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Comprehensive Primary Care: Where we are, What we’ve learned Richard Shonk, MD Chief Medical Officer Barb Tobias, MD Director of Ambulatory Improvement
5-Year Goal for Payment Innovation Goal
80-90 percent of Ohio’s population in some value-based payment model (combination of episodes- and population-based payment) within five years
▪ State’s Role ▪ ▪
Year 1
Shift rapidly to PCMH and episode model in Medicaid fee-for-service Require Medicaid MCO partners to participate and implement Incorporate into contracts of MCOs for state employee benefit program
Patient-centered medical homes
Episode-based payments
▪ In 2014 focus on Comprehensive
▪ State leads design of five episodes:
Primary Care Initiative (CPCi)
▪ Payers agree to participate in design for elements where standardization and/or alignment is critical
▪ Multi-payer group begins enrollment strategy for one additional market
Year 3 Year 5
▪ ▪ ▪ ▪
Model rolled out to all major markets 50% of patients are enrolled Scale achieved state-wide 80% of patients are enrolled
asthma (acute exacerbation), perinatal, COPD exacerbation, PCI, and joint replacement
▪ Payers agree to participate in design process, launch reporting on at least 3 of 5 episodes in 2014 and tie to payment within year
▪ 20 episodes defined and launched across payers
▪ 50+ episodes defined and launched across payers
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Where We’ve Been & Where We’re Headed 1997
Health Information Exchange Comprehensive Primary Care (CPC) Initiative
Medical Home Pilot Multi payer claims data
Qualified Entity
2009
2011
2008 2010 Public Reporting (Bethesda)
Community Quality Improvement (AF4Q)
CPC data
2013
2012
Electronic Medical Record (REC)
State Innovation Model
Data/Information (Beacon)
All payer claims data
2015
Local PCMH Results IMPROVING PRIMARY CARE THROUGH PCMH 2008
2012
Emergency Room Visits per 1000 Members
Hospital Admissions per 1000 Members
PCMH PILOT
PCMH PILOT 119
54 36
106 NON-PCMH MATCHED COHORT 132 139
NON-PCMH MATCHED COHORT 54 67
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Components of CPC
PCMH Transforming primary care through milestone process measures and clinical quality outcomes metrics
Payment Reform
Data Collection
Payment Reform to align payment to outcomes – Comprehensive Primary Care initiative
Building a robust database
PCMH + Payment Reform
Greater Cincinnati
1 of only 7 75 practices and 261 providers Multi- payer: 9 health plans + Medicare 300,000 estimated commercial, Medicaid and Medicare enrollees
chosen sites nationally
65 miles
from Williamstown, KY to Piqua, OH
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A Role We Play: Multi-Stakeholder Convener • • • • • • • •
Monthly Meetings Data Workgroup Employer Group/ASO Provider Group One-on-one payer calls Payer Meetings Data Aggregation Other Work Groups as needed
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Year 1 – 2013 Accomplishments: A Building Year Q1 Quality Metrics Established Q2 Standard Attribution Reports and Claims Data Reporting Definitions Q3 CG CAHPS survey by CMS decided Q4 Milestone Completion Empanelment+ Risk Stratification+ Care Management initiated
Q4 Testing “Practice Level” EHR Quality Reporting Capabilities
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Aligned Quality Measures Survey-Based Quality Measures
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Aligned Quality Measures Claims-Based Quality Measures
2014 CPC EHR Clinical Quality Measure Set CMS ID & Ver. NQF #
Clinical Quality Measure Title
Domain
165v2
0018
Controlling High Blood Pressure
Clinical Process/ Effectiveness
138v2
0028
Tobacco Use: Screening and Cessation Intervention
Population/ Public Health
125v2
00311
Breast Cancer Screening
Clinical Process/ Effectiveness
130v2
0034
Colorectal Cancer Screening
Clinical Process/ Effectiveness
147v2
0041
Preventive Care and Screening: Influenza Immunization
Population/ Public Health
122v2
0059
Diabetes: Hemoglobin A1c Poor Control
Clinical Process/ Effectiveness
163v2
0064
Diabetes: Low Density Lipoprotein (LDL) Management
Clinical Process/ Effectiveness
182v3
0075
Ischemic Vascular Disease :Lipid Panel and LDL Control
Clinical Process/ Effectiveness
144v2
0083
Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction
Clinical Process/ Effectiveness
139v2
0101
Falls: Screening for Future Fall Risk
Patient Safety
2v3
0418
Screening for Clinical Depression and Follow-Up Plan
Population/ Public Health
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A Role We Play: Learning and Diffusion • • • • • • • • • •
Webinars Independent Meetings Care Manager Meetings System Meeting In-practice support 3 day long Learning Sessions/Year Leadership Track Milestone Review Newsletters Phone support
Practice Transformation: Milestones Care Management 24/7 Patient Access Patient Experience Focus Quality Improvement Focus Quality Measure Utilization Measure
Care Coordination Patient Engagement Learning Collaborative Participation Health Information Technology
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Projected Milestone Completion What they thought they could do
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Year 1 Milestone Submission What they did National Oregon Oklahoma Ohio Milestones
New York New Jersey Colorado Arkansas 90%
92%
94%
96%
98%
100%
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Practice Challenges/Opportunities Administrative/Reporting Burden Multiple Payers and Contracts Empanelment Risk Stratification
Risk Adjustment
Operationalizing Care Transformation Across the System Physician and Staff Engagement Expanded Care Management – Multiple Care Mgrs Milestone 2 Sustainable Change
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3Cs to Sustainable Transformation From the physician perspective‌
Culture Confidence
Consumer Engagement
Transformation
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Convening Challenges/ Opportunities Attribution Migration of membership Empanelment Medium Data for Process Improvement Shared Savings Methodology Employer Engagement (especially self funded) Sustainable Change
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Before we get to shared savings‌ What about the $15 million already invested in the first year? • Where is the evidence that the money is being well invested? Can we provide confidence that the initiative is on track and metrics can be captured? • When do we anticipate the first data reports? Do practices have what they need to deliver the results anticipated?
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CPC Vision vs. Payer-Provider Reality Fee for Service
Pay for Value - BARRIER -
Providers Lack Cost Data
Payers Lack Clinical Quality Data
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Implications of the State Innovation Model A Primary Care Practice is becoming the new functional unit of health care As Team Based care becomes dominant in the practice Accountable Care is managed more by the care team; Outcomes become less dependent on the individual physician Attribution of the patient to the practice is more important than attribution to the physician. Payment for Value has to be Made and Measured at the practice level for PCMH Expansion (& Episode of Care Payments)
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All Payer Claims Database Becoming More of a Necessity Need for a neutral, trusted, local source of truth - no one payor or provider has the whole picture Payment is proceeding toward “payment for value” away from “fee for service” necessitating a community-wide view of cost and utilization for decision support and benchmarking Consistent and continuous methodology is needed to monitor progress year over year
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Efficiencies of a Regional APCD Neutral Entity Robust Analysis of Providers’ Performance Utilization data on Patients/Members Applies to Multiple Stakeholders and Research Projects Avoids Redundant Submission of Data One Data Governance Authority Streamlined Legal Processes
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CPC Alignment with Qualified Entity & All Payer Claims Database (APCD) Readily Scalable Across our Community & Ohio APCD Development •
Active Payer and Provider Contracts with Health Collaborative & HealthBridge
•
Established Infrastructure for Data Aggregation of Claims & Clinical Data
•
Regional Data Governance Committee and Data Security
•
CMS Qualified Entity & Access to Statewide
•
Medicare Claims Data for OH, KY, IN Alignment across Ohio on S2MU, SIM, APCD
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Multiple Applications Comprehensive Primary Care State Innovation Model Collective Impact Quality Improvement Organization Intelligent Health Plan design Wherever data is needed
OHIO SIM GOALS: 2015 A CRITICAL YEAR 1. CMS expands in Ohio: If CPC successful ACA allows HHS Secretary to expand it in 2015 2. Secure federal SIM grant: If SIM grant awarded the design calls for rapid expansion in 2015 3. APPCCD: Infrastructure for an All Providor/Payor Clinical/Claims Data base possible in 2015 4. Statewide HIE: Agreements between HealthBridge and OHIP in place; operational in 2015 5. Aligned Inter-Collaborative Activities: alignment to integrate clinical data with claims data in 2015; build on partnership within QIO