july 22nd learning session slides

Webinar Learning SessionJuly 22, 2015

www.hcgc.org

Welcome! We will get started at 1:05pmToday’s Learning Topic: Primary Care Transformation is happening NOW!

Thank you for joining us to explore progress and lessons learned from the CMS-Comprehensive Primary Care (CPC) initiative underway in Southwest Ohio.

CPC is the foundation for spreading patient-centered medical homes aligned with public-private payment innovation as outlined in Ohio’s State Innovation Model (SIM) grant.

Featured Speakers: The Health Collaborative, Cincinnati, OhioCMS-CPC Regional Learning Faculty Richard Shonk, MD PhD

Chief Medical Officer Barbara B Tobias, MD

Medical Director

August 21st In-Person Learning SessionPopulation 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

Lead Supporter

Major Supporters

Individual & CorporateDonations

100% of our Board of Directors

& Staff

Additional Supporters

Our Public-Private Funding Partners

Clarity Consultancy Services, our social enterprise subsidiary


www.hcgc.org

Please share your questions throughout the session by using the webinar chat feature, or by

texting them to (614)906-2440

COMPREHENSIVE PRIMARY CARE

REGIONAL UPDATE

4

Richard Shonk, MD PhD Barbara B Tobias, MD

Chief Medical Officer Medical Director

The Health Collaborative,

Cincinnati, Ohio

CMS-CPC Regional Learning Faculty

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

Greater Cincinnati

1 of only 7chosen sites nationally

65 miles from

Williamstown, KY to Piqua, OH

75 practices and

260 providers

Multi- payer:

8 health plans +

Medicare

220,000 estimated

commercial,

Medicaid and

Medicare enrollees

CPC – Our region

Components of CPC

10

PCMH

Transforming

primary care

through

milestone

process

measures and

clinical quality

outcomes

metrics

PaymentReform

Payment

Reform to align

payment to

outcomes –

Comprehensive

Primary Care

initiative

Data Collection

Building a

robust

database

CPC Change Diagram

The Health Collaborative Roles

• Learning and Diffusion

• Regional Convener

• Data Aggregation

12

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

15

Shared Savings

(2015-2016)

Care management fee for commercially

insured

Care management

fee for Medicare

beneficiaries

CPC Payment Model

Total Care Management Payments to CPC Practices through 12/31/13

16

What payments did payers provide?

17

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

Annual Practice Milestones

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

Quality Improvement

• Using data to guide improvements in care

• Improving quality while reducing cost and

inappropriate utilization

Patient Experience

• Patient Family Advisory Councils

• Office Survey

CPC Milestone Highlights

Shared Decision Making• 8,700 shared decisions on Advance Care

Planning

• 42,000 shared decisions on Smoking

Cessation

What data did payers provide?

22

CPC National Y1 ResultsControl Group Comparison

(October 2012-September 2013)

Bulk of savings generated by patients

in the highest-risk quartile

Expenditures reduced enough to

offset CMS Care Management fee

Decreased hospital admissions by 2%

Decreased emergency department visits by

3%

Additional time and data needed to

assess the impact on care quality

First 12 month findings caveats:

24

An Initiative of the Center for Medicare & Medicaid InnovationProject Timeline: 2013-2016

250 Providers 9 Health Plans220,000 Beneficiaries

Regional Data Transparency + Engaged Physicians = National Leaders in Primary Care Transformation

42,000Discussed Smoking Cessation TreatmentOptions

8,700 Discussed Advance Care Plan Options

Ev

ide

nc

e-B

ase

d C

are

Overall

Hospital

Admissions

Primary Care

Treatable

Admissions

Readmissions

Overall

Expenditures

-8%

-10%

-3%

-3.4%

Data-Driven Improvement

Patient Experience

24/7 Access to Medical Record

Shared Decision Making

Clinical Quality Improvement

Care Management

Medicare Outcomes to Date

Po

pu

lati

on

He

alt

h

Ke

y F

un

cti

on

s 84,000Patients Received Care Management

Medicare Unadjusted Expenditure Trends

Medicare Admission Trends

Medicare ACSC Admission Trends

What’s going on at the practice level?

$0

$200

$400

$600

$800

$1,000

$1,200

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

4-Quarter Risk Adjusted Average Medicare Expenditures per Patient per Month-Practice related to Regional Expenditures

Practice Average-4-QuarterRisk Adjusted AverageMedicare Expenditures perPatient per Month

Regional Average 4-QuarterRisk Adjusted AverageMedicare Expenditures perPatient per Month


www.hcgc.org



LESSONS LEARNED

A N

eu

tral S

pa

ce

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-by-

population

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

Managing The Work of Relationships

12345

Patient Centered

Consumer Advocacy

Clinical

Practices

Health Plans

and Employers

Federal and State

Government

Community Needs

5 E

sse

nti

alE

lem

en

ts 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

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

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

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

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.

A Call to Action:

Recognition by educational and trainingprograms 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.

1Comprehensive Primary Care Drivers

Sustainable

Prospective Care

Management

Payments

2Clinical and Claims

Data Aggregation:

The "Five C's"

3Avoiding

Administrative

Overload for

Practices

4Physician/Provider/

Practice Culture

5Care Coordination

and Care

Management

5 Im

po

rta

nt

Ele

me

nts

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 self-

management 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

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.

Comprehensive Primary Care Drivers

12345

Timely Access

Actionable

Tools

A Supportive

Medical

Neighborhood

Electronic Health

Record Capability

Supported by

Health Information

Exchange (HIE)

Structured Programs

for Budgeting and

Process

Improvement

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

Patient-centered medical homes Episode-based payments

Goal 80-90 percent of Ohio’s population in some value-based payment model (combination of episodes- and population-based payment) within five years

Year 1 ▪ In 2014 focus on Comprehensive 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

▪ State leads design of five episodes:

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

▪ Model rolled out to all major markets

▪ 50% of patients are enrolled

▪ 20 episodes defined and launched across payers

▪ Scale achieved state-wide

▪ 80% of patients are enrolled

▪ 50+ episodes defined and launched across payers

State’s Role▪ 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

5-Year Goal for Payment Innovation

Appendix

38

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 practice-

based surveys or convening a patient and family advisory council

at least quarterly.

• Process

Measures/Milestones

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 follow-

up 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.

Patients in CPC

40

Aligned Measures List

Domain NQF

Number

Measure Title Measure

Steward

Rationale for Inclusion

Patient/Caregiver

Experience

0005 CG-CAHPS: Getting Timely Care,Appointments, and Information; How Well Your Doctors Communicate; Patients'Rating of Doctor; Access to Specialists; Health Promotion and Education; Shared Decision Making

AHRQ CMS CPC Measure

Patient/CaregiverExperience

0006 CAHPS: Health Status/Functional Status AHRQ CMS CPC Measure

Domain NQF

Number


Steward


CareCoordination

1768 All-Cause Unplanned Readmission NCQA CMS CPC Measure

CareCoordination N/A

Ambulatory Sensitive Conditions Admissions: Overall Composite (AHRQ Prevention Quality Indicator PQI #90)


CareCoordination

0275 Ambulatory Sensitive ConditionsAdmissions: Chronic Obstructive Pulmonary Disease (AHRQ Prevention Quality Indicator PQI #5 )


CareCoordination

0277 Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure(AHRQ Prevention Quality Indicator PQI#8 )


Clinical Process/Effectiveness

0058, 0052,N/A

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis, Imaging for Low Back Pain, and/or Imaging for Non-complicated Headache

HEDIS Choosing Wisely

Survey-based Quality Measures

Claims-based Quality Measures

Aligned Measures List

EHR-based Quality Measures

Domain NQF Number Measure Title


0018 Controlling High Blood Pressure

Population/Public Health

0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention


N/A Breast Cancer Screening


0034 Colorectal Cancer Screening


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


0083 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Patient Safety 0101 Falls: Screening for Future Fall Risk


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

Domain NQF

Number


Steward


Care

Coordination

1768

All-Cause Unplanned Readmission NCQA NCQA PCR Measure

Care

Coordination N/A Ambulatory Sensitive Conditions

Admissions: Overall Composite (AHRQ

Prevention Quality Indicator PQI #90)


Care

Coordination

0275

Ambulatory Sensitive Conditions

Admissions: Chronic Obstructive

Pulmonary Disease (AHRQ Prevention

Quality Indicator PQI #5 )


Care

Coordination

0277

Ambulatory Sensitive Conditions

Admissions: Congestive Heart Failure

(AHRQ Prevention Quality Indicator

PQI #8 )


Clinical

Process/

Effectiveness

LBP Use of Imaging Studies for Low

Back Pain

HEDIS HEDIS

Claims-based Quality Measures

OH/KY Data Aggregation Measures

OH/KY Data Aggregation Measures

Cost and Utilization Measures

Source Measure Title

IHA P4P Manual claims

Total Cost PMPY

claims Total Prescription PMPY

IHA P4P Manualclaims

Inpatient PMPY


Emergency Department PMPY


Hospital discharges/1000


Hospital days/1000

IHA P4P Manual claims

ED Visits/1000

claimsPCP visits/1000 and PCP Cost PMPY

claimsSpecialist visits/1000 and Specialty Costs PMPY


www.hcgc.org




www.hcgc.org

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

August 21st In-Person Learning SessionPopulation 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

july 22nd learning session slides

Documents