicted <1 predicted <1 predicted <1 predicted <1 predicted 0.788 4 1.059 3

210018 MEDSTAR MONTGOMERY MEDICAL CENTER 0 0.831 0.827 0 0.637 0.653 0 1.134 8

210019 PENINSULA REGIONAL MEDICAL CENTER 0.127 3.135 0.539 1.036 2.268 1.495 0 0.447 8

210022 SUBURBAN HOSPITAL 0.194 1.548 0 1.653 1.202 1.962 Not Available 0.770 7

210023 ANNE ARUNDEL MEDICAL CENTER Not Available Not Available Not Available Not Available Not Available Not Available 2 0.705 2

210024 MEDSTAR UNION MEMORIAL HOSPITAL 0.116 0.239 0.56 0 1.738 0.869

shorter/no cases met criteria 1.011 7

210027 WESTERN MARYLAND REGIONAL MEDICAL CENTER 0 2.102 1.928 <1 predicted 0.56 1.529 0 0.663 7

210028 MEDSTAR SAINT MARY'S HOSPITAL 0 1.543 0 <1 predicted 2.298 1.342 0 0.741 7

210029 JOHNS HOPKINS BAYVIEW MEDICAL CENTER 0.383 1.818 <1 predicted 1.289 2.468 1.011 0 0.510 7

210030 UNIVERSITY OF MD SHORE MEDICAL CTR AT CHESTERTOWN <1 predicted <1 predicted <1 predicted <1 predicted <1 predicted 0.946

shorter/no cases met criteria excluded due t 1

210032 UNION HOSPITAL OF CECIL COUNTY <1 predicted <1 predicted 1.852 <1 predicted <1 predicted 1.425 10 0.742 4

210033 CARROLL HOSPITAL CENTER 0 1.142 0.221 0 0.805 1.103 0 0.546 8

210034 MEDSTAR HARBOR HOSPITAL 0.417 1.387 0 0.548 0.52 0.569

shorter/too few cases to report 0.703 7

210035 UNIVERSITY OF MD CHARLES REGIONAL MEDICAL CENTER 0.455 0 0 <1 predicted 0 1.4 0 0.668 7

210037 UNIVERSITY OF MD SHORE MEDICAL CENTER AT EASTON <1 predicted 0.831 1.818 <1 predicted 0 0.374 3 0.894 6

210038 UNIVERSITY OF MD MEDICAL CENTER MIDTOWN CAMPUS 1.359 0.538 <1 predicted <1 predicted <1 predicted 0.867

shorter/no cases met criteria 1.092 4

210039 CALVERT MEMORIAL HOSPITAL <1 predicted <1 predicted <1 predicted <1 predicted 0 0.962 8 1.022 4

210040 NORTHWEST HOSPITAL CENTER 0.335 2.636 1.664 <1 predicted 1.025 0.887

shorter/no cases met criteria 0.630 6

210043 UNIVERITY OF MD BALTO WASHINGTON MEDICAL CENTER 0 2.051 1.798 0 <1 predicted 1.448 2 0.626 7

210044 GREATER BALTIMORE MEDICAL CENTER 0.792 0.278 1.582 1.001 0.842 0.992 1 0.720 8

210045 EDWARD MCCREADY MEMORIAL HOSPITAL

Measures does not apply for this reporting period

Measures does not apply for this reporting period

Results not available for this reporting period Not Applicable <1 predicted <1 predicted Not Available excluded due t 0

210048 HOWARD COUNTY GENERAL HOSPITAL 0.236 1.143 0 0.932 0.347 1.004 2 0.808 8

210049 UNIVERSITY OF M D UPPER CHESAPEAKE MEDICAL CENTER 0 3.052 1.145 <1 predicted 1.175 0.669 3 0.509 7

210051 DOCTORS' COMMUNITY HOSPITAL 0.207 0.214 <1 predicted 0 0 1.192 Not Available 1.027 6

210055 LAUREL REGIONAL MEDICAL CENTER 0.774 0 <1 predicted <1 predicted 1.819 0.723 Not Available 0.658 5

210056 MEDSTAR GOOD SAMARITAN HOSPITAL 0.683 0.274 1.99 <1 predicted 0.389 1.727

shorter/no cases met criteria 0.694 6

210057 ADVENTIST HEALTHCARE SHADY GROVE MEDICAL CENTER 0.428 1.01 0.699 0 2.007 1.404 4 0.681 8

210060 FORT WASHINGTON HOSPITAL <1 predicted <1 predicted <1 predicted <1 predicted <1 predicted 0 Not Available 0.831 2

210061 ATLANTIC GENERAL HOSPITAL <1 predicted <1 predicted 0.587 <1 predicted <1 predicted 0.485 Not Available 1.125 3

210062 MEDSTAR SOUTHERN MARYLAND HOSPITAL CENTER 0.297 0 0 0 2.234 1.508 4 0.774 8

210063 UNIVERSITY OF MARYLAND ST JOSEPH MEDICAL CENTER Not Available Not Available Not Available Not Applicable Not Available Not Available 3 0.469 2

Average 6.045454545

Median 7

Minimum 0

Maximum 8

Statewide*SSI-hystertectomy values shaded in grey are from MHCC. These are hospitals that with 12 months of data are estimated to have >1 predicted but currently have < 1 predicted in the 9 months of data on CMS Hospital Compare

1

Maryland Health Services Cost Review Commission

Market Shift Adjustments Update09/09/2015

2

Market Shift Adjustments Market shift adjustment should not undermine the incentives

to reduce avoidable utilization

Market shift adjustment should provide necessary resources for services shifted to another hospital

Calculations are based on 66 inpatient and outpatient service lines Zip codes and county level Excludes Potentially Avoidable Utilization (Readmissions and PQIs*) Hospital service line average charge per ECMAD** 50% variable cost factor applied

*AHRQ Prevention Quality Indicators**Equivalent CaseMix Adjusted Discharges

Market Share vs. Market Shift

50

250

50

100

50

100

150

200

250

300

YEAR1 YEAR2

Hospital A

Hospital B

50

250

5025

50

100

150

200

250

300

YEAR1 YEAR2

Hospital A

Hospital B

Market Shift Adjustment=25Market Shift Adjustment=0

4

RY 2016 Statewide Impact*

Statewide ImpactFY 16 Market Shift Adjustment Results

A BGrand Net Total $756,341

Positive Adjustment Total $27,741,411Negative Adjustment Total -$28,497,752Absolute Adjustment Total $56,239,163

*excludes oncology/radiation therapy/infusion service line and other manual adjustments

5

RY 2016 Hospital Level Impact as % of Revenue

-2.00%

-1.50%

-1.00%

-0.50%

0.00%

0.50%

1.00%

1.50%

2.00%

RY 2016 Market Shift Adjustments by Hospital

6

Technical Report and Reference Materials

http://www.hscrc.state.md.us/gbr-adjustments.cfm

7

Infusion/Chemotherapy/Radiation Therapy Consolidated billing creates a challenge to measure unit

of service HSCRC staff aggregated records for the same patients at

a single hospital into a single measurement unit Assignment of highest EAPG* and weights are under

review

*3M Enhanced Ambulatory Patient Grouping System

Health Jobs Opportunity Program

Health Services Cost Review Commission

September 9, 2015

• What is being proposed?

• Why it is needed?

• How it is funded?

2

Health Jobs Opportunity Program

What is it?

• Up to 1,000 hospital based jobs

• Targeted at high unemployment and poverty zip codes in Baltimore City and throughout state

• Entry level positions with opportunity for advancement

• Includes support services and job readiness training

3

Health Jobs Opportunity Program

Health Jobs Opportunity Program

Why is it needed?

• Recent civil unrest in Baltimore City highlighted the sense of hopelessness in disadvantaged communities based on lack of employment opportunities

• Poverty contributes to poor health; improving the economic stability of certain communities will improve the health of the population hospitals serve

4

Health Jobs Opportunity Program

Role of the hospitals

• Hospitals are the largest private sector employers in the Baltimore City and in many counties throughout the state

• Hospitals are capable of large scale hiring, particularly for entry level positions; hope that other major employers will follow our lead

• Hospitals will serve as model for other industries

5

Health Jobs Opportunity Program

Targeted Hospital Workforce Development

• Community Health Workers

• Certified Application Counselors

• Peer Recovery Support Specialists

6

Health Jobs Opportunity Program

Applications must:• Demonstrate that additional positions are needed and are incremental

• Detail a plan to recruit employees from designated high poverty and unemployment zip codes

• Include proposed competitive wages, benefits and education and enrichment opportunities

• Describe existing or planned programs for employees to improve work skills

• Describe the role new positions will play in meeting goals of the waiver

• Detail job readiness and skills training necessary to prepare individuals for successful employment

• Detail employee retention strategies

• Other requirements to be developed by HSCRC staff

7

Health Jobs Opportunity Program

Funding

• Capped at 0.25% of statewide revenue ($40m)

• HSCRC develops criteria for proposals

• Hospitals voluntarily submit application to HSCRC

• Our view: Awarded funds will be collected by hospital through permanent rate increases

8

Health Job Opportunity Program

September 9 , 2015

BACKGROUND The model waiver brings unprecedented employment challenges to Maryland hospitals.

Maryland hospitals have committed to improving the overall health of the patients they serve

beyond the four walls of the hospital. A shift in focus from care delivered within the hospital

setting to community based care requires a broader hospital employment base such as

community health workers, health care enrollment specialists and peer support specialists.

Currently this employment base needs to be fostered and expanded and there are few

resources available to support the long-term development of this workforce.

Recent civil unrest and rioting in Baltimore City triggered by the death of Freddie Gray

demonstrated the urgent need to address the issues of social inequality in Baltimore City. A

contributing factor to social inequality in the city is the lack of stable, entry level employment

with opportunities for career advancement. The April 2015 unemployment rate in Baltimore

City was 7.4%, compared to the statewide rate of 4.9%, with some areas of city facing

unemployment rates as high as 17%.1 Since 1970, more than 60,000 manufacturing jobs in the

Baltimore metropolitan area have been lost due to plant closures such as Bethlehem Steel,

Western Electric, Proctor & Gamble, General Motors, and Solo Cup. The elimination of

manufacturing jobs, along with the general recession, has caused a severe lack of opportunity

for unskilled workers to obtain adequate employment.

In addition to high rates of unemployment, Baltimore City also faces extreme poverty levels.

Most recent U.S Census Bureau data indicate that as of 2013, 23.8% of Baltimore City residents

live at or below the poverty level, compared to 9.8% statewide.2 In some areas of the city, the

rate of those living below the poverty level is as high at 40.5%.3 The median household income

for Baltimore City is $41,385 compared to $73,538 statewide.4 However, it is important to note

that city’s median household income is not indicative of the widespread poverty plaguing the

city since this number is offset by very wealthy areas within the city such Guilford, Roland Park

and Homeland. Some zip codes within Baltimore City have median household income as low as $25,500.5 Nearly 40% of Baltimore City residents are Medicaid eligible and current Medicaid

enrollment for the city tops 242,000, which exceeds any other jurisdiction in the state.6 In

1 Maryland Department of Labor Licensing and Regulation; “Local Area Unemployment Statistics”, http://www.dllr.state.md.us/lmi/laus/ American Community Survey (2015). 2 U.S. Census Bureau; “State and County Quick Facts – Poverty Level” http://quickfacts.census.gov/qfd/states/24/24510.html (2015). 3 U.S. Census Bureau; “American Community Survey, Easy Stats” http://www.census.gov/acs/www/data/data- tables-and-tools/easy-stats/ (2015). 4 U.S Census Bureau; “State and County Quick Facts – Median Household Income” http://www.census.gov/quickfacts/table/PST045214/24,00 (2015). 5 Bureau of Labor Statistics U.S. Department of Labor “Baltimore Area Employment” http://www.bls.gov/regions/mid-atlantic/news-release/areaemployment_baltimore.htm (2015). 6 Department of Health and Mental Hygiene; “Maryland Medicaid e-Health Statistics – County”; http://www.md- medicaid.org/eligibility/ (2015).

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Baltimore City public schools, 86% of students qualify for free and reduced school meals,

compared to 45% statewide,7 again a statistic that exceeds any other jurisdiction in the state. These data illustrate the employment and income disparities in Baltimore City. The inability to

obtain employment with opportunity for growth contributes to the cycle of poverty and

inequality for many. As city manufacturing employment has nearly disappeared, employment

in the health and education fields has grown. Manufacturing represents 5.1% of city

employment; health and education represents 30.6%. As solutions to the social inequities

facing Baltimore City are explored, there must be a recognition of the evolving employment

landscape. Failure to create sustainable opportunities that are consistent with industry change

will result in continued social and economic instability for Baltimore City. There is significant

opportunity for hospitals to bring more stability to the environment in Baltimore City but funds

will be needed. The financial burden of increased hospital rates will be appropriately shared

with other businesses and major employers as well as public payers who will directly benefit

from a stable civil and business environment in Baltimore City. Hospitals are interested in

retaining good employees and in improving the job skills of these employees.

POOR HEALTH AND POVERTY The correlation between poverty and poor health is widely recognized. A Health Affairs policy

brief noted that people who have limited education or income or who live in poor

neighborhoods have worse health and health care compared to those who are better educated

or financially better off. Adults living at or below the federal poverty level are more than five

times as likely to say they are in poor or fair health compared to those whose incomes are four

times the federal poverty level.8 The health disparities associated with poverty contribute

significant costs to the health care system. Recent analysis estimates that 30% of direct medical

costs for minorities are excess costs due to health inequities and that the economy loses an

estimated $309 billion per year due to the direct and indirect costs of health disparities.9

Despite being recognized as one of the wealthiest states in the nation, Maryland residents also

experience health disparities associated with low income. According to a number of measures,

Maryland is one of the highest performing states in the nation with the 3rd highest median

household income, two of the nation’s top medical schools, and 10th lowest rate of smoking.

Despite these successes, Maryland continues to lag behind other states on a number of key

health indicators. The state ranks 43rd in infant mortality, 35th in infectious diseases, 33rd in

7 Annie E. Casey Foundation Kids Count; “Students Receiving Free and Reduced School Meals” http://datacenter.kidscount.org/ (2015). 8 Health Affairs; “Achieving Equity in Health” http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=53 (October 6, 2011). 9 Kaiser Family Foundation; “Disparities in Health and Health Care: Five Key Questions and Answers”http://kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and- answers/ (November 30, 2012).

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health outcomes, and 33rd regarding geographic health disparities.10 The statistics for

Baltimore City are even more discouraging. Baltimore City experiences higher mortality rates

and burden of disease than both the rest of Maryland, and the overall US population.11 A

commonly quoted statistic notes that residents in Guilford have a life expectancy of nearly 20

years longer than residents of Greenmount East.12 Income plays a significant role in the health

outcomes of Baltimore City residents, with the level of income directly affecting overall health

and mortality. According the most recent Baltimore City Health Disparities Report Card, if all

Baltimore residents had equal opportunity to good health by using income as a sole

determinant of mortality 50.1% of deaths city wide could potentially be averted.13 The

distribution of disparities based on race, gender, education and income highlights opportunities

for more targeted efforts that can assist in achieving better health outcomes for all Baltimore

residents.14 A hospital employment program targeted at the most economically disadvantaged

areas of Baltimore City presents an opportunity to improve health and mortality rates through

increased education and income levels. This targeted approach is also consistent with the

population health goals of the waiver; because of the deep connection between health and

income, improving the economic status of the population will improve the overall health of the

population hospitals serve.

ROLE OF HOSPITALS Hospitals are the largest employers in many jurisdictions through the state, including Baltimore

City. In fact, over half of Baltimore City’s largest employers are hospitals.15 Hospitals offer a

variety of entry level positions with no to minimal education requirements that range from food

service to community health. Hospital based jobs offer competitive salaries with robust

benefits. Some hospitals such as Johns Hopkins and University of Maryland Medical System

offer tuition assistance for both employees and their dependents. The Hospitals and the HSCRC collaborated with the Centers for Medicare and Medicaid Services

to modernize the Maryland Medicare all-payer waiver. This collaborative agreement

10 DHMH; “Health Disparities Workgroup Final Report” http://www.dhmh.maryland.gov/mhqcc/Documents/Health-Disparities-Workgroup-Report-1-12-2012.pdf (January 2012). 11 Baltimore City Health Department; “Baltimore City Health Disparities Report Card 2013”, page 3 http://health.baltimorecity.gov/sites/default/files/Health%20Disparities%20Report%20Card%20FINAL%2024-Apr- 14.pdf (2013). 12 Baltimore City Health Department; “Life Expectancy at Birth” http://health.baltimorecity.gov/sites/default/files/Life-expectancy-2013.pdf (2013). 13 Baltimore City Health Department; “Baltimore City Health Disparities Report Card 2013”, page 17 http://health.baltimorecity.gov/sites/default/files/Health%20Disparities%20Report%20Card%20FINAL%2024-Apr- 14.pdf (2013). 14 Baltimore City Health Department; “Life Expectancy at Birth”, page 20. http://health.baltimorecity.gov/sites/default/files/Life-expectancy-2013.pdf (2013). 15 Department of Labor, Licensing and Regulation; “Baltimore City - Major Employer Lists - March 2013” https://mwejobs.maryland.gov/admin/gsipub/htmlarea/uploads/Major%20Employer_Baltimore%20City%202013. htm (2015).

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transformed the way Maryland hospitals deliver care as of January 1, 2014. Under the

modernized waiver hospitals are restructuring how they provide care by developing strategies

that help individuals stay healthy, reduce readmissions, prevent avoidable adverse incomes and

lower costs. As hospitals strive to meet the goals of the modernized waiver, the focus of care

shifts from the hospital to the community. Community based care is often perceived as

investments in “strategies” to address chronic conditions, care coordination, and integrated

systems of care. Unarguably, these investments are essential to improving the health of the

local population; however these investments alone cannot achieve the broader goal of

improved population health if the underlying issues of chronic unemployment and devastating

poverty are not also addressed.

As hospitals assume a greater role in the health of the community, with appropriate resources,

hospitals are prepared to create additional entry level employment opportunities for local

residents and to increase investments in community health workers (CHWs). Under the new

CMS Waiver agreement hospitals are no longer paid for volume growth in hospital based

patient services. Use of highly specialized and costly inpatient services is strictly monitored and

funding is limited. Consequently, hospitals are implementing strategies to appropriately

provide patient services in lower cost settings, such as outpatient hospital services or in non-

hospital community health centers. Also, strategies are being developed to provide care

coordination services and wellness programs in the community and in patient homes to prevent

illness progression and the need for expensive emergency care. There is no direct payment

mechanism for community based services which are essential to effectively implement

population health management plans. The HSCRC has provided funds to support this function

but more resources are needed to address the severe situations in high poverty neighborhoods

in Baltimore City. These recent changes in HSCRC payment methodology and the strategies

needed to accomplish the financial goals of population health management have caused

hospitals to restructure their workforce to be more in touch with the patient and the broader

community before acute illnesses occur. While hospitals have gradually emerged as the city’s

largest employers, under the modernized waiver, hospitals are faced with unprecedented

challenges. Under the new CMS Waiver agreement hospital revenue is controlled by the HSCRC

under a hospital specific Global Budgeted Revenue (GBR) agreement. Under this new rate

methodology hospitals need to operate annually within a fixed revenue budget. Without special funding by the HSCRC there is very little opportunity to improve hospital services such

as housekeeping, security, food service, etc. where many low skilled employees are engaged.

Hospitals and Workforce Development Community Health Workers: Community Health Workers (CHWs), also referred to as

community health advocates, lay health educators, community health representatives, peer

health promoters, and community health outreach workers, are increasingly being seen as an

important resource for combating health disparities by promoting and supporting healthy

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behaviors in underserved communities.16 Hospitals have already begun to help foster this new

workforce that serves as a connector between health care consumers and providers to promote

health among groups that have traditionally lacked access to adequate health care. The

utilization of CHWs to assist with care management and prevention activities will assist

hospitals in meeting the financial and quality targets under the new model waiver. In response

to House Bill 856/Senate Bill 592, Chapter 259 of the Acts of 2014, the Maryland Department of

Health and Mental Hygiene (DHMH) and the Maryland Insurance Administration (MIA)

established the Workgroup on Workforce Development for Community Health Workers (CHWs)

to study and make recommendations regarding workforce development for CHWs in Maryland.

While the draft report of this workgroup made substantial recommendations regarding the

training and certification of CHWs, the workgroup made no recommendation about

reimbursem*nt of CHWs. Instead the workgroup stated that multiple payment sources should

be explored, including promoting direct hiring of and/or contractual payment to CHWs by

providers operating in risk-based payment structures, such as hospitals under the All Payer

Model.17 While hospitals are already serving a key role in the development of Maryland’s

community health workforce, without a reimbursem*nt structure for CHWs, additional

resources are needed to hire, recruit, train and retain this workforce that has been identified as

essential to meeting the goals of both the Affordable Care Act (ACA) and the modernized

waiver. Innovative employment models are needed because “The use of CHWs in Maryland is

likely to increase in the coming years as the state’s health system continues to transform.”18

CHWs have the potential to assist the transformation of our fragmented health care system

towards a more holistic type of care, centered on the total needs of the individual patient and

embedded in the community and culture in which the patient lives. CHWs can support

individual and population health because, as culturally competent mediators between health

providers and the members of diverse communities, they are uniquely well placed for

promoting the use of primary and follow-up care for preventing and managing disease.19

Certified Application Counselors: The ACA created opportunities for hospitals to serve a greater

role in assisting patients with obtaining health care coverage either through Medicaid or an

Exchange based Qualified Health Plan through the Certified Application Counselor (CAC)

program. Currently, few Maryland hospitals are Application Counselor Sponsoring Entities

employing certified application counselors. CACs educate patients about insurance options and

facilitate enrollment. Hospitals are responsible for the cost of training, educating and

employing CACs. Some hospitals have begun to deploy CACs out in the community to assist

patients in health care enrollment. The costs associated with employing CACs has deterred

many hospitals from developing robust CAC programs. As the Maryland Health Benefit

16 Institute of Medicine, 2002, and Patient Protection and Affordable Care Act, 42 U.S.C. §§ 5313, 10501(c) (2010). 17 Draft Workgroup on Workforce Development for Community Health Workers Final Report to the Maryland General Assembly by the Maryland Department of Health and Mental Hygiene and Maryland Insurance Administration (2015). 18 Id. 19 Id.

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Exchange reduces call center hours, and the scope and funding for Connector and Navigator

program are reduced, there will be an increased need for hospital based CACs to assist

individuals with Medicaid eligibility and Qualified Health Plan enrollment. Community based

CACs would allow for hospitals to assist individuals in health plan enrollment before the

individual’s health rises to a crisis in need of emergent or inpatient care. Community based

CACs would assist hospitals in meeting the population health targets of the waiver by

facilitating health care insurance coverage before someone enters the doors of the hospital.

With appropriate health care coverage, individuals are able to seek health care in the most

appropriate setting, ultimately reducing hospital bad debt, uncompensated care and

inappropriate emergency department utilization.

Peer Recovery Support Specialists: Individuals with behavioral health issues often suffer from

many other chronic conditions and have significantly increased health care costs. Treatment

costs for patients with chronic medical and comorbid behavioral health conditions can be 2-3

times higher than those without the comorbid behavioral health condition. Nationally these

costs are estimated to be $293 billion in 2012.20 Individuals with serious mental illness die, on

average, 25 years earlier than the general population. Patients with mental illness discharged

from acute hospitals have higher rates of readmissions and patients with substance use

disorder are among the highest-risk populations for medical and psychiatric readmissions.

Behavioral health patients suffering from multiple health conditions, may lack a strong support

system or may not adhere to treatment regimens; factors that impede recovery and increase

the likelihood that they will return to the hospital.21 In Baltimore City, there are an estimated

18,916 heroin users.22 In Maryland, the number of overdose deaths associated with heroin

increased by 21% between 2013 and 2014.23 Baltimore City experienced a 28% increase over

the same time period.24 These numbers represent one of the most devastating outcomes of

addiction and highlight the importance of this issue right now.25 These statistics represent both

the need and the opportunity to improve care and lower costs for those suffering from

behavioral health disorders. Disease management programs promise cost containment while

significantly improving the quality of care for enrollees with behavioral health disorders. One of

the primary means by which this is achieved is through peer support.26

Peer recovery support services are delivered by people who have not only experienced mental

health issues or substance use disorder but who have also experienced recovery. Peer recovery

20 Milliman American Psychiatric Report, Economic Impact of Integrated Medical-Behavioral Healthcare, page 4. 21 Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes, American Hospital Association, page 3 (January 2012). 22 Baltimore Mayor’s Heroin Treatment & Prevention Task Force Report, page 17. http://health.baltimorecity.gov/sites/default/files/Task%20force%20report_071015_Full.pdf (July 2015). 23 Id. 24 Id. 25 Id., page 19. 26 Center for Health Care Strategies, Disease Management for Chronic Behavioral Health and Substance Use Disorders, Suzanne Gelber, PhD; Richard H. Dougherty, PhD, page29. (2006).

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support services help people become and stay engaged in the recovery process and reduce the

likelihood of a relapse. Because these recovery services are delivered by peers who have been

successful in the recovery process, these services represent a message of hope as well as

wealth of experiential knowledge. Peer recovery services can effectively extend the reach of

treatment beyond the clinical setting into the community of those seeking to achieve or sustain

recovery.27 Peer support is widely recognized in the medical field as a valuable compliment to

professional medical and social interventions. Improved outcomes are particularly notable

when peer support services are provided to people with chronic conditions. Peer recovery

support services can fill a need often noted by treatment providers for services to support

recovery after an individual leaves a treatment program. Peer recovery support services can

serve as a vital link between systems that treat behavioral health disorders in a clinical setting

and the larger communities in which people seeking to achieve and sustain recovery live.28

Peer-delivered services have been proven to generate superior outcomes in terms of

engagement of “difficult-to-reach” clients, reduced rates of hospitalization and days spent as

inpatient, and decreased substance use among persons with co-occurring substance use

disorders.29 Currently in Maryland, peer support specialists are either grant funded or

volunteer based, making this highly valued workforce underutilized. The Maryland Addictions

and Behavioral-health Professional Certification Board has established certification and

education standards so that peers in both mental health and substance use disorder can

become Certified Peer Recovery Specialists. This certification process creates the ideal platform

for hospitals to expand the peer support workforce to help address the goals of the waiver

through reduced costs and readmission rates while improving quality of treatment for those

suffering from behavioral health disorders.

HEALTH CARE WORKFORCE DEMANDS AND CHALLENGES According to the Baltimore Regional Talent Development Pipeline Study, healthcare has been

the strongest growth industry over the past decade and is expected to add the most new jobs.30

Projections of the healthcare job creation in Maryland expect the health care sector to add

around 75,000 jobs by 2020.31 Within this industry growth, there is an expected demand for

over 20,000 new job openings for workers with an education level at or below a high school

diploma or equivalent. 32 Career Pathways is a workforce development approach that uses

sector based strategies that provide low skilled adults with a clear sequence of education and

training courses, combined with comprehensive wrap-around support services that lead to

27 U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Abuse Treatment; “What Are Peer Recovery Support Services?”, page 1 (2009). 28 Id., page 10. 29 Davidson L., Bellamy C., Guy, K., & Miller R.; “Peer support among persons with severe mental illnesses: A review of evidence and experience.” World Psychiatry, 11(2): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3363389/ (2012). 30 Baltimore Regional Talent Development Pipeline Study 2013, page 47 (2013). 31 Id., page 48. 32 Id., page 109.

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careers in a particular industry sector.33 Certain health care occupations, such as medical

assistants and technicians have been identified by Career Pathways as good targets for

opportunity because hiring demand will exceed the number of new qualified workers entering

the labor market in these occupations. Without a more robust training system for these

occupations, Baltimore’s healthcare employers will likely be forced to look outside the region to

find qualified workers.34

The Maryland Health Care Reform Coordinating Council, Health Care Workforce Workgroup

also identified opportunities for establishing a lay network of health workers. The Workgroup

noted that a network of lay health workers recruited from within the respective communities

being served would help to increase the likelihood that medically underserved residents gain

access to appropriate and timely health information and primary care services. The workgroup

also noted that lay health workers also represent a potential pool of future clinical and allied

health providers.35

One of the recommendations to meet the health care workforce challenges of Baltimore City is

the creation of partnerships between education and the public and private sectors.36 A

partnership between the state, Maryland hospitals, and existing educational providers creates

an opportunity to develop a unique and targeted approach for recruitment, training, hiring,

retention and advancement of individuals from disadvantaged communities for a career in

health care.

HSCRC HISTORY IN ADDRESSING WORKFORCE ISSUES The Nurse Support I Program and the Nurse Support II Program (NSP Programs) represent the

success of the hospitals, payers and state collaborating to respond to a workforce crisis in the

state. The NSP Programs were created to address a growing nursing shortage in Maryland. The

NSP Programs are funded annually through a modest increase in regulated hospital rates.

Hospitals submit proposals to the HSCRC for approval of funding. NSP proposals are aimed to

improve education attainment, retention and recruitment, improved practice environment, and

increased workforce within the nursing profession. Funding for proposals to achieve the goals

of the NSP Programs include: mentoring, extern and intern opportunities, educational

opportunities and scholarships, leadership development, career advancement, new technology,

and minority recruitment and retention.

While the goal of the NSP Programs was to increase the number of nurses in Maryland, the

Programs’ success has exceeded expectations and received widespread recognition. Maryland

33 Id., page 5. 34 Id., pages 16-17. 35 Maryland Health Care Reform Coordinating Council, “Health Care Workforce Workgroup, White Paper”, page 16 (October 31, 2010). 36 The Talent Development Pipeline Study, Prepared by the Baltimore Workforce Investment Board’s Committee on Training and Post-Secondary Education, page 50 (2010).

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nurse workforce increased 38% between 2008-2012 while nationally, the nursing workforce

increase was only 28%.37 Between 2008-2013, Maryland nursing graduates increased by 43%,

compared to 20% nationally.38 The NSP Programs have also been credited with improved

patient care, safety and satisfaction.39 The NSP Programs have also been linked to significant

cost savings. According to the HSCRC Wage and Salary Survey, Maryland hospitals decreased

their dependence on agency nurses by 68%, saving close to $106 million between FY 2007 and

FY 2011.40

NSP Programs have received international recognition for excellence in workforce

development. The NSP II Program has been referenced and highlighted in nursing and health

care journals in multiple publications at the national level.41 Additionally, approval of the NSP

Programs have consistently received unanimous support from HSCRC commissioners. The

support and acclaim of the NSP Programs is not surprising considering the success of the NSP

Programs in addressing a workforce crisis as well improving patient care and reducing costs.

The NSP Programs serve as a model for the development of a health care employment program

targeted at economically disadvantaged communities.

PROGRAM REQUEST Hospitals request that the HSCRC establish a Program effective January 1, 2016 to provide up to

$40 million per year for the purpose of funding a program that will allow for the expansion of

up to 1,000 hospital employed positions to be hired from low income, high unemployment

areas for the purpose of:

(1) Improving the overall socioeconomic determinants of health community by

providing entry level stable employment with advancement opportunities; and

(2) Expanding the community health workforce to assist hospitals in improving

population health.

PROPOSED HSCRC FUNDING METHODOLOGY All hospitals will be eligible to submit proposals for funding of new positions created to hire

residents from designated areas. Hospital specific applications must:

(1) Demonstrate that additional positions are needed and that the new positions are

incremental, rather than replacing existing positions.

- Potential job categories include:

o Community health workers o Medicaid and Maryland Health Benefit Exchange enrollment assisters

37 Id. 38 HSCRC Final Recommendation on the NSPII Program, January 14, 2015. 39 HSCRC Draft Report on Nurse Support I Activities for FY 2007-FY 2013. 40 Id. 41 HSCRC Draft Recommendation: Nurse Support II Program, May 2013.

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o Peer support specialists

o Environmental services

o Dietary functions

o Nurse Assistants

o Escort/Messenger functions

o Security

o Transportation

- Similar to the NSP Programs Funding can be used for:

o Mentoring and internship

o Education

o Skills enhancement

o Outreach

o Other approved innovative proposals that meet the goals of the program

(2) Detail a plan to recruit employees from designated zip codes throughout the state

that have either unemployment rates that are 10% or greater, or have 20% or more

residents below the poverty level.

(3) Include proposed competitive wages, benefits and educational and enrichment

opportunities.

(4) Describe the various hospital programs in place or planned to be available for

employees to improve work skills, including education programs, tuition assistance,

and any additional resources provided to employees to assist with career

advancement.

(5) Describe the role the new positions will play in assisting hospitals in meeting the

targets of the model waiver.

(6) Indicate expected program implementation timing.

(7) Detail any job readiness and job skills training necessary to prepare individuals for

successful employment.

(8) Detail any incumbent worker training necessary to advance individuals currently in

entry level jobs to new positions, so long as new positions are created.

(9) Detail employee retention strategies. HSCRC would establish a program review panel (similar to the Nurse Education Support

Program) to determine which hospital applications should be funded.

HSCRC staff will determine the amount to be funded for each hospital under the

Program.

The HSCRC staff and hospitals shall collaborate to identify and calculate savings under

the Program.

HSCRC staff will keep track of amounts funded to assure that no more than $40 million

is included annually in hospital rates.

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HSCRC staff will adjust annual audit procedures to assure each hospital accurately

accounts for program costs.

HSCRC approved rate increases granted under the Program will permanently adjust the

hospital’s Global Budgeted Revenue base. Revenue provided to a hospital from the

Program will not be counted against the hospital’s cost structure for hospital

productivity comparison purposes, such as the former ROC methodology. In approving proposal HSCRC staff and Commissioners shall take into account proposal that:

Partner with or enhance existing workforce development programs and organizations or

leverage existing workforce grant and funding opportunities.

Align with existing health care innovations already underway in Maryland such as

Regional Partnerships for Health System Transformation Grants, Health Enterprise

Zones, and the State Innovation Model.

Hospitals receiving any grants from the program will be required to submit biannual reports to

the HSCRC detailing the number of incremental employees hired, program actual costs

compared to the HSCRC rate increase granted to fund the program. On an annual basis a

reconciliation will be made between the amount granted in rates and the actual program costs,

and an adjustment will be made to the GBR in the next rate year. Like the NSP Programs, this

Program should be regularly adjusted and updated to meet the goals of the Program.

SUMMARY Under the modernized waiver, hospitals have assumed a greater role in improving the health of

the communities they serve, however, traditional health care alone is not sufficient to address

the chronic poor health facing many communities. A number of studies have linked poverty to

higher levels of cancer, infant mortality, cardiovascular disease, diabetes, and other diseases

and conditions. As hospitals develop strategies to address population health, they must look at

strategies to address the root causes of poor health, including poverty. According to the World

Bank, “the most important contributor to changes in moderate poverty has been the growth in

labor income.”42

An employment program can serve as a model that both addresses the underlying condition of

poverty contributing to poor health in many communities, as well as provide resources to

expand the community health workforce. Hospitals in Maryland are uniquely positioned to help

in this process. Any additional costs to the state through increased rates will largely be offset by reductions in

residents utilizing public programs such as Medicaid and additional tax revenue from the new

jobs. Additionally, the benefit to the employment base in the City of having increased

42 The World Bank; “World Bank Policy Research Working Paper 6414, Is Labor Income Responsible for Poverty Reduction?” http://econ.worldbank.org (2013).

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community stability is both a short and long-term net positive. While there is tremendous

appreciation of the need to constrain health care costs, success of the model waiver is already

being touted. Within the first year of operating under the remodeled waiver, Maryland

hospitals have exceeded the financial targets. Per capita hospital spending was about 1.47% for

calendar year 2014, well below the 3.58% annual CMS limit. Additionally, while the target for

the first year of the waiver was zero, Medicare savings of approximately $90 million were

realized. The actions of the HSCRC and Maryland hospitals have created savings that allow for

flexibility to increase hospital spending without jeopardizing the waiver in any way. Investments

in hospitals based jobs for Baltimore City residents would not in any way threaten the ability of

the Maryland hospital system to meet the targets of the remodeled waiver. Investing in

hospital based Baltimore City jobs is both fiscally prudent and socially responsible. While the

Program is intended to address the immediate crisis facing Baltimore City, pockets of poverty

exist throughout Maryland. The Program should be developed to make funding available for

any hospital seeking to hire employees from any zip code that is plagued with high rates of

unemployment and poverty. APPENDICES

A. Letters of Support:

a. The Honorable Senator Barbara Mikulski b. The Honorable Congressman Elijah Cummings c. The Honorable Congresswoman Donna Edwards d. The Honorable Congressman Dutch Ruppersberger e. The Honorable Congressman John Sarbanes f. The Honorable Congressman Chris Van Hollen g. The Honorable Senate President Thomas V. Mike Miller, Jr. & The Honorable

Speaker of the House Michael E. Busch h. The Honorable Delegate Peter Hammen, Chair Health and Government

Operations Committee i. The Honorable Delegate Maggie McIntosh, Chair Appropriations Committee j. The Honorable Mayor Stephanie Rawlings-Blake

B. Map: Baltimore City, Percent of Population Unemployed and Looking for Work

C. Map: Median Income in Baltimore City

D. Map: Percent of Households Living Below the Poverty Line

E. Map: Percent of Households Earning Less than $25,000

F. Johns Hopkins Training Programs for Lower Income Employees

G. University of Maryland Medical System Training Programs for Lower Income Employees

H. LifeBridge Training Programs for Lower Income Employees

I. Mercy Medical Center Workforce Development

J. Johns Hopkins Policy for Community Based Certified Application Counselors

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September 9, 2015 John M. Colmers Chairman, Health Services Cost Review Commission 4160 Patterson Avenue Baltimore, MD 21215 Dear Chairman Colmers: I am writing to express my strong support of the Hospital Employment Program. As Chairman of the House Health and Government Operations Committee, I work with committee members to shape health policy for our state. As we work to meet the goals of Maryland’s All-Payer Model Agreement, we must look to new sources of partnership and innovation. The Hospital Employment Program aligns with the new All-Payer Model Agreement’s focus on population health by creating community-based jobs targeting overall population health. This program utilizes our unique waiver system to improve economic and health outcomes for the pockets of Maryland that need stability most. As a representative of Baltimore City I welcome the opportunity to support a program poised to provide significant support to City residents. Additionally, this targeted employment program, focused on the State’s most disadvantaged communities, has the potential to produce savings from improved overall community health. The Maryland All-Payer Model Agreement provides Maryland with the unique opportunity for innovation. The Hospital Employment Program is a strong example of the type of collaboration we need to be successful under the new agreement. I strongly support this innovative approach to population health. Sincerely,

Peter A. Hammen cc: Herbert Wong, PhD, Vice Chairman

George H. Bone, MD Stephen F. Jencks, MD, MPH Jack C. Keane Donna Kinzer, Executive Director Bernadette Loftus, MD Thomas R. Mullen

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PROJECT REACH: RESOURCES AND EDUCATION FOR THE ADVACEMENT OF CAREERS AT HOPKINS

The Office of Strategic Workforce Planning encompasses workforce development programs targeted to current employees through Project REACH, and community adults & youth through Community Education Programs. Project R.E.A.C.H. (Resources and Education for the Advancement of Careers at Hopkins) is an Incumbent Worker Career Acceleration Program funded by Johns Hopkins Health Systems. This project is designed to help current Johns Hopkins Health System (JHHS) employees acquire the skills and knowledge to fill vacant healthcare occupations with a focus on those that are experiencing critical and chronic shortages. A few features of this program include: assessments of basic skills and career interest for eligible applicants, the assignment of career coaches, and salary release support for most participants (only for those pursuing school on a full-time basis). Project R.E.A.C.H. offers:

Assists JH departments with specialized training coordination (ie: JHHC medical coding training) Salary-release support for approved trainings (16 hrs/wk during training) Coaching (educational / job / work-life balance) Career & Educational Assessments Career transition services for individuals experiencing a reduction in force

Education & Training Programs

REACH/CEP programs support current employees who may be preparing for career advancement opportunities in any healthcare occupations. We also partner with Hopkins departments/programs (ie: Skills Enhancement, Joint Training Council, & Tuition Assistance) and community organizations to support a broad range of courses from GED and college preparation to medical terminology and computer basics. Many of our programs are supported through partnership with local government, community-based organizations and community colleges. While any Health System employee may receive coaching services from Project REACH, to be considered for the program’s salary release support feature, employees must meet the following requirements:

Current JHHS employee with full-time status (40 hr/wk; 1 FTE) Full-time permanent employment for at least one year prior to submission of application Must have completed the Project REACH application Must have secured a manager recommendation Have achieved minimum rating of “2”' (met expectations) on your most recent annual appraisal.

You also must not have received a score of "1" (needs improvement) for any area on your annual appraisal

Cannot be in active discipline (verbal or written for job performance &/or attendance) and must remain in good standing throughout the Project REACH process

Must be actively employed (physically present and able to perform job duties) in department at all times

Must have completed all educational program pre-requisites

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Be a US citizen (must submit a copy of social security card and a valid Maryland driver's license or Motor Vehicle Identification Card)

Graduated High School or have earned a G.E.D Provide a copy the acceptance letter to the educational program (must be on school letterhead or

printed from your student portal bearing your name and the school’s URL. Provide a copy of current transcript Provide a copy of the course outline/plan of study from the enrolled program (must be on school

letterhead or printed from your student portal bearing your name and the school’s URL). Provide a current professional resume Must be willing to sign a service commitment agreement

Some Training Offerings Here is a list (not all inclusive) of the training programs we have and currently supported.

Surgical Technician Medical Technician Medical Technologist Clinical Technician Registered Nursing (Project LINC) Radiology Technician Respiratory Therapist Pharmacy Technician

Listed below are a few Hopkins employees who have been served by the program. Each successfully completed the program and experience a promotion/career advancement as a result of their educational attainment.

Eric Hill* – started with REACH in 2009 as a Rehab Tech and wanted to become a Physical Therapist. By August of 2010 with REACH salary release support he completed his training and secured a position as a Physical Therapist at Johns Hopkins.

Marta Meier* - started receiving REACH salary release support in 2010 while working as a Clinical Associate taking Surgical Technician courses at BCCC. She completed her education securing her Associates degree and passing her Surgical Technician certification in 2012. She now works in the Pediatrics Operating Room.

Deshane Redd* – started in the Housekeeping department at Hopkins in 1988/1989 and spent a

long time pursuing his education towards becoming a Respiratory Therapist. In 2005 he worked with REACH receiving the salary release support that assisted in his completing the program by 2007 and starting his Respiratory Therapist career at Hopkins.

Brandi Loveless – started with REACH in 2012 receiving salary release support in the LINC

registered nursing training program while she was working as a receivables supervisor. She completed her nursing program and started working as an RN in 2013 on the Nelson 3 unit at Hopkins.

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Pathways to Success….Making the Career Connection

Career Advancement for UMMC Staff UMMC employees are supported with their development through our Pathways to Success Program which focuses on

removing academic barriers. Through assessment-guided enrichment programs (College Prep) workers are afforded

the opportunity to prepare for college enrollment. Participants in our college prep program are given a strong

foundation to help them cope with the rigors of college thereby avoiding the pitfalls of the remedial vacuum to which

many students succumb. Deficits in computer skills are also addressed. As many employees attempt to navigate

their career paths lack of computer skills can be a limiting factor. Our basic computer and Microsoft Office training

addresses these skill gaps. Pulling this all together is career coaching, a vital component of the development

process. Everyone has access to experienced career development specialist who assists with the enhancement of

soft skills necessary to acquire and maintain employment. Coaches also help clients develop, Individualized

Development Plans (IDPs), which map the most effective course to attaining career goals. To augment the process,

employees can access The Employee Tuition Reimbursem*nt Program which provides financial assistance to those

who wish to pursue courses of study related to their employment, upgrade their care of patients, and prepare for

advancement. During FY15, over 400 staff participated in career/skill building programs.

Community Partnerships UMMC provides opportunities for unemployed or underemployed community members, who possess the aptitude and

passion for health care, offering gainful employment at the medical center. These prospective employees are

identified through a variety of partnerships with stakeholders in the community. Recruiting quality workers from the

community supplies replacements as incumbents become upwardly mobile and fulfill their career goals. This is a win

for all parties involved.

These are a few examples of how our Pathways to Success programs have helped individuals make a career

connection:

T’Andria Moore – was introduced to healthcare as an Healthcare Careers Alliance intern at UMMC. After her internship she tried her hand at several positions before deciding that she wanted to be a Pharmacy Technician. In December 2014 that dream became reality as she became certified through UMMC’s Pharm Tech Training program. Kenisha Patterson – Kenisha’s initial contact with UMMC was in 2011, via the Health Care Careers Alliance Program. After her internship she secured a job as a mail clerk. It was always her wish to become a Pharmacy Technician. In June of 2014 she entered UMMC’s Pharm Tech program and is now a certified and working in the main pharmacy at the medical center.

Christine Frank- Christine became employed with the University of Maryland Medical Center January 2014 as a Room Attendant and started using Career Development Services within 6 months of working (July of 2014). She strongly aspired to utilize her transferrable skills and healthcare background to benefit another department. She took computer classes, attended essential skills classes, and received intensive career coaching to develop her resume and sharpen her interviewing skills.

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Life Bridge Health

As the largest, most comprehensive respected provider of health-related services to the people of the

northwest Baltimore region, LifeBridge Health is a model of excellence for both employees and the

surrounding community. Each facility promotes physical, emotional, intellectual, social and spiritual

health by offering a variety of onsite health and wellness programs. In 2010, LifeBridge Health was

honored to receive the James W. Rouse Diversity Award from the Chesapeake Human Resources

Association, which is given to organizations that exemplify world-class leadership in their efforts to

promote diversity through programs and initiatives.

In addition to our focus on employee health, satisfaction and diversity, we also encourage our

employees to pursue career advancement. We offer career counseling and tuition assistance for our

employees. Our coaches work with employees who are interested in moving up. We coach them

around career paths, assist them with their resumes and applications, and facilitate enrollment in

educational programs. Tuition assistance is also available, mainly for degree seeking programs.

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Workforce Development at Mercy Medical Center

Mercy Medical Center offers a comprehensive set of programs and benefits for workforce development

and career advancement to all of its employees. Many of the programs are specifically focused on

creating new opportunity ladders for professional growth for entry level workers though increased

access to education, mentorship, and general skills-building.

Career Ladders Program – Provides opportunities for staff to grow within department/division

(increased skills/experience/role leads to increased wages & title).

o Clinical Nurse ladder

o Patient Access Representatives

o Physical Therapy

o Environmental Services (lead & supervisory roles)

o Materials Management (lead & supervisory roles)

o Food Services (lead & supervisory roles)

o Centers of Excellence (varies by practice)

Tuition Assistance Program ( up to $6,500 annually )

o Mercy also offers Pre-paid tuition options for lower-paid eligible employees (benefits-

eligible employee earning $21/hour or less

Continuing Education Program – reimbursem*nt for non-credited college courses, workshop

and other educational programs. Also covers expenses related to acquiring or maintaining

certification related to one’s job.

Adult Education Program (part-time, RSM role) – provides free tutoring for GED preparation,

and core academic skills (literacy, writing and math skills).

Computer Training Program – free courses offered throughout the year on basic and advance

level in various office software products that are a critical career skill in most workplace

environments

Career Coaching Program– consults with entry-level staff to provide guidance on education

opportunities to gain advancement.

Nurse Mentor Program

o Coordinates Nurse Residency Program for new nurse graduates to ensure growth and

retention, including training, workshops, and regular meetings to solicit feedback

Nursing Support Tech Development (program in development)

o Will work with Patient Service Representatives and entry-level staff on opportunities

to development into Nursing Support Tech role

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Johns Hopkins Health System

Medicaid Re-determination Project

The Affordable Care Act (ACA) included the expansion of Medicaid to adults with no children as well as

the FAC population. The effective date of this expansion was January 1, 2014 and all Maryland

Residents who previously qualified for the minimal PAC (Primary Adult Care) coverage were awarded full

Medicaid Benefits. Each year Medicaid requires recipients to be re-determined to continue their

Medicaid eligibility. With the number of new enrollees and the change in the re-determination process

(the re-determination must be done on line with documentation uploaded where necessary) it is very

challenging for the Medicaid eligible population to complete. Johns Hopkins has found that significant

segments of the expanded Medicaid population, consisting primarily of those recipients who are not

actively suffering from illness, are challenged with completing the re-determination process. Many do

not have computer access or knowledge for the redetermination process. The Maryland Health Benefit

Exchange, its call center, and its Connector entities often have long wait periods that deter individuals

from completing the process.

Since January 2015, the number of re-determination requests have been extremely large; 100,000

between January and April 2015 with another 90,000 expected in September 2015. To assist the

patients within our community to complete the new process we have partnered with our vendors and

the Johns Hopkins Health Plan. We have secured locations within the community to meet with patients

and assist them in completing the process. Johns Hopkins vendors and Certified Application Counselor

staff will be staffing numerous locations within East Baltimore and East Baltimore County that are served

by the Johns Hopkins Hospital and the Johns Hopkins Bayview Medical Center and the Johns Hopkins

Community Physicians Groups to assist members of those communities to re-enroll in Medicaid or

initiate a new application as appropriate. This effort allows Johns Hopkins to assist individuals residing

in the communities we serve with gaining health care coverage while they are healthy, rather than

assisting them only when they are sick enough to come the hospitals. Our Program also allows us to

assist individuals with Qualified Health Plan Enrollment. Should your organization or group have need of

such assistance please contact Sandra Johnson, Senior Director of Patient Financial Services of the Johns

Hopkins health System at 443-997-0001 or [emailprotected].

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Health Services Cost Review Commission

Consumer Engagement Task Force:Final Report

September 9, 2015

Leni Preston, Task Force ChairHillery Tsumba, Task Force Member

1

Task Force MembersTask Force: • Leni Preston, Chair – Maryland Women’s Coalition for Health Care Reform• Linda Aldoory, Herschel Horowitz Center for Health Literacy, University of Maryland • Barbara Brookmyer, Frederick County Health Officer • Kim Burton, Mental Health Association of Maryland• Tammy Bresnahan, AARP• Michelle Clark, Maryland Rural Health Association• Shannon Hines, Kaiser Permanente• Donna Jacobs, University of Maryland Medical System• Michelle LaRue, CASA DE MARYLAND• Karen Ann Lichtenstein, The Coordinating Center • Susan Markley, HealthCare Access Maryland • Suzanne Schlattman, Health Care for All!, MCHI • Novella Tascoe, Keswick Multi-Care• Hillery Tsumba Primary Care Coalition of Montgomery County• Gary Vogan, Holy Cross Hospital

Staff: Dianne Feeney & Steve Ports, HSCRC; Theressa Lee, MHCC; & Tiffany Tate, Consultant

2

HSCRC Consumer Engagement Task Force January – September 2015

Charge 1

– Provide rationale for health literacy and consumer engagement within the context of the New All-Payer Model (NAPM)

– Define audiences, identify messages, and propose engagement strategies as appropriate, including:

• Systemic adjustments

• Education and communication strategies

Charge 2

– Advise decision-makers, regulators, etc. on the impact of system transformation on individual and community health issues

– Provide guidance for ensuring an appropriate and consumer-friendly communications process

– Make recommendations for enhanced ways for consumers to provide feedback and for hospitals to act on that input

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Consumer Engagement – Get It!

Consumer Engagement: Benefits to Consumers & the Community

Engaged consumers may experience:• Improved understanding about their health condition,

related treatment options, & how to access the appropriate services to optimally manage their health

• Improved relationships with health care providers• Improved experience and satisfaction with their health

care• Personal sense of value, ownership, and influence in

health care decision-making • High quality health care• An informed, responsive, and more efficient, health

care system

5

Consumer Engagement: Benefits to Health Care Providers & Institutions

Providers & institutions that meaningfully engage the consumer can experience:

• Patients’ improved understanding of their medical condition(s) and treatment options resulting in improved outcomes and more efficient use of resources.

• Greater confidence that their programs meet the needs of consumers and communities, including those with unique cultural or social needs

• Improved relationships and cooperative partnerships with the individuals and communities they serve

• Streamlined processes for receiving information and insight from the community and applying the insights to inform policy decisions

6

Consumer Engagement: Recommended Mission

Foster a health care system driven by a culture of robust and meaningful consumer engagement that addresses the Triple Aim: – improving the patient experience, including

quality and satisfaction– improving health of populations– reducing per capita cost of health care

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Consumer Engagement: Themes• Clear call to action – at the right time, in the right place and from the

right person• Engagement is dependent on individual’s input and perception that their

actions have an impact• Individuals’ motives are different than institutions’ – identifying the

motivating factors is key for both groups• Health care information should be disseminated and consumer

engagement activities should be led by sources that consumers trust• Sensitivity to diversity and the multitude of cultural differences is critical• Requires extraordinary commitment from health care leadership at all

levels• Ideally, consumers should be engaged, both prior to, and at the point of

contact with the health care system• A more robust and consumer-friendly feedback process (i.e. concerns,

complaints and commendations) is needed• Advanced directives planning is indicative of consumer engagement

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Consumer Engagement:Strategic Communications Goals

Goal #1 • Establish a person-centered health care delivery

system with an ongoing role for consumers to participate in the design and implementation of policies and procedures at all levels.

Goal #2• Engage, educate, and activate people who use, or

are potential users of, hospital services in their own health care in order to promote efficient and effective use of the health care system

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Audiences & Messengers

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Task Force Recommendations

1. Allow for meaningful, ongoing role for consumers at the HSCRC through continued representation of Commissioner(s) with primary consumer interest, and through a newly created standing advisory committee with diverse representation.

2. In collaboration with key stakeholders, develop a statewide public education campaign specific to the NAPM that is part of a broader campaign to promote health and wellness.

3. Convene an interagency task force, with consumer representation, to oversee the public education campaign including the development of related consumer-oriented information.

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Task Force Recommendations

4. Provide options and opportunities that support regular, longitudinal and effective consumer engagement in the development of policies, procedures, and programs by hospitals, health care providers, health care payers, and government.

5. In coordination with the SAC, the MHCC and other key stakeholders, consider development of a Consumer Gold Star system for hospitals based upon consumer engagement standards.

6. Define Community Benefit dollars to include consumer engagement initiatives and promote these dollars for this use, particularly for those supporting vulnerable populations.

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Task Force Recommendations

7. Continue to encourage and incentivize independent and collaborative approaches to support people who are at risk of becoming high utilizers.

8. Encourage hospitals to provide current, consistent, and transparent information on average procedure costs using the data made readily available by the Maryland Health Care Commission (www.marylandqmdc.org) and new pricing transparency tools being created, and make this available on NAPM and/or other appropriate website(s).

9. Include discussions about patient and family decision-making and preferences about advanced directives in the context of consumer engagement and educating consumers.

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Measuring Consumer Engagement

• Currently few validated metrics or tools that could directly and comprehensively evaluate the impact of consumer engagement on health outcomes, patient experience or satisfaction, provider satisfaction, improved program design decision-making, access, or utilization.

• Propose an initial non-exhaustive set of measures which could be adopted from currently available resources:– Existing data sources (e.g., Hospital Consumer Assessment of

Healthcare Providers and Systems (HCAHPS), Medicare claims, CRISP encounter information),

– Suggested some that are not currently collected (e.g., the Communication Climate Assessment Toolkit (C-CAT)).

• Propose others where there are currently measurement gaps, for example: – HSCRC Standing Advisory Committee– Patient Family Advisory Committees at hospitals

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Multi-Agency & Multi-Stakeholder Engagement: HSCRC Role

True consumer engagement promises tremendous benefit to the people who use health services as well as health care providers and institutions. Successful consumer engagement requires proactive and committed leadership. It is imperative that the HSCRC embraces a continued leadership role to promote a coordinated, collaborative and person-centered health care system.

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Questions

• Leni Preston, Maryland Women’s Coalition for Health Care Reform [emailprotected]

• Hillery Tsumba, Primary Care Coalition of Montgomery County

• [emailprotected]

Final Report

Health Services Cost Review Commission Consumer Engagement Task Force

September 9, 2015

Health Services Cost Review Commission

Contents

I. Executive Summary ................................................................................................................................ i

II. Statement of Purpose ............................................................................................................................ 1

A. CETF Charges ................................................................................................................................... 1

B. CETF Methodology .......................................................................................................................... 2

C. Vision and Mission ............................................................................................................................ 2

III. Background ............................................................................................................................................. 3

IV. Introduction to Consumer Engagement ............................................................................................ 4

A. Benefits of Consumer Engagement................................................................................................ 5

B. The Path to Consumer Engagement .............................................................................................. 6

C. Current State of Consumer Engagement Infrastructure ............................................................. 7

D. Consumer Engagement Guiding Principles .................................................................................. 8

V. Developing a Consumer Engagement Communication Strategy ................................................... 9

A. Prioritizing the Audiences and Defining the Distribution Channels ......................................... 9

B. A Consumer-Centered Approach to Material Development ................................................... 10

C. Consumer Communications Strategy Recommended Goals and Objectives ........................ 11

D. Strategies and Tactics ...................................................................................................................... 12

E. Budget Estimate for Statewide NAPM Communication Strategy ........................................... 12

VI. Evaluating Consumer Engagement ................................................................................................... 13

VII. Compelling Consumer Engagement Themes .................................................................................. 15

VIII. Recommendations ............................................................................................................................... 16

IX. Acknowledgements .............................................................................................................................. 17

APPENDIX A. CETF Member Roster ....................................................................................................... 19

APPENDIX B. CETF Methodology ........................................................................................................... 20

APPENDIX C. Consumer Engagement Definitions and Principles ...................................................... 21

APPENDIX D. Communication Strategy ................................................................................................... 23

APPENDIX E. Resource List ....................................................................................................................... 33

i

I. Executive Summary

In December 2014, the Maryland Health Services Cost Review Commission (HSCRC) established a Consumer Outreach and Engagement Workgroup to explore opportunities for and challenges in engaging consumers in the state’s New All-Payer Model (NAPM), a unique health care delivery system transformation initiative. The workgroup was composed of two task forces: the Consumer Outreach Task Force and the Consumer Engagement Task Force. This report represents the work of the Consumer Engagement Task Force (CETF), which was charged with developing recommendations on strategies to engage consumers at multiple levels in the NAPM. The CETF met from January through September 2015. A list of the members can be found in Appendix A. At its core, the NAPM has the goal of achieving the “Triple Aim” of: (1) improving the patient experience, including quality and satisfaction; (2) improving health of populations; and (3) reducing the per capita cost of health care.1 Through its exploration, the CETF concluded that, to achieve the Triple Aim, consumers must have access to a health care delivery system that is reflective of their needs and preferences and equips them to be fully engaged in and take ownership of their health and health care. Moreover, the CETF maintains that the HSCRC must assume a leadership role in promoting and supporting the multi-stakeholder collaboration and commitment required to develop such a system. To enable this level of consumer engagement, the CETF recommended vision and mission statements, as well as goals and objectives for the HSCRC and other stakeholders seeking to transform the health system. The goals are viewed as essential to consumer participation and, therefore, the success of the system as it is reoriented to be more responsive to consumers’ needs as both “patients” and “clients.” Extensive effort is needed to ensure that consumers understand this reorientation so they can make informed decisions and engage in the personal lifestyle changes, self-care, and system design that are essential to health system transformation.

Benefits of Consumer Engagement to Consumers and the Community Engaging consumers in health care delivery system design and personal decision-making can produce substantial and enduring benefits for the individual, community, and overall health care system. Fully engaged consumers may experience:

Improved understanding about their health condition, its related treatment options, and how to access the appropriate services to optimally manage their health

Improved relationships with health care providers

1 Framework developed by the Institute for Healthcare Improvement can be found at: http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx; last accessed 9/4/15.

True consumer engagement promises tremendous benefit to the people who use health services, as well as to health care providers and institutions. Successful consumer engagement requires proactive and committed leadership. It is imperative that the HSCRC embraces a continued leadership role to promote a coordinated, collaborative, and person-centered health care system.

ii

Improved experience and satisfaction with their health care

Personal sense of value, ownership, and influence in health care decision-making

High-quality health care

An informed, responsive, and more efficient health care system

Benefits of Consumer Engagement to Health Care Providers and Institutions

Because person-centered systems must be created and, presumably, funded by institutions, it is imperative that hospitals appreciate the potential benefit to their operation and commit to consumer engagement processes. Institutions that meaningfully engage the consumer can experience:

Patients’ improved understanding of their medical condition(s) and treatment options, resulting in improved outcomes and more efficient use of resources

Greater confidence that their programs meet the needs of consumers and communities, including those with unique cultural or social needs

Improved relationships and cooperative partnerships with the individuals and communities they serve

Streamlined processes for receiving information and insight from the community and applying that insight to inform policy decisions

Communications Strategy: The Mission and Primary Goals

A set of nine principles, detailed later in this report, serve as guidelines for consumer engagement. Our mission is to foster a health care system driven by a culture of robust and meaningful consumer engagement that addresses the Triple Aim.

The CETF established two strategic goals, each with accompanying objectives, to support the recommended mission for consumer engagement activities.

Goal #1 Establish a person-centered health care delivery system with an ongoing role for consumers to participate in the design and implementation of policies and procedures at all levels. Goal #2 Engage, educate, and activate people who use or are potential users of hospital services in their own health care in order to promote efficient and effective use of the health care system.

Principal Recommendations

This report places each of the recommendations below into a larger strategic context substantively outlined in this report. The recommendations include:

iii

1. Allow for a meaningful, ongoing role for consumers at HSCRC through continued representation of Commissioner(s) with primary consumer interest, and through a newly created standing advisory committee with diverse representation.

2. In collaboration with key stakeholders, develop a statewide public education campaign specific to the NAPM that is part of a broader campaign to promote health and wellnes.

3. Convene an interagency task force that allows consumer to participate in the design and implementation of a statewide public education campaign

4. Provide options and opportunities that support regular, longitudinal, and effective consumer engagement in the development of policies, procedures, and programs by hospitals, health care providers, health care payers, and government.

5. In coordination with the HSCRC Standing Advisory Committee (SAC), the Maryland Health Care Commission (MHCC) and other key stakeholders, consider development of a Consumer Gold Star system for hospitals based on consumer engagement standards.

6. Define Community Benefit dollars to include consumer engagement initiatives and promote these dollars for this use, particularly for those supporting vulnerable populations.

7. Continue to encourage and incentivize independent and collaborative approaches to support people who are at risk of becoming high utilizers.

8. Encourage hospitals to provide current, consistent, and transparent information on average procedure costs using the data made readily available by the MHCC (www.marylandqmdc.org) and new pricing transparency tools being created, and make this available on the NAPM’s website and/or other appropriate websites.

9. Include discussions about patient and family decision-making and preferences about advanced directives in the context of consumer engagement and educating consumers.

1

II. Statement of Purpose

The Maryland Health Services Cost Review Commission (“HSCRC” or “the Commission”) created the Consumer Outreach and Engagement Workgroup to complete an exploration that would provide the Commission guidance on incorporating a consumer engagement approach in its efforts to implement the New All-Payer Model (NAPM). The Workgroup was composed of two Task Forces—the Consumer Outreach Task Force and the Consumer Engagement Task Force (CETF)—with the rationale that each would perform distinct yet complementary tasks to provide a comprehensive assessment and approach for involving consumers in planning and evaluating the impact of health system transformation. The CETF was composed of 15 representatives from consumer advocacy groups, professional associations, local public health, community-based organizations, and health service providers. (A complete listing of the members is provided in Appendix A.).

A. CETF Charges The CETF had two separate but related charges:

1. Provide a rationale for health literacy and consumer engagement within the context of the NAPM—and related reform initiatives—that includes core principles of consumer engagement, key audiences and messages that will motivate them, and opportunities for reaching these audiences. This work should reflect the work of the Community Outreach Task Force and other HSCRC workgroups, including Care Coordination and Performance Measurement.

2. Address avenues/strategies to provide consumers with ways to: (i) engage with decision makers, regulators, and others on the impact on individual and/or community health issues of the design and implementation of the reform initiatives and principally the NAPM; and (ii) ensure an appropriate and consumer-friendly communications process for those directly impacted by the NAPM’s goals.

The purpose of this report is to provide the HSCRC with recommendations on the overall approach, goals, and objectives essential to promoting consumer engagement that will enable successful implementation of the NAPM. The report guides and supports the HSCRC’s patient-centered focus and inclusive approach to the design and implementation of this unique model. The HSCRC commissioned this work in full recognition of the central role that consumers—both current and potential users of hospital services—have on its ultimate success. In compiling its recommendations, the CETF considered the complexity of the task; racial, social, cultural, and educational diversity of the target audiences; multiplicity of current and potential stakeholders and the opportunities for their engagement through different avenues and at different levels; potential messengers; and the core messages that can be incorporated in next-phase development of a full Communications Plan.

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B. CETF Methodology

The CETF employed a holistic approach in fulfilling its responsibility to the HSCRC. At its initial meetings, the CETF reached consensus on a set of definitions and core principles upon which to predicate its work (see Appendix B). Next, it conducted a research phase through a survey of literature and presentations that included national research and trends and Maryland-specific initiatives related to concepts relevant to implementation of the NAPM and consumer engagement. A summary of its exploration is provided in Appendix C. The full CETF met monthly, and a subgroup met on a more frequent basis. A second subgroup—composed of representatives from the Consumer Outreach Task Force and the CETF—ensured that the work of the task forces was aligned.

C. Vision and Mission To guide its own work, and that of the HSCRC, the CETF proposes a broad and aspirational vision and mission grounded in the need to create an effective communications strategy. Vision: A fully coordinated, integrated health care system in which all Marylanders can achieve optimal health. Mission: Foster a health care system driven by a culture of robust and meaningful consumer engagement that addresses the Triple Aim, as evidenced by:

Ongoing consumer participation in system decisions

Improved individual and population health

Improved experiences with the health care system

Efficient use of health care resources and reduced costs

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III. Background

In January 2014, the HSCRC began implementation of the NAPM, a new hospital reimbursem*nt system that is unique to Maryland and recognized as a national model. The result of an agreement

with the Center for Medicare and Medicaid Innovation (CMMI), the NAPM provides an exciting opportunity to address a prevailing theme in health care—the Triple Aim—while maintaining and improving Maryland’s unique system. The NAPM’s goals to improve health outcomes, enhance quality and patient satisfaction, and reduce per capita health care costs across the system will directly and positively affect Maryland residents. Achieving these goals will require consumers who are currently and potentially affected by transformation across the health care system to be better informed and fully engaged in their own health care and have a meaningful role in the design of the health care system. The NAPM is but one of the building blocks Maryland has in place to ensure its residents have access to both coverage and care. Examples of other programs include, but are not limited to, the Maryland Health Benefit Exchange (MHBE), the Chesapeake Regional Information System for our Patients (CRISP) (the state’s Health Information Exchange), the Maryland Health Care Commission’s (MHCC’s) Health Care Quality Reports, and Maryland Health Homes for individuals with chronic conditions. The design, implementation, and oversight of the various initiatives and opportunities to modernize health care rest with multiple agencies and organizations; however, they are part of an integrated

approach to reforming the health care system whose overall success rests, in part, on the success of each individual component. A proactive approach to informing and engaging all stakeholders—including consumers—is essential to the success of each program and especially important to the overall success of the NAPM.

Consumers do not distinguish between initiatives overseen by different agencies and organizations. Therefore, the HSCRC must continue to foster partnerships to implement an effective, cohesive, and all-encompassing consumer engagement approach. This would align the numerous initiatives currently underway to transform and modernize Maryland’s health care system.

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IV. Introduction to Consumer Engagement

Consumer Engagement, a relatively new concept being applied nationally and in Maryland’s health care system, has evolved from the longer standing concept of “patient engagement. ” The limited yet growing body of work on the topic falls short of arriving at a standard definition for “consumer” or offering a common distinction between “patient” and “consumer.” For the purposes of this report, “patient” will be defined as a person who directly interacts with health care providers and services about personal health concerns. “Consumer” will be defined as a person who is a current or potential user of health services.2 Consumers may be those who make decisions about accessing health care for themselves or loved ones, including choosing among health plans, services, and health care providers. With the passage of the Affordable Care Act and the innovative approaches it encourages, the concept of “consumer engagement” is now considered and applied broadly. Other countries are more advanced in this area, with Australia emerging as a global leader in consumer engagement in health care. In its 2012 report, Consumer and Community Engagement Framework, Health Consumers Queensland discusses the value of engaging consumers in designing health care systems and offers specific ways consumers can be included in this effort. The report asserts that: “Effective engagement is embedded in an organisation’s [sic] culture and practice. It informs health service organisations about the needs of the people who use their services and people who may be potential users of services who may, for different reasons, experience barriers to access. It is a mechanism that can enable health service organisations to better plan, design and deliver services that meet the needs of the people who use them, to gather feedback about initiatives and reforms that will impact upon service delivery and to monitor the quality and safety of providers to deliver improved services for consumers, their families and carers [sic].” Generally, there are two schools of thought in the consumer engagement arena. One focuses on activities aimed at influencing behavior change in individuals to increase their level of “activation” in managing their health and health care, while the other focuses on identifying structural and procedural enhancements that can create an environment in which consumers have ready access to information, support, and resources that enable them to be actively involved in their own health and health care. Given the context in which this exploration was solicited, the CETF chose to emphasize the second framework due to its interdependence with the first one.

Types of Consumer Engagement

In the emerging field of consumer engagement, three categories of engagement are routinely considered as ways to meaningfully involve consumers in optimizing and reforming health care. They include:

Information and Education: This refers to creating and making accessible to consumers information that they understand and can act upon to make informed health care decisions for themselves or an individual for whom they are providing care.

2 Health Consumers Queensland. (2012). Consumer and Community Engagement Framework.

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Advisory Capacity: This type of engagement entails enlisting consumers in an advisory capacity to provide input on programs and services. In this role, consumers may influence decision-making.

Feedback Process: This category of engagement formally secures feedback from consumers about experiences as a patient or caregiver. This solicited or unsolicited information can be used to refine or create programs and services.

A. Benefits of Consumer Engagement There is an emerging consensus in the health policy community that informed and engaged consumers are vital to achieving the Triple Aim. The expectation is that when consumers are armed with the right information, they will demand high-quality services from their providers, choose treatment options wisely, access care in appropriate locations, and become active participants and self-managers of their own health and health care.3 Moreover, these informed and engaged consumers can have a positive impact on the design of the delivery system model. There is a paucity of research that quantifies the impact of consumer engagement. However, as the field continues to expand, the CETF anticipates more research results similar to a 2012 study of Medicaid beneficiaries that found that patients who lack the skills to manage their health care incur costs 8 to 12 percent higher than those who are highly engaged in their care, even after adjusting for health status and other factors.4 These findings are corroborated by innumerable anecdotal reports on the benefits individuals and the health care system realize as a result of consumer involvement.

Benefits to Consumers and the Community

Engaging consumers in health care design and decision-making can produce substantial, enduring benefits for the individual, community, and the health care system. Individuals who have the resources and mechanisms to be engaged experience:

Improved understanding about their health condition, its related treatment options, and how to access the appropriate services to optimally manage their health

Improved relationships with health care providers

Improved experience and satisfaction with their health care experience

Personal sense of value, ownership, and influence in health care decision-making

High-quality health care

An informed, responsive, and more efficient, health care system

3 Academy Health Care. (2007). Improving Quality Health Care: The Role of Consumer Engagement. 4 Institute for Patient- and Family-Centered Care. (2014). Individual and Family Engagement in the Medicaid Population: Emerging Best Practices and Recommendations.

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Benefits to Health Care Providers and Institutions

Because person-centered systems must be created and presumably funded by institutions, it is imperative that they appreciate the potential benefit to their operation and commit to consumer engagement processes. Institutions that meaningfully engage the consumer can experience:

Greater confidence that their programs meet the needs of consumers—particularly those with unique needs—as well as the community at large

Improved relationships and cooperative partnerships with the individuals and communities they serve

Streamlined processes for receiving information and insight from the community and applying that insight to inform policy decisions

More efficient use of health services by informed, empowered consumers

Reduced privacy concerns, which are top-of-mind issues for consumers

The enhanced opportunity for care coordination for patients

B. The Path to Consumer Engagement The CETF’s work was predicated on a recognition that consumer engagement is a process that begins with an individual’s level of health literacy. The Institute of Medicine defines health literacy as “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.” Nationwide, it is estimated that 80 million Americans have low health literacy, which can be linked to poor health outcomes.5 Figure 1. Path to Consumer Engagement

As illustrated in Figure 1, the second step along the path to engagement is “health care literacy.”6 This, with health insurance, is often incorporated into the broader term of “health literacy.” However, it can be useful to separate out these two concepts becuase research shows that serious impediments may remain after someone becomes insured. A survey of Health Insurance Marketplace Assister Programs found that 90 percent of newly-insured individuals nationwide report post-enrollment

5 Berkman, Nancy D., Stacey L. Sheridan, Katrina E. Donahue, David J. Halpern, and Karen Crotty. 2011. “Low Health literacy and Health Outcomes: An Updated Systematic Review.” Annals of Internal Medicine 155 (2): 97–107. 6 Source: Maryland Women’s Coalition for Health Care Reform.

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problems with their insurance and 44 percent of newly-insured people report that they do not know how to use their insurance. 7 The final step to consumer engagement is predicated on an understanding that individuals who have become “health care aware” through insurance and care literacy are now prepared to take full ownership of their own health in partnership with their providers. It is possible that these consumers will also be empowered to positively impact the health within their communities.

C. Current State of Consumer Engagement Infrastructure The CETF’s independent research, internal professional expertise, and insights gained from subject matter experts led to the conclusion that Maryland’s health care system currently requires a significantly improved infrastructure and integration of programs to support a statewide consumer engagement effort. There are, however, elements of consumer engagement that can be found at all levels in the state. Examples provided below include tools hospitals are currently using, and longer standing community partnerships of “Total Patient Revenue” hospitals where consumer engagement has been at the center. These examples—as well as many other hospital, state, local, community, payer, etc. programs and initiatives in the state—can be leveraged to form the foundation for the vital infrastructure and coordinated growth of successful consumer engagement programs needed to advance the NAPM.

Examples: Hospital Consumer Engagement Tools

Patient and Family Advisory Councils (PFACs) composed of patients, family members, clinicians, staff, and administrators. PFACs provide a structure to receive and respond to consumer input. The Agency for Healthcare Research and Quality (AHRQ) asserts that PFACs are one of the most effective strategies for involving families and patients in the design of care. PFACs do not exercise fiduciary or ultimate decision-making over an institution. However, they can provide valuable input into areas such as program development, implementation and evaluation, capital projects, staff selection, and clinical tools and practices.8

An individual’s knowledge of Patients’ Rights.

Knowledge of, and access to, a formal process to provide feedback (concerns, complaints, and recommendations) that can be used to address immediate concerns but also to provide a basis for future governance and operating decisions.

In April of 2015, the CETF conducted a survey of the websites of Maryland’s 46 acute care hospitals with the purpose of evaluating the ease with which consumers could access information regarding the three areas above. While it is understood that more hospitals currently may have all three of these elements available, the findings highlight opportunities for improvement. Figure 2 below summarizes the findings.

7 Kaiser Family Foundation Survey of Health Insurance Marketplace Assister Programs: A First Look at Consumer Assistance under the Affordable Care Act 8 AHRQ Guide to Patient and Family Engagement found at: http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/howtogetstarted/index.html Last access 9/3/15.

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Figure 2. Hospital Website Survey of Consumer Engagement Tools

Consumer Engagement Elements Number of Institutions Patient Rights 39 Formal Complaint and Response Process 27 Patient & Family Advisory Council (PFAC) 7 Possess All Three 5

The CETF was also briefed by the Maryland Hospital Association on its 2013 hospital survey, which included a question regarding the presence of a PFAC in their institution. Of the 30 respondents, 40 percent said they had a PFAC; 40 percent said they did not; and 20 percent said they had no plans to establish a PFAC.

Consumer Engagement in Total Patient Revenue (TPR) Community Partnerships

Prior to the NAPM, several Maryland hospitals operating under a similar “Total Patient Revenue (TPR)” reimbursem*nt model chose community partnerships and patient engagement to achieve their goals. Presentations and conversations with hospital and public health staff found that there are thriving programs and collaborative partnerships around the state that embody consumer engagement elements. Some examples include: (1) a program in Carroll County that utilizes a coalition of community members, community-based organizations, and health care providers to address mental health issues; (2) a Lower Shore (Worchester, Wicomico, and Somerset Counties) diabetes management program that involves a partnership between the community and health care providers; and (3) an initiative in a Western Maryland institution that utilized patient feedback to improve discharge planning.

D. Consumer Engagement Guiding Principles To develop the specific objectives, strategies, and metrics that are the substance of this report, the CETF agreed to a core set of principles to advance the mission to “foster a health care system driven by a culture of robust and meaningful consumer engagement that addresses the Triple Aim.” The CETF recommends that the HSCRC adopt the following guiding principles.

Principles

Participation: People and communities participate and are involved in decision-making about the health care system.

Person-centered: Engagement strategies and processes are centered on people and communities and personal preferences.

Accessible and Inclusive: The needs of people and communities, particularly those who may experience barriers to effective engagement, are considered when determining steps to enhance accessibility and inclusion.

Partnership: People, including health care providers, community, and health-related organizations work in partnership.

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Diversity: The engagement process values and supports the diversity of people, cultures, and communities.

Mutual Respect and Value: Engagement is undertaken with mutual respect and the valuing of others’ experiences and contributions.

Support: People and communities are provided with the support and opportunities they need to engage in a meaningful way with the health care system.

Influence: Consumer and community engagement influences health policy, planning, and system reform, and feedback is provided about how the engagement has influenced outcomes.

Continuous Improvement: The engagement of people and communities are reviewed on an on-going basis and evaluated to drive continuous improvement.

V. Developing a Consumer Engagement Communication Strategy

Given the complexity and timeframe for the completion of the CETF’s work, it was determined that one of the most productive and useful outcomes would be to provide the HSCRC with a strategic structure on which to build a full communications plan. The following provides such a structure specific to the NAPM. However, as stated above, there should be an integration of communications strategies across Maryland’s multiple reform initiatives.

An NAPM-specific communications plan should be developed to build on the strategies proposed by the CETF, which should be considered as one element of a fully-integrated and coordinated statewide health care awareness campaign.

The following discussion provides the key elements of the Communications Plan. The full document can be found in Appendix D.

A. Prioritizing the Audiences and Defining the Distribution Channels The CETF focused first on identifying target audiences. Given the definition of “consumers” as people who are current or potential users of health services, the CETF recognized that all Marylanders are among the target audiences for this initiative. The CETF segmented the audiences into three groups based on the frequency and level of their interactions with the health care system. Next, CETF worked to (1) articulate messages that might inspire the necessary behavior changes among each audience groups and (2) identify the messengers well-positioned to reach each audience segment.

Figure 3 below illustrates this segmentation noted above. It is important to note that the primary NAPM audiences—those who use the hospitals more than three times in a year—will be exposed to

For consumers to engage and remain engaged, their involvement experience must be positive and their impact visible.

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a set of general messages designed for all audiences in addition to targeted messages focused on the behaviors that should be encouraged specifically within the primary target.

Based on the themes identified through this exploration, the CETF compiled an extensive group of messengers and/or distribution channels for each of the three audience segments. Figure 3 provides examples for each group; a more complete list can be found in Appendix D (the Communication Strategy). During the development of a communications plan, this list would be further refined to ensure the most effective communication avenues and positive outcomes.

Figure 3. Consumer Engagement Communication Audiences and Distribution Channels

B. A Consumer-Centered Approach to Material Development The CETF recommends minimum standards for developing consumer-oriented materials in support of the NAPM and other related reform initiatives. Because all residents could potentially use hospital services, it is critical to adopt policies to tailor materials so they resonate and will be understood by the various segments. The considerations listed below should ensure the cultural and linguistic appropriateness of materials created, as well as the accessibility and usefulness of materials provided by government agencies, hospitals, health and social services providers, insurance carriers, and others.

Minimum Considerations for Material Development

Consumer representatives are involved in developing materials

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Surveys and/or focus groups are used to solicit consumer feedback on the design, format, and final language of materials prior to mass production

Materials reflect the cultural and linguistic diversity of the populations served

Health literacy experts are involved in the development of materials to ensure that basic health literacy and Culturally and Linguistically Appropriate Services (CLAS) standards were followed in the development of materials

Materials for consumers are written at or below a 6th grade reading level

All electronic materials are Section 508 compliant, so they are presented in a manner that is accessible to audiences with disabilities or limitations

All information is available in at least one format that is appropriate for all ability types

All information is available in at least one format that is appropriate for all literacy levels (audio and video recordings or reading assistance for people who cannot read)

All information is available in print, online, and mobile formats, allowing each consumer to select the format that is most helpful to him/her

C. Consumer Communications Strategy Recommended Goals and Objectives

Effective consumer engagement requires that individuals own their own health and health care, and that the HSCRC take ownership of a proactive consumer engagement plan that supports its commitment to a person-centered health care system. Therefore, it is imperative that the HSCRC embraces the principles, goals, objectives, and strategies outlined in the following recommendations and assumes a leadership role in implementing the overall communication strategy.

Goal #1

Establish a person-centered health care delivery system with an ongoing role for consumers to participate in the design and implementation of policies and procedures at all levels.

Objective 1.1 Create connections among government, hospitals, health care providers, community-based organizations, and individuals in the development of policies, procedures, and programs that will improve health outcomes and patient satisfaction while lowering system costs.

Objective 1.2 Engage, educate, and activate people who use hospital services in health policy, planning, service delivery, and evaluation at service and agency levels to ensure ongoing consumer support of and participation in health system decisions.

Goal #2

Engage, educate, and activate people who use or are potential users of hospital services in their own health care in order to promote efficient and effective use of the health care system.

Objective 2.1 Provide people who use or are potential users of hospital services with the information and resources needed to become health care aware consumers who are actively engaged in their own health care.

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Objective 2.2 Support consumers’ decision-making by providing clear, culturally and linguistically appropriate, and actionable information and opportunities for effective interactions with health care professionals.

Objective 2.3 Educate consumers about the most appropriate settings to receive care.

Objective 2.4 Support consumers in the appropriate use of care planning and self-management tools.

D. Strategies and Tactics The following strategies and tactics are described below based on the stakeholder group that would have primary accountability for implementation. Each of these is directly linked to the objectives and strategies discussed in much greater detail in Appendix D.

For All Stakeholders

Develop a statewide public education campaign to promote health and wellness and give consumers a sense of ownership of their health

For Policy Makers

Foster a consumer-centered health care system with policies and procedures informed by stakeholder involvement

For Hospitals and Providers

Incentivize hospitals to support patients’ and caregivers’ ability to manage their own care, including access to community based health care resources

For Consumers

Provide consumers with the information, tools, and resources they need to make informed decisions and fully comprehend how to better manage their care

Create a sense of ownership and involvement in the NAPM for the prime audiences by educating Marylanders about the NAPM and instilling pride and excitement that Maryland is creating a unique model of delivery system transformation

Engage local and regional news media to distribute frequent updates about the NAPM to their audiences

E. Budget Estimate for Statewide NAPM Communication Strategy To provide the HSCRC with an initial estimate of the required budget for a statewide NAPM-focused communications strategy, the CETF obtained cost estimates from two marketing and communications firms. These estimates ranged from $1.2 to $2.4 million for the initial campaign development and rollout. Both firms noted that the exact budget would vary based on the final scope of work and the extent/geographic coverage of any media buy associated with a campaign.

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The CETF also undertook preliminary research to determine the cost of care interventions that support consumer engagement in both rural and urban settings. Because of the differences in the population, needs, and cost of living in various communities throughout the state, the cost of care interventions varies from place to place. The CETF notes that many of the proposed care interventions are underway in some parts of the state and are being considered by Regional Transformation Initiatives in other parts of the state.

Greater specificity will be required to develop a full project budget and funding resources. This would have to be based on the scope of work, the financial incentives and obligations of key stakeholders, and the range of funding options. Two factors should be taken into account when considering both the communications and care interventions aspects of the budget. One factor is the potential to leverage the work currently under way through the Transformation Planning Grants and other hospital and community-based initiatives, as well as future grant opportunities. The second factor is the innovative approach Maryland is taking to delivery system reform with the NAPM. This should provide a range of funding opportunities that would include state-based agencies and organizations, foundations, and local and national entities.

VI. Evaluating Consumer Engagement

As previously mentioned, consumer engagement in health care is an emerging field. Consequently, the CETF was unable to locate validated metrics or tools that could directly and comprehensively evaluate the impact of consumer engagement on health outcomes, patient experience or satisfaction, provider satisfaction, improved program design decision-making, access, or utilization.

There are some measures that are currently available or that can be more readily developed with existing or potential data sources on the identified consumer engagement goal and objective “impact” areas, and there are areas where measures must be developed. Therefore, as illustrated in Figure 4, the CETF provides for consideration an initial non-exhaustive set of measures that could be adopted from:

Existing data sources (e.g., Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS], Medicare claims, CRISP encounter information)

Developed potential sources but not currently collected (e.g., the Communication Climate Assessment Toolkit (C-CAT))

New sources that could potentially address the identified goals and objectives in which there are measurement gaps (e.g., HSCRC standing advisory committee, Patient Family Advisory Committees at hospitals)

It is important to note that there may be a “many to many” relationship for the candidate measures and the goals and objectives with which they are listed.

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Figure 4. Potential Measures of Consumer Engagement Goals and Objectives Possible Measure(s) Notes Goal 1:Establish a consumer-centered health care delivery system with an ongoing role for consumers to participate in the design and implementation of policies and procedures at all levels.

HSCRC Consumer centered advisory committee

Suggestion to establish a standing advisory committee similar that of the Maryland Health Benefit Exchange

Objective 1. Create connections among government, hospitals, health care providers, community-based organizations, and individuals in the development of policies, procedures, and programs that will improve health outcomes, and patient satisfaction while lowering system costs.

Hospital meaningful use of Patient Family Advisory Committees

New measure to be developed Need to define “meaningful”

Objective 2. Engage, educate, and activate people who use hospital services in health policy, planning, service delivery and evaluation at service and agency levels to ensure ongoing consumer support of and participation in Health System decisions.

HCAHPS question on consumer overall rating of hospitals

HCAHPS in use since 2012

Goal 2:Engage, educate, and activate people who use or are potential users of hospital services in their own health care in order to promote efficient and effective use of the health care system.

HCAHPS CTM-3 Questions 1-The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. 2-When I left the hospital, I had a good understanding of the things I was responsible for in managing my health 3-When I left the hospital, I clearly understood the purpose for taking each of my medications.

CTM-3 currently in use (since January 2014)

Objective 1. Provide people who use or are potential users of hospital services with the information and resources needed to become health care aware consumers who are actively engaged in their own health care.

For users of hospital services: # of individuals with personal health

records Volume of materials disseminated about

options for engaging in care For potential users of hospital services: Visits to NAPM websites tools provided Number of subscribers to telehealth

resources Posts/comments on NAPM related

articles Volume of sharing of NAPM news

articles, etc.

New measures need to be developed. Need to determine universe of websites, and electronic resources we want to monitor.

Objective 2. Support consumers’ decision-making by providing clear, culturally and linguistically appropriate, and actionable information and opportunities for effective interactions with health care professionals.

1-measuring each of health literacy, language services and individual engagement related to patient-centered communication, (0-100 score_ derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit 2-HCAHPS questions- Consumer ratings on communications with doctors and nurses, and responsiveness of hospital staff

1-CCAT would be a new survey to implement in the state 2-HCAHPS in use since 2012 Monitor for increase in percentages

Objective 3. Educate consumers about the most appropriate settings to receive care.

1-HCAHPS questions- Consumer rating of Discharge Information they received 2-Prevention Quality Indicators(PQI)- hospitalizations for ambulatory sensitive conditions

1-HCAHPS in use since 2012-monitor for increase in percentage 2-PQI measures currently in use in Maryland- monitor for decrease 3-NAPM measure (Medicare only- claims)

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Goals and Objectives Possible Measure(s) Notes 3-Appointment within 7 days after hospital stay 4- Person discharged where primary provider notified

4- NAPM measure (CRISP collects)

Objective 4. Support consumers in the appropriate use of care planning and self-management tools.

1-HCAHPS questions- Consumer rating of Communication About Medicines

2-Care plan usage for identified high risk target populations

3-Percentage of patients with chart documentation of advanced directives

4-Claims for advanced directive discussions

1-HCAHPS in use since 2012- monitor for increase in percentage 2-New measure to be developed and implemented- monitor for increase in percentage 3-New measure to be implemented in the state. Could build upon the current law that requires Medical Order for Life Sustaining Treatment (MOLST). Derived from EHR. Monitor for increase in percentages by hospital over time 4-CPT code 99497 covers a discussion of advance directives with the patient, a family member, or surrogate up to 30 minutes. The add-code of 99498 covers an additional 30 minutes of discussion. In July 2015 CMS proposed to cover these discussions for Medicare patients.

VII. Compelling Consumer Engagement Themes The overarching themes and concepts that emerged during the research phase largely informed the CETF’s recommendations. The themes include:

Consumer engagement efforts must offer a clear call to action. Consumers’ continued engagement is dependent on their input and perception that their actions have an impact.

Because individuals’ motives are different than institutions’ motives, successful engagement efforts must ascertain the motivating factors for both groups.

Health care information should be disseminated and consumer engagement activities should be led by sources that consumers trust.

Sensitivity to diversity and the multitude of cultural differences are critical in engagement efforts.

Consumer engagement requires extraordinary commitment from health care leadership at all levels.

Ideally, consumers should be engaged, both prior to and at the point of contact with the health care system.

A more robust and consumer-friendly feedback process (i.e., concerns, complaints, and commendations) is needed.

Advanced directives planning is indicative of consumer engagement.

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VIII. Recommendations

The HSCRC holds an important leadership role in influencing statewide adoption of meaningful consumer engagement in the use and design of the health care system. Based on extensive exploration of the current state of, and opportunities for, consumer engagement, the CETF makes the following recommendations. These are presented as specific activities the HSCRC can undertake to foster a person-centered, collaborative, coordinated system in Maryland.

1. Allow for continued meaningful, ongoing role for consumers at the HSCRC: a. Include continued representation of Commissioner(s) with primary consumer

interest. b. Create an HSCRC Standing Advisory Committee (SAC) with representation that

reflects the gender, racial, ethnic and geographic diversity of the state and a diverse cross-section of consumers, consumer advocates, relevant subject matter experts, and other stakeholders (see the MHBE and the Maryland Medicaid Advisory Committee [MMAC] as examples). In addition to providing expertise in the area of consumer engagement, the SAC would advise on the NAPM implementation, including evaluation of responsiveness to consumer feedback (concerns, complaints and commendations), and ensure that there is a clear infrastructure and process to provide the SAC with information from hospital patient advisory councils and other policy making boards, as well as providers and organizations working with potentially impacted consumers.

2. In collaboration with key stakeholders, develop a statewide public education campaign specific to the NAPM that is part of a broader campaign to promote health and wellnes.

3. Convene an interagency task force that allows consumers to participate in the design and implementation of a statewide public education campaign. As its foundation, this would have the advancement of consumer engagement and ownership in individuals’ health with the use of the CETF’s Communication Strategy as the foundation. Its charge and activities should be coordinated with the proposed SAC to ensure consumer representation. Moreover, it should be in coordination with the Maryland Department of Health and Mental Hygiene, Department of Human Resources, the MHBE, the MHCC, and all other relevant state agencies producing consumer-oriented information regarding engagement with the health care system.

4. Provide options and opportunities that support regular, longitudinal, and effective consumer engagement in the development of policies, procedures, and programs by hospitals, health care providers, health care payers, and government.

5. In coordination with the SAC, the MHCC and other key stakeholders, consider development of a Consumer Gold Star system for hospitals based on consumer engagement standards to include:

a. Websites that reflect a commitment to consumer engagement and appropriate service to the community

b. Educating patients about their rights c. An effective and meaningful consumer feedback process that includes access to

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information and a process for prompt and substantive responses to consumer concerns

d. Multiple opportunities for patients/consumers to participate in patient and family advisory councils and other hospital policy board

6. Define Community Benefit dollars to include consumer engagement initiatives and promote these dollars for this use, particularly for those supporting vulnerable populations

7. Continue to encourage and incentivize independent and collaborative approaches to support people who are at risk of becoming high utilizers such as:

a. Medication therapy management. b. Motivational interviewing.� c. Health coaches.� d. Peer support specialists for behavioral health and other special populations. � e. Community clinical teams doing in home assessments. f. Incorporate clear simple case/care management screening during discharge that

covers social and health aspects necessary for a successful care transition. Ensure that active listening and “teach back” methods are used during this screening. �

g. Emergency Department-based patient navigation that connects patients with appropriate community based resources (primary care, behavioral health care, social work case management, etc.). �

h. Collaboration with current recipients of Regional Transformation Planning Grants and future grantees to encourage them to engage consumers in developing their transformation plans. �

8. Encourage hospitals to provide current, consistent, and transparent information on average procedure costs using the data made readily available by the MHCC (www.marylandqmdc.org) and new pricing transparency tools being created, and make this available on NAPM and/or other appropriate website(s).

9. Include discussions about patient and family decision-making and preferences about advanced directives in the context of educating and engaging consumers.

IX. Acknowledgements

The CETF commends the HSCRC Commissioners for their understanding of the value of engaging consumers at all levels. Their commitment to this effort has been both meaningful and substantive and stands as a model for other state reform efforts. We also wish to recognize the leadership of Donna Kinzer and to thank the HSCRC staff. In particular, Steve Ports and Dianne Feeney have made critical contributions to the work of the CETF and to the content of this report. Theressa Lee of the MHCC also deserves recognition for her expertise and insights and her dedication to the concept of consumer engagement. In addition, the CETF’s work would not have been possible without the able assistance of Tiffany Tate, project consultant.

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This report represents not an end, but rather a beginning, to ensure that consumers are fully engaged not only in their own health, but also in the evolution and success of Maryland’s NAPM. The members of the CETF are grateful for the opportunity to inform that process and are committed to supporting this effort as we move forward.

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APPENDIX A. CETF Member Roster

LeniPreston,ChairChair/ExecutiveDirectorMarylandWomen’sCoalitionforHealthCareReformLindaAldooryAssociateProfessor,BehavioralandCommunityHealthEndowedDirectorandChair,HerschelS.HorowitzCenterforHealthLiteracy,UniversityofMarylandTammyBresnahanAssociateStateDirectorofAdvocacyAARPBarbaraBrookmyerHealthOfficer,FrederickCountyHealthDepartmentKimBurtonDirectorofOlderAdultProgramsMentalHealthAssociationofMarylandMichelleClarkExecutiveDirectorMarylandRuralHealthAssociationShannonHinesSeniorDirector,HealthEducation/HealthPromotion/Women’sHealthKaiserPermanenteMAS

DonnaJacobsSeniorVicePresident,GovernmentandRegulatoryAffairsUniversityofMarylandMedicalSystemMichelleLaRueSeniorManagerHealthandSocialServiceProgramsCASADEMARYLANDKarenAnnLichtensteinCEO/PresidentTheCoordinatingCenterSusanMarkleyVicePresident,BusinessDevelopmentHealthCareAccessMarylandSuzanneSchlattmanDeputyDirector,MarylandCitizensHealthInitiativeHilleryTsumbaManagerofCommunicationsandDevelopment,PrimaryCareCoalitionofMontgomeryCountyNovellaTascoeExecutiveDirectorCommunityHealthServicesKeswickMulti‐CareGaryVoganSeniorAdvisortotheCEO,HolyCrossHealth

STAFFDianneFeeneyAssociateDirector,QualityInitiativesHealthServicesCostReviewCommissionTheressaLeeDirector,CenterforQualityMeasurement&ReportingMarylandHealthCareCommission

StevePortsDeputyDirector,PolicyandOperationsHealthServicesCostReviewCommissionTiffanyTateConsultanttoHealthServicesCostReviewCommission

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APPENDIX B. CETF Methodology Through its exploration of the existing literature both within and outside the United States, the CETF agreed to a definition of consumer engagement, collected data and information on the current state of consumer engagement infrastructure in Maryland, identified strategies to implement consumer-centric communication strategy, and devised metrics that can be used measure the impact of this consumer engagement activities. The CETF met at least monthly to expand their knowledge about consumer engagement and monitor progress towards the two charges. A subgroup, composed of members and interested professionals, met more frequently to collaborate on more involved activities of the workgroup. Finally, a few members from the CETF were represented on a subgroup that also included representatives from the Consumer Outreach Task Force. It was the role of this combined group to ensure alignment between the individual taskforces. The CETF responded to the limited evidence-based on consumer engagement by seeking information and insight from individuals and organizations that had expertise or experience in related areas. These entities presented at task force and subgroup meetings and participated in e-mail discussions and one-on-one conversations. Below are the areas for which the subject matter experts and independent research provided the CETF’s insight and guidance. Expertise and Perspectives Explored

Consumer Advocacy

Care Coordination

Population Health Management

Health Care Quality Report

Consumer Engagement in Total Patient Revenue (TPR) environment

Geographic Targeting

Patient/Consumer Engagement Infrastructures in Hospital Settings

Disposition of Consumer Complaints by Hospital and Government Entities

Online Resources to Support

Performance Measures to Assess Consumer/Patient Engagement

Consumers

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APPENDIX C. Consumer Engagement Definitions and Principles

Health Services Cost Review Commission New All-Payer Model: Consumer Engagement Taskforce

Proposed Useful Definitions and Principles ====================================================== The following are based on the Consumer and Community Engagement Framework1 developed by Health Consumers Queensland and are proposed here as a basis for consumer engagement. Proposed Useful Definitions

Consumers: Consumers are defined as current or potential users of health services. This may include family members as well as those who provide care in an unpaid capacity. Community: Community refers to groups of people or organizations with a common local or regional interest in health. There are three primary ways in which a community may be formed: (1) geographic boundaries (neighborhood, region, etc.); (2) interests such as patients, health care providers, industry sector, profession, etc.; and/or (3) specific issue such as improvements to public health or groups that share cultural backgrounds, religions, or language(s). Consumer Engagement: Consumer engagement informs broader community engagement. Health consumers are people who actively participate in their own health care and, more broadly, in health policy, planning, service delivery and evaluation at service and agency levels. Community Engagement: Community engagement refers to the connections between government, communities and citizens in the development of policies, programs, services, and projects. It encompasses a wide variety of government community interactions, ranging from information sharing to community consultation and, in some instances, active participation in government decision-making. It incorporates public participation, with individuals being empowered to contribute in decisions affecting their lives, through acquisition of skills, knowledge, and experience.

1 The full document can be found at http://www.health.qld.gov.au/hcq/publications/consumerengagement

Proposed Principles - Consumer and Community Engagement #1 - Participation: People and communities participate and are involved in decision-making about the health care system. #2 - Person-centered: Engagement strategies and processes are centered on people and communities.

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#3 - Accessible and Inclusive: The needs of people and communities, particularly those who may experience barriers to effective engagement, are considered when determining steps to enhance accessibility and inclusion. #4 - Partnership: People, including health care providers, community, and health-related organizations work in partnership. #5 - Diversity: The engagement process values and supports the diversity of people and communities. #6 - Mutual Respect and Value: Engagement is undertaken with mutual respect and the valuing of others’ experiences and contributions. #7 - Support: People and communities are provided with the support and opportunities they need to engage in a meaningful way with the health care system. #8 - Influence: Consumer and community engagement influences health policy, Planning, and system reform, and feedback is provided about how the engagement has influenced outcomes. #9 - Continuous Improvement: The engagement of people and communities are reviewed on an on-going basis and evaluated to drive continuous improvement.

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APPENDIX D. Communication Strategy Maryland All Payer Model Consumer Engagement Communication Strategy Developed by the Consumer Engagement Task Force September 9, 2015

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Audiences and Messages

It is imperative to recognize that:

Consumers/patients who have appropriate information about disease prevention and tools targeted for their specific circ*mstances will have better health outcomes with lower costs to the system.

Individualized engagement is critical. Meet the patient where they are and consider their cultural background, literacy level, and prior experience with the health care system.

Trust, dialogue, collaboration, and shared decision-making with consumers produce better outcomes.

"Health literate" consumers are more likely to make wise decisions and adopt a healthy lifestyle

Audience Segmentation All Marylanders are among the target audiences for this initiative. Target audiences are segmented based on their priority and include: People who are frequent users of hospital

services (three or more hospital visits per year), and who need to know how to manage specific health problems and work with a care team to avoid hospitalization.

People who use hospital services, but are not frequent users, and need to know where to go for episodic or diagnostic care; how to play an active role in managing health; and, how to establish a relationship with a primary care provider.

The general public, who are potential users of hospital services and need to become aware of the care options available; know how to access timely and appropriate health services; be prepared to make their health care desires known; and understand that their actions can impact a unique initiative taking place in Maryland.

Next steps are to articulate messages that will motivate the specific behavior change needed among each audience segment and identify the messengers well positioned to reach each audience group.

Messaging Framework The messaging framework illustrated below in Figure 2 is based upon the audience pyramid and conveys key information and concepts to share with consumers in order to increase their engagement with the health system and, ultimately incentivize and empower them to be more active in their health. The messaging framework for each audience builds upon itself and channels messages to audiences based on their priority so that people who frequently use hospital services,

Figure 1: Target Audience Segmentation

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who require a greater level of engagement, will receive specific information tailored for them in addition to the more general information people who use hospital services but aren’t frequent users, and the general public. These proposed messages were developed in coordination with the findings of the focus groups and community forums conducted by the Consumer Outreach Task Force. The messaging framework does not represent the final language to be used on communications materials, rather it outlines the concepts to be shared with consumers in order to heighten their awareness of the NAPM and evolving health care system transformation, increase their engagement with the health care system, and motivate them to take a more active role in self-management.

Figure 2. Messaging Framework Audiences and Potential Messages

Audience PotentialMessages

All

• Gen

eralpublic

• Peo

plewhousehospitalservices

• Highutilizers

Marylandisdoingsomethinguniqueandyouareapartofit.

Thereisanagencythatsetstherateshospitalsarepaid.Concept:Hospitalsdonothavethefreedomtosettheirownpricing..

Transformationofthehealthcaredeliverysystemshouldhelpyoutogettherightcare,intherightplace,attherighttime.

Yourhealth.Yourlife.–Yourhospitalisheretohelpyoubeashealthyaspossible.

o Preventionisthemostaffordablecare‐seeyourdoctor,eathealthy,livewell.

o Teamworkamonghospitalandinthecommunity,willmakeiteasierforyoutogetcare.

o Knowwheretogetthecarethatbestmeetsyourneeds(youmightpaymoreifyougetcareinthewrongsetting).

o Makegooddecisionsbybeinginformedaboutthecostofyourhealthcareandyourfinancialresponsibility

o Shopforhealthcarethatmeetsyourneeds.

o Shopforhealthcarequality;highcostdoesnotalwaysequalhighqualitycare.

o Youcancontrolwhoseesyourhealthinformation.

o Usethetoolsthatareavailabletohelpmakehealthcaredecisionsthatarebestforyou.

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Audience PotentialMessagesPrimary&Secondary

Peo

plewhousehospitalservices(nothigh

utilizers)

Highutilizers(3+hospitalvisits/yr)

Createaplantogethealthyandstayhealthy

Beactiveinmanagingyourownhealth

Findatrustedpersontohelpmanageyourcare

Makesureatrustedpersonknowshowyouwanttobecaredforifyoucan’tmakedecisionsforyourself.

Havearelationshipwithyourprimarycareprovider

Beforeyouleavethehospitalmakesureyouhaveaplanandunderstand:

o Whatyoushoulddowhenyouleavethehospital

o Whoyoushouldcallifyouhaveaproblemwhenyouleavethehospital

o Whoyoushouldcallbeforeyougotothehospitalagain

o Wheretogoifyouneedhelplookingafteryourself

Knowwhatmightcauseyourreadmissiontothehospital

Knowhowtoaccessthesupportandservicesyouneedtokeepyoufromhavingtogobacktothehospital

Primary

HighUtilizers

(3+hospital

visits/yr)

Youandyourcareteammanageyourhealthtostayoutofthehospital

Stayinvolvedinmanagingyourownhealthcare

Createatrustedrelationshipwithyourproviders

Understandyourcareoptions

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Messengers and Distribution Channels

Figure 3 below, while not providing a wholly inclusive list, illustrates the breadth of opportunities to engage with patients and consumers.

Figure 3. Audiences and Key Messengers/Opportunities

Audience KeyMessengers

Primary

HighutilizersCaregivers/Guardians

Hospitals

o Medicalstaff

o Hospitalvolunteersandclergy

o Dischargeplanners

o CaseManagers/Patientnavigators

o Billingoffice

o Web‐basedresources

Payers

Communityhealthworkers

Communityhealthclinics

Faithandothercommunity‐basedorganizations

Rehabilitationcenters

Homehealth

Pharmacists

Primarycarephysicians

Caregiversupportgroups

Urgentcareproviders

Socialworkers/casemanagers

Long‐termcarefacilities/providers

Rehabilitationfacilities/providers

Behavioralhealthproviders

DHMH/LocalHealthDepartments

DSSoffices

Departmentofa*ging

MarylandAccessPoint

PhilanthropicFoundations

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Audience KeyMessengersSecondary

Peo

plewho

usehospital

services

Alloftheaboveplus:

Consumeradvocacygroups

Advocacyandsupportgroupsforchronicconditions

ERwaitingrooms(toreduceinappropriateuse)

All

Gen

eralpublic

Alloftheaboveplus:

Newsmedia(traditionalandonlineincludinglocalnewspapers,magazines,andradiostations)

Faithandothercommunity‐basedorganizations(materials,meetings,healthfairs,etc.)

Urgentcareproviders

MHBE/ConnectorEntities&PartnerOrganizations

Membersoftownandcountycouncils

Localcommunityactivists

Strategies and Tactics for Consumer Engagement Strategies must be applied at all levels in order to maximize the potential for successfully achieving a health care system with a culture of consumer engagement and all the benefits that brings. The text below outlines the strategies and tactics that can be undertaken by all stakeholders as well as at the policy maker, provider and consumer levels.

For All Stakeholders

Develop a statewide public education campaign to promote consumer ownership of their own health and wellness.

Coordinate with the Department of Health and Mental Hygiene, Department of Human Resources, Maryland Health Benefit Exchange, Maryland Health Care Commission, and all other relevant state agencies producing consumer oriented information regarding engagement with the health care system.

Create an inter-agency task-force that includes consumer representatives, convened by HSCRC to design and facilitate the campaign. Its charge and activities should be coordinated with the proposed HSCRC Standing Advisory Committee.

A note about reaching vulnerable populations:

This document provides recommendations for general consumer engagement. It is critical to note that effective engagement of some populations may require specialized efforts beyond what is proposed in this document. This includes people with severe mental illness, active substance

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Establish a descriptive, compelling, and memorable brand for the NAPM including a logo with visual style guidelines (colors, fonts, imagery, etc.) and tagline with consistent supporting messages (see Messaging Framework)

Ensure that all “official” consumer engagement materials are branded with core visual elements and messages

Develop standard materials as templates that can be customized with branding and sub messages specific to diverse stakeholders including hospitals, primary care practices, specialty care practices, advocacy and support groups for chronic conditions, etc.

To the extent possible, develop materials with a neutral appearance that complements the branding and visual style guides of as many hospitals as possible.(Be realistic about the extent to which this is possible, if branding styles are too disparate complement the look and feel of MHA materials.)

Encourage hospitals, social service providers, consumer advocates, etc. to localize NAPM materials as appropriate for the distinct communities they serve while being careful not to compromise the brand.

For Policy Makers

Foster a consumer-centered health care system with policies and procedures informed by stakeholder involvement:

Continue to foster representation on the Health Services and Cost Review Commission (HSCRC) whose principal role is to represent the interests of consumers.

Create an HSCRC standing advisory committee with representation that reflects the gender, racial, ethnic and geographic diversity of the state and a diverse cross-section of consumer groups and other stakeholders (see MHBE and MMAC as examples). The purpose would be to advise on the NAPM implementation, including evaluation of responsiveness to consumer feedback (concerns, complaints and commendations, and ensuring that there is a clear infrastructure and process to provide the Committee with information from hospital patient advisory councils and other policy making boards, as well as providers and organizations working with potentially impacted consumers. [or targeted populations]

Educate consumers and consumer groups about how to effectively impact: NAPM implementation, including opportunities to serve on and/or interact with HSCRC SAC and hospital patient and family advisory councils, and/or other hospital policy boards

Promote standardizing hospitals' process for receiving feedback from consumers, including for comments, complaints and commendations

Establish data systems to aggregate and analyze consumer feedback in a timely and transparent fashion

Ensure that there is a meaningful evaluation of and response to complaints at the agency level.

Continue to provide incentives to support regular, longitudinal and effective consumer engagement in the development of policies, procedures, and programs by hospitals, health care providers, health care payers, and government.

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Develop and distribute information about how to provide consumer feedback for both state agencies and hospitals - in multiple formats (print and electronic) and that is culturally and linguistically appropriate for diverse populations

Promote hospitals’ providing multiple opportunities for consumers, representing the diversity of its community, to provide meaningful input on hospital policies such as Patient and Family Advisory Councils or seats on relevant policymaking bodies.

In coordination with the SAC, develop and promote a Consumer Gold Star system for hospitals based upon consumer engagement standards may include: o websites that reflect a commitment to consumer engagement and appropriate service to

the community o ensuring that patients understand their rights o the consumer feedback process, including access to information and process for prompt

and meaningful responses to consumer concerns o multiple opportunities for patients/consumers to participate in patient and family

advisory councils and other hospital policy boards

For Hospitals and Providers

Incentivize hospitals to support patients and care-givers ability to manage their own care, including access to community based health care resources

Incentivize ongoing collaborations between hospitals and community-based organizations including health and social services organizations, faith communities, neighborhood associations, fraternal organizations (rotary clubs, lions clubs, masons, etc.) and other groups working to better their communities

Promote the use of Community Benefit dollars to advance consumer engagement initiatives, particularly for those supporting vulnerable populations

Incorporate clear simple case management screening during discharge that covers social and health aspects necessary for a successful care transition. Ensure active listening and teach back methods are used during this screening.

Reward independent and collaborative approaches to support patients who are at risk of becoming high utilizers such as: o Medication therapy management o Motivational interviewing

o Health coaches o Peer support specialists for behavioral health and other special populations o Community clinical teams doing in home assessments

Encourage and reward Emergency Department based patient navigation that connects patients with appropriate community based resources (primary care, behavioral health care, social work case management, etc.).

Require hospitals to provide current, consistent, and transparent information on average procedure costs using the data made readily available by the Maryland Health Care Commission

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(www.marylandqmdc.org) and new pricing transparency tools being created, and make this available on NAPM and/or other appropriate website(s)

Collaborate with current recipients of Regional Transformation Planning Grants, and future grantees to encourage them to engage consumers in developing their transformation plans.

For Consumers A. Provide consumers (patients, caregivers, etc.) with the information and resources they

need to make wise decisions and better manage their care.

Educate and empower consumers to seek care in the most appropriate setting for their needs. Inform consumers about appropriate vs. inappropriate use of hospital services and provide realistic community-based alternatives.

Develop patient informed care planning resources to promote personal responsibility for care including advance directive assistance, power of attorney for healthcare, etc.

Provide patients and caregivers with a care-transitions roadmap that illustrates each step of the care transition and directs consumers to helpful community-based health and social service resources.

Create a comprehensive, searchable guide to community-based resources (print and online) and allocate resources to keep this up to date. The guide should include the name and description of services as well as operating hours, average cost of services, payer types etc.

Provide consumers with a health care passport to complement electronic data transfer. The health care passport will be a hard copy document that consumers can use to keep track of their health records including lists of health care providers, procedures, medications, vaccinations, etc. (Relying 100% on electronic health records and CRISP leaves out the most important person in the care team, the patient!)

Incentivize hospitals and providers to offer consumers the option of electronic resources such as tele health, SMS follow up reminders, patient portals, health apps, etc. to help patients and caregivers participate more actively in self-care.

Work with CRISP et al, to develop clear communication materials about the HIE, including one consent form that can be used for any hospital or community provider.

Employ Singh Index of neighborhood disadvantage to identify localized communities with high rates of hospital readmission. Focus engagement strategies for high utilizers and care givers on these areas.

B. Create a sense of ownership and involvement in the NAPM for the prime audiences by educating Marylanders about the NAPM and instilling pride and excitement that Maryland is creating a unique model of delivery system transformation

Create a NAPM-specific website to serve as a single online resource that includes information on NAPM progress and successes as well as information directly relevant to consumers with links from that site to appropriate external resources, such as MHCC. o Use simple, memorable web addresses and links that are optimized for search engines. o Ensure that the front-end of this website appears sleek and easy to navigate, avoid

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adding information to a crowded existing site.

Raise awareness of the NAPM and involve the public in the countdown.

Modify display of state dashboard showing progress toward meeting NAPM goals so that it is meaningful to consumers (similar to a fundraising campaign). Promote this dashboard so that the public can easily find it.

Mobilize grass-roots consumer advocates and community organizers and partners to act as “ambassadors” for the NAPM throughout the state in their home communities.

C. Engage local and regional news media to distribute frequent updates about the NAPM to their audiences

Distribute frequent news releases and host press events to highlight NAPM successes, challenges; and, opportunities for consumer engagement.

Issue frequent “report cards” illustrating progress toward meeting NAPM goals. Use this as a mechanism to celebrate successes and be transparent and forthcoming about challenges, possible solutions, and impact on consumers.

Develop talking points and engage people who command public attention as “champions” to talk about the NAPMs goals for improved quality of care and patient experience to their captive audiences and local communities (elected officials, community activists, local athletes and celebrities, business leaders, faith leaders, etc.).

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APPENDIX E. Resource List American Hospital Association- Strategies for Leadership: Patient and Family Centered Care http://www.aha.org/advocacy-issues/quality/strategies-patientcentered.shtml Agency for Healthcare Research and Quality – Patient & Family Engagement www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/index.html Center for Advancing Health

Patient Engagement http://www.cfah.org/engagement/ A New Definition of Patient Engagement: What is Engagement and Why is it Important

http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf Centers for Medicare and Medicaid Services– From Coverage to Care https://marketplace.cms.gov/technical-assistance-resources/c2c.html Consumers Union Engaging Consumers on Health Care Costs & Value Issues http://consumersunion.org/research/engaging-consumers-on-health-care-cost-and-value-

issues/ Consumer Attitudes Toward Health Care Costs, Value, and System Reforms: A Review of the Literature http://consumersunion.org/research/consumer-attitudes-toward-health-care-costs-value-and-system-reforms-a-review-of-the-literature/

Health Affairs Blog. “The Time is Now for a Consumer Health Movement.” http://healthaffairs.org/blog/2015/09/03/the-time-is-now-for-a-consumer-health-movement/ Institute for Patient and Family Centered Care- Patient and Family Advisory Committee Toolkit and other resources http://www.ipfcc.org/tools/index.html Maryland Citizens’ Health Initiative Education Fund (“MCHI”)/Health Care for All http://healthcareforall.com/ Maryland Women’s Coalition for Healthcare Reform- Checklists www.mdhealthcarereform.org University of Maryland Extension – Smart Choice for Health Insurance http://extension.umd.edu/insure

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University of Maryland – Horowitz Center for Health Literacy http://sph.umd.edu/center/hchl Urban Institute - Health Literacy http://hrms.urban.org/briefs/Low-Levels-of-Self-Reported-Literacy-and-Numeracy.html

Consumer Outreach Taskforce Report

Maryland Citizens’ Health Initiative Education Fund, Inc.Vincent DeMarcoSeptember 2015

Rationale

Marylanders are unaware of the state’s unique and long-standing status as an all-payer state or of the new state/federal agreement that is further transforming the health system in Maryland.

Consumer engagement in these efforts is crucial to make Maryland’s new system a success.

Task force members

Tresa Ballard, AARPTammy Bresnahan, AARPDarren Brownlee, National Association of Health ServicesCarmela Coyle, MHAVincent DeMarco, MCHIPatrick Dooley, UMMSStan Dorn, Urban InstituteMichaeline Fedder, AHADiane Feeney, HSCRCSandy Ferguson, BWCUMCIsabelle Firth, LifeSpan NetworkHank Greenberg, AARPDr. Dan Hale, JHMIRev. Diane Johnson, Collective Empowerment GroupThressa Lee, MHCCPat Lippold, 1199 SEIUMark Luckner, CHRC

Susan Markey, HCAMBishop Douglas Miles, BUILDFran Phillips, ConsultantLeni Preston, MD Women’s CoalitionThomas Pruski, Health Ministries AssociationLynn Quincy, Consumers UnionSteve Raabe, OpinionWorksDr. Irance ReddixDr. Maura RossmanChaplain Susan Roy, UMMSDavid Simon, MHAGlenn Schneider, Horizon FoundationGerald Stansbury, NAACPTerry Staudenmaier, AbellTiffany Tate, ConsultantNikki Highsmith Vernick, Horizon FoundationRev. Fred Weimert, Central Maryland Ecumenical Council

Forums

Format Welcome from host Presentation by

HSCRC/MHA Local panel of stakeholders Presentation of Faith

Community Health Network concept

Q&A Evaluations

Forums

Number of forums 11

Number ofparticipants

800+

Evaluationresponse rate

42%1

Presenters • HSCRC• Local Health

Improvement Coalitions

• Hospitals and health systems

• Community health providers

• Health Departments • Faith communities • MCHI • Foundations

Attendees • Consumers• Government

agencies • Community groups • Providers/provider

groups

• Hospitals/healthsystems

• Faith-based • Civic organizations • Union Members

Constituents ofAttendees

• Diverse populations/minorities

• Seniors • Low-income

populations • Immigrants • Chronically Ill

• Children • Families • Caregivers • Parishioners • Healthcare

providers and workers

1 Excluding Lower Easter shore, which did not have evaluation forms.

Consumer Feedback

Consumers are eager for more information Timely

Prior to hospitalization

Design phase/launch of care coordination programs

Consistent

Esp. in areas with competing providers

Available in multiple formats

Primary care providers, faith leaders

Traditional news outlets

Social media

Recommendations

Periodically convene stakeholders and consumers to provide updates on the progress of health system transformation

Continue to give consumers a voice in the transformation of Maryland’s health system

Encourage local leaders to develop and join a dynamic Faith Community Health Network

Collaborate to educate primary care providers on—and engage them in—health system transformation

Maximize communications with consumers via traditional and new media

Thank you!

Vincent DeMarco, President

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul StreetBaltimore, MD 21218

Work: 410-235-9000Fax: 410-235-8963

[emailprotected]

A NEW DAY FOR HEALTHCARE IN MARYLAND

HSCRC Consumer Outreach Task Force Report

Maryland Citizens’ Health Initiative Education Fund, Inc.August 2015

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

1

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

2

Executive Summary

As leader of the Health Services Cost Review Commission’s (HSCRC) Consumer Outreach Task Force (Appendix A), over the past seven months the Maryland Citizens’ Health Initiative Education Fund, Inc. (MCHI) has collaborated with Local Health Improvement Coalitions (LHIC), health departments, hospitals, local community and faith leaders, and the Maryland Hospital Association (MHA) to hold eleven public forums all across the state about health system transformation.

Over 800 Marylanders representing over 300 community, health, faith, business, government, union, and policy organizations have heard the message that their local hospitals, healthcare providers, and community-based organizations are working together to help Marylanders be as healthy as possible. Feedback shows that Marylanders are unaware of the state’s unique and long-standing status as an all-payer state or of the new state/federal agreement that is further transforming the health system in Maryland. Once informed, however, consumers are eager to be engaged. They want a clear call to action and follow-up steps for ongoing collaboration.

This report details MCHI’s rationale for the forums and our process, themes in the consumer feedback and our recommendations. We also include region-specific summaries and broad themes for local application and analysis. The recommendations to the HSCRC for continued outreach to consumers are summarized below and described in detail on Page 10 of this report. This guidance is based on our work and on consumer feedback gathered from communities across the state.

Recommendations to the HSCRC for Continued Consumer Outreach

1. Periodically convene stakeholders and consumers to provide updates on the progress of health system transformation

2. Continue to give consumers a voice in the transformation of Maryland’s health system 3. Encourage local leaders to develop and join a dynamic Faith Community Health Network 4. Collaborate to educate primary care providers on—and engage them in—health system

transformation 5. Maximize communications with consumers via traditional and new media

As a leading consumer advocacy organization, MCHI has laid a strong foundation upon which deeper consumer involvement in health system transformation in communities across the state can be built. We are committed to further supporting these efforts as our health care system continues to evolve. We have greatly appreciated the HSCRC’s support of the work detailed in this report and look forward to continuing this fruitful collaboration to ensure that Maryland’s reformed health care system is built upon the needs and interests of all Maryland health care consumers.

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

3

Summary

Number of forums 11 Number of participants 800+ Evaluation response rate 42%1 Presenters • HSCRC

• Local Health Improvement Coalitions

• Hospitals and health systems

• Community health providers

• Health Departments • Faith communities • MCHI • Foundations

Attendees • Consumers • Government agencies • Community groups • Providers/provider groups

• Hospitals/health systems • Faith-based • Civic organizations • Union Members

Constituents of Attendees

• Diverse populations/minorities

• Seniors • Low-income populations • Immigrants • Chronically Ill

• Children • Families • Caregivers • Parishioners • Healthcare providers and

workers

Rationale

Hospitals in Maryland have new incentives to prevent unnecessary hospital admissions and readmissions, and provide even higher quality of care to their patients by strengthening their relationships with their local communities.2 The intended results are better outcomes for patients, healthier people, lower costs, lower health care costs per capita and a health care system that is easier for consumers to navigate. In order to maintain this new system, Maryland must achieve ambitious goals that have been set by the Centers for Medicare and Medicaid Services.

Consumer engagement in these efforts is crucial to make Maryland’s new system a success. During these eleven forums, representatives from the health care delivery system received feedback from health agencies, providers and consumers to help define organizational

1 Excluding Lower Easter shore, which did not have evaluation forms. 2 The new incentives are part of a five-year demonstration project that the state of Maryland and Maryland hospitals entered into with the federal government’s Centers for Medicare and Medicaid Services. This demonstration project is one of a kind in the nation.

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

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priorities, address current problems, and develop and strengthen new relationships. At the same time, consumers and their caregivers learned more about how to understand their newly modified health delivery system and the incentives that it creates to integrate their care. The meetings also addressed how the system is using their feedback for continued quality improvement.

Process

To arrange forums, MCHI collaborated with local health departments and hospitals through LHICs and MHA. We also reached out to our current coalition partners and did more broad-based outreach to local groups. These collaborations were critical to ensure that the forums were tailored to the specific needs of the local communities. We joined existing meetings wherever possible, which resulted in greater participation and allowed us to build relationships with new partners.

To ensure high turnout, MCHI and local partners invited their coalitions and networks through email, social media and phone calls. Outreach to faith communities, vulnerable older adults and their caregivers, and community groups were prioritized. People who expressed an interest in attending were encouraged to share the invitation with others who might be interested. As a result, over 800 people from more than 300 organizations participated. See Appendix B for a full list of organizations.

The most common format for the forums was as follows:

• Welcome by the local host(s) and MCHI; • Presentation on the new Maryland health care landscape by a representative of the

Health Services Cost Review Commission (HSCRC) or MHA;

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

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• Local panel of representatives from hospitals, health departments and/or community organizations;

• Presentation on the Maryland Faith Community Health Network by MCHI and a faith leader often from the Baltimore Washington Conference of the United Methodist Church (BWCUMC);

• Q&A and discussion with the attendees.

Evaluation forms were collected as attendees left. These forms evolved based on feedback from the HSCRC Consumer Engagement Taskforce as each forum was completed. For forums that were integrated into the agendas of LHIC meetings in very rural areas, there were shorter presentations and discussions. Following every forum, participants who provided their email addresses received a link to minutes, agendas, and presentations from the forums.

Region People State presenters

Local presenters

Howard Co. 130 HSCRC, MCHI, BWCUMC

Howard County Local Health Improvement Coalition, Howard County Health Department, Howard County General Hospital, MD Health Care Innovations Collaborative, Horizon Foundation

Prince George's Co.

90 HSCRC, MCHI

Collective Empowerment, Prince George’s Health Department, Dimensions Health Care System, MedStar Southern Maryland Hospital Center

Northern MD 69 HSCRC, MCHI, BWCUMC

Carroll County Health Department, Carroll Hospital Center, Partnership for a Healthier Carroll County

Lower Shore 30 HSCRC, MCHI

Tri County Health Improvement Coalition

Mid Shore 37 MCHI Mid Shore Health Improvement Coalition Southern MD 65 DHMH,

MHA, MCHI, BWCUMC

Health Partners Free Clinic, Charles County Health Department

Western MD 25 HSCRC, MCHI

Cumberland Ministerial Association, Western Maryland Health System, St. John’s Lutheran Church, Western MD Health System, Allegany County Health Department

Baltimore Co. 70 HSCRC, MCHI

Baltimore County Health Department, GBMC, LifeBridge Health, MedStar Health

Montgomery Co.

73 HSCRC, MCHI, BWCUMC

Holy Cross Health, Adventist Health Care, Suburban Hospital, MedStar Montgomery

Anne Arundel Co.

65 HSCRC, MCHI

Anne Arundel County Health Department, University of Maryland Baltimore Washington Medical Center, Anne Arundel Medical Center, United Christian Clergy of Anne Arundel County, Keswick Community Health Services

Baltimore City 160 HSCRC, MCHI, BWCUMC

Bon Secours Hospital, Central Baptist Church of Baltimore, Baltimore City Health Department, Johns Hopkins Bayview Medical Center, MedStar Health, St. Agnes Hospital

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

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Hospitals discussed existing and potential new partnerships with other hospitals and community health providers, many of which were made possible through Community Health Resources Commission (CHRC) grants. The CHRC has prioritized supporting efforts that involve intensive care coordination for at-risk populations and awarded a number of grants that are designed to expand access and help reduce avoidable hospital costs. Several of these grantees, such as Anne Arundel Medical Center, Medstar Union Memorial Hospital, the Allegany County Health Department, and multiple Local Health Improvement Coalitions, spoke at the forums.

Consumer feedback was collected in multiple ways to identify themes from as many participants as possible, including minutes, observations, conversations with attendees and evaluation forms. Minutes are available online and summaries of the evaluation forms were written for forums that utilized them. Although the evaluation form response rate was relatively high at 42%, these forms alone do not form a complete picture. They evolved over time and no testing (e.g. cognitive debriefing) was conducted due to lack of time.

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

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Feedback from Consumers and Local Leaders

Understanding the Health Care System is Empowering

Forum participants overwhelmingly found the information useful and, based on evaluations, had never heard of Maryland’s unique health care landscape before. Participants described health system transformation as a system in which health care providers work together to help keep the public healthy. Consumers and local leaders are willing and ready to take a deeper dive with their local health care providers on how to improve local health systems. It is clear that consumers understand that they have a stake in the success of this major policy experiment and felt empowered by having a voice at these regional discussions. Learning more about what is happening in Maryland left them feeling empowered personally, socially, physically and financially.

Personally and Socially Empowering

While many of the people who participated in the forums have a professional interest in the health and well-being of the community, many acknowledged a personal interest in the success of our unique health care system as well. During discussions, participants were quick to identify community challenges and resources to address social determinants of health, challenges accessing primary care, behavioral health services, culturally and linguistically appropriate services, housing and nutrition. They were excited for new opportunities to form partnerships with hospital systems.

People of faith were intrigued and expressed interest in supporting this work. Faith Community Health Nurses were particularly interested in working with hospitals; they saw themselves as natural allies in building a bridge to the communities a hospital serves. Following the forums many provided their contact information specifically to stay in touch about developing a local Faith Community Health Network.

Physically and Financially Empowering

Hospitals discussed existing and potential new partnerships with other hospitals and community health providers to improve care coordination. Consumers personally responded positively to the idea of broader access to preventive care and new resources in the community

“FAITH COMMUNITY HEALTH NURSES

ARE THERE FOR THEIR CONGREGATIONS

AND THEIR BROADER COMMUNITIES.”

Becky Boeckman, Director of Pastoral Care at First United Methodist Church in Laurel

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that can help them be well and stay healthy. Consumers also appreciated the financial advantages of accessing timely care in their communities rather than stressful and costly ER visits. In the midst of these changes, consumers appreciated learning about the role played by the HSCRC as an independent agency overseeing Maryland’s health system transformation.

Consumers Want More Information

Consumers want more easy-to-understand information about how they can use new health care resources and fully leverage new resources under the demonstration project to preserve their health and save costs. Communication should be timely, consistent and available in a variety of formats from trusted sources. There is a separate HSCRC consumer engagement taskforce working on communication strategies and messages that would help consumers utilize the new system appropriately.

Timely Information

In evaluations, consumers voiced a preference for learning about new developments in health care now and whenever there is a major development or new program from which they might benefit. Many requested follow-up meetings or regular updates over the course of the five-year demonstration project.

Consistent Information

Consumers want information that is consistent and centralized. Consumers in areas where there is great competition among providers were more likely to express feeling overwhelmed by different streams of messaging and less able to take action (an example would be multiple poorly coordinated case managers or care coordinators through different programs working with the same patient). Discussion time in these areas was often used for consumers to clarify what partnerships and programs already existed. As we learned from the experience with the ten rural Total Patient Revenue hospitals (a precursor to the new demonstration project) where local stakeholders collaborate and coordinate consistent messaging, consumers are better able to take part in the work being done at the system level and have more prior awareness of Maryland’s unique health care landscape.

Information Available in a Variety of Formats

There was wide variation in how forum participants preferred to receive information about health system transformation. Many identified their primary care providers and faith leaders as

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an important source of information. These local leaders are therefore important allies, not only in successful implementation of population health programs, but in their roles as trusted

messengers to consumers.

In addition, consumers are very interested in receiving information from a wide variety of other outlets, including social media, websites, TV and radio commercials, public meetings, and their hospitals. In order to meet consumers’ needs, information should be distributed in all of these formats.

“WE ALL NEED TO WORK HARD TO REACH

PATIENTS IN THE WAY THAT WORKS BEST

FOR THEM. THEY CARE ABOUT THEIR

HEALTH.”

Community Health Worker, Baltimore County

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Recommendations

These forums were an exciting and productive first step in engaging consumers in health system transformation. Now state and local organizations can continue this work by collaborating to provide easy-to-understand information that is consistent and available in a wide variety of formats, and to continuously integrate and respond to consumers’ experiences. The unifying message should emphasize that health care providers are working together to keep the public healthy, and that it is empowering to learn how the health care system can help consumers with health and costs. Below are recommendations we believe will build on these forums to make sure the consumer voice is heard in health system transformation in Maryland. Making these recommendations a reality will require additional financial resources. It is anticipated that the recommendations from this task force will combine with the recommendations of the HSCRC’s Consumer Engagement Task Force to provide a comprehensive picture of the current state of consumer outreach and engagement and specific guidance for engaging consumers and creating a health care environment that supports consumers’ full, informed participation in managing their health and health care.

1. Periodically convene stakeholders and consumers to provide updates on the progress of health system transformation

The forums MCHI held across the state have laid the foundation for future consumer outreach and involvement in health system transformation. Consumers value having local forums and want to continue the conversation. It may be helpful to have panels of consumers speak directly about how health system transformation has affected them. MCHI is uniquely positioned to build on this progress and provide the continued consumer input that is necessary to make health system transformation a success in Maryland. MCHI can continue to lead this effort in close partnership with those leaders with whom we co-hosted these forums.

2. Continue to give consumers a voice in the transformation of Maryland’s health system

As the success of the forums demonstrated, MCHI is the right organization to continue giving Maryland consumers a voice in health system transformation. Over 750 faith, community, labor, business and health care groups from across the state are part of our Healthy Maryland Initiative coalition, representing hundreds of thousands of Marylanders of all walks of life. (See list in Appendix C). As we did with the forums, we can reach out to these organizations and other groups throughout Maryland to educate them about what health system transformation means and get their input on how it can work best for Marylanders. MCHI can continue to represent consumer/stakeholder voices on various taskforces, workgroups and committees and maintain and leverage relationships with stakeholders to

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support HSCRC’s outreach and engagement of various consumer groups. MCHI can also commission polling and focus groups to broadly determine public attitudes on health system transformation in Maryland.

3. Encourage local leaders to develop and join a dynamic Faith Community Health Network

At each of our forums consumers expressed strong interest in closer collaboration among local health and faith institutions. The Faith Community Health Network will be piloted this November at LifeBridge Health. MCHI will track and report the network’s impact on population health outcomes to inform similar efforts across the state.

4. Collaborate to educate primary care providers on and engage them in health system transformation

Health care providers, especially primary care providers, will be important partners in making health system transformation a success. Focus groups and information sessions specifically designed for providers may provide valuable insight on how best to engage and mobilize these partners. Because MCHI led a similar effort for consumers and has strong ties with provider organizations such as MedChi and others, we can lead this undertaking.

5. Maximize communications with consumers via traditional and new media

Consumers are eager for more information on health system transformation. MCHI can work with the HSCRC and other key partners through traditional and new media to maximize coverage of local partnerships—such as the Faith Community Health Network—and to raise consumer awareness, utilization of and involvement in these efforts. The HSCRC and MHCC consumer-facing websites are strong tools for centralized communication and call-to-action for consumers. The agencies may also want to consider developing a social media strategy to communicate directly with consumers. This social media campaign could be enhanced through partnerships with MCHI, MHA, and other local organizations that have broad reach through social media, email lists and website publications.

As a part of this communications strategy, MCHI suggests that health delivery systems and providers collect and share stories from consumers about real-life examples of how health system transformation benefits them. Stories humanize programs and provide easy-to-understand information to consumers about how to take care of their health. Stories can be conveyed in any number of different formats (publications, social media, videos, consumer panels, radio ads, etc.), making them useful tools to reach consumers through all available channels.

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Regional Trends and Consumer Feedback Howard County Forum

January 22, 2015 at 8:30AM Oakland Mills Interfaith Center, Columbia

“In the midst of all the national and state policy changes that have led to historic health care

reforms, we’re reminded in Maryland that all health care is local.” – Nikki Highsmith Vernick, The Horizon Foundation

Over 120 participants joined in the forum in January at a meeting convened by the Local Health Improvement Coalition. Local primary care providers were well represented among the group and expressed great interest in deeper collaboration to support local health system transformation under the demonstration project. They also described the impressive impact of having the Community Care Team work with their patients, suggesting that this program be continued or expanded. Faith Community Nurses and other local caregivers are also eager to engage. One neighborhood caregiver relayed a story about several frustrations trying to get the information she needed to help care for ailing neighbors who had identified her as their key caregiver. The CEO of Howard County General Hospital indicated that the hospital is committed to protecting patient privacy, and will be taking a hard look at how to improve their partnerships with outside care providers, both within and beyond the medical field. We congratulate Howard County for their recent award of a Regional Transformation Partnership Grant. The work of the partnership appears to address the feedback from this forum—that local providers and faith community nurses are interested and important allies in achieving the success of the demonstration project, and that the Local Health Improvement Coalition is a great convener. As the efforts advance the regional transformation partnership and related Faith Community Health Network based out of Healthy Howard, MCHI is happy to work with local partners to highlight successes and continue to inform and engage county residents in this important work.

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Prince George’s County Forum February 6, 2015 8:30AM

Sanctuary at Kingdom Square, Capital Heights

Nearly 100 participants attended the forum convened by the Collective Empowerment Group, a powerful faith-based, grassroots organization that is active in the region. There was great interest in the information being shared, since most were hearing about the demonstration project, Health Enterprise Zones and other programs for the first time. Their interest, energy and role as trusted messengers in the county make them important allies in improving public health. In their evaluation forms, they expressed great interest in a follow-up meeting or at least more regular updates on local progress. They also expressed great interest in the possibility of locally implementing the Faith Community Health Network. The great news that the Southern Maryland Coalition for Health System Transformation received funding to support community-based collaboration and planning for regional population health interventions presents an opportunity for deeper engagement with these trusted community leaders. The planning group is currently conducting an inventory of faith based entities in the region and identifying ministries that may be able to better support high need, high cost patients. Engaging these faith leaders in that process will be critical to success. As the efforts advance the regional transformation partnership and related Faith Community Health Network, MCHI is happy to work with local partners to highlight successes and to inform and engage county residents in this important work. In maximizing the impact of these communications, participants recommended featuring more client testimonials to describe program impact rather than just statistics. This approach may be more motivating to the target audience.

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Carroll County Forum February 11, 2015 8:30AM

Carroll Hospital Center, Westminster

“What…do you think the average person would be interested to learn?”

“How important the community is to this process.” “How it is more affordable to be treated outside of the hospital and how the hospital is

helping make health care more affordable.” – Forum Participants

Over 60 local residents participated in the forum. Unlike in other forums, about half were already familiar with Maryland’s unique health care landscape, perhaps because the hospital had entered into this payment structure agreement with HSCRC prior to the statewide roll-out and because many of the participants were already working closely with the health department, hospital and Partnership for a Healthier Carroll County. In the evaluations, there was encouragement to include other community health nonprofits/agencies who are “boots on the ground” serving target populations and delivering care. The group was informed, engaged and eager for ongoing discussion about local developments under the demonstration project. They appreciated the use of client stories in describing the impact of the new approach to health care. A hospital representative described how the hospital helped a family get a better heating system so that the family’s woodstove stopped triggering a child’s asthma. Forum participants suggested engaging the local business community in this work and deepening the scope of community benefits reporting to include social determinants of health, including issues related to homelessness. They also expressed great interest in the Faith Community Health Network. As a direct result of the tremendous community interest expressed at this forum, LifeBridge Health (Carroll, Northwest and Sinai hospitals) will be piloting the Faith Community Health Network. MCHI is thrilled to be working with LifeBridge Health and local faith leaders on this important effort. This region is a great example of strong, dynamic community-hospital partnerships and has much to share with other regions where these relationships may be less developed.

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Lower Shore Forum February 25, 2015 9:00AM

Somerset County Health Department, Westover (No picture available.)

About 30 local residents participated in the Tri-County Local Health Improvement Coalition Meeting which served as the public forum for this region. Unlike other forums, no evaluations were collected due to the meeting format. General sentiment expressed at the forum and in the minutes reflected broad familiarity with the global budgeting due to prior experience with the model prior to statewide roll-out. There was great interest in how this might support better access to mental and behavioral health locally. The region recently was awarded an Opioid Misuse Prevention Grant from the federal government that can support the goals of the demonstration project and vice-versa. There was discussion about the RFP for Regional Transformation Partnerships, but because the eligibility criteria specified minimum population requirements, the participants were disappointed and felt that they would not qualify. The region is doing great work to partner across county lines—something that is often easier said than done. Other systems can benefit from the experience and knowledge gained from the region’s developments under previous global budgets. Additional funding opportunities to address the unique needs and interests of rural communities should be considered.

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Midshore Forum March 9, 2015

Queen Anne’s County Health Department, Centreville

About 40 local residents attended the Mid Shore Health Improvement Coalition meeting that graciously served as the public forum for this region. Based on the evaluations collected, about half of the participants had already heard about the changes under the demonstration project and half had not. The majority of respondents felt that after attending the forum the best way to describe health system transformation in Maryland was that “hospitals, health care providers and community-based organizations would be working together to help Marylanders be as healthy as possible.” They wanted to be more knowledgeable about health care services and options that can improve their health and save costs. Most wanted to get this information from their provider and in follow-up public meetings. They also prefer to get this information immediately, rather than waiting until they are in the hospital or when another program is started. The majority of those who submitted evaluations serve minorities and low-income families. Consumers are eager for more transparency and information about health care services and what they can do to support their own health care. Sharing information via multiple channels, especially via trusted messengers like primary care providers and faith leaders, as well as print and online can help meet consumers where they are and build stronger community partnerships necessary to improve population health. Some consumers expressed concerns about losing their local hospital. Embracing deeper partnerships with the Local Health Improvement Coalition, providers and faith leaders and providing more information about these changes as other regions have done may help address consumers’ concerns.

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Southern Maryland Forum April 20, 2015 6:00PM

St. Charles High School Auditorium, Waldorf

“What is the best way to describe Maryland’s health system transformation?”

“Reducing ER visits by using community resources.”—Forum participant The forum attracted 65 residents from Charles, St. Mary and Calvert Counties, in part thanks to special guest Secretary of Health Van Mitchell and a unique opportunity to view an installment of the AIDS quilt on display in the gymnasium. This was the only forum where no local hospitals chose to participate in a formal role, although many attended and brought their staff. Based on the evaluations collected, about three quarters of the participants learned about the demonstration project for the first time at this forum and they were eager for more information. They expressed interest in “growing more primary care providers” and expanding access to telemedicine. They appreciated knowing that hospitals, healthcare providers and community-based organizations will be working together to help Marylanders be as healthy as possible and that they have new incentives to keep people healthy. They encouraged hospitals to consult “front-line workers” before creating or changing programs. Specifically they encouraged health care providers to enlist the support of Administrative Care Coordination Unit workers in local health departments who often work with vulnerable patients. There was also strong interest in the Faith Community Health Network. Unlike in other regions, the majority of evaluations indicated social media as the preferred source for new information about health system transformation. As the efforts described at the forum progress locally, MCHI can work with local partners to highlight successes and continue to engage county residents in this important work, particularly via our strong social media channels.

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Western Maryland Forum

April 22, 2015 Western Maryland Health Systems, Cumberland 11:00AM

(No picture available.) About 25 people attended this meeting thanks to the Cumberland Ministerial Association and Western Maryland Health Systems graciously opening their regular meeting to the public. Because this region has been operating as a Total Patient Revenue hospital for the past five years, the aim of this forum was to learn about their process and highlight progress. Of those who completed evaluations, most were aware of the unique changes to Maryland’s health system and said that the best way to describe it was that hospitals have an added incentive to keep people healthy. This sentiment was strongly reiterated by the HSCRC presentation as well as the presentation by a local physician on the creation of a new Accountable Care Organization. Consumers and faith leaders were interested in getting more information about this work as soon as new programs are available to them (as opposed to when they are admitted to the hospital). They want to learn about it from their health care providers and other (low-tech) resources. Western Maryland should trumpet its successes. Other health systems can learn a lot by the region’s example engaging community partners and improving population health under global budgets. A pastor and doctor participated in the subsequent meeting of the Cumberland Ministerial Association to discuss the Faith Community Health Network in detail. There may be very fertile ground to create such a network locally. MCHI will be piloting the model with LifeBridge Health with rural, suburban and urban sites this fall and will share lessons learned from this pilot in the spring that may be useful.

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Baltimore County Forum June 2, 2015 8:30AM

Sheppard Pratt Conference Center, Towson

“What can help you have a more active role in your health care?”

“A unified message from partnership groups across hospital systems and government.” –Forum participant

About 70 people participated in the public forum at Sheppard Pratt Conference Center. Of those who completed evaluations, slightly more than three quarters were unfamiliar with Maryland’s unique hospital system prior to attending this forum. They were interested in learning that it creates a system where all health care providers work together to help keep the public healthy, although they stressed the importance of having a unified message across major stakeholders in order to clearly communicate with consumers. They are interested in being more active in and knowledgeable about their own health care, and felt that more easy-to-understand information about their disease or condition would best help them achieve that goal. They most wanted to get updated information about local developments under the demonstration project via local news outlets and social media (as opposed to getting the information from their primary care provider or when they are admitted to the hospital). Faith leaders, community leaders and health care providers alike expressed great interest in the Faith Community Health Network. It was a pleasure working with the Baltimore Local Health Improvement Coalition to host the forum. Continued deep engagement of Baltimore County hospitals in the coalition may help facilitate consistent, clear, easy-to-understand information to and from consumers who can most benefit from the changes under Maryland’s Health System Transformation project. MCHI can help promote communications via earned and social media to ensure that pertinent information is reaching these consumers in the manner they prefer. MCHI is thrilled to be working with Northwest Hospital as a part of the LifeBridge pilot of the Faith Community Health Network this fall.

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Montgomery County Public Forum June 15, 2015 5:00PM

Holy Cross Hospital, Silver Spring

“In Maryland, there are still a lot of disparities. I hope this work will help address those

disparities.” – Rev. Louise Malbon Reddix, forum participant

This forum was unique for several reasons. First, Holy Cross Hospital and the Primary Care Coalition had previously hosted a public forum on this topic. Second, they had just learned that the HSCRC had awarded a $400,000 planning grant for a new collaborative called Nexus Montgomery to help spur collaboration across community partners to improve population health. And finally, both Washington Adventist Hospital and Holy Cross hospitals have long established, strong faith community nursing programs, making the presentation on the faith community health network particularly of interest and leading to strong turn-out among local Faith Community Nurses at the forum. In all, about 70 people attended the forum. Of those who returned evaluations, most had never heard about Maryland’s unique health care landscape or health system transformation before. They appreciated that the demonstration project as described enhances the overall healthcare system by improving the quality of care and reducing costs and they expect to see hospitals, health care providers and community and faith based organizations working together to help Marylanders be as healthy as possible. They would like to be more knowledgeable about healthcare services and options that can help improve their health and save costs, and are interested in serving on advisory boards to help hospitals and the state understand how health system transformation is impacting health care consumers. They also want more easy-to-understand information about their disease or condition and want to get this information (as well as information about local developments under the demonstration project) from their health care provider, when at the hospital, through TV/radio and at public meetings. The unique richness and diversity of this region presents many opportunities as well as challenges in promoting population health. MCHI can help promote awareness of the great work of the Nexus Montgomery project via earned media, collaborating with local primary care providers with MedChi and/or sharing what we learn from our pilot of the Faith Community Health Network with LifeBridge.

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Anne Arundel County Forum June 24, 2015 8:30AM

Rams Head LIVE!, Hanover

“The faith community has and will always have a holistic approach to caring for people and

we look forward to being involved as these partnerships and alignments take shape.” – Bishop Larry Lee Thomas, forum presenter

About 65 people participated in the forum, which was co-hosted with Healthy Anne Arundel as a part of their regular meeting. A majority of these participants had no prior knowledge of Maryland’s unique health system transformation efforts according to collected evaluations. The forum followed the recent announcement of a major grant award from the HSCRC to the Bay Area Transformation Coalition that includes county hospitals, public agencies, nursing homes, clinics and providers. Many local community and faith based organizations were present and volunteered their services to support the goals of health system transformation including programs for the elderly, immigrants and low-income county residents. They appreciated that the demonstration project aims to enhance the overall healthcare system by improving the quality of care and reducing costs. They expect to see hospitals, health care providers and community-based organizations working together to help Marylanders be as healthy as possible. They would like to be more knowledgeable about healthcare services and options that can help improve their health and help save costs and are interested in getting this information from their primary care provider. There is great enthusiasm and interest in ongoing conversations with the community about local developments in health care. Another public forum, perhaps announcing new opportunities under the planning grant or to share its results, may be appropriate. The location for this forum was not ideal due to some significant IT/noise challenges and we can help facilitate another location that may be a better fit for the purpose of the meeting. Specific outreach to primary care providers and faith leaders to engage them as trusted partners and messengers may also be fruitful.

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Baltimore City Forum July 7, 2015 6:00PM

Central Baptist Church, Baltimore

“If you want to go fast, go alone. If you want to go far, go together.” African proverb quoted

by Dr. Sam Ross, Bon Secours CEO

This was the final forum and was standing-room-only with over 160 participants. Like prior forums, it was co-hosted as a part of a regular quarterly series of public forums that Bon Secours Hospital convenes. Many participants were local community residents affiliated with the church and neighborhood that hosted the event. Others were partners from the Health Enterprise Zone initiative and other related efforts, as well as members of MCHI’s Health Care for All! Coalition from across Baltimore. There was significant discussion of social determinants of health, perhaps owing to recent unrest in the area. Based on the evaluations that were collected, we learned that 81% of respondents had never heard about the demonstration project or Maryland’s unique hospital system before. They felt the best way to describe it was that it creates a system where all health care providers work together to keep the public healthy and that it enhances the overall healthcare system by improving the quality of care and reducing costs. They saw it as an opportunity to “address root causes of health disparities by addressing social determinants of health.” They expressed concerns about costs, especially for prescription drugs. They’re eager for more information and want to get that information from their health care provider. The Faith Community Health Network received a tremendously positive response. Congratulations on the successful awards for regional transformation partnerships that have been awarded in this region! The goal to share lessons learned and resources across hospitals to promote population health and reduce avoidable utilization holds tremendous promise, as the region’s hospitals all have much to share and learn. MCHI’s coalition can be an ally in engaging and sharing information with trusted messengers. We will be piloting the Faith Community Health Network with LifeBridge Health and local faith leaders this fall and hope to eventually expand to other interested institutions.

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Special Thanks

These forums would not have been possible without the tremendous support from the HSCRC, our coalition and our funders. Thank you to all of those individuals and organizations who share our commitment to strengthening consumer voices to improve consumers’ access to quality affordable health care. Below are those who were integral to the success of this effort.

Individuals: Dr. Dianna Abney Matey Barker Dr. Gregory Branch Barbra Brookmeyer Judith Carmichael Dr. Jinlene Chan Annice Cody Renee Cohen John Colmers Dr. Darnell Cooper Carmela Coyle Christine Crabbs Pam Creekmur Danielle DaSilva Lesa Diehl Cheri Ebaugh Nancy Forlifer Dorothy Fox Patrick Garrett Dr. Rohit Gulati Darcy Haldeman Dr. Dan Hale Joyce Hendrick Kathleen Imhoff

Tricia Isennock Rev. Dianne Johnson Rev. Manfred Kaseman Kevin Kelby Dr. Niharika Khanna Donna Kinzer Heather Kirby Jennifer LaMade Bill Lebold Della Leister Beverly Lofton Mark Luckner Rev. Anthony Maclin Susan Markley Michele Martz Sec. Van Mitchell Pastor Rodney Morton Chrisie Mulcahy Andi Mullin Patrick Mutch Karen Olscamp Becky Paesch Steve Ports Leni Preston

Dr. Irance Reddix Barb Rodgers David Romans Dr. Sam Ross Dr. Maura Rossman, Robert Rothstein Sharon Sanders T.J. Senker Kevin Sexton Glenn Schneider Rabbi Stephen Sniderman Steve Snelgrove Dr. Leeland Spencer Tormod Svensson Novella Tascoe Tiffany Tate Dr. Henry Taylor Bishop Larry Lee Thomas Nikki Highsmith Vernick Gary Vogan Dr. Leana Wen Paula Widerlite Darleen Won Ms. Cristine Wray

Organizations: 1199SEIU, AARP, Baltimore County Health Department/Baltimore County Health Coalition, Bon Secours Health System, Central Baptist Church, Charles County Health Department, Collective Empowerment Group, Community Catalyst, Community Health Resources Commission, Cumberland Ministerial Alliance, Healthy Anne Arundel, Holy Cross Hospital, Howard County Local Health Improvement Coalition, Mid-Shore Health Improvement Coalition, NAACP, NAMI, Nexus Montgomery, Partnership for a Healthier Carroll County, Tri-County Health Improvement Coalition Funders: Community Catalyst ACA Implementation Fund, Consumer Health Foundation, Horizon Foundation, Jacob and Hilda Blaustein Foundation

Staff: Vincent DeMarco, Matthew Celentano, Stephanie Klapper and Suzanne Schlattman

Interns: Sara Philippe, Jack Sheehy, Abeer Hamid, Kelleigh Eastman

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Appendix A – List of Consumer Outreach Taskforce members

Appendix B – List of organizations represented at regional forums

Appendix C – List of Healthy Maryland Initiative Coalition members

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Appendix A

HSCRC Consumer Outreach Taskforce Members

Tresa Ballard Communications Director, AARP Maryland

Tammy Bresnahan Associate State Director of Advocacy, AARP Maryland

Darren Brownlee President, National Association of Health Services, Baltimore Chapter

Carmela Coyle President & CEO, Maryland Hospital Association

Vinny DeMarco President, Health Care for All

Patrick Dooley University of Maryland Medical System

Stan Dorn Senior Fellow, Urban Institute

Michaeline Fedder

Government Relations Director, American Heart Association

Diane Feeney Health Services Cost Review Commission

Sandy Ferguson Dir. Social Justice & Missions, Balt-Wash Conference of The United Methodist Church

Isabelle Firth President, LifeSpan Network

Hank Greenberg State Director, AARP, Maryland

Dr. Dan Hale Special Advisor, Office of the President Johns Hopkins Bayview

Rev. Diane Johnson Collective Empowerment Group

Theressa Lee Maryland Health Care Commission

Pat Lippold Vice President for Political Action, 1199 SEIU United Health Care Workers East

Mark Luckner Executive Director, Community Health Resources Commission

Susan Markley Vice President of Business Development, HealthCare Access Maryland

Bishop Douglas Miles Co-Chairman, BUILD

Fran Phillips Consultant, Community Health Resources Commission

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Leni Preston Chair, Maryland Women's Coalition for Health Care Reform

Thomas Pruski Director, Health Ministries Association

Lynn Quincy Assistant Director Health Policy Reform, Consumers Union

Steve Raabe Founder and President, OpinionWorks

Reverend Irance Reddix Pastor, St. John's United Methodist Church

Dr. Maura Rossman Health Officer, Howard County Health Department

Susan Roy Director of Chaplain Services, University of Maryland Medical System

David Simon Senior Writer, Maryland Hospital Association

Glenn Schneider Chief Program Officer, Horizon Foundation

Gerald Stansbury President, NAACP, Maryland

Terry Staudenmaier Program Officer, Abell Foundation

Tiffany Tate Consultant

Nikki Highsmith Vernick President & CEO, Horizon Foundation

Reverend Fred Weimert Pastor, Central Maryland Ecumenical Council

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Appendix B

Organizations Represented at Regional Forums

Howard County Amerigroup Corporation Anne Arundel, Howard, and Prince

George’s County Medical Societies

Association of Community Services Baha’i Community Baltimore Washington Conference,

United Methodist Church (BWCUMC)

British American Auto Care Build Haiti Foundation Calvary/Centennial Memorial

United Methodist Centennial Medical Group Chase Brexton Health Services City of Baltimore Health

Department Columbia Assn. Sr. Advisory Columbia Association Columbia Medical Practice Columbia Presbyterian Delta Sigma Thea Dorsey Emmanual United

Methodist Church Evergreen Health Care Family & Nursing Care First UMC Laurel HC Drug Free HCCA Health Promotion on Call Healthy Howard Horizon Foundation Howard Community College Howard County Citizens Association Howard County Dental Association Howard County Department of

Citizen Services Howard County DSS Howard County Health Department Howard County Local Health

Improvement Coalition Howard County Mental Health

Authority Howard County NAACP Howard County Public School

System Johns Hopkins Judy Center Partnership Long and Foster Realtors Maryland DHMH Maryland Hunger Solutions Maryland Pediatrics

Maryland University of Integrative Health

Meals on Wheels of Central MD MHCC PATH Primary Care Coalition of

Montgomery County PRJ The ARC Howard County Transition Howard County Unitarian Universalist Congregation

of Columbia Walgreens We Promote Health Well Being Medical Care Wesley Theological Seminary Prince George’s County A CTIS, Program American Cancer Society Cancer

Action Network, Inc. AMERIGROUP Antioch Baptist Church of Clinton Assembly of Petworth Baltimore Washington Conference,

United Methodist Church Behavioral Health Navigators

Center, Inc. University of Maryland School of

Medicine & Shock Trauma Center Collective Empowerment Group

(representatives from many faith communities)

Dimensions Healthcare System DIO and Vice President of Medical

Affairs, Prince George's Hospital Center

Edward E. Smith & Associates Family Services, Inc. Government Affairs Health Insurance Commission Healthy Kinder, Inc Heart to Hand, Inc. March of Dimes Maryland Insurance Administration

Consumer Education and Advocacy Unit

MD Women's Coalition for Health Care Reform

MedStar Health NAACP of Prince George's County NAMI Prince George's County Office of Prince George’s County

Executive Rushern L. Baker, III

Prince George's County Council Prince George's County Department

of Social Services Priority Partners of Johns Hopkins Regulatory Compliance

Government Affairs Seabury Resources for Aging Northern MD Access Carroll, Inc. Asian American Center of Frederick BWCUMC Caring Carroll Carrol County Health Department Carroll County Commission of Aging

and Disabilities Carroll County Public Schools

Student Services Department Carroll Hospital Center Frederick Community Action

Agency Frederick County Health

Department Frederick Regional Health System Gale Recovery, Inc. Gaudenzia Get Connected Family Resource

Center Health Care is a Human Right MD

Frederick County Maryland Women’s Coalition for

Health Reform MD DHMH Mental Health Association of

Frederick County Mission of Mercy NAMI Carroll County Partnership for Healthier Carroll

County UMCC University of Maryland School of

Nursing Office of Environmental Health

VHQC Lower Eastern Shore Choptank Community Health

Systems Crisfield Clinic McCready Memorial Hospital Amerigroup Somerset County Health

Department

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

28

Wicomico County Health Department

Worcester County Health Department

Mid Shore Associated Black Charities-

Dorchester County Caroline and Kent County Health

Departments Choptank Community Health

Systems Crossroads Community, Inc Eastern Shore Area Health

Education Mid Shore Health Improvement

Coalition Mid Shore Mental Health Services Queen Anne County Health

Department Regional Opioid Misuse Prevent

Grant Group Shore Health Systems Southern MD University of Maryland Charles

Regional Medical Center 1199 SEIU American Red Cross Angel's Watch Shelter BWCUMC Calvert County Branch of the

NAACP Calvert Memorial Hospital Catholic Charities - Angel's Watch

Shelter Center for Children, Inc. Charles County Department of

Health Charles County Dept of Community

Services Charles County Freedom Landing Charles County Branch of NAACP Charlotte Hall Veterans Home Community Catalyst DHMH Free Gospel Church of Bryan’s Road Greater Baden Medical Services, Inc Health Partners, Inc. Healthcare Solutions Hospice of Charles County, Inc. Journey of Faith Church in Waldorf Kadie Pro Health Maryland Rural Health Association Maryland Hospital Association Maryland Women’s Coalition for

Health Reform

Missionary Baptist Church and House to House Bible Ministries

NAMI Southern Maryland Radiance Health Services Senator Cardin's office SMTCCAC Inc. Head Start Spring Dell Center, Inc St. Charles High School St. Mary's Adult Medical Day Care St. Mary's County Health

Department The Gospel Church of Bryans Road UM CRMC University of Maryland Charles

Regional Medical Center University of Maryland Extension-

Charles County Working out Wonders, Inc. Western MD A D Naylor & CO, INC Allegany County Health

Department Cumberland Ministerial Association Centenary/Zion United Methodist

Churches Healthy Howard NAACP Rural Area Enrollment Network Tri-State Community Health Center United Way Western MD Health System Baltimore County 1199 SEIU Adult Evaluation and Review

Services Alpha&Omega Counseling

Consultation Svcs. LLC Anthem, Inc. Baltimore County DHHS Baltimore County Department of

Health- Behavioral Health Baltimore County Department of

Planning Baltimore County DSS Baltimore County Executive Office Baltimore County Medical

Association Baltimore County NAACP Baltimore County Public Libraries Board of Child Care BWCUMC Carroll Hospital Center Chase Brexton College of Health Professions

Communicable Disease Control Baltimore County Department of Health

Delegate Clarence Lam Diane Kretzschmar's parish nurse

support group Empowerment Temple's Health and

Wellness Ministry Family Health Center Friendship Baptist Church GBMC HealthCare System Gilchrist Hospice Good Shepherd United Methodist

Church Heal the Sick Program LifeBridge Health Lochearn Improvement Association Lutherville Community Association Maryland Academy of Family

Physicians Family Health Center Maryland Health Connection Maryland Legislature Maryland Rural Health Association Maryland State Advisory Council on

Physical Fitness MD Logix MDCCC AmeriCorps VISTA MedStar Franklin Square Medical

Center New All Saints Church-Health

Committee Northwest Hospital Office of Senator Ben Cardin Ombudsman Program Baltimore

County Department of Aging Planning and Administration,

Baltimore County Department of Planning

Priority Partners Progressive Health Group Inc Prologue Inc Riverside Health Sacred Heart Parish Sinai/Northwest Hospital St. Clare Medical Outreach St. Johns Methodist Church Stella Maris Hospice and HomeCare Stella Maris Senior Day Center Stephens OMT, Inc. University of Maryland School of

Medicine Department of Epidemiology and Public Health

Wesley Theological Seminary White Oak Health Care Y of Central Maryland Montgomery County AAUW, Holy Cross

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

29

Adventist Health Care Adventist HealthCare from the

Center for Health Equity and Wellness

Advocates for Children and Youth African American Health Program

of Mont. Co. American Cancer Society, Inc. Baltimore City League of Women

Voters Brooke Grove Foundation Brooke Grove Retirement CASA Catholic Charities Center for Public & Nonprofit

Leadership Collingswood Nursing and

Rehabilitation Center Emmanuel Brinklow SDA Church Georgetown University Glen Ridge SDA Church Health Programs Delivery Help Africa Inc. Holy Cross Health Homeless Services Institute for Public Health

Innovation, MC DHHS Interfaith Community Liaison for

Montgomery County Interfaith Works McInnis & Associates Consulting,

LLC MD Women's Health Coalition MedStar Montgomery Medical

Center Montgomery County DHHS Montgomery Health Care Action NAACP Montgomery County NAMI Montgomery County NMS Healthcare OFA Primary Care Coalition of

Montgomery County River Road Unitarian Church RRUUC St Francis of Assisi RC Church St. Francis of Assisi Parish St. Johns United Methodist Church Suburban Hospital Universalist Unitarian Wesley Seminary Maryland Women’s Coalition for

Health Reform

Anne Arundel County 2-1-1 Maryland/United Way

Helpline AAMC AMERIGROUP - Provider Solution Amerigroup Community Care Anne Arundel County Department

of Aging and Disabilities Anne Arundel County Department

of Health Anne Arundel County Health Officer Anne Arundel County Mental

Health Agency Anne Arundel Medical Center Asbury Broadneck United

Methodist Church Baltimore Washington Medical

Center BWMC DeCesaris Cancer Center First UM Laurel Greater Annapolis Family Center Y Health Policy Research Consortium IMAGE Center of Maryland Keswick Community Health Services Maryland Department of Aging Maryland Naturopathic Doctors

Association Medi Rents and Sales MedStar Family Choice MHAMD Mount Olive AME Church NAACP New Life Fellowship Int. Ministries OFA Office of Councilman Andrew C.

Pruski Office of County Executive Steven

R. Schuh Office of U.S. Senator Ben Cardin Owensville Primary Care Pathways Reilly Benefits, Inc. Sarah's House Seeds 4 Success Spencerville Adventist Church St Anne's Episcopal Parish Student Services, AACPS United Healthcare United Methodist Men United Way of Central Maryland University of Maryland Baltimore

Washington Medical Center

Y of Central Maryland Baltimore City 1199 SEIU Advocates for Children and Youth Adrian Harpool Associates All Saints Church Attorney General Office Baltimore Alliance for Careers in

Healthcare Baltimore City Council Baltimore City Cancer Program Baltimore City Health Department Behavioral Health System Baltimore Bon Secours Health System CARA plans Central Baptist Church DHMH Enoch Pratt/Families USA Bound FSO, Inc God's Church HPRC A CTIS Program Job Opportunities Task Force Johns Hopkins Bayview Medical

Center Johns Hopkins School of Public

Health Johnson & Johnson LifeBridge Health Matthew A. Henson Neighborhood

Association Maryland Environmental Health

Network Maryland Health Connection MD General Assembly MDCCC AmeriCorps VISTA Medstar Health NAACP Cecil County NAACP Maryland New Saint Mark Baptist Church Recovery in Community Sen. Ben Cardin's office Seniors Helping Seniors St. Agnes Hospital St. John AME Church St. Johns Methodist Church Timothy Baptist Church UMB\Southwest Partnership Union Memorial Hospital United Way of Central MD UMMC Midtown Campus WBC Community Development

Corporation

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

30

Appendix C

MCHI’s Healthy Maryland Initiative Coalition Members June 5, 2015 – 760 Endorsers

Statewide and Regional 1199 SEIU United Health

Care Workers East AARP Maryland Abilities Network Action on Smoking and

Health (ASH) Advocates for Children and

Youth American Academy of

Family Physicians American Academy of

Pediatrics, Maryland Chapter

American Baptist Churches - South

American Cancer Society – South Atlantic Division

American College of Physicians, Maryland Chapter

American Federation of Teachers - Maryland

American Heart Association

American Jewish Congress, Maryland Chapter

American Lung Association of Maryland

American Minority Contractors’ Association, Inc.

Asian American Anti-Smoking Foundation

Baltimore Healthy Start, Inc. Baltimore Intersection Baltimore Jewish Council Baltimore Medical System Baltimore Washington

Conference Board of Church & Society

Baltimore Washington Conference of the United Methodist Church

Baltimoreans United In Leadership Development (B.U.I.L.D.)

Baptist Deacons Conference of Baltimore

Baptist Ministers Conference of Baltimore

Campaign for Tobacco Free Kids

Cancer Support Foundation, Inc. CASA de Maryland Central Atlantic Conference

of the United Church of Christ

Central Maryland Ecumenical Council Chesapeake Climate Action

Network Chesapeake Quarterly

Meeting – Religious Society of Friends (Quakers)

Church Women United in Maryland – Executive Council

Coalition for a Healthy Maryland

Collective Empowerment Group, Inc.

Columbia Union Conference of the Seventh-day Adventist Church

Community Behavioral Health Association of Maryland

Community Health Integrated Partnership

Delaware Maryland Synod, Evangelical Lutheran Church in America

Ecumenical Leaders Group (ELG)

Emmanuel Episcopal Diocese of

Maryland Episcopal Diocese of

Washington Friends of Lower

Beaverdam Creek Funeral Directors and

Morticians Association of Maryland

Greater Baden Medical Services, Inc.

Greater Baltimore Urban League Habitat for Humanity of

the Chesapeake Health Care Access

Maryland Health Care for the

Homeless Institutes for Behavioral

Resources, Inc. Interdenominational

Ministerial Alliance

Interfaith Works Jewish Community

Relations Council Johns Hopkins Pediatric

Liver Center Latino Providers Network Lili Amsel Children’s

Foundation March of Dimes, MD

National Capital Area Chapter

Maryland Academy of Family Physicians

Maryland Assembly on School-Based Health Care

Maryland Association of County Health Officers

Maryland Association of Student Councils

Maryland Citizens Against State Executions

Maryland Consumer Rights Coalition

Maryland Dental Hygienists’ Association

Maryland Environmental Health Network

Maryland Federation of Chapters, National Active and Retired Federal Employees’ Association (NARFE)

Maryland Group Against Smoker’s Pollution

Maryland Healthy Eating and Active Lifestyle Coalition (HEAL)

Maryland Hospital Association

Maryland Legislative Agenda for Women

Maryland Multicultural Youth Centers

Maryland Non-Profits Maryland Nurses

Association Maryland PIRG Maryland Public Health

Association Maryland Rural Health

Association Maryland State Conference

NAACP Maryland State Education

Association Maryland/District of

Columbia Society For Respiratory Care

Mautner Project: The National Lesbian Health Organization

MedChi, The Maryland State Medical Society

Medicaid Matters! Mid-Atlantic Association of

Community Health Centers

Mid-Atlantic P.A.N.D.A. (Prevent Abuse & Neglect through Dental Awareness)

Morgan State University School of Community Health and Policy

NAMI Lower Shore NAMI Maryland NAMI Metropolitan

Baltimore NAMI Southern Maryland National Action Network –

Greater Baltimore Chapter

National Association of Social Workers – Maryland Chapter

National Congress of Black Women – Greater Baltimore Chapter

National Council on Alcoholism &Drug Dependence – Maryland Chapter

National Society of Pershing Rifles Alumni Association

National Tobacco Independence Campaign

Nurse Practitioners Association of Maryland

Oncology Nursing Society Organizing for Action

Maryland Pan African Collective Pastors’ Conference of

Baltimore People Encouraging People Planned Parenthood of

Maryland Presbytery of Baltimore Progressive Baptist

Convention of Maryland

Progressive Maryland Pure Potential Enterprises R.E.S.P.E.C.T.

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

31

REACH Safe and Sound Campaign SEIU Local 400 SEIU Maryland/DC State

Council Top Ladies of Distinction UFCW Local 400 Unitarian Universalist

Legislative Ministry of Maryland

United Baptist Missionary Convention

United Christian Clergy Alliance

United Council of Christian Community Churches of Maryland

United Seniors of Maryland Women Accepting

Responsibility Women’s Suburban

Democratic Club Anne Arundel County Abby Bay Designs All In His Hands Barbershop Annapolis Book Store Annapolis Ice Cream Annapolis

Interdenominational Ministerial Alliance

Annapolis Post Box, Inc. Annapolis Running Shop Anne Arundel County

Medical Society Anne Arundel Medical

Center Care Management

Asbury Broadneck United Methodist Church

Asbury Town Neck United Methodist Church

Asbury United Methodist Church

Aurora Gallery BE Home Beefalo Bob’s The Big Cheese Blue Crab Antiques Cager Counseling Service Caspersen Floral Design Chez Amis Bed & Breakfast Classy Image Creative Impressions Deliverance Temple

Sanctuary Ministries Dr. Saad Kuwanja Medical Practice Dream Helpers Global Mission Emmanuel Temple of Praise Empowering Believers Church Eyes on Main First Lady’s Salon

Fresh Start Church Fun of All! Tours Girl Scouts Troop 61 Granny Family Care Hands of Hope Iglesia Misionera Masque

Vencedora Band In His Hands Ministry It’s Just That Good James B. Hyman, PHO, Inc. Jeanie’s Salon & Day Spa,

Inc. Jesus Love Temple John Wesley United

Methodist Church of Glen Burnie

Judah Temple Ministries Kingdom Celebration

Center Kingdom Life Church Lifegate Chapel Light of the World Light of the World Family

Ministries Madison Boutique Magothy United Methodist

Church of the Deaf Margaret Johnson Mary

Kay Beauty Mary & Blanche! Matrix Design Build McNeill’s Day Care Men 2 Men Metropolitan United

Methodist Church Mount Olive African

Methodist Episcopal Church

Mount Zion United Methodist Church

Mount Zion United Methodist Church - Magothy

MRT, LLC Ms. Granny’s Family Child Care My Body Count NAACP – Anne Arundel

County Branch NAMI Anne Arundel

County Nano Natalie Silitch Folk Art New Hope Sabbath

Christian Center New Life Fellowship New Pslamist Church NLACS Oliver’s One Accord Apostolic

Church Opportunities

Industrialization Center of Anne Arundel County, Inc.

Owensville Primary Care, Inc.

The Pink Crab Potomac Physicians Rejoice TV re:Source Return to Oz Consignments Rhena Word Worship &

Praise Center Richardson Trucking, LLC Rose of Sharon Church Saint Matthew’s United

Methodist Church Scittino’s Groceries &

Meats Servants Ministry, Inc. Severn School Student

Council Shear Bella Beauty Salon Silas First Baptist of

Severna Park Smoke Free Holy Ground Stevens Hardware Straight Way Apostolic

Temple Suzanne’s Florist, Inc. Tammy Loves Us, Inc. Treasure Island Union Memorial United

Methodist Church The Pizza Shop, Inc. The Unknown Artist Viet-Thai Paradise

Restaurant Vivo! Wayman Good Hope

A.M.E. Church Baltimore City AARP 4636 The ANA Group, LLC Antioch Ever Increasing

Faith International Church, Inc.

Apostolic Ministerial Alliance, Inc. Arcadia Improvement Association Ark Church Austin Consulting Baltimore City Council Baltimore City Young Democrats Baltimore Ethical Society Baltimore Medical System, Inc. Baptist Ministers Night Conference Berean Baptist Church Big Brothers Big Sisters of the Greater Chesapeake Black CORDZ Barbershop Bmore Fit Body Posse, LLC Bolton Street Synagogue

Brown, Goldstein & Levy, LLP Brown Memorial Park

Avenue Presbyterian Church

BUILD Fellowship - Tabitha’s House Cadet Martial Arts & Fitness Callegary & Steedman, P.A. Canaan Missionary Baptist

Church Charm City Clinic, Inc. Chase-Brexton Health

Services, Inc. Chemical People Task

Force of Cherry Hill Child First Authority, Inc. Christian Community Church of God Church of the Holy Nativity City Temple of Baltimore Community Assistance Network Concord Baptist Church Cookie Lee Jewelry Destiny Baptist Church Dream Hair Lounge Dynamic Deliverance

Cathedral Eastern Technical High

School Student Council First Apostolic Faith Gospel

Tabernacle First Mount Carmel Christian Community

Church Freedom Temple AME Zion Church Friendship Baptist Church From Bankruptcy to Bounty Worldwide Ministries Garden of Prayer Baptist Church Gateway to Beauty Gennuso Barber Shop Gethsemane African

Methodist Episcopal Church

Gillis Memorial Christian Community Church

God’s Grace Apostolic Faith God’s Women of Promise,

Inc. Gordon’s Florist Govans Ecumenical

Development Corporation

Greater Bethlehem Temple Greater Homewood Interfaith Alliance Greater St. John Baptist Church Greater St. Peter Church of God

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

32

Harbor Pediatrics Highrock Baptist Church Historic Saint Paul

Community Baptist Church

Holy Comforter Lutheran Church

Holy Rock Christian Community Church

Homebody Fitness Homewood Friends

Meeting Hope Community

Ministries Hopkins United Methodist

Church HR Construction Hunting Ridge Presbyterian

Church Infinite Biomedical

Technologies, LLC Interfaith Association of

Roland Park The Intersection Intrepid Foundation for

Urban Youth Empowerment

Joan Carpenter - Mary Kay KBC Fanci Fixins Kerygma Ministries Kidz Nite Inn King’s Landing Women’s Service Club Koinonia Baptist Church Koinonia Baptist Daycare Lake Evesham Community Association Lewis Grocery Lin’s Loving Care Assisted Living Livingston Construction Mandarin Taste Maryland Group Faculty Practice Memorial Baptist Church Men and Families Center Messiah Lutheran Church Midtown Edmondson

Avenue Improvement Association

Missey’s Desserts Mount Lebanon Baptist Church Mount Olive Holy Evangelist Church Mount Sinai Baptist Church Muslim Community

Cultural Center of Baltimore

NAACP – Baltimore City Branch NAACP – Baltimore City

Health Committee New All Saints Catholic Church

New Antioch Baptist Church New Christian Memorial Church New Faith Deliverance New Hope Baptist Church New Joy Church and Ministry New Life Kingdom Ministry New Light A.M.E. Zion Church New Pleasant Grove

Missionary Baptist Church

Northeast Community Organization (NECO)

Old Goucher Business Alliance

Park Heights Community Health Alliance

People’s Community Health Centers, Inc.

Perkins Square Baptist Church

Phi Beta Sigma Fraternity, Inc.

Pilgrim Temple Church, Inc. Prince of Peace Baptist

Church Progressive First Baptist

Church Project PLASE (People

Lacking Ample Shelter and Employment)

Project Safe Haven Rehoboth Church of God in Christ Refuge of the Cross Church of Christ Restoration Community Church Resurrection Ministry Save Another Youth, Inc. SBC Outreach Sharon Bond - Avon Shiloh Christian Community Church Sisters Together and Reaching, Inc. Small Office Solutions Snoball Hut Some New Creations Souls for Christ Spanner In the Works, LLC St. Edward Roman Catholic

Church St. Elizabeth of Hungary

Roman Catholic Church St. Joseph Freewill Baptist

Church St. Matthew Church St. Matthew’s Gospel

Tabernacle Church St. Matthew’s New Life

United Methodist Church

St. Vincent de Paul Church – Peace & Justice Committee

Stony Run Friends Meeting Stop the Violence Coalition Tastefully Simple Techs 4IT, Inc. The Children’s Mission, Inc. The Holy One of Israel Ministries, Inc. The Lord’s Church The Lord’s Church

Ministries The New Good Samaritan

Baptist Church Time Printers Total Health Care, Inc. Traffic Managers, Inc. Treatment Resources for Youth, Inc. Trinity Baptist Church Trinity Baptist Church – Health Ministry Union Baptist Church Union Baptist Head Start Victory Missionary Baptist Church Village Baptist Church Will’s Barbershop Wilson Park Christian

Community Church Winston Avenue Baptist Church Zion Baptist Church Zion Baptist Church of Christ Baltimore and Harford Counties A Better Way Against the Grain All American Tag & Title ASAS Asbury United Methodist Church At Event Planning Atwaters Awaken the Spirit Wellness Baltimore County Medical Association Baltimore County Young Democrats Baltimore Network of the

Esimorp Coalition Bodyworks Tannery Business Plans, LLC Café Di Roma Caton Auto Clinic Caton Auto Clinic Fleet Center Caton Auto Clinic Maintenance Shop Catonsville Car Center Catonsville Chamber of Commerce

Catonsville Custom Framing Children’s Home Athletic Department Constellation Design Group, Inc. Dealysa Agency Diane’s Dinette Dings N Things Doris’ Closet Consignment Douggie’s Downtown Massage Therapists Dr. David Hoffman Dental Practice Dr. Neeraj Verma Medical Practice Dundalk Pediatric Associates Empowerment Temple Floor Matt, LLC Glencoe Auto Goody’s Folkart Hairoglyphics Halethorpe Liquors Hamis Yoga Harford County Regional

Association of Student Councils

Head Graphics Hill’s Car Service Holy Comforter Lutheran Indiana Floor, Inc. IRC, Inc. Isaiah Baptist Church Iskcon Baltimore Larry Goodwin & the Divine Shepherds Larry’s Quality Cuts Lee Myles Transmissions Lemon Meringue Thrift & Gift Lighthouse, Inc. Lily’s Bridal McDonals Michael A. Zwaig, PA NAACP – Baltimore County Branch NAACP – Harford County Branch NAMI Harford County NARFE Chapter 1936 New Harford Democratic Club New Life Fellowship New Royal Baptist Church Objects Found Oella Physical Therapy Park Moving and Storage, Inc. Park School Student Senate The Parks Agency Peason Travel Service Performance Collision Renewed Hope Church Robinson Consulting

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

33

The Session of Brown Memorial Woodbrook Presbyterian Church

Shulman & Associates, Inc. Sigman & Summerfield

Association, Inc. Sister’s Treasures Southwest Baltimore County Democrat Club Speed’s Cycle Staub Art Studio Timothy Taylor Homes Services, Inc. Towson Unitarian Universalist Church Towson University Wellness Center Traci Lynn Fashion Jewlery TRG Networking, Inc. Trucking & Transportation, Inc. Village Elders Senior Shopping Service Eastern Shore (Caroline, Cecil, Dorchester, Kent, Queen Anne’s, Somerset, Talbot, Wicimico, Worcester Counties) Alpha Cleaning Systems Associated Black Charities

of Cambridge Brooklett’s Place Talbot

Senior Center Cambridge Church of Christ Family Care of Easton, LLD Family & Friends of Asbury

& Green Chapel, Inc. Great Event Planners Kent County High School

Student Government Association

Mount Zoar AME Church NAACP – Caroline County

Branch NAACP – Cecil County

Branch NAACP – Dorchester

County Branch NAACP –Kent County

Branch NAACP – Queen Anne’s

County Branch NAACP – Somerset County

Branch NAACP – Talbot County

Branch NAACP – Wicomico County

Branch #7028 NAACP –Worcester County

Branch NAMI Cecil County New St. John’s United

Methodist Church

Samuel T. Hensley Elks Lodge #974

Scott’s United Methodist Church

Talbot County Democratic Forum

Talbot County Democratic Women’s Club

Talbot County Health Department

Talbot Partnership for Alcohol and Other Drug Abuse Prevention

Upper Shore Aging, Inc. West Cecil Health Center, Inc. Wicomico County Medical Society Wicomico Neighborhood Congress Frederick County Asian American Center of

Frederick Frederick County Medical

Society Frederick Keys Baseball

Club Mental Health Association

of Frederick County NAACP – Frederick County Branch NAMI Frederick County Opal Ridge Dental Smoke Free Maryland

Coalition – Frederick County

Women’s Democratic League of Frederick County

Unitarian Universalist Congregation of Frederick – Social and Environmental Just ice Committee

United Democrats of Frederick County

Howard County American Renal Ardinger Consultants &

Associates (ACA) Artists and Frames Association of Community

Services Bethany United Methodist Church British American Auto Care, Inc. Child Health Foundation Columbia Church of God in

Christ Columbia Democratic Club

Columbia Personal Trainer Charlotte Lysic

Elite SFN Ellicott City Dialysis Emilia’s Acrobatics

Gymnastics and Cheerleading

Emory United Methodist Church

Excel Cleaners Fit and Healthy You with

Dr. Ali Fox’s Firearms Genesis Arts, LLC Granite Tutorial Grassroots Crisis

Intervention Center, Inc.

Healthy Howard Howard County Association

of Student Councils Howard County Cancer and

Tobacco Coalition Howard County Medical

Society Howard County Student

Government Association

James Ferry Photography Kernal Mission Church Kristie’s Salon and Barber Kyoto Day Spa Let There be Rock Schools Lights Out Gym Lord is My Shepard Baptist

Church M.L. Smith Electric, Inc. Moving by Faith Cleaning

Service, LLC NAACP – Howard County

Branch NAMI Howard County New Hope Seventh-day

Adventist Church No Excuses Fitness One For All Dance

Academy, LLC Patapsco Friends Meeting Pinky Nails Roll Up N Dye Snowden River Liquor Spring Water Designs

Quilting Springfield Presbyterian

Church St. John United

Methodist/Presbyterian Church

Twig Variations, Inc. Vickey’s Nails US Carpet

Montgomery County Adventist HealthCare African American Health

Program – Montgomery County Health & Human Services

Am Kolel Art Saunders Consulting, Inc. Bethel World Outreach Church Bethesda Cares, Inc. Boy Scouts of Takoma Park Charles E Smith Jewish Day School Student Council Citi Center, Inc. Community Clinic, Inc. Dr. Karen Fleischer Medical Practice Dr. Mauricio Cortina Medical Practice Fernand Body Shop Flamingo Terrace

Enterprises, Inc. Go Mom Go Hughes United Methodist

Church Illuminata Healing Arts JBA Coaching Services, LLC Long Branch Neighborhood

Initiative Montgomery County Junior

Council, Student Councils

Montgomery County Region, Student Councils

Montgomery Health Care Action

Montrose View Psychotherapy Associates, LLC

Morse Enterprises, Inc. NAACP – Montgomery

County Branch NAMI Montgomery County NARFE Chapter 1892 –

Aspen Hill NARFE Chapter 0581 --

Gaithersburg Oak Grove AME Zion

Church Ocean’s Away River Road Unitarian

Universalist Congregation – Social Justice Council

Robin Richmond Music Robin Richmond Yoga & Massage Salem Gospel Ministries Sandy Spring Friends School Student

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

34

Government Association Smoke Free Promenade Somah American

Community Association

Suburban Video Takoma Park Home Learning Network Takoma Parents & Kids Takoma Plays Woman’s Democratic Club

of Montgomery County, MD

Women on a Mission Coalition, Inc. Prince George’s County AD/HD Health & Wellness Coaching Affordable Behavioral

Consultants (ABC), Inc. Afrique Caribbe International American Caner Society’s

Volunteer Prince George’s Leadership Council

American Medical Student Association –University of Maryland Chapter

AmpVita, LLC Ancestral Knowledge Antioch Baptist of Clinton Art Works Now Artistic Nails Beth Shalom AME Zion

Church Bowie One Barbershop Boy Scout Troop 257 Bridge to Health Care, Inc. Camp Fire Patuxent Casa Blanca Bakery Center Point Baptist

Church Chef Lou’s Desserts Cheverly Boys & Girls Club Cheverly Community

Market Cheverly Meals on Wheels Cheverly STEM Education

Center Cheverly Weekday Nursery Cheverly Weekday Security Cheverly United Methodist

Church Cheverly Woman’s Club Cheverly Young Actors

Guild Christ Kingdom Church Christian Community

Presbyterian Church Church of the Great

Commission

Crossover Church Food Pantry

Curves of Greenbelt Darlene Terrell Artistic

Designs Deaf Ministry of Greater

Mt. Nebo AME Church Deciduous Dave’s Walking

Sticks and Stuff Disciples of Christ Christian

Church Ministry Dr. Joel Lang Financial Planning Ebenezer AME Church El Buen Gusto Electronic Center Empire Cleaners Flexin Car Club G – 12 Youth Empowerment Center G&G Heating and Cooling Galbraith AME Zion Church Gayle Electric General Accounting & Tax Services Girl Scouts Troop 437 Girl Scouts Troop 3443 Greater Mount Nebo AME Church Greenbelt Dental Care, P.C. Generous Joe’s Deli Greenbelt Sportsplex Hair Afrique Haircut 2000 Healthy Futures Family

Program Highland Park Christian Academy Insurance USA Corporation Jitterbug Construction LLC Jones, Mitchell and Associates, LLC Kentland Civic Association King David Productions Latin American Youth Center Laurel Advocacy and

Referral Services (LARS), Inc.

Lee’s Nail Day Spa Livin’ the Light, LLC Living Faith Baptist Church

and International Ministries

Living Word Bible Fellowship Majestik Events Manorstone Security Marlboro Meadows Baptist

Church Maryland Center at Bowie

State University Master Sivananda’s

Institute for Yoga and Health

Merino Home Improvement Corporation Mighty Men of Strength, Inc. Mitchellville Florist Mobilizing Communities Mount Zion AME Church My Cell Phone Repairs NAACP – Prince George’s

County Branch NAMI Prince George’s County New Deal Cafe New Hope Baptist Church NJR Auto Services Prince George’s County Council Prince George’s County Medical Society Prince George’s Regional Association of Student Government Rainbow 1627 Realty 1, Inc. The Sanctuary at Kingdom Square SIDS Educational Services, Inc. Social Action Committee, Paint Branch Unitarian Universalist Church Sport Outlet St. Vincent Pallotti High School SGA Take Charge Juvenile Program Tonya Rodgers Health Ministry Touch As Art University Liquor Vina Fabrics Vine Corps, Inc. Visiting Angels Volunteers of America –

Prince George’s County Chapter

Woodland Job Corps Center

Southern Maryland (Calvert, Charles, St. Mary’s Counties) 9 Pearls Production Abuja International Foods Calvert Association of

Student Councils Checks Cashed & More

Wireless Expo Choptican High School

Student Government Association

Country Nutrition Dee’s Wild Bird Lovers

Direct Auto Brokerage, LLC DWI Services Inc. DBA The

Carol M. Porto Treatment Center

Esperanza Middle School Student Government Association

Family Med’s, Inc. Fancy Vans Mobility Father Andrew White

Student Council Association

Feli’s Salon & Spa Good Shepard United

Methodist Church HB Medical & Wellness

Care House of Pop Culture John’s Automotive &

Transmission La Plata United Methodist

Church Leonardtown High School

Student Government Association

Lucky PALS Margaret Brent Middle

School Student Government Association

Melbourne One Hair Studio Mike’s Chicken & Ribs NAACP – Calvert County

Branch NAACP – Charles County

Branch NAACP - St. Mary’s County

Branch NARFE Chapter 1260 New Horizon Child

Development Center Real Deal Boutique Oeufs Auto Patuxent High School Student Government Q’s Barbering Real Deal Boutique Southern Maryland Pawn Brokers, LLC St. Mary’s Association of

Student Councils St. Mary’s Ryken Student

Government Association

TW Racing Vogel’s Flowers Waldorf RC & Hobbies Waldorf Shoe Repair Waldorf Signs, Inc. Waldorf Trucking Yori’s Cleaners Young’s Auto Service

Maryland Citizens’ Health Initiative Education Fund, Inc. 2600 St. Paul St.

Baltimore, MD 21218 (410) 235-9000

35

Western Maryland (Allegany, Carroll, Garrett, Washington Counties) A.D. Naylor & Co., Inc. Allegany County

Association of Student Councils

Church Women United in Washington County – Executive Council

First Missionary Baptist Church

Mountain Laurel Medical Center, Inc.

NAACP – Allegany County Chapter

NAACP – Carroll County Branch

NAACP – Garrett County Branch

NAACP – Washington County Branch

NAMI Allegany County NAMI Carroll County NAMI Garrett County NAMI Washington County Phi Alpha – McDaniel

College Chapter

HSCRC2014 CBR Findings

Steve Ports, Principal Deputy Director

1

Findings from FY 2014 Summary Report

• FY14 – total of 52 hospitals: 46 acute and 6 specialty hospitals• FY13 – total of 47 hospitals: 46 acute and 1 specialty hospital

• Reported Total Community Benefits • FY 14 – $1.5 billion • FY 13 – $1.5 billion

• CBR Dollars as a Percentage of Hospital Operating Expenses• FY 14 –10.62% - Ranging from 2.61% to 27.46% with an average of 10.47%• FY 13 –11.05% - Ranging from 3.12% to 24.06% with an average of 11.12%

• Staff Hours Dedicated to CB• FY 14– Average 1514 hours• FY 13 – Average 1699 hours

2

Offsetting Charity Care, DME, and NSPI

• 2014 Charity Care DME and NSPI Rate Funding:• Charity Care - $463.9 million• DME - $294.4 million• NSPI - $15.1 million

• Total Net Community Benefit Expenditures• 2014 - $724.7 million (5.14% of expenses)• 2013 - $712.4 million (5.23% of expenses)

• In FY 14 Hospitals provided $19.9 million more in charity care than was provided in rates – down from $54.6 million in FY13.

• Due to increase in insured population?

3

FY2008-FY2014 Community Benefit Expenditures• Increase from $861 million to $1.5 billion

4

Narrative Highlights

• Top Health Needs to be addressed by hospitals - Identified through CHNA process:

• Heart Disease• Obesity• Behavioral/Mental Health/Substance Abuse• Diabetes• Access to Care• Cancer

• Prevalent unmet health needs identified but not to be addressed by hospitals.

• Behavioral/Mental Health/Substance Abuse• Transportation• Cancer• Safe Housing• Dental Health

5

Observations• Dollars and effort toward CB has continued to grow but the total

amount has appeared to level off in FY 2014 (however net CB continues to grow)

• Reductions in the percentage of charity care may impact the total amount invested in CB

• The quality of the narrative reporting is getting better but still room for improvement

• Describing information gaps impacting ability to assess needs of community• Describing process and methods to conduct CHNA’s• Prioritizing community needs with criteria• Explanation of unmet needs

• Strategic transformation planning and partnerships will likely provide more information to address these issues in future

6

Maryland Hospital Community Benefit Report: FY 2014

September 9, 2015

Health Services Cost Review Commission 4160 Patterson Avenue

Baltimore, Maryland 21215 (410) 764-2605

FAX: (410) 358-6217

Maryland Hospital Community Benefit Report: FY 2014

Table of Contents

Introduction ......................................................................................................................................1

Background .................................................................................................................................1

Definition of Community Benefits .............................................................................................2

ANALYSIS ...........................................................................................................................................3

FY 2014 Data Reporting Highlights ............................................................................................3

FY 2014 Narrative Reporting Highlights .....................................................................................8

FY 2004 – FY 2014 Eleven-Year Summary ........................................................................................9

Changes to FY 2015 Reporting Requirements .................................................................................11

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1

INTRODUCTION

Each year, the Maryland Health Services Cost Review Commission (HSCRC) collects community benefit information from individual hospitals to compile into a publicly available, statewide Community Benefit Report (CBR). Current year and previous CBRs submitted by the individual hospitals are available on the HSCRC’s website.

This summary report provides background information on hospital community benefits and the history of CBRs in Maryland. It is followed by an overview of the data and narrative reporting for fiscal year (FY) 2014, which includes, for the first time, reporting from Maryland specialty hospitals. It concludes with a summary of data reports from the past eleven years. Additional information regarding hospital rate support, community benefit data for each hospital, and the breakdown of costs by community benefit activity is included as attachments.

Background

Section 501(c)(3) of the Internal Revenue Code (IRC) identifies as tax-exempt, organizations that are organized and operated exclusively for specific purposes including religious, charitable, scientific, and educational purposes.1 Nonprofit hospitals receive many benefits from their tax-exempt status. They are generally exempted from federal income and unemployment taxes, as well as state and local income, property, and sales taxes. In addition, they are allowed to raise funds through tax-deductible donations and tax-exempt bond financing.

Originally, the Internal Revenue Service (IRS) considered hospitals to be “charitable” if they provided charity care to the extent of their financial ability to do so.2 However, in 1969, the IRS issued Revenue Ruling 69-545, which modified the “charitable” standard to focus on “community benefits” rather than “charity care.”3 Under this IRS ruling, nonprofit hospitals were required to provide benefits to the community in order to be considered charitable. This created the “community benefit standard,” which is necessary for hospitals to satisfy in order to qualify for tax-exempt status.

In March 2010, Congress passed the Patient Protection and Affordable Care Act (ACA).4 Section 9007 of the ACA established IRC §501(r), which identifies additional requirements for hospitals that seek to maintain tax-exempt status. Every §501(c)(3) hospital, whether independent or part of a hospital system, must conduct a community health needs assessment (CHNA) at least once every three years in order to maintain its tax-exempt status and avoid an annual penalty of up to $50,000.5 The first CHNA was due by the end of FY 2013. Each assessment must incorporate

1 26 U.S.C. §501(c)(3) 2 Rev. Ruling 56-185, 1956-1 C.B. 202. 3 Rev. Ruling 69-545, 1969-2 C.B. 117. 4 The Patient Protection and Affordable Care Act, P.L. 111-148 (2010),as amended by the Health Care and Education Reconciliation Act of 2010, P.L. 111-152. 5 26 U.S.C. §501(r)(3); 26 U.S.C. §4959

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input from individuals who represent the broad interests of the community served, including those with special knowledge or expertise in public health, and the assessment must be made widely available to the public.6 An implementation strategy describing how a hospital plans to meet the community’s health needs must be included, as well as a description of what the hospital has done historically to address its community’s needs.7 Furthermore, the hospital must identify any needs that have not been met by the hospital and explain why those needs have not been addressed. Tax-exempt hospitals must report this information on Schedule H of the IRS 990 forms.

The Maryland CBR process was adopted by the Maryland General Assembly in 2001,8 with FY 2004 established as the first data collection period. Under Maryland law, the CBR must include the hospital’s mission statement, a list of the hospital’s initiatives, and the cost of each community benefit initiative. It must also include the objectives of each community benefit initiative, a description of efforts taken to evaluate the effectiveness of the initiatives, a description of gaps in the availability of specialist providers, and a description of the hospital’s efforts to track and reduce health disparities in the community.9

The HSCRC worked with the Maryland Hospital Association (MHA), interested hospitals, local health departments, and health policy organizations and associations on the details and format of the CBR. In developing the format for data collection, the group drew heavily on the experience of the Voluntary Hospitals of America community benefit process, which possessed, at the time, more than ten years of voluntary hospital community benefit reporting experience across many states. The resulting data reporting spreadsheet and instructions were used by Maryland hospitals to submit the FY 2004 data to the HSCRC in January 2005. The HSCRC’s first CBR, detailing FY 2004 data, was published in July 2005. The HSCRC continues to work with the MHA, public health officials, individual hospitals, and other stakeholders to further improve the reporting process and refine the definitions, as needed. The data collection process offers an opportunity for each Maryland nonprofit hospital to critically review and report the activities it has designed to benefit the community.

The FY 2014 report represents the HSCRC’s eleventh year of reporting on Maryland hospital community benefit data.

Definition of Community Benefits

Maryland law defines a “community benefit” (CB) as an activity that is intended to address community needs and priorities, primarily through disease prevention and improvement of health status, including:10

6 26 U.S.C. §501(r)(3)(B) 7 26 U.S.C. §501(r)(3)(A) 8 Health-General Article §19-303 Maryland Annotated Code 9 Health-General Article §19-303(a)(3) Maryland Annotated Code 10 Health-General Article §19-303(c)(2) Maryland Annotated Code

Maryland Hospital Community Benefit Report: FY 2014

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• Health services provided to vulnerable and underserved populations • Financial or in-kind support of public health programs • Donations of funds, property, and other resources that contribute to a community priority • Health care cost containment activities • Health education screening and prevention services

As evidenced in the individual reports, Maryland hospitals provide a broad range of health services to meet the needs of their communities, often receiving partial or no compensation. These activities, however, are expected from Maryland’s 46 acute, and 8 specialty, nonprofit hospitals in return for their tax-exempt status.

ANALYSIS

Following are highlights of the FY 2014 data reporting and narrative reporting.

FY 2014 Data Reporting Highlights

The reporting period for this CBR is July 1, 2013, through June 30, 2014. Hospitals submitted their individual CBRs to the HSCRC by December 15, 2014. Audited financial statements were used to calculate costs for each of the community benefit categories in the data reports. Of the 54 nonprofit hospitals in Maryland, 52 submitted individual data reports. Two hospital systems, University of Maryland Shore Regional Health and the University of Maryland Upper Chesapeake Health, each submitted narratives covering both hospitals in their system. Shore Health submitted a single narrative covering both the University of Maryland Shore Medical Center at Easton and the University of Maryland Shore Medical Center at Dorchester. Upper Chesapeake Health submitted a single CBR covering both the University of Maryland Upper Chesapeake Medical Center and the University of Maryland Harford Memorial Hospital.

As shown in Table 1, Maryland hospitals provided approximately $1.5 billion dollars in total community benefit activities in FY 2014 (the same total as in FY 2013). This total comprises $483.8 million in charity care, $420.5 million in health professions education, $393.6 million in mission-driven health care services (subsidized health services), $86.3 million in community health services, $59.3 million in unreimbursed Medicaid cost, $17.5 million in community-building activities, $16.5 million in financial contributions, $10 million in research activities, $8.5 million in community benefit operations, and $2.1 million in foundation-funded community benefits (see Table 1). These totals include hospital reported indirect costs, which vary by hospital and by category from a fixed dollar amount to a calculated percentage of the hospital’s reported direct costs.

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Table 1. Total Community Benefits

Community Benefit

Category

Number of Staff Hours

Number of Encounters

Net Community

Benefit Expenses

Percentage of Total

Community Benefit

Expenditures

Net Community

Benefit Expense Less Rate Support

Percentage of Total

Community Benefit

Expenditures without Rate

Support

Charity Care * 0 0 $483,833,108 32.3% $19,924,270 2.7%

Health Professions Education * 6,594,984 225,260 $420,486,081 28.1% $110,938,100 15.3%

Mission-Driven Health Services 2,553,469 858,131 $393,614,096 26.3% $393,614,096 54.3%

Community Health Services 1,012,490 13,494,384 $86,287,120 5.8% $86,287,120 11.9%

Unreimbursed Medicaid Cost 0 0 $59,270,451 4.0% $59,270,451 8.2%

Community Building 177,077 583,447 $17,530,347 1.2% $17,530,347 2.4%

Financial Contributions 46,548 178,978 $16,484,643 1.1% $16,484,643 2.3%

Research 128,704 4,440 $9,998,833 0.7% $9,998,833 1.4%

Community Benefit Operations 78,722 1,561 $8,529,825 0.6% $8,529,825 1.2% Foundation-Funded Community Benefits 40,924 13,702 $2,090,806 0.1% $2,090,806 0.3% Total 10,632,917 15,359,902 $1,498,125,311 100.0% $724,668,492 100.0%

(*) Indicates category adjusted for rate support (direct medical education, Nurse Support Program I, and charity care)

In Maryland, the costs of uncompensated care (including charity care and bad debt) and graduate medical education are built into the rates for which hospitals are reimbursed by all payers, including Medicare and Medicaid. Additionally, the HSCRC rates include amounts for nurse support programs provided at Maryland hospitals. These costs are, in essence, “passed-through”

Maryland Hospital Community Benefit Report: FY 2014

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to the purchasers and payers of hospital care. To comply with IRS form 990 requirements and avoid accounting confusion among programs that are not funded by hospital rate setting, the HSCRC requests that hospitals not submit revenue included in rates as offsetting revenue on the CBR worksheet. Attachment I details the amounts that are included in rates and funded by all payers for charity care, direct graduate medical education, and nurse support programs in FY 2014.

As noted, the HSCRC includes a provision in hospital rates for uncompensated care; this includes charity care, which is a considered to be a community benefit. It also includes bad debt, which is not considered to be a community benefit. Attachment I shows that $463.9 million in charity care was provided through Maryland hospital rates in FY 2014, which was funded by all payers. When offset by the $483.8 million in charity care reported by hospitals, the net amount of charity care provided by the hospitals was $19.9 million.

Another social cost funded through Maryland’s rate-setting system is the cost of graduate medical education, generally for interns and residents who are trained in Maryland hospitals. Included in graduate medical education costs are the direct costs (direct medical education, DME), which include the residents’ and interns’ wages and benefits, faculty supervisory expenses, and allocated overhead. The HSCRC’s annual cost report quantifies the DME costs of physician training programs at Maryland hospitals. In FY 2014, DME costs totaled $294.4 million.

The HSCRC’s Nurse Support Program I (NSPI) is aimed at addressing the short- and long-term nursing shortage impacting Maryland hospitals. In FY 2014, $15.1 million was provided in hospital rate adjustments for NSPI. See Attachment I for detailed information about funding provided to specific hospitals.

When the reported community benefit costs for Maryland hospitals are offset by rate support, the net community benefits provided in FY 2014 totaled $724.7 million, or 5.14 percent of total hospital operating expenses.11 This is an increase from the $712.4 million in net benefits provided in FY 2013, which totaled 5.2 percent of hospital operating expenses (see Attachment II for additional detail).

Table 2 shows the breakdown of staff hours, number of encounters, and expenditures for health professions education by activity. The education of physicians and medical students comprises the majority of expenses in the category of health professions education, totaling $362.4 million. The second most expensive is the education of nurses and nursing students at $31.8 million and the third is the education of other health professionals, with $19.7 million.

11 FY 2014 includes 5 additional specialty hospitals versus FY 2013.

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Table 2. Health Professions Education Activities Health Professions Education Number of

Staff Hours Number of Encounters

Net Community Benefit with Indirect Cost

Physicians and Medical Students 5,597,736 32,558 $ 362,397,942 Nurses and Nursing Students 552,129 99,058 $ 31,826,084 Other Health Professionals 337,606 63,913 $ 19,662,486 Other 96,404 28,748 $ 3,838,063 Scholarships and Funding for Professional Education

11,110 947 $ 2,761,506

Total 6,594,984 225,260 $ 420,486,081

Table 3 provides a breakdown of staff hours, number of encounters, and expenditures for community health services by activity. Health care support services comprise the largest portion of expenses in the category of community health services, with $33.3 million. Community health education is the second most expensive with $23.1 million, and community-based clinical services is the third most expensive with $10.5 million.

For additional detail and a description of subcategories of the remaining community benefit categories, see Attachment III – FY 2014 Hospital Community Benefit Aggregate Data.

Table 3. Community Health Services Activities Community Health Services Number of Staff

Hours Number of Encounters

Net Community Benefit Expense

Health Care Support Services 233,587 193,063 $ 33,298,581 Community Health Education 275,495 12,608,953 $ 23,083,885 Community-Based Clinical Services 294,224 367,537 $ 10,537,173 Other 73,023 58,416 $ 8,011,395 Free Clinics 33,733 58,062 $ 5,141,824 Screenings 32,692 80,129 $ 2,293,163 Self-Help 25,129 68,568 $ 1,625,214 Support Groups 12,852 30,068 $ 1,043,498 Mobile Units 28,262 10,104 $ 873,520 One-Time and Occasionally Held Clinics

3,494 19,484 $ 378,865

Total 1,012,490 13,494,384 $ 86,287,120

The distribution of expenses by category is significantly impacted by rate offsetting. Figure 1 shows expenditures in each community benefit category as a percentage of total expenditures. Charity care, health professions education, and mission-driven health services represent the majority of the expenses, at 32 percent, 28 percent, and 26 percent, respectively. Figure 1 also shows the percentage of expenditures by category without rate support, which changes the configuration significantly: Mission-driven health services becomes the category with the highest

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percentage of expenditures, at 54 percent. Health professions education follows with 15 percent of expenditures, and community health services comprises 12 percent of expenditures.

Figure 1. Percentage of Community Benefit Expenditures by Category with and without Rate Support

*Rate supported expenditures

Utilizing the data reported, Attachment II - FY 2014 Community Benefit Analysis compares hospitals on the total amount of community benefits reported, the amount of community benefits recovered through HSCRC-approved rate supports (charity care, direct medical education, and nurse support), and the number of staff and staff hours dedicated to community benefit operations. On average, in FY 2014, 1,514 staff hours were dedicated to community benefit operations, a decrease of 19 percent from 1,848 staff hours in FY 2013. Seven hospitals reported zero staff hours dedicated to community benefit operations, compared with four hospitals reporting zero staff hours during FY 2013. The HSCRC continues to encourage hospitals to incorporate community benefit operations into their overall strategic planning.

The total amount of community benefit expenditures as a percentage of total operating expenses ranges from 2.61 percent to 27.46 percent, with an average percentage of 10.47. This is a decrease from an average of 11.12 percent in FY 2013. Twenty-two hospitals report providing benefits in excess of 10 percent of their operating expenses, compared with 23 hospitals in FY

0%

10%

20%

30%

40%

50%

60%

32%28% 26%

6% 4% 1% 1% 1% 1% 0%3%

15%

54%

12%8%

2% 2% 1% 1% 0%

FY14 PERCENT OF CB EXPENDITURES WITH AND WITHOUT RATE SUPPORT

Percent of Total CB Expenditures Percent of Total CB Expenditures w/o Rate Support

Maryland Hospital Community Benefit Report: FY 2014

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2013. In addition, 17 hospitals report providing benefits between 7.5 percent and 10 percent of their operating expenses, compared with 15 hospitals in FY 2013.

FY 2014 Narrative Reporting Highlights

In FY 2014, hospitals were again asked to answer narrative questions regarding their community benefit programs. The questions were developed, in part, to create a standard reporting format for all hospitals. This uniformity provided readers of the individual hospital reports with more information than was previously available and allowed for comparisons across hospitals. When possible, the narrative guidelines were aligned with IRS form 990, schedule H, in an effort to provide as much consistency as is practicable in reporting at the state and federal levels.

The HSCRC also considers the narrative guidelines to be a mechanism for assisting hospitals in critically reviewing their community benefit programs. Examination of the effectiveness of major program initiatives enables hospitals to better determine which programs are achieving the desired results and which are not. The point scoring system used previously to evaluate community benefit narrative reports was eliminated for FY 2014, and a new evaluation tool was created that increases the level of detail in the evaluations provided to each hospital. It is expected that this change will allow hospitals to improve future reports and increase consistency among all hospital reports in the future.

Fifty-two hospitals provided their CHNAs, but they varied significantly in length and the content and quality of the descriptions provided. The CHNA covers six topics: community served, information gaps, CHNA process and methods, prioritized needs, third-party collaboration, and facilities and resources available. For example, 44 hospitals provided clear descriptions of their community served and how it was determined, whereas eight hospitals did not provide clear descriptions or definitions. Only 15 hospitals clearly described information gaps that affect the hospitals’ ability to assess the health needs of their community. Sixteen hospitals identified a gap within one area of data collection, but did not provide a detailed description of the information gaps. Twenty-one hospitals did not make any reference to information gaps.

Only 13 hospitals provided clear descriptions of the process and methods used to conduct their CHNAs and included sources, dates of data, and other information. Thirty-nine hospitals failed to include the names and titles of input providers, dates of data collection, or data from primary data collection methods. Only one hospital provided a prioritized description of all of the community health needs and the process and criteria used in prioritizing the needs. Seventeen hospitals provided a prioritized description of the top needs selected for implementation of initiatives, but not all identified needs. Thirty-four hospitals failed to provide their identified needs in any priority order or failed to describe the process used in prioritizing their needs. Most hospitals contracted with a third party to assist with the CHNA and clearly described the qualifications of the third party, whereas 21 hospitals did not contract with a third party. Twenty-one hospitals provided a description of existing health care facilities and other resources within the community to meet needs identified through the CHNA, whereas the remaining hospitals only provided part of this information.

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Fifty-one hospitals provided an implementation strategy that clearly described how the hospital plans to meet the identified needs, although two of these hospitals’ implementation strategies did not match the needs outlined in their community benefit narrative report. Thirty-eight hospitals identified and justified their unmet needs, whereas five hospitals did not provide explanations for all of their unmet needs. Two hospitals did not clearly define their unmet needs, and one hospital reported that it had no unmet needs. Similar to the CHNAs, the quality and level of detail in the hospitals’ community benefit initiatives varied greatly.

FY 2004 – FY 2014 ELEVEN-YEAR SUMMARY

FY 2014 marks the eleventh year since the inception of the CBR. In FY 2004, community benefit expenses represented $586.5 million, or 6.9 percent of operating expenses. In FY 2014, these expenses represented $1.5 billion, or 10.6 percent of operating expenses. As Maryland hospitals have increasingly focused on implementation of cost- and quality-improvement strategies, an increasing percentage of operating expenses has been directed toward community benefit initiatives.

The reporting requirement for revenue offsets and rate support has changed since the inception of the CBR in FY 2004. For consistency purposes, the following figures illustrate community benefit expenses from FY 2008 through FY 2014. Figures 2A and 2B show the trend of community benefit expenses with and without rate support. On average, approximately 50 percent of the expenses have been reimbursed through the rate setting system.

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Figure 2A. FY 2008 – FY 2014 Community Benefit Expenses with and without Rate Support

Figure 2B. FY 2008 – FY 2014 Percentage of Community Benefit Operating Expenses

with and without Rate Support

$861 $946

$1,051

$1,203

$1,378 $1,506 $1,498

$416 $466

$614 $580 $652

$713 $725

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

2008 2009 2010 2011 2012 2013 2014

FY2008-FY2014 CB Expense(in millions)

CB Expense CB Expense Less Rate Support

7.2% 7.6%8.3%

9.2%10.2%

11.0%10.6%

3.5% 3.7%

4.9%4.5% 4.8%

5.2% 5.1%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

2008 2009 2010 2011 2012 2013 2014

FY2008-FY2014 % of Operating Expense

% of Operating Expense % of Operating Expense less rate support

Maryland Hospital Community Benefit Report: FY 2014

11

CHANGES TO FY 2015 REPORTING REQUIREMENTS

The changes to Maryland’s hospital narrative reporting requirements have resulted in more detailed narrative reports. For FY 2015, the community benefit administration section requires detailed explanations for each question rather than a “yes” or “no” response. A community benefit external collaboration section was also added to address hospital collaboration with external organizations, such as community-based organizations and local health departments, to perform activities to improve their community’s health and conduct the CHNA. These changes and the elimination of the point scoring system will allow the HSCRC to send more detailed evaluations to hospitals, which in turn will assist them in submitting more consistent community benefit reports in the future. The HSCRC will continue to modify the community benefit reporting requirements to enhance consistency and improve evaluations.

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Attachment I - Hospitals FY 2014 Funding for Nurse Support Program I, Direct Medical Education, and Charity Care

Hospital Name Nurse Support

Program I (NSPI)

Direct Medical Education

(DMI)

Charity Care in Rates

Total Rate Support

Meritus Medical Center $ 295,465 - $ 7,505,016 $ 7,800,481 UMMC* $ 1,420,398 $ 91,440,450 $ 73,498,009 $ 166,358,857 Dimensions Prince Georges Hospital Center $ 255,904 $ 3,988,330 $ 17,544,927 $ 21,789,161 Holy Cross Hospital $ 453,732 $ 2,757,760 $ 25,676,243 $ 28,887,735 Frederick Memorial $ 334,410 - $ 11,690,942 $ 12,025,352 UM Harford Memorial $ 104,451 - $ 3,046,391 $ 3,150,843 Mercy Medical Center $ 459,266 $ 4,675,330 $ 21,375,445 $ 26,510,041 Johns Hopkins Hospital $ 1,851,352 $ 103,050,920 $ 34,749,786 $ 139,652,057 UM Shore Medical Dorchester $ 59,360 - $ 1,760,573 $ 1,819,933 St. Agnes $ 401,564 $ 6,888,070 $ 9,860,633 $ 17,150,268 LifeBridge Sinai $ 676,603 $ 15,265,590 $ 12,231,834 $ 28,174,027 Bon Secours $ 130,652 - $ 11,914,216 $ 12,044,868 MedStar Franklin Square $ 477,082 $ 7,574,040 $ 17,181,539 $ 25,232,661 Adventist Washington Adventist $ 260,716 - $ 12,237,739 $ 12,498,455 Garrett County Hospital $ 42,710 - $ 3,045,380 $ 3,088,090 MedStar Montgomery General $ 165,915 - $ 5,404,355 $ 5,570,270 Peninsula Regional $ 414,766 - $ 11,675,563 $ 12,090,329 Suburban Hospital $ 272,892 $ 314,920 $ 4,354,574 $ 4,942,386 Anne Arundel Medical Center $ 523,717 - $ 4,779,088 $ 5,302,805 MedStar Union Memorial $ 422,531 $ 11,238,490 $ 13,694,623 $ 25,355,644 Western Maryland Health System $ 308,556 - $ 10,507,545 $ 10,816,101 MedStar St. Mary’s Hospital $ 151,897 - $ 4,606,886 $ 4,758,783 Johns Hopkins Bayview Medical Center $ 584,860 $ 21,979,800 $ 19,315,954 $ 41,880,614 UM Shore Medical Chestertown $ 65,052 - $ 1,619,812 $ 1,684,863 Union Hospital of Cecil County $ 148,428 - $ 3,466,914 $ 3,615,342 Carroll Hospital Center $ 243,424 - $ 3,885,617 $ 4,129,042 MedStar Harbor Hospital $ 209,694 $ 4,402,330 $ 10,513,303 $ 15,125,328 UM Charles Regional Medical Center $ 126,394 - $ 2,019,045 $ 2,145,439 UM Shore Medical Easton $ 184,648 - $ 4,330,984 $ 4,515,632 UM Midtown $ 185,438 $ 4,245,770 $ 12,068,847 $ 16,500,055 Calvert Hospital $ 135,741 - $ 6,787,442 $ 6,923,183 Lifebridge Northwest Hospital $ 238,730 - $ 5,797,834 $ 6,036,564

Maryland Hospital Community Benefit Report: FY 2014

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Hospital Name Nurse Support

Program I (NSPI)

Direct Medical Education

(DMI)

Charity Care in Rates

Total Rate Support

UM Baltimore Washington $ 381,065 $ 421,820 $ 10,211,355 $ 11,014,241 GBMC $ 426,432 $ 5,078,600 $ 4,352,953 $ 9,857,986 McCready $ 17,710 - $ 647,065 $ 664,775 Howard County Hospital $ 275,202 - $ 7,117,813 $ 7,393,015 UM Upper Chesapeake $ 283,588 - $ 5,072,096 $ 5,355,684 Doctors Community $ 214,285 - $ 12,025,485 $ 12,239,770 Dimensions Laurel Regional Hospital $ 118,724 - $ 4,544,597 $ 4,663,321 Fort Washington Medical Center $ 46,176 - $ 3,281,075 $ 3,327,251 Atlantic General $ 95,474 - $ 2,452,495 $ 2,547,970 MedStar Southern Maryland $ 249,258 - $ 3,383,194 $ 3,632,453 UM St. Joseph $ 354,786 - $ 4,751,548 $ 5,106,334 UM Rehabilitation and Ortho Institute $ 117,995 $ 3,801,620 $ 863,428 $ 4,783,044 MedStar Good Samaritan $ 311,855 $ 4,767,170 $ 7,018,282 $ 12,097,308 Adventist Shady Grove Hospital $ 348,706 - $ 10,040,391 $ 10,389,097 Lifebridge Levindale $ 52,499 - - $ 52,499 Adventist Rehab of Maryland $ 51,233 - - $ 51,233 Adventist Behavioral Health at Eastern Shore - - - $ - Sheppard Pratt $ 140,136 $ 2,436,050 - $ 2,576,186 Adventist Behavioral Health Rockville - $ 80,000 - $ 80,000 Mt. Washington Pediatrics $ 49,447 - - $ 49,447 Total $ 15,140,921 $ 294,407,060 $ 463,908,838 $ 773,456,820

*Contains both UMMC and Shock Trauma

Maryland Hospital Community Benefit Report: FY 2014

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Attachment II – FY 2014 Community Benefit Analysis

Hospital Name Number of Employees

Number of Staff Hours

for CB Operations

Total Hospital Operating Expense

Net CB Expense

Total CB as % of Total Operating

Expense

Total in Rates for Charity Care,

DME, and NSPI*

Net CB minus Charity Care, DME, NSPI in

Rates

Net CB (minus charity Care, DME, NSPI in Rates) as % of Total Operating

Expense

CB Reported Charity Care

Meritus Medical Center 0 828 $292,347,127 $23,844,610 8.16% $7,800,481 $16,044,128 5.49% $7,993,597 UMMC 8,288 1,164 $1,305,636,000 $201,474,942 15.43% $166,358,857 $35,116,085 2.69% $55,444,257 Dimensions Prince Georges Hospital Center

1,678 160 $217,477,100 $59,720,405 27.46% $21,789,161 $37,931,244 17.44% $15,861,400

Holy Cross Hospital 3,293 5,776 $390,575,586 $55,856,400 14.30% $28,887,735 $26,968,665 6.90% $30,739,060 Frederick Memorial 2,110 0 $319,313,000 $30,580,563 9.58% $12,025,352 $18,555,211 5.81% $14,227,000 UM Harford Memorial 875 941 $80,416,000 $8,026,523 9.98% $3,150,843 $4,875,680 6.06% $3,428,179 Mercy Medical Center 3920 2,785 $426,907,600 $61,821,825 14.48% $26,510,041 $35,311,784 8.27% $24,885,600 Johns Hopkins Hospital 0 7,063 $1,928,280,000 $188,270,622 9.76% $139,652,057 $48,618,565 2.52% $32,721,000 UM Shore Medical Dorchester

627 375 $39,674,000 $5,394,100 13.60% $1,819,933 $3,574,167 9.01% $2,305,000

St. Agnes 2,690 0 $392,471,132 $26,869,027 6.85% $17,150,268 $9,718,760 2.48% $11,750,468 LifeBridge Sinai 4,612 5,971 $669,579,000 $58,776,319 8.78% $28,174,027 $30,602,292 4.57% $12,880,700 Bon Secours 785 0 $119,439,002 $22,271,852 18.65% $12,044,868 $10,226,984 8.56% $12,073,632 MedStar Franklin Square 3,309 3,360 $469,241,214 $35,491,348 7.56% $25,232,661 $10,258,687 2.19% $13,581,700 Adventist Washington Adventist*

1389 1,432 $217,791,712 $38,552,255 17.70% $12,498,455 $26,053,799 11.96% $14,404,325

Garrett County Hospital 344 80 $38,194,377 $4,687,445 12.27% $3,088,090 $1,599,356 4.19% $3,225,760 MedStar Montgomery General

1,166 0 $141,655,632 $9,749,053 6.88% $5,570,270 $4,178,783 2.95% $4,722,141

Peninsula Regional 2,538 184 $368,170,415 $35,900,136 9.75% $12,090,329 $23,809,807 6.47% $13,261,500 Suburban Hospital 1,753 1,797 $225,204,531 $21,432,492 9.52% $4,942,386 $16,490,105 7.32% $4,501,300 Anne Arundel Medical Center

4,136 1,440 $514,545,000 $36,050,991 7.01% $5,302,805 $30,748,186 5.98% $5,688,100

MedStar Union Memorial 2,256 0 $394,669,299 $42,190,902 10.69% $25,355,644 $16,835,258 4.27% $13,169,128

Western Maryland Health System

2,141 324 $282,308,921 $36,523,850 12.94% $10,816,101 $25,707,749 9.11% $14,413,981

MedStar St. Mary’s Hospital

1,277 9,370 $131,503,457 $10,240,708 7.79% $4,758,783 $5,481,925 4.17% $3,430,456

Johns Hopkins Bayview Medical Center

3,367 1,256 $530,603,000 $58,159,948 10.96% $41,880,614 $16,279,333 3.07% $22,183,000

Maryland Hospital Community Benefit Report: FY 2014

15

Hospital Name Number of Employees

Number of Staff Hours

for CB Operations

Total Hospital Operating Expense

Net CB Expense

Total CB as % of Total Operating

Expense

Total in Rates for Charity Care,

DME, and NSPI*

Net CB minus Charity Care, DME, NSPI in

Rates

Net CB (minus charity Care, DME, NSPI in Rates) as % of Total Operating

Expense

CB Reported Charity Care

UM Shore Medical Chestertown

374 500 $47,354,000 $7,895,987 16.67% $1,684,863 $6,211,124 13.12% $2,067,000

Union Hospital of Cecil County

1,109 2,179 $146,635,757 $10,648,111 7.26% $3,615,342 $7,032,769 4.80% $3,064,396

Carroll Hospital Center 2,027 2,080 $209,384,000 $16,040,970 7.66% $4,129,042 $11,911,928 5.69% $3,355,681 MedStar Harbor Hospital 1,241 177 $189,700,114 $22,372,526 11.79% $15,125,328 $7,247,198 3.82% $6,997,842 UM Charles Regional Medical Center

0 1,622 $108,755,000 $9,583,933 8.81% $2,145,439 $7,438,494 6.84% $1,864,000

UM Shore Medical Easton

1,292 820 $160,829,000 $15,078,264 9.38% $4,515,632 $10,562,633 6.57% $5,828,000

UM Midtown 1,120 1,188 $178,869,000 $35,810,878 20.02% $16,500,055 $19,310,823 10.80% $14,755,634 Calvert Hospital 1,400 183 $119,481,772 $19,895,054 16.65% $6,923,183 $12,971,872 10.86% $7,010,751 Lifebridge Northwest Hospital

1,607 583 $212,164,000 $17,551,055 8.27% $6,036,564 $11,514,492 5.43% $6,203,971

UM Baltimore Washington

2,909 104 $319,031,000 $31,234,487 9.79% $11,014,241 $20,220,246 6.34% $13,307,038

GBMC 2,559 4,370 $381,697,000 $18,320,492 4.80% $9,857,986 $8,462,507 2.22% $4,337,420 McCready 250 30 $14,682,491 $758,175 5.16% $664,775 $93,400 0.64% $572,384 Howard County Hospital 1,671 803 $231,080,000 $21,136,745 9.15% $7,393,015 $13,743,730 5.95% $6,010,720 UM Upper Chesapeake 2,037 2,197 $236,718,000 $15,009,652 6.34% $5,355,684 $9,653,968 4.08% $4,956,053 Doctors Community 1,466 2,200 $176,796,204 $18,627,103 10.54% $12,239,770 $6,387,333 3.61% $14,726,686 Dimensions Laurel Regional Hospital

743 160 $104,245,600 $15,661,030 15.02% $4,663,321 $10,997,709 10.55% $4,507,400

Ft. Washington 417 0 $38,620,727 $2,222,903 5.76% $3,327,251 -$1,104,348 -2.86% $1,614,129 Atlantic General 835 158 $101,574,098 $14,249,336 14.03% $2,547,970 $11,701,367 11.52% $3,594,293 MedStar Southern Maryland

1,638 7,807 $219,466,790 $10,833,218 4.94% $3,632,453 $7,200,765 3.28% $3,582,453

UM St. Joseph 2,332 0 $310,933,000 $35,667,680 11.47% $5,106,334 $30,561,346 9.83% $7,375,769 Lifebridge Levindale 832 520 $74,832,811 $1,955,388 2.61% $52,499 $1,902,889 2.54% $767,401

UM Rehabilitation and Ortho Institute

686 728 $102,736,500 $11,513,710 11.21% $4,783,044 $6,730,666 6.55% $841,000

MedStar Good Samaritan 0 1,788 $303,307,419 $24,043,260 7.93% $12,097,308 $11,945,952 3.94% $7,581,945

Maryland Hospital Community Benefit Report: FY 2014

16

Hospital Name Number of Employees

Number of Staff Hours

for CB Operations

Total Hospital Operating Expense

Net CB Expense

Total CB as % of Total Operating

Expense

Total in Rates for Charity Care,

DME, and NSPI*

Net CB minus Charity Care, DME, NSPI in

Rates

Net CB (minus charity Care, DME, NSPI in Rates) as % of Total Operating

Expense

CB Reported Charity Care

Adventist Rehab of Maryland*

414 170 $33,160,122 $1,792,947 5.41% $51,233 $1,741,714 5.25% $756,000

Adventist Behavioral Health at Eastern Shore*

131 42 $9,317,745 $1,084,396 11.64% - $1,084,396 11.64% $161,347

Sheppard Pratt 2,485 395 $198,270,704 $12,705,185 6.41% $2,576,186 $10,128,999 5.11% $8,367,519 Adventist Behavioral Health Rockville*

395 146 $33,990,541 $4,309,098 12.68% $80,000 $4,229,098 12.44% $2,546,393

Mt. Washington Pediatrics

650 1,677 $50,042,312 $1,567,465 3.13% $49,447 $1,518,018 3.03% $173,338

Shady Grove* 2027 1,790 $295,844,877 $28,669,946 9.69% $10,389,097 $18,280,849 6.18% $10,015,261

Totals 77,805 78,722 $14,105,523,690 $1,498,125,311 10.62% $773,456,820 $724,668,492 5.14% $483,833,108 Averages 1,729 1,514 10.47% 6.18% * The Adventist Hospital System has requested and received permission to report their community benefit activities on a calendar year basis to allow them to more accurately reflect their true activities during the community benefit cycle. The numbers listed in the “Total in Rates for Charity Care, DME, and NSPI*” column reflect the HSCRC's activities for FY 2014 and therefore are different from the numbers reported by the Adventist Hospitals.

Maryland Hospital Community Benefit Report: FY 2014

Attachment III - FY 2014 Hospital Community Benefit Aggregate Data

Type of Activity Number of Staff Hours

Number of Encounters Direct Cost ($) Indirect Cost ($) Offsetting

Revenue

Net Community Benefit with Indirect Cost

Net Community Benefit without

Indirect Cost

Unreimbursed Medicaid CostT00

Medicaid Costs

T99 Medicaid Assessments 0 0 $ 373,183,714 $ 1,225,750 $ 315,139,013 $ 59,270,451 $ 58,044,701

Community Health Services

A10 Community Health Education 275,495 12,608,953 $ 16,009,920 $ 8,928,580 $ 1,854,615 $ 23,083,885 $ 14,155,305

A11 Support Groups 12,852 30,068 $ 697,438 $ 357,667 $ 11,607 $ 1,043,498 $ 685,831

A12 Self-Help 25,129 68,568 $ 1,560,401 $ 843,538 $ 778,726 $ 1,625,214 $ 781,675

A20 Community-Based Clinical Services 294,224 367,537 $ 13,456,136 $ 4,105,502 $ 7,024,464 $ 10,537,173 $ 6,431,672

A21 Screenings 32,692 80,129 $ 1,604,903 $ 897,952 $ 209,692 $ 2,293,163 $ 1,395,211

A22 One-Time and Occasionally Held Clinics 3,494 19,484 $ 338,809 $ 101,124 $ 61,067 $ 378,865 $ 277,742

A23 Free Clinics 33,733 58,062 $ 4,419,729 $ 2,191,789 $ 1,469,694 $ 5,141,824 $ 2,950,035

A24 Mobile Units 28,262 10,104 $ 1,298,417 $ 498,561 $ 923,458 $ 873,520 $ 374,959

A30 Health Care Support Services 233,587 193,063 $ 23,848,131 $ 11,398,249 $ 1,947,798 $ 33,298,581 $ 21,900,333

A40 Other 27,191 47,462 $ 3,367,343 $ 1,422,320 $ 62,631 $ 4,727,032 $ 3,304,712

A41 Other 43,752 8,045 $ 2,985,269 $ 81,657 - $ 3,066,926 $ 2,985,269

A42 Other 2,080 2,909 $ 133,479 $ 83,958 - $ 217,437 $ 133,479

A99 Total 1,012,490 13,494,384 $ 69,719,974 $ 30,910,898 $ 14,343,752 $ 86,287,120 $ 55,376,222 Health Professions Education

B1 Physicians and Medical Students 5,597,736 32,558 $ 292,186,105 $ 70,211,837 $ - $ 362,397,942 $ 292,186,105

B2 Nurses and Nursing Students 552,129 99,058 $ 25,911,056 $ 6,226,543 $ 311,515 $ 31,826,084 $ 25,599,541

B3 Other Health Professionals 337,606 63,913 $ 16,015,672 $ 3,990,109 $ 343,295 $ 19,662,486 $ 15,672,377

Maryland Hospital Community Benefit Report: FY 2014

Type of Activity Number of Staff Hours

Number of Encounters Direct Cost ($) Indirect Cost ($) Offsetting

Revenue

Net Community Benefit with Indirect Cost

Net Community Benefit without

Indirect Cost

B4 Scholarships and Funding for Professional Education

11,110 947 $ 2,700,403 $ 61,103 - $ 2,761,506 $ 2,700,403

B50 Other 90,291 25,219 $ 3,193,463 $ 324,381 $ 11,938 $ 3,505,906 $ 3,181,525

B51 Other 1,089 483 $ 1,835,855 $ 242,032 $ 2,029,982 $ 47,905 $ (194,127)

B52 Other 2,384 3,016 $ 158,637 $ 43,289 $ 96,984 $ 104,942 $ 61,653

B53 Other 2,640 66 $ 111,069 $ 68,241 - $ 179,310 $ 111,069

B99 Total 6,594,984 225,260 $ 342,112,260 $ 81,167,535 $ 2,793,714 $ 420,486,081 $ 339,318,546

Mission-Driven Health Services

C. Mission-Driven Health Services Total

30,377 15,680 $ 6,168,660 $ 1,953,170 $ 1,933,811 $ 6,188,019 $ 4,234,849

Research D1 Clinical Research 85,220 4,423 $ 10,853,505 $ 2,741,850 $ 6,694,353 $ 6,901,002 $ 4,159,152 D2 Community Health Research 8,082 17 $ 644,356 $ 301,510 $ 14,000 $ 931,866 $ 630,356

D3 Other 35,402 0 $ 1,754,352 $ 411,612 $ - $ 2,165,964 $ 1,754,352 D99 Total 128,704 4,440 $ 13,252,213 $ 3,454,973 $ 6,708,353 $ 9,998,833 $ 6,543,860

Financial Contributions

E1 Cash Donations 1,558 30,176 $ 9,789,828 $ 31,011 $ 7,996 $ 9,812,843 $ 9,781,832 E2 Grants 45 53 $ 580,060 $ 68,105 $ 259,435 $ 388,730 $ 320,625

E3 In-Kind Donations 39,574 143,639 $ 5,515,496 $ 323,566 $ 211,206 $ 5,627,856 $ 5,304,290

E4 Cost of Fund Raising for Community Programs 5,372 5,110 $ 520,723 $ 134,491 - $ 655,214 $ 520,723

E99 Total 46,548 178,978 $ 16,406,108 $ 557,173 $ 478,637 $ 16,484,643 $ 15,927,471

Community Building Activities

F1 Physical Improvements and Housing 7,917 307,927 $ 3,584,407 $ 199,302 $ 2,690,625 $ 1,093,083 $ 893,782

Maryland Hospital Community Benefit Report: FY 2014

Type of Activity Number of Staff Hours

Number of Encounters Direct Cost ($) Indirect Cost ($) Offsetting

Revenue

Net Community Benefit with Indirect Cost

Net Community Benefit without

Indirect Cost

F2 Economic Development 2,099 4,824 $ 690,819 $ 411,177 $ 361,691 $ 740,305 $ 329,128

F3 Support System Enhancements 66,859 23,704 $ 3,628,701 $ 1,787,213 $ 648,463 $ 4,767,451 $ 2,980,238

F4 Environmental Improvements 6,176 601 $ 913,922 $ 535,969 $ 1,500 $ 1,448,392 $ 912,422

F5

Leadership Development and Training for Community Members

5,979 2,868 $ 234,184 $ 139,434 $ - $ 373,618 $ 234,184

F6 Coalition Building 18,055 16,841 $ 1,341,048 $ 749,249 $ 19,065 $ 2,071,232 $ 1,321,983

F7 Community Health Improvement Advocacy 11,536 4,314 $ 1,352,464 $ 741,594 $ 6,356 $ 2,087,702 $ 1,346,107

F8 Workforce Enhancement 45,936 56,556 $ 2,490,081 $ 1,459,469 $ 373,262 $ 3,576,288 $ 2,116,819

F9 Other 11,320 165,763 $ 876,146 $ 417,685 $ 4,352 $ 1,289,479 $ 871,794

F10 Other 1,200 48 $ 54,000 $ 28,798 $ - $ 82,798 $ 54,000 Total 177,077 583,447 15,165,772 6,469,890 4,105,314 17,530,347 11,060,458

Community Benefit Operations G1 Dedicated Staff 74,157 1,166 $ 4,872,178 $ 2,366,265 $ 20,811 $ 7,217,632 $ 4,851,367

G2 Community health and health assets assessments 2,811 202 $ 223,424 $ 103,979 $ 21,406 $ 305,997 $ 202,018

G3 Other Resources 1,747 193 $ 623,540 $ 243,684 $ 44 $ 867,180 $ 623,496 G4 Other 7 0 $ 144 $ 91 - $ 235 $ 144

G5 Other 0 0 $ 85,194 $ 53,587 - $ 138,781 $ 85,194

Total 78,722 1,561 5,804,480 2,767,606 42,261 8,529,825 5,762,219 Charity Care H Charity Care (report total only) $483,833,108

Foundation-Funded Community Benefits J1 Community Services 3,805 2,349 $ 1,038,696 $ 69,066 $ 592,644 $ 515,118 $ 446,052 J2 Community Building 37,119 11,353 $ 1,594,158 $ 17,358 $ 46,091 $ 1,565,425 $ 1,548,067 J3 Other 0 0 $ 10,264 - - $ 10,264 $ 10,264

Maryland Hospital Community Benefit Report: FY 2014

Type of Activity Number of Staff Hours

Number of Encounters Direct Cost ($) Indirect Cost ($) Offsetting

Revenue

Net Community Benefit with Indirect Cost

Net Community Benefit without

Indirect Cost

J99 Total 40,924 13,702 $2,643,118 $86,424 $638,735 $2,090,806 $2,004,383

Total Hospital Community Benefit T99 Medicaid Assessments 0 0 $ 373,183,714 $ 1,225,750 $ 315,139,013 $ 59,270,451 $ 58,044,701 A

Community Health Services 1,012,490 13,494,384 $ 69,719,974 $ 30,910,898 $ 14,343,752 $ 86,287,120 $ 55,376,222

B Health Professions Education 6,594,984 225,260 $ 342,112,260 $ 81,167,535 $ 2,793,714 $ 420,486,081 $ 339,318,546 C

Mission-Driven Health Services 2,553,469 858,131 $ 465,107,383 $ 105,386,289 $ 176,879,576 $ 393,614,096 $ 288,227,807

D Research 128,704 4,440 $ 13,252,213 $ 3,454,973 $ 6,708,353 $ 9,998,833 $ 6,543,860

E Financial Contributions 46,548 178,978 $ 16,406,108 $ 557,173 $ 478,637 $ 16,484,643 $ 15,927,471 F Community Building 177,077 583,447 $ 15,165,772 $ 6,469,890 $ 4,105,314 $ 17,530,347 $ 11,060,458 G

Community Benefit Operations 78,722 1,561 $ 5,804,480 $ 2,767,606 $ 42,261 $ 8,529,825 $ 5,762,219

H Charity Care 0 0 $ 483,833,108 - - $ 483,833,108 $ 483,833,108

J Foundation-Funded Community Benefits 40,924 13,702 $ 2,643,118 $ 86,424 $ 638,735 $ 2,090,806 $ 2,004,383

K99 Community Hospital Benefit Total 10,632,917 15,359,902 $ 1,787,228,131 $ 232,026,537 $ 521,129,356 $1,498,125,311 $ 1,266,098,774

Total Operating Expenses $14,105,523,690

Percentage of Operating Expenses with Indirect Cost 10.62%

Percentage of Operating Expenses without Indirect Cost 8.98%

John M. Colmers Chairman

Herbert S. Wong, Ph.D.

Vice-Chairman

George H. Bone, M.D.

Stephen F. Jencks,

M.D., M.P.H.

Jack C. Keane

Bernadette C. Loftus, M.D.

Thomas R. Mullen

Donna Kinzer

Executive Director

Stephen Ports Principal Deputy Director

Policy and Operations

David Romans Director

Payment Reform and Innovation

Gerard J. Schmith Deputy Director

Hospital Rate Setting

Sule Calikoglu, Ph.D. Deputy Director

Research and Methodology

Health Services Cost Review Commission 4160 Patterson Avenue, Baltimore, Maryland 21215

Phone: 410-764-2605 · Fax: 410-358-6217 Toll Free: 1-888-287-3229

hscrc.maryland.gov

State of Maryland Department of Health and Mental Hygiene

TO: Commissioners FROM: HSCRC Staff DATE: September 9, 2015 RE: Hearing and Meeting Schedule

October 14, 2015 To be determined - 4160 Patterson Avenue

HSCRC/MHCC Conference Room November 18, 2015 To be determined - 4160 Patterson Avenue

HSCRC/MHCC Conference Room Please note that Commissioner’s binders will be available in the Commission’s office at 11:45 a.m.. The Agenda for the Executive and Public Sessions will be available for your review on the Thursday before the Commission meeting on the Commission’s website at http://www.hscrc.maryland.gov/commission-meetings-2015.cfm Post-meeting documents will be available on the Commission’s website following the Commission meeting.