Webinar Learning Session July 22, 2015
Welcome! We will get started at 1:05pm Today’s Learning Topic: Primary Care Transformation is happening NOW!
August 21st In-Person Learning Session Population Health Management: Why it matters, How it's done, What's next? Thank you for joining us to explore progress and Featured Speaker: lessons learned from the CMS-Comprehensive Pamela Peele, PhD, Chief Analytics Officer, Primary Care (CPC) initiative underway in University of Pittsburgh Medical Center Southwest Ohio. (UPMC) Health Plan Regional Panel CPC is the foundation for spreading patient David Applegate, MD, Chief, Primary Care centered medical homes aligned with publicTransformation, OhioHealth Physician Group private payment innovation as outlined in Ohio’s Arick Forrest, MD, Medical Director, State Innovation Model (SIM) grant. Ambulatory Services, The Ohio State University Wexner Medical Center Featured Speakers: Tricia Schmidt, Client Advocate, Willis of The Health Collaborative, Cincinnati, Ohio Ohio CMS-CPC Regional Learning Faculty Ben Shaker, Vice President and COO, Mount Richard Shonk, MD PhD Carmel Health Partners Chief Medical Officer King Stumpp, President and CEO, Netcare Barbara B Tobias, MD Access Medical Director Bruce Wall, MD, Senior Medical Director, Aetna www.hcgc.org
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Webinar Learning Session July 22, 2015
Please share your questions throughout the session by using the webinar chat feature, or by texting them to (614)906-2440
www.hcgc.org
COMPREHENSIVE PRIMARY CARE REGIONAL UPDATE Richard Shonk, MD PhD Chief Medical Officer
Barbara B Tobias, MD Medical Director
The Health Collaborative, Cincinnati, Ohio CMS-CPC Regional Learning Faculty
4
AN OVERVIEW
Proof of Concept
6
Source: CMS.gov
What is the Comprehensive Primary Care Initiative
• CPC is a multi-payer initiative fostering collaboration between public and private health care payers to
strengthen primary care. • Medicare is working with commercial and state health insurance plans to offer per member per month (PMPM) payments to primary care doctors to better coordinate care for their patients. • Primary care practices selected to participate in this initiative are provided payments, tools and other resources to better coordinate primary care for their patients.
CPC National Regions
CPC – Our region
Greater Cincinnati
1 of only 7 75 practices and 260 providers Multi- payer: 8 health plans + Medicare 220,000 estimated commercial, Medicaid and Medicare enrollees
chosen sites nationally
65 miles
from Williamstown, KY to Piqua, OH
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
10
CPC Change Diagram
The Health Collaborative Roles • Learning and Diffusion • Regional Convener • Data Aggregation
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CPC Provider Stakeholders
Generations Family Medicine Springfield Health Care Center Springfield Center for Family Medicine Maineville Family Physicians Lawrence P. Wang MD LLC
Family Practice Associates
CPC Payer Stakeholders
CPC Payment Model
Care management fee for Medicare beneficiaries
Shared Savings (2015-2016)
Care management fee for commercially insured
15
Total Care Management Payments to CPC Practices through 12/31/13
16
What payments did payers provide?
17
Annual Practice Milestones 1. Annual Budget 2. Care Management of High-Risk patients
3. Patient Access and Continuity 4. Assess and improve patient experience of care 5. Use data to guide improvement 6. Care coordination across the medical neighborhood 7. Improve patient shared decision-making 8. Participate in market based learning collaborative 9. Health Information Technology
PROGRESS TO DATE
CPC Milestone Highlights Care Management and Care Coordination • 84,000 patients receiving personalized care management • Post-Discharge and Emergency Department Visit follow-up
24/7 Access • All practices offering enhanced access via Patient portals, after hours call lines, structured phone visits, text messaging, eVisits
CPC Milestone Highlights Shared Decision Making • 8,700 shared decisions on Advance Care Planning • 42,000 shared decisions on Smoking Cessation
Patient Experience • Patient Family Advisory Councils • Office Survey Quality Improvement • Using data to guide improvements in care • Improving quality while reducing cost and inappropriate utilization
What data did payers provide?
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CPC National Y1 Results Control Group Comparison (October 2012-September 2013) Decreased hospital admissions by 2% Decreased emergency department visits by 3% Bulk of savings generated by patients in the highest-risk quartile Expenditures reduced enough to offset CMS Care Management fee Additional time and data needed to assess the impact on care quality
First 12 month findings caveats:
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An Initiative of the Center for Medicare & Medicaid Innovation Project Timeline: 2013-2016
Regional Data Transparency + Engaged Physicians = National Leaders in Primary Care Transformation
250 Providers
24/7 Access to Medical Record Shared Decision Making
Clinical Quality Improvement Care Management
84,000 Patients Received Care Management
42,000 Discussed Smoking Cessation Treatment Options
8,700 Discussed Advance Care Plan Options
9 Health Plans
Evidence-Based Care
Patient Experience
Population Health
Key Functions
220,000 Beneficiaries
Medicare Outcomes to Date Overall Hospital Admissions
-8%
Primary Care Treatable Admissions
-10%
Readmissions
-3%
Overall Expenditures
-3.4%
Data-Driven Improvement
Medicare Unadjusted Expenditure Trends
Medicare Unadjusted Expenditure Trends
Medicare Admission Trends
Medicare ACSC Admission Trends
What’s going on at the practice level? 4-Quarter Risk Adjusted Average Medicare Expenditures per Patient per Month-Practice related to Regional Expenditures $1,200
Practice Average-4-Quarter Risk Adjusted Average Medicare Expenditures per Patient per Month
$1,000
$800
Regional Average 4-Quarter Risk Adjusted Average Medicare Expenditures per Patient per Month
$600
$400
$200
$0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75
Webinar Learning Session July 22, 2015
Please share your questions throughout the session by using the webinar chat feature, or by texting them to (614)906-2440
www.hcgc.org
LESSONS LEARNED
Managing The Work of Relationships
1 2 3 4 5
A Neutral Space
Patient Centered Consumer Advocacy
Clinical Practices
Health Plans and Employers
Federal and State Government
Community Needs
Promote the consumer voice from the patient perspective Discern what access looks like when it is convenient Determine how information can be transmitted and made understandable
Provide practices with needed cost, quality and patient feedback views that permit them to manage the Triple Aim patient-by-patient and population-bypopulation Keep a constant eye on the administrative burden and unintended consequences to clinical workflow Identify best practices, subject matter experts, learning networks
Maintain alignment among payers regarding measurement, attribution and risk adjustment Avoid programs that undermine the pay for value incentive Maintain focus on clinical and cost outcomes Provide forum for aggregating data, analyzing trends and reporting results
A forum to advocate for necessary Policy, Accountability, and Standardization Liaison with government as payer/employer to maintain alignment
A forum for the community to address the health care system as a whole and not system-by-system Integrate Population Health initiatives into Comprehensive Primary Care approach
5 Essential Elements
Comprehensive Primary Care Drivers
1 2 3 4 5
Sustainable Prospective Care Management Payments
Clinical and Claims Data Aggregation: The "Five C's"
Avoiding Administrative Overload for Practices
Multi-payer approach Transparent payment and practice compensation models are critical for physician engagement and payer comfort
Consistent; standard measures Contiguous; tracked over time Comprehensive; a majority of practice's patient panel is included
Credible; timely, accurate, and usable; e.g. identifying high risk patients/patterns Cost/Quality Balance; measuring to manage value
Aligned: Similar Payment/financial model Attribution Risk adjustment Guidelines and goals
Physician/Provider/ Practice Culture
Care Coordination and Care Management
Investment up front – Infrastructure to convert a practice is costly Payment Models – gradual movement from FFS to value-based Critical Mass – over 50% of practice population covered by participating payers
Standardized: Same Metrics Reports Communication Format and Links Employers, Health Plans, and Government need to eliminate conflicting incentives for clinicians
Create ownership mentality; empowerment vs employment Integrate into workflow; if what we do distracts providers from patient care then we have failed
Identification of high risk patients for outreach and management.
Stakeholder recognition that primary care practice must be the quarterback for all care management for all entities that touch their attributed patients.
Incentives and rewards have to be palpable Willingness to change from physician autonomy to team-based care Delegation – team members practicing at highest extent of licensure A Call to Action: Recognition by educational and training programs that the availability of individuals competent in this role are at a premium today and will only grow as this approach to health care is expanded.
Comprehensive Primary Care Drivers
1 2 3 4 5
5 Important Elements
Timely Access
Actionable Tools
A Supportive Medical Neighborhood
Electronic Health Record Capability Supported by Health Information Exchange (HIE)
Patients need to connect easily to their Medical Home and their medical record via office, phone, email, virtual visits etc… Practices need to know when patients access other points of the health system.
Practices need cost, quality and patient feedback views that permit them to manage the Triple Aim patient-by-patient and population-by-population. Information needs to be less than three clicks away in the EHR. Behavioral Health Integration: co-management of common co-morbid mental health conditions; integration of behavioral components in selfmanagement of chronic disease. Specialist Care: warm hand offs; quality and cost information about hospitals and other providers
Reliable Programs and Outreach Efforts for the management of the patient’s medical and social needs Awareness of Population Health efforts within the community and how they can be integrated for their patients
Real time communication within the Medical Neighborhood Real time communication by and with the patient Transform health information exchange into health information knowledge
Structured Programs for Budgeting and Process Improvement
Payment upfront for value requires that a practice demonstrate credibly to payers that they can account for how value is generated and increased. Required process measures and their milestones need to be clear and aligned across payers.
OH/KY CPC Data Aggregation Project • Providers and Payers agreed contract with the Health Collaborative and jointly fund the effort • CMS now able to participate with its data • The Health Collaborative Powered by HealthBridge, subcontracts with OnPoint Health Data • All Health Plans submit claims data to develop aggregated reports
5-Year Goal for Payment Innovation Goal
State’s Role
Year 1
80-90 percent of Ohio’s population in some value-based payment model (combination of episodes- and population-based payment) within five years
▪ ▪ ▪
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 Primary
▪ State leads design of five episodes:
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
Appendix
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Process and Milestones Milestone #1: Budget Record actual CPC funding and expenditures from previous program year and complete annotated annual budget with anticipated revenue and spending for upcoming program year. Milestone #2: Provide care management for high-risk patients Empanel active patients to a provider/care team, stratify patients by risk status, and implement one or more of the following advanced primary care strategies: Behavioral Health Integration, Medication Management, and Self-Management Support for 3 high risk conditions. Milestone #3: 24/7 Access to medical record and continuity Expand access to medical record outside of office hours, implement an asynchronous form of communication, and measure visit continuity of patients with their empaneled provider. Milestone #4: Assess and improve patient experience of care Assess patient experience by conducting monthly practicebased surveys or convening a patient and family advisory council at least quarterly.
Milestone #5: Data-Driven Quality Improvement Use EHR Clinical Quality Metric (CQM) data to perform continuous quality improvement on 3 such measures and use health plan data to identify and reduce a high cost area. Milestone #6: Coordination Across the Medical Neighborhood Implement two of the following: Track % of patients receiving a followup call within 1 week of an ED visit, Contact at least 75% of patients discharged from target hospital(s) within 2 business days or 72hrs. Milestone #7: Shared Decision Making Use at least 3 decision aids to support shared decision making for preference-sensitive conditions and track the amount of eligible patients receiving those decision aids. Milestone #8: Participation in the Learning Collaborative Fully engage and cooperate with Regional Learning Faculty, participate in webinars and attend all CPC Learning Sessions in their region. Milestone #9: Health Information Technology All eligible professionals must work toward attestation of Meaningful Use stages 1 and 2 in the timelines set by the EHR incentive program.
• Process Measures/Milestones
Patients in CPC
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Aligned Measures List Survey-based Quality Measures Domain
NQF Measure Title Number 0005 CG-CAHPS: Getting Timely Care, Patient/Caregiv er Appointments, and Information; How Well Your Doctors Communicate; Patients' Experience Rating of Doctor; Access to Specialists; Health Promotion and Education; Shared Decision Making 0006 CAHPS: Health Status/Functional Status Patient/Caregiv er Experience
Measure Steward AHRQ
Rationale for Inclusion
AHRQ
CMS CPC Measure
Measure Steward NCQA
Rationale for Inclusion
AHRQ
CMS CPC Measure
AHRQ
CMS CPC Measure
AHRQ
CMS CPC Measure
HEDIS
Choosing Wisely
CMS CPC Measure
Claims-based Quality Measures Domain
Care Coordination Care Coordination
NQF Measure Title Number 1768 All-Cause Unplanned Readmission
N/A
Care Coordination
0275
Care Coordination
0277
Clinical Process/ Effectiveness
0058, 0052, N/A
Ambulatory Sensitive Conditions Admissions: Overall Composite (AHRQ Prevention Quality Indicator PQI #90) Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease (AHRQ Prevention Quality Indicator PQI #5 ) Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure (AHRQ Prevention Quality Indicator PQI #8 ) Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis, Imaging for Low Back Pain, and/or Imaging for Noncomplicated Headache
CMS CPC Measure
Aligned Measures List EHR-based Quality Measures Domain
NQF Number
Measure Title
Clinical Process/ Effectiveness
0018
Controlling High Blood Pressure
Population/ Public Health Clinical Process/ Effectiveness Clinical Process/ Effectiveness
0028 N/A
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Breast Cancer Screening
0034
Colorectal Cancer Screening
Population/ Public Health Clinical Process/ Effectiveness Clinical Process/ Effectiveness Clinical Process/ Effectiveness Clinical Process/ Effectiveness Clinical Process/ Effectiveness Patient Safety
0041
Preventive Care and Screening: Influenza Immunization
0043
Pneumonia Vaccination Status for Older Adults
0059
Diabetes: Hemoglobin A1c Poor Control
0064
Diabetes: Low Density Lipoprotein (LDL) Management
0075
Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Falls: Screening for Future Fall Risk
Population/ Public Health
0418
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Patient Safety
0419
Documentation of Current Medications in the Medical Record
*Practices Report 9 of 13
0083 0101
OH/KY Data Aggregation Measures Claims-based Quality Measures Domain
Care Coordination Care Coordination
NQF Number
Measure Steward
Rationale for Inclusion
1768
N/A
Care Coordination
0275
Care Coordination
0277
Clinical Process/ Effectiveness
Measure Title
All-Cause Unplanned Readmission
NCQA
NCQA PCR Measure
Ambulatory Sensitive Conditions Admissions: Overall Composite (AHRQ Prevention Quality Indicator PQI #90)
AHRQ
CMS CPC Measure
Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease (AHRQ Prevention Quality Indicator PQI #5 )
AHRQ
CMS CPC Measure
Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure (AHRQ Prevention Quality Indicator PQI #8 )
AHRQ
CMS CPC Measure
LBP Use of Imaging Studies for Low Back Pain
HEDIS
HEDIS
OH/KY Data Aggregation Measures Cost and Utilization Measures Source
Measure Title
IHA P4P Manual claims claims
Total Cost PMPY
IHA P4P Manual claims
Inpatient PMPY
IHA P4P Manual claims
Emergency Department PMPY
IHA P4P Manual claims
Hospital discharges/1000
IHA P4P Manual claims
Hospital days/1000
IHA P4P Manual claims
ED Visits/1000
Total Prescription PMPY
claims PCP visits/1000 and PCP Cost PMPY claims Specialist visits/1000 and Specialty Costs PMPY
Webinar Learning Session July 22, 2015
Please share your questions throughout the session by using the webinar chat feature, or by texting them to (614)906-2440
www.hcgc.org
Webinar Learning Session July 22, 2015
Thanks to Dr. Shonk and Dr. Tobias for sharing learning from SW Ohio! Please respond to a brief online survey! Please join us on August 21st. Register at www.hcgc.org
www.hcgc.org
August 21st In-Person Learning Session Population Health Management: Why it matters, How it's done, What's next? Featured Speaker: Pamela Peele, PhD, Chief Analytics Officer, University of Pittsburgh Medical Center (UPMC) Health Plan Regional Panel David Applegate, MD, Chief, Primary Care Transformation, OhioHealth Physician Group Arick Forrest, MD, Medical Director, Ambulatory Services, The Ohio State University Wexner Medical Center Tricia Schmidt, Client Advocate, Willis of Ohio Ben Shaker, Vice President and COO, Mount Carmel Health Partners King Stumpp, President and CEO, Netcare Access Bruce Wall, MD, Senior Medical Director, Aetna