Arkansas Health Care Payment Improvement Initiative: 2 nd Annual Statewide Tracking Report

Transcription

1 Arkansas Health Care Payment Improvement Initiative: 2 nd Annual Statewide Tracking Report January 2016 Participating Payers: Prepared by: A nonpartisan, independent, health policy center that serves as a catalyst to improve the health of Arkansans.

2 Acknowledgements The staff at the Arkansas Center for Health Improvement (ACHI) appreciate the opportunity to work with individuals leading the implementation of the. The production of this report would not have been possible without the efforts of: The Arkansas Department of Human Services, Division of Medical Services staff including Lee Clark, Sharon Donovan, William Golden, MD, Kiral Gunter, Brandi Hinkle, Lech Matuszewski, Maggie Newton, Sheila Nix, Anne Santifer, Dawn Stehle, Shelley Tounzen, David Walker, Michelle Young-Hobbs and other members of the Arkansas Medicaid team. General Dynamics Health Solutions staff including Jane Gokun, Marlo Harris, Nena Sanchez,and E.J. Shoptaw. Arkansas Blue Cross and Blue Shield Staff including Alicia Berkemeyer, Matt Flora, David Greenwood, Randal Hundley, MD, Steve Spaulding, and Sarah Wang among others. QualChoice staff including Mark Johnson, Lubna Maruf, MD, and Stephen Sorsby, MD. ACHI staff including Michael Motley, Debra Pate, Leah Ramirez, and Joseph W. Thompson, MD, MPH. This report was made possible in part by grant funding from Walmart. Contact Information: For general inquiries please contact: Mike Motley, MPH Interim Director, Health Care System Transformation Arkansas Center for Health Improvement 1401 West Capitol Avenue, Suite Victory Building Little Rock, AR mwmotley@uams.edu For Arkansas Blue Cross and Blue Shield Inquiries: APIIcustomersupport@arkbluecross.com For Medicaid Inquiries: Christine (Tina) Coutu Business Operations Manager DHS - Division of Medical Services P. O. Box 1437, Slot S416 Little Rock, AR Desk Mobile Christine.Coutu@dhs.arkansas.gov Suggested citation: Arkansas Center for Health Improvement,, 2 nd Annual Statewide Tracking Report, Little Rock, AR: ACHI, January 2016 Page 2

3 Table of Contents Page Executive Summary 4 Introduction 9 Patient-Centered Medical Homes Arkansas PCMH Progress Overview Commercial Payer PCMH Support 14 PCMH Practice Transformation Milestone Progress 14 PCMH Quality Metric Outcomes for Medicaid 15 Hospital and Emergency Department Utilization Impacts 16 PCMH Financial Outcomes for Medicaid 17 Provider Response to Shared Savings 18 Episodes of Care Provider Spotlight: Episodes of Care Overview of Episode Results 21 Conclusion 28 Appendix A Patient-Centered Medical Home Case Study: Aligning Incentives and Rewarding Innovative Collaboration (Regional Family Medicine, Mountain Home, Arkansas) Appendix B Patient-Centered Medical Home Fact Sheet: Shared Savings Update Appendix C Episodes of Care Detailed Report Page 3

4 Executive Summary Statewide, multi-payer implementation of Arkansas s Health Care Payment Improvement Initiative (AHCPII) has positioned Arkansas as a national leader in value-based health care innovation. Since the first components were launched in the summer of 2012, AHCPII has supported and incentivized delivery of highquality, efficient care for a large and increasing number of the state s citizens. As a key part of the state s total health system transformation effort, the AHCPII has fortified broad goals that include improving quality, expanding access, and avoiding unnecessary costs. Arkansas was one of only six states awarded an initial State Innovation Model Testing grant by the Centers for Medicare and Medicaid Services, receiving $42 million in federal funds to implement the AHCPII. AHCPII now has a strong foothold across the state through deployment of two primary strategies: Patient-centered medical homes (PCMH), designed to improve quality and contain costs by supporting the delivery of bettercoordinated, team-based care; a and a retrospective episodes of care model, designed to improve quality and reduce variation in treatment of acute conditions and delivery of specialty procedures. A third component, originally introduced in 2012 by Arkansas DHS was a Health Home model a client-based support strategy for individuals with needs exceeding the traditional medical home model. The health home strategy proposed to optimize coordination of services for those individuals, including the frail elderly, the severe and persistently mentally ill, and the developmentally disabled. These populations represent a large proportion of the state s overall Medicaid expenditure. As a Medicaid-only component of the AHCPII, the model has been met with challenges from both the provider community and other stakeholders and has not been implemented. The state is currently weighing alternative options to improve delivery of high-quality and efficient care to these special needs populations and through their deliberations may choose to pursue components of the Health Home model. The AHCPII has the strength of multiple payer engagement with the participation of a majority of the state s health care payers including Arkansas Medicaid, Blue Cross and Blue Shield (AR BCBS), QualChoice (QC), Centene, and United Healthcare, along with Walmart, the State and Public School Employee benefits program, and other self-funded employers. Support for AHCPII includes a broader team of individuals at the Arkansas Department of Human Services, Hewlett-Packard, General Dynamics Health Solutions, Arkansas Foundation for Medical Care, Qualis Health, and the Advanced Health Information Network, among others. As a result of continued progress and demonstrated success, additional payers have shown interest in joining the AHCPII. Importantly, leaders at the Center for Medicare & Medicaid Innovation (CMMI) have acknowledged the success of Arkansas s model and approached the state regarding expanding the program to include federal support for the approximately 71,000 Medicare beneficiaries in the state s PCMH program. As additional practices enroll, more of the state s 400,000 Medicare Part A and B beneficiaries could be served in a PCMH. CMMI has committed to assisting the state in exploring this opportunity one that, if successful, would make Arkansas only the second state in the nation (behind Maryland) to receive a Federal Medicare waiver for a state-specific, value-based model. AHCPII progress as well as quality and cost impacts are captured in this second annual AHCPII Statewide Tracking Report. The Arkansas Center for Health Improvement (ACHI) has worked with individual payers and providers to gather content for development of this report, designed to track progress and to help identify challenges and lessons learned. a To view a comprehensive video about AHCPII, visit Page 4

5 Patient-Centered Medical Homes (PCMH) b This multi-payer, team-based primary care strategy has received legislative support and been adopted widely by providers across the state. Primary care clinics are given responsibility for total cost of care for their panel of patients and receive upside gain-sharing if they meet quality metrics and bring total costs under preset thresholds. Provider enrollment in the program is voluntary. The Medicaid PCMH results depicted in this report are for beneficiaries that are managed by Arkansas Medicaid and do not include results for those beneficiaries who are covered under a commercial qualified health plan (QHP). Results from the QHP beneficiary PCMH experience are anticipated to be available for inclusion in the next annual Statewide Tracking Report. PCMH Highlights Medicaid has more than 80 percent of its beneficiaries under this model. In 2014, Medicaid realized $34.3 million in direct cost-avoidance through trend reduction. Of the $34.3 million in savings, $12.1 million went toward care coordination payments to providers. The remaining $22.2 million in net cost avoidance was shared between the state and those providers who met both quality and cost savings requirements. Shared savings checks were issued in October 2015, with several clinics receiving over $100,000. In 2014, enrolled practices experienced a cost decrease of 1.2 percent, beating both the 2.6 percent benchmark trend increase and the 0.6 percent cost growth of non-participating practices. b Medicaid PCMH data provided by Arkansas DHS, pulled from PCMH Q4 reporting as of December 10, Enrollment figures include practices that enrolled for 1/1/14, 7/1/14 and 1/1/15 start dates. Commercial carrier data provided by individual carriers. Page 5

6 In 2014, the vast majority of practices met transformation milestones and either improved or maintained prior-year levels for 78 percent of PCMH quality metrics. Quality metrics include: increased pediatric wellness visits, Hemoglobin A1c testing, breast cancer screenings, improved Attention Deficit Hyperactive Disorder (ADHD) management, and thyroid medication management. AR BCBS has recognized value and extended attribution of patients to all of its covered lives; AR BCBS has publicly stated intent to increase payment to primary care through markedly increased per-member per-month (PMPM) payments and hold/reduce fee-for-service (FFS) payments for services rendered over time. The federal Medicare program has approached the state to expand their participation to all Medicare beneficiaries (participation is currently limited to the original 69 clinics in the Comprehensive Primary Care Initiative). Arkansas would be only the second state for which Medicare has modified national payment strategies to support local payment transformation. Qualified health plans operating on the insurance exchange and dual-specialized needs managed care plans are required to participate in the state PCMH program by either legislative or regulatory requirements. Performance target requirements for a proportion of hypertensive and diabetic individuals under clinical control are proposed to explicitly link population health needs and clinical performance expectations. Enrollment for Arkansas Medicaid (as of October 2015): 136 practices are participating out of 263 eligible (52%). For 2016, Medicaid will continue recruitment of new practice participants as will both AR BCBS and Ambetter. 780 primary care providers are participating (69% of eligible Medicaid providers) 331,000 eligible Medicaid beneficiaries are covered under the state PCMH program (82%) Enrollment for Commercial Carriers: (PCMH beneficiary attribution is still underway for the commercial carriers. These are estimates for the number of attributed beneficiaries for each payer) AR BCBS: 157,000 attributed beneficiaries QC: 4,300 attributed beneficiaries c Centene / Ambetter: 44,000 eligible beneficiaries (final attribution numbers pending) United Healthcare: United is offering a QHP and will attribute members in 2016 Enrollment for Self-Insured Payers: Self-insured payers are also participating in the program, with an anticipated increase in 2016 and beyond. Two of the largest self-insured participants are Walmart and Arkansas State Employee and Public School Employee (ASEPSE) Plans, each with substantial numbers of employees served under a PCMH: Walmart: ~21,000 beneficiaries Arkansas State Employees and Public School Employees: ~30,000 beneficiaries c Data provided by QualChoice in October Page 6

7 Retrospective Episodes of Care This model to improve quality and efficiency and eliminate variation has achieved both quality enhancement and cost-saving goals. Since 2013 there have been 14 types of episodes launched with new episode development focused primarily in the areas of surgical intervention and hospitalization management. While employers, consumers, and the state strive to optimize the value of their health care expenditures, Arkansas s episodes of care model puts the clinical leader in charge and aligns incentives to achieve the highest quality at the lowest cost. In an ongoing coordinated effort that includes close involvement with providers and other stakeholders, Arkansas Medicaid, AR BCBS, and QC all participate in the episodes model. Providers benefit from consistent incentives and reporting tools across payers. Together these payers cover a majority of Arkansas citizens, generating enough scale to promote change in practice patterns. Medicaid has achieved quality improvements and cost avoidance d Perinatal: C-section rate reduced from 39 percent to 34 percent, with an estimated 2-4 percent direct savings to date. URI: 17 percent reduction in antibiotic prescriptions; episode costs remained flat despite a 10 percent increase in drug prices. ADHD: Average episode cost fell by 22 percent, with 400 providers contacted by Medicaid regarding appropriate stimulant prescribing. Total Joint Replacement: Number of episodes down from 141 to 101; 30-day all-cause readmission rate reduced from 3.9 percent to 0 percent; estimated 5-10 percent direct savings to date. The most recent gain and risk sharing calculations from finalized episodes resulted in 648 providers receiving gain-share payments totaling $642,200 and 605 providers deemed eligible for risk sharing totaling $710,034. AR BCBS reported that this year they will pay out nearly $1.3 million in shared savings with approximately $250K being recovered in the form of risk-sharing payments. d Data provided by Arkansas DHS/Medicaid. Information was presented by Arkansas Medicaid Director Dawn Stehle to the Arkansas Legislative Health Care Task Force on July 16 th, Page 7

8 Following Arkansas s lead, Medicare has now implemented its own version of mandatory episodes for hip and knee replacement in 50 market areas nationally inclusive of Hot Springs and Memphis e. Implementation of Episodes for Specialty, Surgical and Hospital Care Additional episodes of care were launched by AR BCBS in January 2015, including Percutaneous Coronary Intervention (PCI), Coronary Artery Bypass Grafting (CABG), Asthma, and Chronic Obstructive Pulmonary Disease (COPD). Medicaid and AR BCBS are considering potential development of additional episodes including appendectomy, pediatric pneumonia, hysterectomy, and urinary tract infection (when an ER visit is involved). AR BCBS is also reviewing tympanostomy (ear tube procedure) for possible episode development. Experience from episode analysis is aiding in the creation of chronic disease profiles, which can be used by PCMHs in coordinating care for high risk patients as they pursue per member, per year cost curve management. System Infrastructure Development The episode and PCMH models would not be possible without development of an advanced analytic infrastructure allowing participating payers to process large amounts of data. This analytic capability has been developed including a multi-payer portal on a common platform, enabling production of quarterly reports to providers. These new tools detail utilization and quality indicators to support better decision making and improved clinical outcomes. A large and increasing number of providers have accessed their reports: Approximately 500 million medical claims have been processed through the analytic engines for both episodes and PCMH. For episodes, those claims resulted in over 3.78 million episodes. As of October 2015, for episodes 31,781 reports were delivered to 2,252 distinct principal accountable providers (PAP). f Through September 2015, for PCMHs 1,918 reports have been provided to practices. Today, the state s Medicaid growth rate is relatively flat, the PCMH program has demonstrated quality improvements and system savings, private payers have reported quality improvements and cost avoidance in episodes of care, and providers and patients are benefitting from practice support and improvements in quality of care. While results are encouraging, early challenges have helped identify opportunities to improve the AHCPII. Continued engagement and input from providers, patients, state leaders, and others is necessary to sustain progress of this initiative. e f Reporting totals provided by Arkansas DHS, October 2015 Page 8

9 Introduction In 2011, Arkansas, like other states, faced an increasingly fragmented health care system and escalating costs that threatened to exceed available revenue. With growing concern for the value of health care expenditures in both public and private sectors, the State of Arkansas, through its Department of Human Services (DHS), convened its Medicaid program and the two largest commercial carriers Arkansas Blue Cross and Blue Shield (AR BCBS) and QualChoice (QC) to develop an initiative to transform the Arkansas health care payment system to a value-based purchasing model. From this convening, the collaborative effort known as the (AHCPII) was established. Arkansas Medicaid (Medicaid), AR BCBS, and QC have worked in concert with hundreds of physicians, hospital executives, patients, and advocates in designing, building, and implementing Arkansas s new payment and delivery system. More recently, Centene /Ambetter (CAM) and United Healthcare, along with self-insured employers including Walmart and the State and Public School Employee Benefits Program have joined and are participating in the initiative. The result is a bold statewide innovation tailored to the needs of Arkansas patients and providers. The AHCPII is designed to improve on the traditional fee-for-service (FFS) system by rewarding physicians, hospitals, and other providers that deliver high-quality care in an optimally efficient manner. Strategies to align financial incentives through structured provider payments across all payers result in consistent, large-scale support that enables providers to transform their practices and achieve desired outcomes. To view a comprehensive video about the AHCPII produced by the Arkansas Center for Health Improvement (ACHI), please visit The AHCPII incorporates two complementary strategies. First is the commitment to support a robust patient-centered medical home (PCMH) model. Through team-based preventive care and coordinated chronic disease management along with increased information and responsibility for the total experience of care, the PCMH is positioned to optimize appropriate patient utilization of services and guide referrals to the highest-value specialty providers. With design and implementation led by Medicaid, the expansion of the PCMH model throughout the state has exceeded enrollment expectations. In 2015, additional payers, Including AR BCBS, QC, and Centene/Ambetter have begun or expanded their participation in Arkansas s PCMH model, and United Healthcare will engage in the PCMH model in Complementing the PCMH model is the second major component Arkansas s retrospective episodes of care model for acute conditions that require care coordination and a more intensive use of resources. In an episode of care, a principal accountable provider (PAP) is identified to manage quality, minimize treatment variations, and control cost. Through identified opportunities to improve quality and reduce complications for the entire episode, established performance expectations enable the PAP to benefit from system Improvements in Quality of Care Reduction in use of unnecessary antibiotics 5.9% increase in Hemoglobin A1c screenings for diabetic treatment Increased follow-up care and reduced readmissions for congestive heart failure patients 14.6% increase in adolescent wellness visits efficiencies. More details and additional graphical representations of results from the episodes of care program can be found in Appendix C of this report. Page 9

10 In addition to the episodes of care and PCMH models, a third component called health homes was introduced by Arkansas DHS in Through independent assessment, tiered provider payments, and accountability for quality targets, the health homes model was designed to provide additional support for some of the most vulnerable populations in the state. These include individuals with developmental disabilities, those who need long-term services and supports, and those with severe or persistent behavioral health needs including mental health and substance abuse disorders. These populations represent a major proportion of overall Medicaid expenditures in the state. However, implementation of the health homes model was subsequently halted as a result of challenges from the provider community and other stakeholders. The state is currently weighing alternative options to provide higher-quality and efficient care for these high-needs and higher-cost populations and through their deliberations may choose to pursue components of the developed health homes model as a viable option. This AHCPII Statewide Tracking Report is the second of three annual reports on the progress of the state s system transformation effort. Included as appendices are a PCMH practice-level case study (Appendix A), a PCMH shared-savings update and fact sheet (Appendix B), and a detailed report on quality and cost indicators for episodes spanning (Appendix C). Information contained in this report represents aggregate results provided by individual payers for descriptive purposes. The state s health care system has been impacted by the AHCPII in several ways. Enrollment in the state s PCMH model is widespread, having over half of all eligible primary care providers enrolled, with the vast majority successfully completing practice transformation activities. Approximately 82 percent of eligible beneficiaries are now receiving care under the state s program, far exceeding the initial year-one goal of 40 percent. In 2015, commercial carriers including AR BCBS, QC, and CAM have supported the model with an increasing number of beneficiaries now attributed to PCMH clinics. The episodes of care model has generated meaningful impacts on quality and efficiency, and many providers have received enhanced payments for commendable performance or have been required to pay back a portion of the cost overage for not achieving acceptable performance. For example, AR BCBS results showed that quality of perinatal (pregnancy) care improved, and overall perinatal costs fell by 1.6 percent in Efforts to increase support for the AHCPII continue. Expansion of the PCMH model through commercial carriers operating as qualified health plans (QHPs) on the Health Insurance Marketplace was mandated through legislation implemented in In addition, some commercial carriers are extending the PCMH model to their fully insured, non-exchange Financial Impact and Cost Containment $34 million in savings from the PCMH program in the first year -1.2% cost trend reduction in PCMH practices AR BCBS congestive heart failure costs were reduced by 10.3% from 2013 to 2014 Medicaid tonsillectomy episode costs were reduced by 14.6% products. Self-insured interest continues to grow, with both public and private sector expansions anticipated. New episodes have been launched and others are under development, which continues to accelerate the proportion of surgical, specialty, or intensive care under value-based purchasing strategies. The largest challenge to full-scale implementation of the AHCPII remains the lack of total participation by Medicare which represents a significant portion of Arkansas s population and care usage in the state. The Centers for Medicaid and Medicare Services (CMS) has taken notice of Arkansas s nation-leading effort. Continued demonstration of successful progress will be used Page 10

11 to solicit full federal participation. Continued success of the AHCPII relies on statewide participation, ongoing innovation, and research. Initial findings from the PCMH and episodes of care models have shown successes in the areas of improved practice patterns and more efficient treatment for patients. Continued efforts to support practitioners with actionable information and to enable the more appropriate use of the highest quality providers will enhance system transformation. Through the avoidance of complications, re-hospitalizations, and unnecessary care, the goals of bending the cost curve will be supported. Updated information on the AHCPII progress can be found at Page 11

12 Patient-Centered Medical Home (PCMH) Now heading into the second year of implementation, Arkansas s PCMH model is one of the largest of its kind in the U.S. The state s PCMH model is designed to support primary care providers with new tools and resources in an effort to deliver high-quality primary care that is patient-centered and team-based, with an emphasis on care coordination and proactive preventive care. Goals of the PCMH program are to help patients stay healthy, increase the quality of care they receive, and reduce costs. PCMH transformation has been underway in Arkansas since October 2012, with 69 practices initially selected to participate in the Comprehensive Primary Care (CPC) initiative a multi-payer PCMH program sponsored by the Center for Medicare and Medicaid Innovation (CMMI). 1 Building on successes and lessons learned from the CPC initiative, wave-two expansion of the state s Medicaid-led PCMH model began in January While the first wave of the state s program was predominately comprised of pediatric practices, subsequent enrollment periods and multi-payer participation have expanded the range of participation. With more providers delivering care under the PCMH model, Arkansas has made substantial progress Provider Spotlight: Dr. Lonnie Robinson* We formed a PCMH transformation team early in the process and everyone wanted to be on the team. Empowering our staff through the PCMH model has been very helpful. In the past our model was very physician-centric now we are all taking care of the patients as a team. Dr. Lonnie Robinson of Regional Family Medicine Practice Accomplishments Include: 9% reduction in inpatient admissions 24/7 live voice access to care and improved patient communication Improved staff engagement and job satisfaction towards the goal of having all of the state s citizens receiving comprehensive primary care under the PCMH model. This year, for the first time, detailed information about system-wide cost and quality impacts of the PCMH model are available. After only one year of implementation, the state s model has demonstrated improvements in a range of quality indicators, while saving the state approximately $34 million and generating approximately $5 million in shared savings distributed to eligible providers. At the same time, the Medicare-led CPC initiative has continued to support many of the state s primary care providers in delivering high-quality and efficient care. While this report focuses on the state s own multi-payer PCMH model, recent CPC program outcomes are available and have been detailed in separate reports. 2 Participating PCMH practices receive up-front payments that enable them to more proactively meet patient needs and practice transformation milestones, which include providing extended office hours and 24/7 access to medical assistance. In addition to financial support for care coordination and practice transformation in the form of per-member, per-month (PMPM) payments, PCMHs can receive upside gain-sharing based on either performance improvements or high performance compared to statewide averages. Quality metrics must be met under both options. *A detailed PCMH case study of Dr. Lonnie Robinson and Regional Family Medicine is included as appendix A in this report. Page 12

13 Arkansas PCMH Progress Overview Enrollment 136 PCMHs are currently enrolled g in the state s Medicaid-led, multi-payer PCMH program. Approximately twelve of these practices are also enrolled in the CPC initiative. Approximately 780 primary care providers are participating, representing 69 percent of all eligible providers. Approximately 331K Medicaid beneficiaries are covered, representing 82 percent of all eligible Medicaid beneficiaries. 58 practices h are currently enrolled in the Medicare-led CPC initiative. Multi-payer participation in either the CPC initiative or the Arkansas PCMH program includes Medicaid, Medicare, AR BCBS, QC, United Healthcare, Centene/Ambetter, Humana, Arkansas State and Public School Employee Benefits Plan, Federal Employee Plan, Walmart, and Mercy Accountable Care Organization (Medicare shared savings program accountable care organization (ACO) in alignment with PCMH). As of 2015, QHPs operating on the Health Insurance Marketplace are required to participate in PCMH as mandated through the state s Health Care Independence Act, known as the Private Option. Preliminary 2016 enrollment totals for Medicaid indicate sustained momentum, with approximately 188 PCMHs enrolled, including 47 new PCMHs. Practice Achievements In 2014, the vast majority of practices met transformation milestones and either improved or maintained prior-year levels for approximately three-fourths of PCMH quality metrics. Quality metrics include: Increased pediatric wellness visits, Hemoglobin A1c testing for diabetics, breast cancer screenings, improved ADHD treatment management, and thyroid medication management. Cost Savings The state realized $34.3 million in savings because of the PCMH program, of which $12.1 million went towards care coordination payments to providers. The remaining $22.2 million in net cost avoidance was shared between the state and 19 provider groups who met both quality and cost savings requirements. Shared savings checks were issued in October 2015, with several clinics receiving over $100,000. In 2014, enrolled practices experienced a cost decrease of 1.2 percent, exceeding both the 2.6 percent benchmark trend increase and the 0.6 percent cost growth of non-enrolled practices. g Data provided by Arkansas DHS, pulled from PCMH Q4 reporting as of October, Includes practices that enrolled for 1/1/14, 7/1/14, and 1/1/15 start dates. h Practices are enrolled individually in the CPC initiative and current enrollment numbers are tracked by the Centers for Medicaid and Medicare Services: Page 13

14 Proposed Performance Target Performance target requirements for a proportion of hypertensive and diabetic individuals under clinical control are proposed to explicitly link population health needs and clinical performance expectations. i Commercial Payer PCMH Support Beginning in 2015, AR BCBS, QC, and CAM offered financial support to practices enrolled in the state s PCMH program. United Healthcare will join in During the fall of 2015, AR BCBS and CAM held open enrollment for practices to sign up for PCMH program support. In addition to offering support to those PCMHs enrolled through Arkansas Medicaid, both AR BCBS and CAM have extended their support to include those practices that are certified as PCMHs by the National Committee for Quality Assurance (NCQA). For 2016, QC and United Healthcare will offer support to those PCMHs enrolled via Arkansas Medicaid. Dual-specialized needs managed care plans are also required by regulation to participate in the state PCMH program. PCMH beneficiary attribution is still underway for the commercial carriers, but estimates for the number of attributed beneficiaries for each payer are: Arkansas Blue Cross Blue Shield: 157,000 attributed beneficiaries QualChoice: 4,300 attributed beneficiaries Centene / Ambetter: 44,000 eligible beneficiaries (attribution totals pending) United Healthcare: United is offering a qualified health plan (QHP) on the Health Insurance Exchange and will attribute members in 2016 In an effort to improve overall population health management and support the PCMH model, AR BCBS conducted a primary care provider attribution initiative for all beneficiaries in their fully-insured plans. In a process that spanned most of 2015, AR BCBS identified which beneficiaries had not selected a primary care provider. Those beneficiaries were subsequently assigned a primary care provider in their geographic proximity. These newly-attributed beneficiaries were then notified by AR BCBS of their assigned primary care provider. Beneficiaries are free to select a different primary care provider at any time. This process will allow AR BCBS to accurately track progress of population health management and quality metric outcomes across their enrolled PCMH practices. PCMH Practice Transformation Milestone Progress j Figure 1 displays required progress towards PCMH practice transformation. i For a full list of 2015 and 2016 PCMH performance targets and quality metrics, please visit or j All Medicaid PCMH data, including enrollment totals, quality measure outcomes, activity metric outcomes, and financial results were provided by Arkansas DHS in October Page 14

15 Figure 1: Patient-Centered Medical Homes Milestones As shown in Table 1, a vast majority of practices were validated as having completed these activities. Table 1: Number of Practices Completing Transformation Milestones Activity 2015 Activity A: Identify top 10% of high-priority beneficiaries (3 months) 133 Activity B: Assess operations of practice and opportunities to improve (6 months) Activity C: Develop and record strategies to implement care coordination and practice transformation (6 months) Activity D: Identify medical neighborhood barriers to coordinated care at the practice level (6 months) Activity E: Make available 24/7 access to care (6 months) 123 Activity F: Track same-day appointment requests (6 months) Activity G: Establish processes that result in contact with beneficiaries who have not received preventive care (12 months) Activity H: Complete a short survey related to beneficiaries ability to receive timely care, appointments and information from specialists, including Behavioral Health (BH) specialists (12 months) Activity I: Invest in health care technology or tools that support practice transformation (12 months) Activity J: Join SHARE and be able to access inpatient discharge and transfer information (12 months) Activity K: Incorporate e-prescribing into practice workflows (18 months) 97 Activity L: Use Electronic Health Record (EHR) for care coordination (24 months) *Deadline to complete 12/31/2015. Validation will be completed after 12/31/2015 * Page 15

16 PCMH Quality Metric Outcomes for Medicaid Figure 2 displays the percent change in PCMH quality metrics. The majority of quality metric outcomes showed improvement over 2013 baseline levels. Figure 2: PCMH Quality Metric Percent Change Hospital and Emergency Department Utilization Impacts Figure 3 displays hospital and emergency department utilization among PCMH beneficiaries in 2013 and Hospitalizations per 1,000 beneficiaries were reduced by 6 percent in 2014, while emergency room visits were reduced by 1.7 percent over the same period. Figure 3: PCMH Reductions in Hospitalizations and ED Visits Page 16

17 PCMH Financial Outcomes for Medicaid Figure 4 displays PCMH cost growth comparisons across 2013 and 2014 for PCMH practices and practices not enrolled in the program. Participating practices experienced a 1.2 percent reduction in trend growth, while their peers who were not enrolled in the program experienced a 0.6 percent cost growth. Both groups achieved cost growth below the pre-set 2.6 percent benchmark trend, which is based on historical Arkansas cost growth. Figure 4: PCMH Cost Growth Comparisons Figure 5 displays PCMH cost avoidance for Of the $34.3 million in savings, $12.1 million was reinvested in system infrastructure via PMPM care coordination payments to providers, resulting in net savings of $22.2 million. Once quality and activity target outcomes were assessed, qualifying practices received a portion of $5.3 million in shared savings. In 2014, 19 provider groups throughout the state received shared savings payments ranging from approximately $9,000 to $900,000. Figure 6 displays the location and shared savings amounts of these providers groups. Appendix B of this report includes a detailed description of PCMH shared savings recipients, outcomes, and methodology. Figure 5: PCMH Cost Avoidance Page 17

18 Figure 6: Locations of PCMHs Receiving Shared Savings Payments Provider Response to Shared Savings With many practices throughout the state receiving the first round of shared-savings incentive payments, providers have responded positively and pragmatically. Anecdotal reports from the field indicate that some providers have chosen to reinvest these additional resources back into their practices. In many instances, practices are now being enhanced by new staff roles, infrastructure and tools. As the PCMH program continues to support primary care delivery in the state, providers may benefit by enhancing their practice infrastructure including use of health information technology, expansion of facilities, or adding additional staff members. Anecdotal reports also indicate that some sharedsavings recipients have chosen to reward their staff members individually with a portion of the shared Provider Spotlight: PrimeCare Medical Clinic Searcy, AR We set aside a large amount of our savings payment to be shared among our staff we consider everyone a contributor and we have used this incentive to get our staff motivated over the past year. For 2016 we are looking at ways to provide more frequent and timely incentives to our staff, and with more payers supporting the program we think the likelihood of that will increase. Eric Booth, CEO PrimeCare Medical Clinic Page 18

19 savings. Under the PCMH model the entire staff, from the front desk to the lead doctor, is considered part of the care team. This comprehensive, team-based approach is now being further reinforced as incentive payments are shared among team members. Episodes of Care An episode of care is the collection of care provided to treat a particular condition for a given length of time. The episode model assigns a PAP for each type of episode. The patient journey was developed and reviewed by patients, providers, and payers to determine quality events that should happen and potentially avoidable complications that should not happen. All providers submit claims and are paid at the time service is provided. However, after each performance period, each provider s average costs are compared to pre-determined cost thresholds that have been established for each episode using historical Arkansas data. Each payer sets their own cost thresholds independently. The thresholds establish commendable, acceptable and unacceptable cost levels. PAPs are given quarterly reports that outline their team s performance across the entire episode, including quality metrics, utilization variation, and aggregate costs. Upon completion of a retrospective performance period (usually one year), each PAP may be eligible for gain-sharing if their team s performance has achieved commendable status. If the team s performance is not acceptable and exceeds the acceptable threshold, the PAP may be required to refund a portion of their payments. To date, Medicaid has introduced fourteen different episodes of care. The following episodes have completed at least one full performance period and have been reported by payers for this report: Upper respiratory infections (URI), total hip and knee replacements, congestive heart failure (CHF), attention deficit hyperactivity disorder (ADHD), perinatal, colonoscopy, tonsillectomy, cholecystectomy, and coronary artery bypass grafting (CABG). For these episodes, payers agreed upon the following strategies for aligning financial incentives to improve care: Upper Respiratory Infections (URI): The episode trigger is the first diagnosis of a URI; the PAP is the initial diagnosing clinician; the time period is 21 days; quality metrics include appropriate testing prior to antibiotic use; costs include all associated diagnostic and therapeutic costs. Perinatal: The episode trigger is delivery of a live infant; the PAP is the delivering provider; the time period is the prenatal period and 60 days postpartum; quality metrics include prenatal screenings and appropriate utilization of diagnostic tests; costs include all pregnancy related costs. Total Hip and Knee Replacements: The episode trigger is the total joint replacement; the PAP is the orthopedic surgeon; the time period is 30 days preoperative to 90 days postoperative; quality metrics include the use of deep-vein thrombosis prophylaxis and complication rates; costs include all orthopedic related costs during the episode. Congestive Heart Failure (CHF): The trigger is a hospitalization for CHF; the PAP is the admitting hospital; the time period is the admission day plus 30 days; quality metrics include appropriate cardiac medication management and follow up to avoid readmission; costs include all facility services, inpatient professional services, emergency department visits, observation, and postacute care; any CHF-related outpatient labs and diagnostics, outpatient costs, and medications are also included. Attention Deficit Hyperactivity Disorder (ADHD): The trigger is diagnosis of ADHD; the PAP is the provider (primary care or mental health provider) with the majority of visits; the time period Page 19

20 is 12 months; complexity and quality assessments are through provider attestation; costs include all ADHD-related charges. Colonoscopy: The trigger is an outpatient colonoscopy procedure and primary or secondary diagnosis indicating conditions that require a colonoscopy; the PAP is the primary provider providing the colonoscopy; an episode begins with the initial consult with the performing provider (within 30 days prior to procedure) and ends 30 days after the procedure; includes all related costs 30 days prior to 30 days after the procedure except ER visits on the day of the procedure; Quality metrics include cecal intubation rate and withdrawal time, perforation rate, and post polypectomy/biopsy bleed rate. Tonsillectomy: Episode is triggered by an outpatient tonsillectomy, adenoidectomy, or adenotonsillectomy procedure, and a primary or secondary diagnosis indicating conditions that require tonsillectomy/adenoidectomy; the PAP is the provider performing the procedure; episode begins with the initial consult with the performing provider (within 90 days prior to procedure) and ends 30 days after the procedure; costs include all related services within the episode duration. Quality metrics include the percent of episodes with administration of intraoperative steroids (must meet a minimum of 85% of episodes), post-operative primary bleed rate, secondary bleed rate, and avoidance of post-operative antibiotics prescriptions. Cholecystectomy: The episode is triggered by open or laparoscopic cholecystectomy procedure and a primary or secondary diagnosis indicating related conditions; the PAP is the surgeon; episode begins with the cholecystectomy procedure and ends 90 days post-procedure and includes all related costs; Quality metrics include pre-operation CT scan rate (must be below 44%), rate of major complications, rate of procedures converted from laparoscopic to open surgery, and number of procedures initiated via open surgery. Coronary Artery Bypass Graft (CABG): The trigger is a CABG procedure; PAP is the physician performing the CABG; episode duration is the timeframe from the date of surgery through 30 days post discharge from the facility stay during which the procedure occurred; costs include all procedure services and all related services within 30 days of discharge; quality metrics require PAPs to meet 2/3 of adverse outcome metrics inclusive of stroke, deep sternal wound, and renal failure. Provider Spotlight: Episodes of Care The success and sustainability of the episodes model, and the AHCPII overall, would not be possible without ongoing feedback and engagement from Arkansas s provider community who have helped shape the initiative throughout the course of its development. While provider-level feedback and successes have been previously documented for the state s PCMH program k, examples of provider-level episode impacts have been documented more recently. The following examples are representative providers experience in the episodes of care program: Episode Provider Spotlight: Tonsillectomy For Medicaid, the surgical pathology utilization rate has improved, down from 70.6 percent in 2013 to 50.1 percent in 2014, or a 29 percent relative decrease in utilization. Post-procedure antibiotic k A series of PCMH provider case studies are available at Page 20

21 prescribing rate has improved from 12.8 percent in 2013 to 3.3 percent in 2014, and average episode costs fell by 14.6 percent from 2013 to Tonsillectomy: Dr. H. Graves Hearnsberger Affiliated Practice: Arkansas Otolaryngology Center As a PAP for the tonsillectomy episode, Dr. Hearnsberger and his team have attested to using quarterly episode reports to assess practice patterns and quality metrics, and have been recipients of gain-share payments for providing high-quality and efficient care. The reports have been helpful to track steroid use and lack of use of post-operative antibiotics, said Hearnsberger. As a result of the episodes model, the team has changed their practice patterns in an effort to provide more efficient care. We have stopped routinely sending tonsillectomy and adenoidectomy tissue specimens for pathology analysis, added Hearnsberger. Regarding the episodes model overall, Dr. Hearnsberger concluded, The model makes physicians assess what they are doing and why including the costs and benefits of costly treatment options. Episode Provider Spotlight: Congestive Heart Failure (CHF) For Medicaid CHF episodes, the rate of follow-up outpatient visits improved from 38.7 percent in 2013 to 47.6 percent in For AR BCBS CHF episodes, the 30-day all-cause readmission rate improved from 14 percent in 2013 to 1% in 2014, and average episode costs were reduced by 10.3 percent over the same period. Congestive Heart Failure: Mercy Clinic Northwest Arkansas As a PAP for CHF and other episodes, Mercy hospital and clinic has met quality metrics, received gain-share payments and, to a lesser extent, has been subject to risk-share penalties. Mercy Clinic serves the communities of Bella Vista, Bentonville, Centerton, Rogers, Lowell, and Springdale, Arkansas. One provider at Mercy Clinic stated, The AHCPII has motivated and helped us assess our practices and to initiate an organizational project to standardize work flow and use the care team to provide care where appropriate. Providers also indicated that continued advancements in provision of timely data and continued multi-payer reporting alignment will make the initiative more successful. Mercy providers noted that, We are historically a low cost provider but are quick to say we have found improvement in our quality metrics. Providers also expressed willingness to supply ongoing feedback on their experience and concluded that, The episodes model is in general, an excellent way to raise awareness of the change of payment model and the refocus to quality and cost of care. Page 21

22 Overview of Episode Results Payers selected the episodes for implementation that met their covered population needs and corporate interests; thus, not every episode was implemented by each payer. While design consistency was achieved across all episodes by the payers, performance thresholding for gain and risk sharing was established independently for each payer. Results from the first and second performance year, which span approximately 2013 through 2014, are reported below for Medicaid, AR BCBS, and QC. Perinatal Episode The perinatal episode aims to ensure a healthy pregnancy and follow-up care for the mother and baby, requiring months of care, possibly involving many different providers ranging from obstetricians, family practice physicians, and nurse midwives, to hospitals, emergency departments, obstetric specialists, and others. The perinatal episode includes all pregnancy-related care provided during the course of the pregnancy. This includes all of the prenatal care, care related to labor and delivery, and postpartum maternal care roughly 40 weeks before delivery and 60 days postpartum. It encompasses the full range of services provided during this time period. Quality metrics for the perinatal episode are aimed at increasing pregnancy screenings as a form of preventive care to reduce high-risk pregnancies. Perinatal care has three quality metrics that PAPs must pass in order to participate in shared savings. Providers must provide the following quality metrics to pregnant patients: HIV, Group B streptococcus (GBS), and Chlamydia screenings. Each screening must meet the minimum threshold of 80 percent to pass. There are five additional quality metrics that PAPs are tracked on in the perinatal episode for quality of care and care improvement opportunities. Four of these metrics are the following screenings: ultrasound, gestational diabetes, asymptomatic bacteriuria, and hepatitis B specific antigen. The fifth metric is Cesarean section (C-section) rate. Medicaid, AR BCBS, and QC are participating in the perinatal episode. Key findings from this episode include the following: Screening rates generally remained at prior year levels or continued to improve for QC, AR BCBS and Medicaid. The Chlamydia screening rate showed the most improvement for both QC and ARBCBS, while Medicaid showed the most improvement in asymptomatic bacteriuria screening. Medicaid s C-section rate improved from 38.6 percent in the baseline year to 34.7 in 2013 and 33.5 percent in The average length of inpatient stay for a C-section decreased slightly from 2.7 days in 2013 to 2.6 days in AR BCBS average perinatal episode cost fell 1.6 percent from 2013 to Total Joint Replacement (TJR): Hip and Knee Episode Previously, multiple providers have been involved at each stage of total hip and knee replacements without optimal care coordination. This led to duplication of efforts, increased costs, and the potential for decreased quality of care. The hip and knee total joint replacement (TJR) episode includes all services related to elective hip and knee replacement procedures, from the initial consultation to post surgery follow-up care. 3 Hip and knee replacements resulting from joint degeneration and osteoarthritis are among the top five elective procedures performed. Each operation involves pre-surgery diagnostics and testing, hospitalization, the procedure itself, and post-surgery rehabilitation. 4 TJR includes all care related to the procedure in the period 30 days prior to the surgery to 90 days after. 3 This episode has four quality metrics to track in place for quality of care and improvement opportunities: 30-day all-cause readmission rate; l frequency of use of prophylaxis against postoperative Deep Venous Thrombosis l The 30-day all-cause readmission rate is for patient readmissions only related to the TJR procedure. Occurrences between days postsurgery count toward the episode. Page 22

23 (DVT)/Pulmonary Embolism (PE); frequency of postoperative DVT/PE; and 30-day wound infection rate. Medicaid, AR BCBS, and QC are participating in the TJR episode. Key findings for the episode include: For AR BCBS, the trend decreased for average length of stay for inpatient admissions for TJR, from 2.7 days in the baseline year to 2.6 days and 2.3 days in 2013 and 2014 respectively. For Medicaid, the 30-day wound infection rate improved to 1.7 percent for 2014, down from 2.0 percent in However, the post-operation complication rate worsened from 8.0 percent in 2013 to 14.1 percent in AR BCBS was responsible for the majority of TJR episodes, with 862 episodes in 2014, compared to 121 for QC and 121 for Medicaid. Congestive Heart Failure (CHF) Episode In Arkansas, 24 percent of hospitalized Medicare patients with congestive heart failure (CHF) will be readmitted within 30 days annually. 5 Active management of CHF through adherence to proper diet, weight management, and medication can reduce symptoms and improve quality of life for CHF patients. CHF affects a significant number of Arkansans, and represents an opportunity to improve quality, patient experience, and efficiency. CHF can be acute, sub-acute, or chronic. This episode focuses on acute CHF exacerbations that result in hospitalization and post-acute follow-up care. The focus is on improved care coordination and effectiveness between the hospital and post-discharge providers. Patient education and post-discharge follow up are key factors to prevent readmission. Increased use of evidence-based therapies could save the lives of up to 700 Arkansans each year. 5 Quality metrics for the CHF episode include the prescribing rate of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy at hospital discharge to patients with left ventricular systolic dysfunction (LVSD); frequency of outpatient follow up within seven and 14 days after discharge; proportion of patients matching hyper dynamic, normal to severe dysfunction (for qualitative assessments of the left ventricular ejection fraction [LVEF]); average quantitative ejection fraction value; 30-day all-cause readmission rate; 30-day heart failure readmission rate; and 30-day outpatient observation care rate (a utilization metric). 6 Medicaid and AR BCBS are participating in the CHF episode. Key findings include: For Medicaid, the rate of follow-up outpatient visits improved from 38.7 percent in 2013 to 47.6 percent in For AR BCBS, the 30-day all-cause readmission rate improved greatly from 14 percent in 2013 to 1 percent in For AR BCBS, CHF episode costs were reduced by 10.3 percent from 2013 to Cholecystectomy Episode Cholecystectomy is the surgical removal of the gall bladder, most commonly to alleviate gallstones. The most common procedure used is called laparoscopic cholecystectomy. The cholecystectomy episode includes all related services during cholecystectomy procedure and 90 days after procedure. This includes inpatient and outpatient facility services, professional services, related medications, complications and post procedure admissions. The cholecystectomy episode is triggered by services provided by the responsible surgical team, and the PAP is the primary surgeon performing the procedure. This episode includes patients between the ages of one year and 65 years. In order to participate in Medicaid gain-sharing, providers are required to pass a quality metric related to the percentage of episodes with CT scan 30 days prior to cholecystectomy. An acceptable threshold Page 23

24 would be less than the state average of 44 percent of cases. Metrics intended for reporting only include the rate of major complications occurring in the episode, either during the procedure or in the postprocedure window, such as common bile duct injury, abdominal blood vessel injury, bowel injury, the number of laparoscopic cholecystectomies converted to open surgeries and the number of cholecystectomies initiated via open surgery. For Medicaid and AR BCBS, the CT scan rate increased from 2013 to Medicaid s CT scan rate increased from 16.6 percent in 2013 to 23.9 percent in 2014 m, while AR BCBS CT scan rate increased from 15 percent in 2013 to 19 percent in For Medicaid there were 41 valid PAPs, 93 percent of whom met the quality metric for gainsharing. Among those PAPs, 20 also had costs within the commendable range and received an average of $700 in gain-sharing payments for the 2014 performance period. Colonoscopy Episode Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel. It is used for visual diagnosis or biopsy/lesion removal purposes. Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer death in both men and women in the US, with an overall incidence rate per 100,000 of 57.2 for men and 42.5 for women 7. The colonoscopy is the only therapeutic technique used for removal of a potentially precancerous growth during the screening procedure. The episode applies to patients between the ages of 18 and 64 and includes all related services within seven days prior to the procedure, the day of the procedure and within 30 days after the procedure. Two quality metrics cited by the American Society of Gastrointestinal Endoscopy are included in this episode. To participate in gain-sharing payments at least 80 percent of a provider s valid colonoscopy episodes must meet the following quality metrics: 1) documentation of endoscopy procedures reaching cecum, and 2) an endoscope withdrawal time greater than six minutes. Reaching the cecum is critical to a complete examination. Episode advisors have selected the following quality metrics to track for future evaluation: 1) perforation rate and 2) post-polypectomy/biopsy bleed rate. For Medicaid, the perforation rate and post polypectomy/biopsy bleed rate remained at 0 percent in Average episode costs fell from $893 in 2013 to $813 in 2014 for an estimated overall cost avoidance of $122,528. For AR BCBS, among the 138 PAPS across 2013 and 2014, nearly all either moved to or remained in the commendable cost range in All 32 of the PAPS who had unacceptable costs in 2013 improved, with 27 (90%) moving into the commendable cost range. Overall, 130 (94%) of all PAPS were in the commendable range in 2014, compared to 60 (43%) PAPs that were in the commendable range in Tonsillectomy Episode Tonsillectomy is one of the most common surgical procedures in Arkansas in children under the age of It is performed to alleviate such conditions as recurrent tonsillitis and sleep breathing disorder. A m For the Medicaid Cholecystectomy episode, additional CT scan codes were added to the episode algorithm for 2014 in order to more accurately assess provider practice and service delivery. Page 24

25 tonsillectomy episode is an outpatient tonsillectomy, adenoidectomy, or adeno-tonsillectomy procedure on a patient between the ages of three and 21. It includes related procedure services during and within 90 days prior to and 30 days post-procedure. Examples of related services include initial consult, inpatient and outpatient facility services, professional services, and related medications, or any postprocedure complications that result in additional care. To participate in episode gain-sharing, providers are required to pass a quality metric to administer intra-operative steroids in a minimum of 85 percent of their tonsillectomy episodes. The report-only quality metrics are postoperative primary bleed rate, secondary bleed rate, and avoidance of postoperative antibiotic prescriptions. The American Academy of Otolaryngology recommends against the use of antibiotics post-procedure. 9 For Medicaid, surgical pathology utilization rate was greatly improved, down from 70.6 percent in 2013 to 50.1 percent in 2014, or a 29 percent relative decrease in utilization. The post-procedure antibiotic prescribing rate was decreased from 12.8 percent to 3.3 percent in The post procedure secondary bleed rate improved from 2.5 percent to 1.6 percent from 2013 to For Medicaid, average episode cost fell from $1,024 in 2013 to $954 in 2014, for a 14.6 percent cost decrease and an estimated overall cost avoidance of $226,427. Upper Respiratory Infection (URI) Episode Upper Respiratory Infection (URIs) is one of the most common illnesses suffered by Arkansans, leading to more doctor visits than any other ailment each year. 10 These infections are typically unaffected by antibiotics, though antibiotics are routinely prescribed. Most URIs are viral infections that resolve themselves without antibiotic use within 10 days. This episode encourages efficient treatment and consultation with the physician, including follow-up appointments as well as urging physicians to better manage prescribing antibiotics. The URI episode includes three different types of URI non-specific URI, sinusitis, and pharyngitis. Currently, Medicaid is the only payer participating in the URI episode. All three of the URI (pharyngitis, sinusitis and non-specified URI) episode metrics for antibiotic prescribing rates improved from the baseline to performance period. n,o Non-specific URI: Among the valid episodes of non-specified URI, the prescribing rate decreased from 44.6 percent of patients receiving antibiotic prescriptions in the baseline year to 37.3 percent in the performance year, with the trend continuing to decrease to 34.1 percent in This decrease is an improvement toward the CDC recommendation that antibiotics should not be used to treat non-specific URIs in adults, since antibiotics do not improve URI. 11 Sinusitis URI: Of the valid episodes of sinusitis URI, the antibiotic prescribing rate decreased from 90.1 percent in the baseline year to 88.9 percent in Pharyngitis URI: Among the valid episodes of pharyngitis URI, the antibiotic prescribing rate improved from 70.1 percent in 2013 to 69.2 percent in n Medicaid s baseline period was 10/1/2011 through 9/30/2012, while the performance period (initial period for payment) was 10/1/2012 through 9/30/2013, and the second performance period was 10/1/2013 through 9/30/14. o Having consistent start and end dates for baseline and performance effectively removes seasonality associated with URI rates. Page 25

26 Attention Deficit Hyperactivity Disorder (ADHD) Episode The American Psychiatric Association states in the Diagnostic and Statistical Manual of Mental Disorders that 5 percent of children have ADHD. 12 The primary care clinician should initiate an evaluation for ADHD for any child four through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. 13 In 2011, Arkansas ranked 2 nd nationally in parent-reported diagnoses of ADHD at 14.6 percent of children in the state. 14 The episode includes all ADHD-related care provided during the 12-month duration of the episode, excluding initial assessment. This includes the full range of services provided (e.g., physician visits, psychosocial therapy) as well as all medication used to treat ADHD. If a patient continues treatment after the end of the initial 12-month episode, a new episode is triggered. The ADHD episode consists of Level 1 and Level 2 patients. Level 1 patients who do not respond adequately to medication and other primary treatments will begin a Level 2 episode once their provider certifies the severity and rationale for Level 2 designation. ADHD is only being implemented by Medicaid at this time. For ADHD Level 1 episodes, the average number of behavioral therapy visits per episode improved from 3.3 visits per episode in 2013 to 1.2 visits per episode in The number of episodes with medication also improved from 97.1 percent in 2013 to 98.9 percent in The average ADHD Level 1 cost fell from $1,808 in 2013 to $1,523 in 2014, for a decrease of 15.8 percent and an overall cost avoidance of $1,075,746. Coronary Artery Bypass Grafting Episode Coronary artery bypass graft (CABG) is the re-routing of blood vessels in the heart around blockages using arteries or veins from other parts of the body. It is an open-chest surgery and is performed when less invasive methods are not sufficient to restore blood flow through the blocked vessels. CABG episodes begin on the first day of the procedure and end 30-days after discharge from the facility in which the procedure occurred, or at the end of a readmission where the patient entered the hospital within the 30 day post-discharge period. All inpatient, outpatient, professional, and pharmacy services related to the CABG, delivered within the episode timeframe are included in the episode. The proportion of CABG episodes with an adverse outcome, including stroke and/or deep sternal wound within 30 days, was decreased from 3.1 percent in 2013 to 2.6 percent in The average episode cost fell 11.3 percent from $10,820 in 2013 to $9,599 in 2014, for an estimated savings of $47,632. Page 26

27 Additional Episodes Additional episodes deployed or under development are increasing the proportion of surgical, specialty, or intensive care under value-based purchasing strategies. Additional episodes of care were launched by AR BCBS in January 2015, including Percutaneous Coronary Intervention (PCI), Coronary Artery Bypass Graft (CABG), Asthma, and Chronic Obstructive Pulmonary Disease (COPD). Medicaid and AR BCBS are exploring development of additional episodes including appendectomy, pediatric pneumonia, hysterectomy, and urinary tract infection (when an ER visit is involved). AR BCBS is also reviewing tympanostomy (ear tube procedure) for possible episode development. Medicaid has agreed not to develop any more episodes where a primary care provider will serve as the principal accountable provider. This is because the state s PCMH model is designed to support higher-quality and efficient care for the bulk of care delivered by primary care providers. Experience from episode analysis is aiding in the creation of chronic disease profiles which can be used by PCMHs in coordinating care for high risk patients as they pursue per member, per year cost curve management. The consistent definition of the episode, identification of the PAP, and articulation of quality expectations across payers will continue to reinforce and support the desired reduction in variability in utilization, outcomes, and costs. Quarterly reports for each PAP will continue to inform and identify areas of threat to quality and practice variation. Table 2 below illustrates the additional episodes deployed or under development. Table 2: Episodes Deployed, In Development, or Under Review for Potential Development Episode Payer Participation Performance Period Start Date* Upper Respiratory Infection (URI) Medicaid July 2012 Attention Deficit Hyperactivity Medicaid July 2012 Disorder (ADHD) Perinatal Medicaid, AR BCBS, QC July 2012: Medicaid January 2013: AR BCBS January 2014: QC Congestive Heart Failure (CHF) Medicaid, AR BCBS October 2012: Medicaid January 2013: AR BCBS Total Joint Replacement (TJR) Cholecystectomy (Gall Bladder Removal) Medicaid, AR BCBS, QC** Medicaid, AR BCBS, QC October 2012: Medicaid January 2013: AR BCBS January 2014: QC July 2013: Medicaid January 2014: AR BCBS, QC Colonoscopy Medicaid, AR BCBS, July 2013: Medicaid January 2014: AR BCBS Tonsillectomy Medicaid, AR BCBS July 2013: Medicaid January 2014: AR BCBS Oppositional Defiant Disorder (ODD) Coronary Artery Bypass Grafting (CABG) Medicaid October 2013 Medicaid, AR BCBS January 2014: Medicaid January 2015: AR BCBS Page 27

28 Asthma Medicaid, AR BCBS April 2014: Medicaid January 2015: AR BCBS Chronic Obstructive Pulmonary Disease (COPD) Percutaneous Coronary Intervention (PCI) Medicaid, AR BCBS Medicaid, AR BCBS, QC October 2014: Medicaid January 2015: AR BCBS July 2015: Medicaid January 2015: AR BCBS ADHD/ODD Comorbidity Medicaid January 2016 Neonatal Medicaid TBD Appendectomy Medicaid, AR BCBS TBD Urinary Tract Infection Medicaid, AR BCBS TBD Hysterectomy Medicaid, AR BCBS TBD Pediatric Pneumonia Medicaid, AR BCBS TBD Tympanostomy AR BCBS TBD Conclusion Now in its third year of implementation, the AHCPII has demonstrated statewide improvements in quality and cost containment, while positioning Arkansas as a national leader in shifting a majority of care to value-based models. Multi-payer participation has been more fully realized and in turn has increased provider incentives and bolstered participation. The total transformation of Arkansas s health system will be strengthened if every payer in the state, including Medicare, operates under the AHCPII. As more providers join the PCMH program, and more care is delivered under value-based strategies, patients, providers, and payers all stand to benefit. Updated information on the AHCPII progress can be found at Subsequent annual statewide tracking reports will capture future system impacts, including more detailed information on PCMHs, episodes of care, and other applicable value-based models. 1 Patient Centered Medical Home.. [Online] Last Updated April Accessed on November 4, 2014 at 2 Taylor E, Dale S, Peikes D, et al. Evaluation of the Comprehensive Primary Care Initiative: first annual report. Princeton, NJ: Mathematica Policy Research, 2015 ( ). 3 Episode Summary: Total Hip and Knee Replacement.. [Online] Accessed on November 15, 2015 at 4 Arkansas Blue Cross Blue Shield. Provider Manual: Hip and Knee Replacement Episode Reimbursement Program. Little Rock, AR: Arkansas Blue Cross and Blue Shield. Accessed on November 15, 2015 at 5 Episode Summary: Acute/Post-acute Congestive Heart Failure.. [Online] Accessed on November 11, 2015 at 6 Congestive Heart Failure Algorithm Summary.. [Online] [Cited: November 10, 2015]. Page 28

29 7 North American Association of Central Cancer Registries. Mortality: National Center for Health Statistics, Centers for Disease Control and Prevention, as provided by the Surveillance, Epidemiology, and End Results Program, National Cancer Institute 8 Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, Natl Health Stat Report 2009; :1. 9 American Academy of Otorhinolaryngology Guidelines for Episode Summary: Ambulatory Upper Respiratory Infection (URI).. [Online] Accessed on December 15, 2014 at 11 Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. Use of Antibiotics for Adult Upper Respiratory Infections in Outpatient Settings: A National Ambulatory Network Study. Family Medicine May; 38(5): American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth edition: DSM-5. Washington: American Psychiatric Association, American Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on Attention- Deficit/Hyperactivity Disorder. Clinical practice guideline: diagnosis and evaluation of the child with attentiondeficit/hyperactivity disorder. Pediatrics. 2000;105(5): Arkansas State Profile: Parent-Reported Diagnosis of ADHD by a Health Care Provider and Medication Treatment Among Children 4-17 Years: National Survey of Children s Health Conducted by the CDC 2003 to [Online] [Cited: November 19, 2015]. Page 29

30 APPENDIX A Patient-Centered Medical Home Case Study: Aligning Incentives and Rewarding Innovative Collaboration (Regional Family Medicine, Mountain Home, Arkansas)

31 Case Study Patient-Centered Medical Homes: Aligning Incentives and Rewarding Innovative Collaboration ACHI is a nonpartisan, independent, health policy center that serves as a catalyst to improve the health of Arkansans. Regional Family Medicine December 2014 The Arkansas Health System Improvement Initiative is designed to create a sustainable patient-centered health system that embraces the triple aim of (1) improving the health of the population; (2) enhancing the patient experience of care, including quality, access, and reliability; and (3) reducing, or at least controlling, the cost of health care. While the initiative has broader goals of expanding coverage, enhancing health information technology, and developing a quality health care workforce, a major focus has been payment innovation and restructuring the system to incentivize quality outcomes. Patientcentered medical homes (PCMH) are a primary strategy of this innovation. Design and implementation of the state s PCMH efforts has been led by Arkansas Medicaid with support from Arkansas Blue Cross and Blue Shield, Qualchoice of Arkansas, Humana, Centene/Ambetter, Medicare, Walmart, the State Employees Plan, and others. This study is part of a series of case studies spotlighting practice transformation to the PCMH model, emphasizing how individual practices have approached innovation and implementation. For more information on the Arkansas Health System Improvement Initiative, and access to additional case studies, visit or The PCMH program is exciting for primary care providers who ve typically been underpaid for the value they bring to the table it s an opportunity to demonstrate their worth --Dr. Lonnie Robinson of Regional Family Medicine in Mountain Home, AR As a leader in the state s patient centered medical home (PCMH) program, Regional Family Medicine (RFM), nestled in Mountain Home, AR, in Baxter County, serves a panel of approximately twenty-six thousand patients. Including Dr. Robinson, RFM employs a staff of around fifty employees at their Main and East Branch Clinics, both in Mountain Home. The staff consists of eight doctors, three certified nurse practitioners (NP), several licensed practical nurses (LPNs) around ten administrative personnel, four X- ray technicians, two ultrasound technicians, and other staff. RFM began participating in Arkansas s PCMH model in January 2014, and are now receiving per-member per-month financial support to enhance their patient-centered approach. RFM is also participating in the Ft. Smith Physician s Alliance, an Accountable Care Organization (ACO) within the Medicare Shared Savings Program (MSSP). Both programs incentivize providers to manage the overall quality and total cost of patient care. With the multi-payer PCMH model and other programs, RFM is now delivering a majority of care under a value-based purchasing model. Robinson said, When the Medicaid PCMH opportunity arose, I thought we needed to participate, but I was concerned that it was a thin slice of our payer mix. Adding the private insurers to the model has been the critical part. Now with the PCMH program and the ACO, we have eighty to ninety percent of our care being delivered under some sort of value based model or alternative payment. A major factor in the success of Arkansas s PCMH program to this point has been ongoing provider input. Many providers, including Dr. Robinson, who previously served as President of the Arkansas Patient-Centered Medical Homes Through improved care coordination and communication, the goal of the Arkansas patient-centered medical home (PCMH) program is to help patients stay healthy, increase the quality of care received, and reduce costs. A PCMH accomplishes this by identifying and treating at-risk persons before they become sick. Success of the Arkansas PCMH program relies on statewide multi-payer participation, ongoing innovation, and achievement of a specific set of improvement milestones, such as 24/7 patient access to care via phone or , use of electronic health records, and development of customized care plans for each patient W Capitol Avenue, Suite 300 Little Rock, Arkansas (501)

32 BAXTER COUNTY PROFILE Overall County Health Ranking: 20 (of 75) Social & Economic Factor Ranking: 21 (of 75) Uninsured: 20% (AR: 20%) Poor or Fair Health: 18% (AR: 19%) Primary Care Physicians: 1,093:1 (AR: 1,586:1) Mental Health Providers: 507:1 (AR: 696:1) Diabetic Screening: 88% (AR: 82%) Low Birth Weight: 7.3% (AR: 9.0%) Mammography Screening: 69% (AR: 58%) Unemployed: 7.7% (AR: 7.3%) * Academy of Family Physicians, have worked with public and private payers on a strategic advisory group to shape the state s Arkansas-centric program. A key design element of the model is that providers have the opportunity to partner or pool with other participating practices. This feature enables more providers, many of whom are in smaller practices, to be potentially eligible for shared savings. The pooling feature also incentivizes PCMHs to share best practices and work together towards meeting quality targets and managing costs. Robinson said, We are pooling with Baxter Regional Medical Center (BRMC) clinics and Lincoln-Paden Clinic. We have met with members of the Lincoln-Paden team to offer some advice about selecting an EHR and getting started on the path to PCMH transformation. I think that collaboration between provider groups is going to be important to our mutual success. For them to succeed is for us to succeed. Currently within the states PCMH program, 71 individual PCMHs have formed 25 voluntary pools, and 63 PCMHs are in a statewide pool. We formed a transformation team early in the process and everyone wanted to be on the team. Empowering our staff through the PCMH model has been very helpful. In the past our model was very physician-centric now we are all taking care of the patients as a team --Lonnie Robinson, MD Like many PCMHs throughout the state, RFM has refined the roles of their staff to achieve better-coordinated, team-based care. Each physician at RFM works closely with two nurses, one of whom serves as the care coordinator. When we began thinking about what team member might best serve as care coordinator, it became obvious to us that one of the nurses on each care team was already filling that role to a large degree. Thus, we re able to fill the role without hiring another employee, said Robinson. By facilitating optimal communication, including 24/7 livevoice access, RFM has influenced patients to seek care in an appropriate setting. Robinson said, I tell my patients to call me if they have an issue, and we ll keep them out of the emergency room. I think patients like it, knowing there is someone they can talk to gives them comfort - access is what matters most to patients, being able to be seen in a timely manner. In addition to the benefits to patients, the staff at RFM has become more engaged in the team-oriented model and as a result is more satisfied with their jobs. Robinson said, Engaging with staff about how we talk to patients and giving them a voice has been good. I m a fan of the quadruple aim, provider satisfaction added, with the whole team operating at the top of their license. By aligning incentives and assigning responsibility for overall patient We ve seen a 9% drop in inpatient care to primary care providers (PCPs), The PCMH model has improved admissions from RFM, and we re linkages and transitions of care between clinics and hospitals or other expecting that number to drop more care settings. We ve seen a nine percent drop in inpatient admissions --Ivan Holleman, CFO, Baxter from RFM, said Ivan Holleman, VP and CFO of BRMC, one of the main hospitals serving Mountain Home and the surrounding areas. BRMC has joined the state s health information exchange, The State Health Alliance for Records Exchange (SHARE), to receive alerts for patient admissions, discharges, or transfers (ADTs) that will notify RFM and other groups and help reduce unnecessary readmissions. We re working on sending real-time data back to primary care providers. SHARE will put us in a better position to work with PCMHs as we transition patients, from inpatient to outpatient settings, said Holleman. For many providers working to manage care and referrals efficiently, a challenge is gaining access to data, improved data transparency. We have had discussions with BRMC about the expected impact of PCMH on their bottom line. PCPs have an inherent obligation to pursue the options for patients that provide the best quality and outcome at the lowest cost, now that this information is available to them. We will all have to adjust to this new environment, and we want to engage with our hospital and specialist providers to seek out ways we can all thrive while caring for patients in this new reality Robinson said. This report was composed using information obtained during an in-person interview with Dr. Robinson of Regional Family Medicine. The Arkansas Center for Health Improvement was granted written permission to use this information. Additional information was gathered from the Arkansas Department of Human Services Division of Medical Services, the Arkansas Center for Health Improvement, and County Health Rankings from the Population Health Institute at the University of Wisconsin. Copyright December 2014 by the Arkansas Center for Health Improvement. All rights reserved. Case Study Patient-Centered Medical Homes: Aligning Incentives and Rewarding Collaboration Page 2

33 APPENDIX B Patient-Centered Medical Home Fact Sheet: Shared Savings Update

34 Patient-Centered Medical Homes: Medicaid Shared Savings Update FACT SHEET OCTOBER 2015 Arkansas has been a leader among states in full-scale healthcare system transformation. The state s transformation efforts have been successful in part because of multi-payer collaboration from both public and private sectors and alignment of financial incentives across initiatives to achieve higher quality, more patientcentered, cost-effective care. The (AHCPII) is at the core of these efforts and includes two primary strategic models for supporting these efforts: Patient-Centered Medical Homes (PCMHs) and Episodes of Care. Both models are designed to incentivize providers and reward those who meet quality and financial targets while providing better-coordinated, high-quality care. Support for Medicaid components of the state strategy includes a team of individuals at the Arkansas Department of Human Services, Hewlett-Packard, General Dynamics Health Solutions, the Arkansas Foundation for Medical Care, Qualis Health, and the Advanced Health Information Network, among others. These efforts include providing quarterly progress reports and leading, not only practice support initiatives across the state, but also monthly advisory calls with frontline physicians to shepherd the effort. For PCMH providers who achieve practice transformation and quality of care targets, the program offers a shared-savings opportunity in which practices may receive up to half of the generated savings. The 2014 outcomes from the PCMH program demonstrate a reduction in cost growth and improvements in quality outcomes, resulting in significant shared savings for some providers. This fact sheet describes Arkansas Medicaid s shared-savings methodology and 2014 results. SHARED SAVINGS METHODOLOGY Arkansas Medicaid has established a PCMH shared-savings model that rewards providers if they meet eligibility requirements and achieve quality and financial targets. 1 To ensure that savings are the result of real improvement and not random variation in utilization and cost, enrolled practices must maintain a minimum patient volume of 5,000 attributed Medicaid beneficiaries. This threshold was selected as the smallest actuarially approved number, with the goal of extending eligibility to as many practices as possible. In 2014, practices could meet the volume requirement independently or by joining with another practice. Of the 123 practices or groups in the PCMH program in the first year, 37 met the 5,000 Medicaid beneficiaries mark. 1 Quality and efficiency targets must be met in order to receive shared savings. Practices must meet a majority of practice support metric targets, achieve PCMH transformation milestones, and meet at least two-thirds of the shared-savings quality metrics all designed to increase preventive care and improve chronic disease management. In 2014, the vast majority of practices met transformation milestones, and Practice Requirements 1 Must have at least 5,000 attributed Medicaid beneficiaries as a shared-savings entity Must achieve PCMH transformation milestones and process measures Must meet at least two-thirds of shared-savings quality metrics Must meet financial targets by either beating a historical statewide benchmark trend or improving on their own historical benchmark costs 78 percent of quality measures improved or maintained prior-year levels. These quality measures include an increase in pediatric wellness visits, hemoglobin A1c testing for diabetics, breast cancer screenings as well as improved Attention Deficit Hyperactive Disorder management and thyroid medication management SHARED-SAVINGS OUTCOMES 2 In the first year of the program, there were 659 primary care physicians in 123 PCMH practices or groups enrolled in the PCMH program covering 295,000 Medicaid beneficiaries. Among the 123 participating practices who enrolled in January 2014, 37 practices or groups were potentially eligible for shared savings, having at least 5,000 Medicaid beneficiaries either as a stand-alone practice or by joining or pooling with one other participating practice. Among the 37 eligible practices or groups, 19 received shared savings by both meeting quality and financial targets. Shared savings amounts ranged from approximately $9,000 to $900,000, with an average shared-savings payment of approximately $278, Overall, the PCMH program saved the state $34 million in Medicaid costs in Per-member per-month payments to practices were factored into the overall program cost, resulting in a net-shared savings of $5.3 million paid out to qualifying practices. After only one program year, the results are indicative of the program being cost effective and sustainable beyond its first year of implementation. ACHI is a nonpartisan, independent, health policy center that serves as a catalyst to improve the health of Arkansans W Capitol Avenue, Suite 300 Little Rock, Arkansas (501)

35 Some participating practices met quality targets but not financial benchmarks, while others met financial targets but failed to achieve quality targets. In both scenarios, shared savings were not awarded to those practices. Sharedsavings outcomes for the 2014 performance year based on preliminary claims analysis and final reconciliation based on fully adjudicated claims will be completed in the first quarter of This final reconciliation may slightly alter the final payment amounts for some practices SHARED-SAVINGS AWARDEES 2 1. University of Arkansas for Medical Sciences (UAMS) Regional Programs (Area Health Education Centers in Ft. Smith, Fayetteville, Springdale, Jonesboro and Texarkana) $927, Mercy Clinic Northwest Arkansas (Bentonville) $749, Drs. Collom and Carney Clinic (Texarkana) $642, Monticello Medical Clinic PLC $484, Hot Springs Pediatric Clinic $448, Pillow Clinic PLC (Helena-West Helena) $387, Mountain View Clinic LLC $237, The Children s Clinic of Jonesboro $236, John Paul Wornock (Searcy) $234, Central Arkansas Pediatric Clinic (Benton) $229, Medical Associates of Northwest Arkansas (Fayetteville) $214, Pediatric Associates of West Memphis $201, Arkansas Pediatric Clinic PLLC (Little Rock) $66, Little Rock Pediatric Clinic $65, Apache Drive Children s Clinic (Jonesboro) $57, Regional Family Medicine (Mountain Home) $54, Conway Children s Clinic $32, Ozark Internal Medicine (Clinton) $9, Mercy Health System of NWA (Rogers) $8, INCREASING INCENTIVE OPPORTUNITIES Performance Expectations 1 Take responsibility for total care experience Provide 24/7 live-voice access to clinical advice Demonstrate improved chronic disease management Identify and develop care plans for top 10% of highpriority patients Coordinate care of highpriority beneficiaries, including post-hospital and transitional care across facilities and providers Utilize health information technology tools, including use of Electronic Health Records and incorporation of e- prescribing into practice workflows Because additional payers have joined in supporting the PCMH model, the incentives for participating in the program are increasing. Beginning in 2015, Qualified Health Plans (QHPs) operating on the insurance exchange and dual-specialized needs managed care plans are required to participate in the state PCMH program by either legislative or regulatory requirements. 3 These carriers include Arkansas Blue Cross and Blue Shield, Qualchoice, Centene/Ambetter, United Healthcare, and other carriers. Commercial carriers are already supporting PCMH practices with per-member per-month payments for care coordination and practice transformation and are required to develop their own shared-savings methodology in These increased incentives will support and reinforce changes in practice patterns and improvements in quality and efficiency of care delivery. In addition to more payers supporting the program and offering shared savings in the future, all PCMH practices will have an opportunity to achieve shared savings beginning in While practices had to meet the 5,000 Medicaid beneficiary threshold either as a stand-alone practice or with one other practice in 2014 the pooling options increased in For the current 2015-performance year, the opportunity to be eligible for shared savings will be extended to all PCMH practices practices without at least 5,000 Medicaid beneficiaries as a stand-alone practice may pool with one or more practices or be placed in a statewide default pool to meet eligibility requirements. While there is no downside risk for PCMH providers, the opportunity cost of not participating in the program is becoming greater as multi-payer per-member per-month payments and shared-savings potential increase. For this reason, enrollment in the PCMH program is anticipated to increase beyond current levels and foster a rebalancing of the state s healthcare workforce toward primary care delivery and overall population health management. REFERENCES 1 Arkansas Medicaid. Patient-Centered Medical Homes: Provider Manual Section II. Accessed on October 26, 2015; 2 Amy Webb, Arkansas Department of Human Services Director of Communications, message to the Arkansas Center for Health Improvement on October 23, Rule 108, Patient-Centered Medical Home Standards, effective January 1, Fact Sheet: Patient-Centered Medical Homes Medicaid Shared Savings Update Page 2 Copyright All rights reserved.

36 APPENDIX C Episodes of Care Detailed Report

37 Appendix C: Detailed Report on Episodes of Care An integral component created and implemented as part of the AHCPII is an episode-based care delivery model. The episode of care model is designed to improve quality and reduce or control the cost of care. Episodes are focused on all the care provided to treat a particular condition for a given length of time. For each episode of care, a principal accountable provider (PAP) is designated. The PAP is the provider with responsibility for the majority of care in a given episode. In some cases, the PAP will be a physician or midlevel provider. In others, it will be a hospital or facility. Payers provide quarterly data reports to providers outlining a peer level comparison of quality, cost, and utilization patterns associated with specific episodes of care. These reports provide PAPs with information they did not have access to prior to the implementation of episodes of care. PAPs are subject to upside and downside cost-sharing based on achievement of established quality metrics and cost thresholds. Actionable information contained in the reports allows for a better understanding of areas in which providers are excelling and of areas in need of improvement in advance of performance cost-sharing. Payer participation in episodes of care is voluntary. While quality metrics established for each episode are common across all payers, cost thresholds are set separately by each participating payer based on historical Arkansas cost data. Payers have also aligned on common definitions for the patient journey, or course of service delivery for each type of episode. Within each patient journey definition there are key drivers for quality and utilization. For example, Figure 1 displays the patient journey for the perinatal (pregnancy) episode. More information on episode development, design parameters and rationale, including patient journey and quality metric definitions, can be found at: Figure 1: Perinatal Patient Journey Initial Assessment Prenatal Care Prenatal Care Complications Vaginal Delivery Unplanned C-section Prenatal Care Prenatal Care C-section A total of 14 episodes of care have been developed to date. Of those, the results of nine, for which at least one performance year has been completed with results reported by at least one payer, are included in this report. Page 1

38 Perinatal Episode The perinatal episode aims to ensure a healthy pregnancy and follow-up care for the mother and baby, requiring months of care, possibly involving many different providers, ranging from obstetricians, family practice physicians and nurse midwives, to hospitals, emergency departments, obstetric specialists, and others. Figure 2: Perinatal Episode Yearly Volume Episode Definition: The perinatal episode includes all pregnancy-related care provided during the course of the pregnancy. This includes all of the prenatal care, Medicaid 5,845 5,946 12,596 care related to labor and delivery, and postpartum AR BCBS 2,871 2,536 2,858 maternal care roughly 40 weeks before delivery and 60 days postpartum. It encompasses the full range of QC NA services provided during this time period (e.g., labs, imaging, specialist consultations, and inpatient care). The initial episode design excludes neonatal care. Designated PAP: The PAP for the perinatal episode is the physician or nurse midwife (provider or provider group) who performs the delivery. This provider must also perform the majority of prenatal care for the patient identified by claims with the appropriate global OB bundle procedure, prenatal care bundle procedure, or office visit procedures. 1 Participating Payers: Medicaid, AR BCBS, and QC a Performance and Results: Quality metrics have been put in place to help with the overall goal of increasing pregnancy screenings as a form of preventive care to reduce high-risk pregnancies. Perinatal care has three quality metrics that PAPs must pass in order to participate in shared savings. Providers must provide the following quality metrics to pregnant patients: HIV, Group B streptococcus (GBS), and Chlamydia screenings. Each screening must meet the minimum threshold of 80 percent to pass. 2 Five additional tracked quality metrics in the perinatal episode include: Ultrasound, gestational diabetes, asymptomatic bacteriuria, and hepatitis B specific antigen screenings and Cesarean (C-section) rate. Payer Overall Quality Outcomes Summary (AR BCBS, Medicaid, and QC): Screening rates improved or generally remained at prior levels across the board for all reporting payers. Medicaid Quality Measure Summary: While Medicaid s C-section rate decreased, the average length of inpatient stay for a C-section increased, which may signify a shift to more appropriate C-section use. The C- section rate improved from 34.7 percent in 2013 to 33.5 percent in the 2014 performance year lower than the two participating commercial payers. The average length of stay for C-sections decreased very slightly from 2.7 days in 2013 to 2.6 days in b a Unlike Medicaid and AR BCBS episodes of care participation among QCA providers is voluntary. Due to low volume in some QC episodes, yearto-year provider cost range comparisons were not available for this report. b Medicaid s baseline period was 3/1/2012 through 9/30/2012, while the performance period for 2013 was 3/1/2013 through 9/20/2013, and the 2014 performance year was 10/1/2013 through 9/30/2014. Page 2

39 2013 PAP Baseline Range Figure 3: Perinatal Episode Quality Metric Outcomes (Medicaid) 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 83.1% 84.6% 84.3% 88.7% 83.6% 73.7% 82.9% 81.8% 85.3% 87.1% 81.5% 81.7% 76.9% 67.5% 76.5% Asymptomatic Bacteriuria Screening Chlamydia Screening HIV Screening Hepatitis B Screening Group B Strep Test Provider Cost Range Movement: PAP Perinatal Performance (Medicaid): Figure 4 displays PAP movement for Medicaid perinatal episodes across cost categories from 2013 through There were a total of 109 PAPs who had 5,946 valid episodes of care in 2013, and 12,596 valid episodes in the 2014 performance period. The increase in episode volume in 2014 was the result of additional codes being added to the Medicaid perinatal episode algorithm to more accurately capture valid perinatal episodes. Of the 20 PAPs who achieved costs within the commendable range in 2013, five moved to the acceptable range and 15 remained in the commendable range in the 2014 performance year. Of the 77 PAPs who experienced costs in the acceptable range in their baseline year, five moved to the unacceptable category, 65 remained in the acceptable category, and seven improved to the commendable category. Of the 12 PAPs who experienced average perinatal episode costs in the unacceptable range in the baseline year, seven remained in the unacceptable category, and five improved to the acceptable category in the performance year. Figure 4: 2014 Provider Cost Movement: Perinatal (Medicaid) Commendable: 20 PAPs 5 15 Acceptable: 77 PAPs Unacceptable: 12 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable Page 3

40 2013 PAP Baseline Range AR BCBS Quality Metric Summary: All AR BCBS perinatal quality metrics (for screenings), either improved or remained at or near prior year levels, with Chlamydia screening improving the most from 81.7 percent in 2013 to 91.5 percent in The AR BCBS C-section rate increased slightly, from 38 percent in 2013 to 39 percent in the 2014 performance year. c The C-section length of stay remained flat at an average of 2.5 days across 2013 and Figure 5 displays perinatal screening outcomes for AR BCBS, among which chlamydia screening rates have shown the most improvement from 2012 through AR BCBS has the highest perinatal screening rates overall when compared to the other two participating payers. Figure 5: Perinatal Episode Quality Metric Outcomes (AR BCBS) 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 99.4% 98.8% 99.5% 96.4% 96.3% 93.8% 94.0% 81.7% 91.5% 94.3% 96.3% 95.3% 96.2% 90.1% 64.7% Provider Cost Movement: PAP Perinatal Performance (AR BCBS): There were a total of 141 PAPs who had 2,536 valid episodes of care in 2013 and 2,858 valid episodes in the 2014 performance period. Figure 6 displays PAP movement across cost categories from the baseline year to the performance year. Of the 64 PAPs who achieved costs within the commendable range, two moved to the acceptable range, and 62 remained in the commendable range in the performance year. Of the 47 PAPs who experienced costs in the acceptable range in their baseline year, one moved to the unacceptable category, 20 remained in the acceptable category, and 26 improved to the commendable category. Of the 30 PAPS who experienced average perinatal episode costs in the unacceptable range in the 2013, six remained in the unacceptable category, 21 improved to the acceptable category, and three improved to the commendable category in Figure 6: 2014 Provider Cost Movement: Perinatal (AR BCBS) Commendable: 64 PAPs 2 62 Acceptable: 47 PAPs Unacceptable: 30 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable c AR BCBS baseline period was 1/1/2012 through 12/31/2012, while the first performance period was 1/1/2013 through 12/31/2013, and the second performance period was 1/1/13 through 12/31/14. Page 4

41 QC Quality Measure Summary: For QC, the majority of quality metrics either improved or stayed very near prior-year levels. Chlamydia screening improved the most with a rate of 67 percent in 2014, up from 64 percent in The HIV screening rate fell slightly from 77 percent in 2013 to 73 percent in The C-section rate was comparable to AR BCBS and remained flat at 36 percent across 2013 and Figure 7 displays the perinatal screening rates for QCA from 2013 through Figure 7: Perinatal Episode Quality Metric Outcomes (QualChoice) 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 72.1% 87.7% 71.8% 76.5% 74.7% 63.9% 66.6% 72.9% 74.9% 86.3% QC Provider Cost Outcomes for Perinatal d : Among QC PAPs, the proportion with average episode costs in the commendable, acceptable or unacceptable range remained about the same from 2013 through Among 185 PAPs in 2013, 55 had average costs in the commendable range, 109 had costs in the acceptable range, and 21 had costs in the unacceptable range. Among 187 PAPs in 2014, 49 had commendable costs, 118 were in the acceptable range, and 20 PAPS had average costs that were in the unacceptable range. Total Joint Replacement Episode Previously, multiple providers were involved at each stage of total joint replacement (TJR) procedures without optimal coordination. 3 This Figure 8: Total Joint Replacement Episode Yearly Volume led to duplicative work, increased costs and the potential for decreased quality of care. The hip and knee Medicaid episode includes all services related to elective hip and knee replacement AR BCBS procedures, from the initial QC NA consultation to post surgery followup care. Hip and knee replacements resulting from joint degeneration and osteoarthritis are among the top five elective procedures performed. 4 Each operation involves pre-surgery diagnostics and testing, hospitalization, the procedure itself, and post-surgery rehabilitation. d Due to relatively low volume across performance years, QCA did not provide PAP cost movement in the same format as Medicaid and AR BCBS. While Medicaid and AR BCBS data enable display of individual provider movement across years, QCA cost outcomes were provided at the aggregate level within each cost category for each year. It is anticipated that additional PAP cost movement information will be available in the next annual Statewide Tracking report. Page 5

42 Episode Definition: The hip and knee TJR episode includes all services and care related to elective hip and knee replacements from 30 days prior to the surgery through 90 days after surgery. This includes all-cause readmissions within 30 days of hospital discharge, all facility services, inpatient professional services, and rehabilitation services, as well as any hip/knee-related outpatient labs and diagnostics, outpatient costs, and medications. Designated PAP: The PAP for the hip and knee TJR episode is the orthopedic surgeon who performs the surgical replacement procedure. Participating Payers: Medicaid, AR BCBS, and QC Performance and Results: Postoperative infection, blood clots, and pulmonary or other complications are associated with hip and knee replacements, which can lead to readmissions and further complications. Within the course of treatment for patients deemed eligible for hip and knee replacement surgeries, PAPs have several opportunities to improve the quality and cost of care, including ordering appropriate preoperative tests, using appropriate surgical techniques, utilizing appropriate precautions and medications before and after surgery, and timely discharge from the hospital. These activities can help reduce infections and other complications that may lead to readmissions. Improved outcomes are aimed at the overall goals of improving quality and containing or improving costs. Required quality metrics for participation in shared savings have not been selected. However, the following four quality metrics are tracked for quality of care and improvement opportunities: 30-day all-cause readmission rate; e frequency of use of prophylaxis against post-op Deep Venous Thrombosis (DVT)/Pulmonary Embolism (PE); frequency of post-op DVT/PE; and 30-day wound infection rate. The American Association of Orthopedic Surgeons recommends that pharmacologic and/or mechanical prophylaxis should be used for the prevention of DVT/PE in patients undergoing elective hip or knee arthroplasty who are not at elevated risk of DVT/PE or bleeding. 5 Medicaid Quality Metric Summary: For the 2012 baseline year, post-operation DVT/PE prophylaxis prescribing rate was not reported, but increased from 13 percent in 2013 to 17.4 percent in Postoperation DVT/PE rate was also not reported in the 2012 baseline year, but remained at 0 percent for 2013 and 2014 performance years. Average length of stay for inpatient admissions trended upwards from 3.7 days in the 2012 baseline year to an average of 4.3 days in both 2013 and Figure 9: TJR Quality Metric Outcomes (Medicaid) 15.0% 10.0% 5.0% 3.6% 0.0% 0.0% 2.0% 1.4% 1.7% 6.4% 8.0% 14.1% % 30-day All Cause Readmission Rate 30-day Wound Infection Rate Post-op Complication Rate 2014 e The 30-day all-cause readmission rate is for patient readmissions only related to the TJR procedure. Occurrences between 30 and90 days post-surgery count toward the episode. Page 6

43 2013 PAP Baseline Range Provider Cost Outcomes: PAP Total Joint Replacement Performance (Medicaid): The average episode cost increased slightly for Medicaid, from $9,194 in 2013 to $9,248 in There were a total of three separate PAPs for the TJR episode with 100 valid episodes of care in 2013 and 121 valid episodes of care in the 2014 performance year. One PAP s baseline year costs fell within the commendable threshold, and moved to acceptable during The remaining two PAPs stayed in the commendable cost threshold in 2013 and AR BCBS Quality Measure Summary: The trend decreased for average length of stay for inpatient admissions for TJR, from 2.7 days in the baseline year to 2.6 days and 2.3 days in 2013 and 2014 respectively. Figure 10 displays additional quality metrics. The 30-day all-cause readmission rate remained flat at 1.0 percent, while the post-op complication rate increased very slightly from 2.0 percent to three percent in The prescribing rate of post-op DVT/PE prophylaxis decreased from 40 percent to 31 percent, which may indicate more appropriate prescribing patterns. Figure 10: TJR Episode Quality Metric Outcomes (AR BCBS) 39.9% 40.0% 30.0% 31.0% % 10.0% 0.0% 2.6% 1.0% 30-day all Cause Readmission Rate 1.0% 0.6% Post-op DVT/PE Prophylaxis Rx Rate 0.2% 0.9% 0.0% 0.0% 0.1% 0.0% Post-op DVT/PE Rate 30-day Wound Infection Rate 3.4% 2.0% 3.0% Post-op Complication Rate Provider Cost Outcomes: PAP TJR Performance (AR BCBS): There were a total of 28 PAPs who had 659 valid episodes of care in 2013 and 862 valid episodes in the 2014 performance period. Figure 11 displays PAP movement across cost categories from the baseline year to the performance year. Of the 18 PAPs who achieved costs within the commendable range, one moved to the acceptable range, and 17 remained in the commendable range in the 2014 performance year. Of the seven PAPs who Figure 11: 2014 Provider Cost Movement:TJR (AR BCBS) experienced costs in the acceptable range in 2013, all seven remained in the acceptable category. Of the three PAPS Commendable: 18 PAPs 1 17 who experienced average TJR episode costs in the unacceptable range in 2013, all remained in the unacceptable category Acceptable: 7 PAPs 7 in QC Quality Metric Summary for TJR: Only two metrics were reported in the 2013 baseline year and in the 2014 performance year. The 30-day all-cause readmission rate improved from 3.6 Unacceptable: 3 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable Page 7

44 percent in 2013 to 0 percent in The 30-day wound infection rate worsened from 0 percent in 2013 to 12.2 percent in It is possible that some of this increase can be attributed to incorrect diagnosis on the part of a very few providers. QC Provider Cost Outcomes for TJR: Among QC PAPs, provider cost range outcomes from 2013 through 2014 for hip replacements and knee replacements were reported separately as they are recognized as separate episodes by QC. For QC hip replacements, the proportion of PAPs with average episode costs in the unacceptable range was slightly higher in Among 14 PAPs in 2013, four had average costs in the commendable range, six had costs in the acceptable range, and four had costs in the unacceptable range. Among 20 PAPs in 2014, five had commendable costs, seven were in the acceptable range, and eight PAPs had average costs that were in the unacceptable range. For QC knee replacements the proportion of PAPs in the unacceptable cost range increased slightly in Among 40 PAPs in 2013, 13 had average costs in the commendable range, 22 had costs in the acceptable range, and five had costs in the unacceptable range. Among 39 PAPs in 2014, nine had commendable costs, 20 were in the acceptable range, and 10 PAPS had average costs that were in the unacceptable range. Cholecystectomy Episode Cholecystectomy is the surgical removal of the gall bladder, most generally to alleviate gallstones. The most common procedure used is called laparoscopic cholecystectomy. Episode Definition: The cholecystectomy episode is triggered by services provided by the responsible surgical team. All related services during the cholecystectomy procedure and 90 days after the procedure, including inpatient and outpatient facility services, professional services, related medications, related complications and post-procedure Figure 12: Cholecystectomy Episode Yearly Volume admissions. This episode includes patients between the ages of 1 year and 65 years PAP: The PAP is the primary surgeon performing the Cholecystectomy. Participating Payers: Medicaid, AR BCBS, and QC. Medicaid AR BCBS 1,606 1,368 QC Performance Results: In order to participate in Medicaid gain-sharing, providers are required to pass a quality metric related to the percentage of episodes with CT scan 30 days prior to cholecystectomy. An acceptable threshold would be less than the state average of 44 percent of cases. Metrics intended for reporting only include the rate of major complications occurring in the episode, either during the procedure or in the post-procedure window, such as common bile duct injury, abdominal blood vessel injury, bowel injury, the number of laparoscopic cholecystectomies converted to open surgeries, and the number of cholecystectomies initiated via open surgery. Medicaid Quality Metric Summary: There are six quality metrics that were reported for the Cholecystectomy episode. These were CT scan rate, Common bile duct injury rate, bowel perforation/ injury rate, abdominal blood vessel injury rate, rate of episodes converted from laparoscopic to open surgery, and rate of episodes initiated as open surgery. Page 8

45 2013 PAP Baseline Range For Medicaid, all metrics remained at 0 percent from 2013 to 2014, with the exception of CT scan rate. The CT scan rate increased from 16.6 percent in 2013 to 23.9 percent in 2014 f. Provider Cost Range Movement: PAP Cholecystectomy Performance (Medicaid): Figure 13 displays PAP movement for Medicaid Cholecystectomy episodes across cost categories from 2013 through There were a total of 29 PAPs who had 523 valid episodes of care in 2013 and 578 valid episodes in the 2014 performance period. Of the eight PAPs who achieved costs within the commendable range in 2013, four moved to the acceptable range and four remained in the commendable range in the 2014 performance year. Of the 17 PAPs who experienced costs in the acceptable range in their baseline year, two moved to the unacceptable category, eight remained in the acceptable category, and seven improved to the commendable category. Of the four PAPs who experienced average costs in the unacceptable range in the baseline year, two improved to the acceptable category and two improved to the commendable category in Figure 13: 2014 Provider Cost Movement: Cholecystectomy (Medicaid) Commendable: 8 PAPs Acceptable: 17 PAPs Unacceptable: 4 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable AR BCBS Quality Metric Summary: Figure 14 displays cholecystectomy quality outcomes for AR BCBS. The CT scan rate increased from 15 percent in 2013 to 19 Percent in The rate of episodes converted from laparoscopic to open surgery increased slightly from 0.8 percent in 2013 to 1.1 percent in 2014, while the rate of episodes initiated as open surgery slightly decreased from 3.5 percent in 2013 to 2.7 percent in Figure 14: Cholecystectomy Quality Metric Outcomes (AR BCBS) 19.0% % 15.0% 15.0% % 5.0% 0.0% CT Scan Rate 0.8% 1.1% Rate of Episodes Converted from Laparoscopic to Open 3.5% 2.7% Rate of Episodes Initiated as Open 2014 f For the Cholecystectomy episode, additional CT scan codes were added to the episode algorithm for 2014 in order to more accurately assess provider practice and service delivery. Page 9

46 2013 PAP Baseline Range Provider Cost Range Movement: PAP Cholecystectomy Performance (AR BCBS): Figure 15 displays PAP movement for AR BCBS Cholecystectomy episodes across cost categories from 2013 through There were a total of 87 PAPs who had 1,606 valid episodes of care in 2013 and 1,368 valid episodes in the 2014 performance period. Of the 22 PAPs who experienced costs within the commendable range in 2013, four moved to the acceptable range and 18 remained in the commendable range in the 2014 performance year. Of the 55 PAPs who experienced costs in the acceptable range in their baseline year, seven moved to the unacceptable category, 44 Figure 15: 2014 Provider Cost Movement: Cholecystectomy (AR BCBS) remained in the acceptable category, Commendable: 22 PAPs 4 18 and four improved to the Acceptable: 55 PAPs commendable category. Of the 10 Unacceptable: 10 PAPs 3 7 PAPs who experienced average costs in the 2014 PAP Movement Range Distribution unacceptable range Unacceptable Acceptable Commendable in the baseline year, three remained in the unacceptable range, while seven improved to the acceptable category in QC Quality Metric Summary: No quality metrics were reported for QC for the cholecystectomy episode. Provider Cost Outcomes: PAP Cholecystectomy Performance (QC): Among QC PAPs, the proportion of PAPs with average episode costs in the commendable and acceptable ranges slightly decreased from 2013 through 2014, while the proportion of PAPs with average costs in the unacceptable range increased. Among 112 PAPs in 2013, 45 had average costs in the commendable range, 44 had costs in the acceptable range, and 23 had costs in the unacceptable range. Among 106 PAPs in 2014, 22 had commendable costs, 39 were in the acceptable range, and 45 PAPS had average costs that were in the unacceptable range. Congestive Heart Failure (CHF) Episode In Arkansas, 24 percent of hospitalized Medicare patients with congestive heart failure (CHF) will be readmitted within 30 days annually. 6 CHF affects a significant number of Arkansans and represents an opportunity to improve quality, patient experience, and Figure 16: CHF Episode Yearly Volume efficiency. CHF can be acute, sub-acute or chronic. This episode focuses on acute CHF exacerbations that result in hospitalization and post-acute follow-up care, with a focus Medicaid on improved care coordination and effectiveness among AR BCBS hospital care providers. Patient education and postdischarge follow-up are key ingredients to preventing readmission. Increased use of evidence-based therapies could save the lives of up to 700 Arkansans each year. 7 Episode Definition: The CHF episode focuses on acute and post-acute CHF care, defined as the CHF hospitalization and the 30 days after discharge, including readmissions. All facility services, inpatient professional services, emergency department visits, observation, and post-acute care, as well as any CHFrelated outpatient labs and diagnostics, outpatient costs, and medications are included. Page 10

47 Designated PAP: Given the hospital s critical role in discharge education and planning, the hospital for the initial inpatient admission has been designated as the PAP for the CHF episode. When a CHF patient is transferred from another facility, the facility that accepts the transfer patient and subsequently discharges the patient will be considered the PAP. Participating Payers: Medicaid and AR BCBS Performance and Results: The CHF episode aims to improve coordination and effectiveness by extending the hospital s accountability beyond discharge. In doing so, the episode will reward lower readmission rates and improved patient education, transitions, and quality of care. A substantial number of CHF deaths in this country could potentially be prevented by optimal implementation of evidence-based therapies. 8 In the CHF episode, one of these therapies has been adopted as a quality metric that PAPs must pass in order to participate in upside savings. The metric requires a minimum threshold of 85 percent of patients with left ventricular systolic dysfunction (LVSD) be prescribed an ACE-inhibitor or angiotensin II receptor blocker (ARB) therapy at hospital discharge. Six other quality metrics are in place to track quality of care and improvement opportunities. The quality metrics are: frequency of outpatient follow-ups within seven and 14 days after discharge; proportion of patients matching hyper-dynamic, normal to severe dysfunction, (for qualitative assessments of the left ventricular ejection fraction [LVEF]); average quantitative ejection fraction value; 30-day all-cause readmission rate; 30-day heart failure readmission rate; and 14-day outpatient observation care rate (a utilization metric). Outpatient observation may occur when a provider feels a patient needs to be monitored in a hospital setting so that CHF patients may be in an appropriate setting to allow evaluation of the patient s condition and assessment for potential inpatient admission. Medicaid Quality Metric Summary: The trend for average length of stay has continued to slightly increase, with an average of 4.2 inpatient days in 2012, 4.5 days in 2013, and 4.8 days in Figure 17 displays CHF quality measure outcome from 2012 through 2014 for Medicaid. The 30-day all-cause readmission rate improved from 17.2 percent in 2013 to 16.6 percent in 2014, as did the 30-day heart failure readmission rate, which improved slightly from 6.9 percent to 6.6 percent from 2013 to The proportion of episodes in which the patient had an outpatient visit within 14 days of hospital discharge also improved Figure 17: CHF Episode Quality Metric Outcomes (Medicaid) 60.0% 40.0% 20.0% 42.7% 38.7% 47.6% 16.0% 17.2% 16.6% 7.6% 6.9% 6.6% % % of Episodes with Outpatient Visits Within 14 Days 30-Day All-Cause Readmission Rate 30-day Heart Failure Readmission Rate 2014 from 38.7 percent in 2013 to 47.6 percent in Page 11

48 2013 PAP Baseline Range Three metrics were not reported by Medicaid in the 2012 baseline year: ACEI/ARB prescription rate for LVSD patients, LVEF assessment, and 30-day outpatient observation care rate. Figure 19 displays outcomes for these quality metrics from 2013 through 2014 for Medicaid CHF episodes. The ACEI/ARB prescription rate for LVSD patients improved from 23.1 percent in 2013 to 27.4 percent in The LVEF assessment rate also improved over the same period, from 35.8 percent to 39.7 percent. The 30-day outpatient observation rate increased from 8.3 percent in 2013 to 10.0 percent in Figure 18: CHF Episode Quality Metric Outcomes (Medicaid) 40.0% 30.0% 20.0% 10.0% 0.0% 23.1% 27.4% ACEI/ARB Prescription Rate for LVSD Patients 39.7% 35.8% LVEF Assessment 8.3% 10.0% 30-Day Outpatient Observation Care Rate Provider Cost Range Movement: PAP CHF Performance (Medicaid): The average episode cost increased from $4,708 in 2013 to $5,210 in 2014 for an estimated increase in overall episode costs of $114,944. Figure 19 displays PAP movement for Medicaid CHF episodes across cost categories from 2013 through There were a total of 10 PAPs who had 204 valid episodes of care in 2013 and 229 valid episodes in the 2014 performance period. Of the six PAPs who experienced costs within the commendable range in 2013, three moved to the unacceptable range, and three moved to the acceptable range in the 2014 performance year. Of the three PAPs who Figure 19: 2014 Provider Cost Movement: CHF (Medicaid) experienced costs in the acceptable range in their baseline year, one Commendable: 6 PAPs 3 3 moved to the unacceptable category, Acceptable: 3 PAPs 1 2 while two remained in the acceptable category. Unacceptable: 1 PAPs 1 The one PAP whose average costs were in 2014 PAP Movement Range Distribution the unacceptable range in 2013 improved to the Unnaceptable Acceptable Commendable acceptable category in AR BCBS Quality Metric Summary g : Though lower overall than Medicaid s average length of inpatient stay, the AR BCBS trend for average length of stay has continued to slightly increase, with an average of 3.4 inpatient days in 2012, 3.6 days in 2013, and 4.1 days in g AR BCBS did not have portal entries in 2013 for the following measure: Patients with LVEF assessment results in hospital record. Year-on-year comparisons of this measure are anticipated to be included in the next annual Statewide Tracking Report. Page 12

49 Figure 20 displays CHF quality measure outcomes from 2013 through 2014 for AR BCBS. The 30-day all-cause readmission rate improved greatly from 14 percent in 2013 to 1 percent in The 30-day heart failure readmission rate worsened slightly from 1 percent to 3 percent from 2013 to The proportion of episodes in which the patient had an outpatient visit within 14 days of hospital discharge improved from 57 percent in 2013 to 66 percent in 2014 Figure 20: CHF Episode Quality Metric Outcomes (AR BCBS) 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 57.0% 66.0% % of Episodes with Outpatient Visits Within 14 Days 14.0% 30-Day All-Cause Readmission Rate 15.0% 1.0% 1.0% 3.0% 4.0% 30-Day Heart Failure Readmission Rate 30-Day Outpatient Observation Care Rate Provider Cost Range Movement: PAP CHF Performance (AR BCBS): There was only one valid PAP, who remained in the commendable cost zone in 2013 and Colonoscopy Episode Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel. It is used for visual diagnosis or biopsy/lesion removal purposes. The colonoscopy is the only therapeutic technique which can remove a potentially precancerous growth during the screening Figure 21: Colonoscopy Episode Yearly Volume procedure. Episode Definition: The colonoscopy episode applies to patients between the ages of 18 and 64 and includes all related services within seven days prior to the procedure, the day of the procedure and within 30 days after the procedure. Designated PAP: The provider performing the colonoscopy has been designated as the PAP. Participating Payers: Medicaid and AR BCBS Medicaid 1,283 1,517 AR BCBS 9,264 8,430 Performance and Results: Two quality indicators cited by the American Society of Gastrointestinal Endoscopy are included in this episode. To participate in gain-sharing payments, a provider s valid colonoscopy episodes must meet the following quality metrics: Documentation of endoscopy procedures reaching cecum (at least 75%) and; an endoscope withdrawal time greater than six minutes (at least 80%). Reaching the cecum is critical to a complete examination. 9 Episode advisors selected the following quality metrics to track for future evaluation: Perforation rate and; post-polypectomy/biopsy bleed rate. Medicaid Quality Metric Summary: Comparisons of two quality metric outcomes for the Medicaid colonoscopy episode from 2013 through 2014 are not available at this time, including cecal intubation rate and withdrawal passing rate (percent of episodes with at least six minute withdrawal time). These metrics Page 13

50 2013 PAP Baseline Range were not reported for 2013 because available baseline data is based on historical data for a period in which quality metrics for gain-sharing were not yet implemented. The perforation rate and post-polypectomy bleed rate remained at 0 percent for all episodes across 2013 and The anesthesiologist rate increased from 2.26 percent to percent from 2013 to h Additional quality measure comparisons for the Medicaid colonoscopy episode are anticipated to be included in the next annual Statewide Tracking Report. Provider Cost Range Movement: PAP Colonoscopy Performance (Medicaid): The average episode cost fell from $893 in 2013 to $813 in 2014 for an estimated overall cost savings of $122,528. Figure 22 displays PAP movement for Medicaid colonoscopy episodes across cost categories from 2013 through There were a total of 56 PAPs who had 1,283 valid episodes of care in 2013 and 1,517 valid episodes in the 2014 performance period. Of the 10 PAPs who experienced costs within the commendable range in 2013, one moved to the unacceptable range, six moved to the acceptable range, and three PAPs remained in the commendable range in the 2014 performance year. Of the 15 PAPs who experienced costs in the acceptable range in 2013, three moved to the unacceptable range, six remained in the acceptable range, and six improved to the commendable range in Of the 31 PAPs whose average costs were in the unacceptable range in 2013, seven remained in the unacceptable range, 19 improved to the acceptable range, and five improved to the commendable range in Figure 22: 2014 Provider Cost Movement: Colonoscopy (Medicaid) Commendable: 10 PAPs Acceptable: 15 PAPs Unacceptable: 31 PAPs AR BCBS Quality Metric Summary: PAP Movement Range Distribution Unacceptable Acceptable Commendable Quality measure outcomes for the AR BCBS colonoscopy episode are limited because provider portal entries were not collected for cecal intubation rate, withdrawal passing rate (percent of episodes with at least 6 minute withdrawal time), or perforation rate. The post-polypectomy bleed rate was lowered slightly from 0.03 percent in 2013 to 0.01 percent in Additional quality measure outcomes for the AR BCBS colonoscopy episode are anticipated to be included in the next annual Statewide Tracking Report. Provider Cost Range Movement: PAP Colonoscopy Performance (AR BCBS): Figure 23 displays PAP movement for AR BCBS colonoscopy episodes across cost categories from 2013 through There were a total of 138 PAPs who had 9,264 valid episodes of care in 2013 and 8,430 valid episodes in the 2014 performance period. Of the 60 PAPs who experienced costs within the commendable range in 2013, all but one remained in the commendable range in the 2014 performance year. Of the 46 PAPs who experienced costs in the acceptable range in their baseline year, two remained in the acceptable range, while 44 improved to the commendable range in Of the 32 PAPs whose average costs were in the unacceptable h The original logic for calculating anesthesia rates for Medicaid colonoscopy episodes was corrected for The 2014 rate is correct, while the 2013 rate is artificially low due to the incorrect logic in place in Page 14

51 2013 PAP Baseline Range range in 2013, all improved with five moving to the acceptable category and 27 moving to the commendable category in Figure 23: 2014 Provider Cost Movement: Colonoscopy (AR BCBS) Commendable: 60 PAPs 1 59 Acceptable: 46 PAPs 2 44 Unacceptable: 32 PAPs 5 27 Tonsillectomy Episode 80.0% 60.0% 40.0% 20.0% 0.0% PAP Movement Range Distribution Unacceptable Acceptable Commendable Tonsillectomy is one of the most common surgical procedures in the United States in children under the age of It is performed to alleviate such conditions as recurrent tonsillitis and sleep breathing disorder. Episode Definition: A tonsillectomy episode is an outpatient tonsillectomy, adenoidectomy, or adenotonsillectomy procedure on a patient between the ages of three and 21. It includes related procedure services during and within 90 days prior to and 30 days postprocedure. Examples of related services include initial Figure 24: Tonsillectomy Episode Volume consult, inpatient and outpatient facility services, professional services, and related medications. The episode Medicaid 2,693 3,204 also includes complications that may occur after the procedure. AR BCBS Designated PAP: The designated PAP is the provider performing the tonsillectomy/adenoidectomy. Participating Payers: Medicaid and AR BCBS Performance and Results: To participate in episode gain-sharing, providers must pass a quality metric requiring that intra-operative steroids be administered in a minimum of 85 percent of tonsillectomy episodes. The report-only quality metrics are: Postoperative primary bleed rate; secondary bleed rate and; avoidance of postoperative antibiotic Figure 25: Tonsillectomy Episode Quality Metric Outcomes (Medicaid) 12.8% Post-Prcdr Abx Rx Rate 3.3% 0.3% 0.3% 2.5% 1.5% Post-Prcdr Primary Bleed Rate Post-Prcdr Secondary Bleed Rate 70.6% 50.1% Surgical Pathology Utilization Rate Page 15

52 2013 PAP Baseline Range prescriptions. Medicaid Quality Metric Summary: i Figure 25 displays the tonsillectomy quality measure outcomes for 2013 through 2014 for Medicaid. Among Medicaid tonsillectomy episodes, the post-procedure antibiotic prescribing rate decreased from 12.8 percent to 3.3 percent. The post-procedure secondary bleed rate improved from 2.5 percent to 1.55 percent and the surgical pathology utilization rate was greatly improved, down from 70.6 percent in 2013 to 50.1 percent in 2014, or a 29 percent relative decrease in utilization. Provider Cost Range Movement: PAP Tonsillectomy Performance (Medicaid): The average episode cost fell from $1, in 2013 to $ in 2014 for an estimated overall savings of $226,427. Figure 26 displays PAP movement for Medicaid tonsillectomy episodes across cost categories from 2013 through There were a total of 40 PAPs who had 2,693 valid episodes of care in 2013 and 3,204 valid episodes in the 2014 performance period. Of the 20 PAPs who experienced costs within the commendable range in 2013, one moved to the unacceptable range, while 13 moved to the acceptable range and six remained in the commendable range in the 2014 performance year. Of the 13 PAPs who experienced costs in the acceptable range in their baseline year, five remained in the acceptable category while eight improved to the commendable category. Of the seven PAPs whose average costs were in the unacceptable range in 2013, only one remained in the unacceptable category, while four improved to the acceptable category and two PAPS improved to the commendable category in Figure 26: 2014 Provider Cost Movement: Tonsillectomy (Medicaid) Commendable: 20 PAPs Acceptable: 13 PAPs 5 8 Unacceptable: 7 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable AR BCBS Quality Metric Summary: For the tonsillectomy episode for AR BCBS, some quality measure comparisons are not available from 2013 through AR BCBS is not reporting surgical pathology utilization and, for 2013, intra-operative steroid use and the post-secondary bleed rate metrics were not collected via portal entry as they were in Postoperative bleed rate was available and was extremely low, with two reported cases out of 670 episodes in 2013 and no reported cases among 409 episodes in Additional quality outcomes for the AR BCBS tonsillectomy episode are anticipated to be available in the next annual Statewide Tracking report. Provider Cost Range Movement: PAP Tonsillectomy Performance (AR BCBS): Figure 27 displays PAP movement for AR BCBS tonsillectomy episodes across cost categories from 2013 through There were a total of 31 PAPs who had 670 valid episodes of care in 2013 and 409 valid episodes in the 2014 performance period. All of the 15 PAPs who experienced costs within the commendable range in 2013 remained i For the tonsillectomy episode, intra-operative steroid Rx rate was not reported for 2013 because baseline data is based on historical data in which quality metrics for gain-sharing were not yet implemented. The intra-operative steroid Rx rate is anticipated to be reported in the next annual Statewide Tracking Report. Page 16

53 2013 PAP Baseline Range commendable in 2014Of the eight PAPs who experienced costs in the acceptable range in their baseline year, two moved to the unacceptable category, while five remained in the acceptable category and one improved to the commendable category. Of the eight PAPs whose average costs were in the unacceptable range in 2013, three remained in the unacceptable category, while five improved to the acceptable category in Figure 27: 2014 Provider Cost Movement: Tonsillectomy (AR BCBS) Commendable: 15 PAPs 15 Acceptable: 8 PAPs Unacceptable: 8 PAPs 3 5 Upper Respiratory Infection Episode PAP Movement Range Distribution Unacceptable Acceptable Commendable An upper respiratory infection (URI), such as a cold, is one of the most common illnesses suffered by Arkansans, leading to more doctor visits than any other ailment each year. 11 Most URIs are viral infections that resolve themselves within 10 days. 12 These infections are typically unaffected by antibiotics; therefore, antibiotics are rarely needed to treat these infections, but are still regularly prescribed in Arkansas. This Figure 28: URI Episode Volume (Medicaid) episode encourages efficient treatment and consultation with the physician, including follow-up appointments, as well as urging physicians to better Non-Specific 55,069 50,764 41,045 manage prescribing antibiotics. Pharyngitis 40,428 51,739 49,646 Episode Definition: Three types of episodes are covered nonspecific URIs, acute pharyngitis, and acute Sinusitis 22,696 22,643 19,890 sinusitis. These share common characteristics, but are treated as separate episode types. Designated PAP: The designated PAP for the URI episode is the first provider to see the patient in an inperson setting, even if other providers see the patient during the episode. Participating Payers: Medicaid Performance and Results: One of the primary goals of the URI episode is to improve quality of treatment by reducing the rate of unnecessary antibiotic prescribing. Although patients often expect an antibiotic prescription when they present with a URI, the majority of URIs are non-bacterial and therefore not improved by antibiotics. The Institute of Medicine has identified antibiotic resistance as one of the key threats to health in the United States, and has listed the decrease in inappropriate use of antibiotics as a primary solution to this threat. 13 Page 17

54 Medicaid Quality Metric Summary: Antibiotic prescribing rates improved from the baseline to performance period for all three types of episodes within the URI episode. j,k Non-specific URI: Among the valid episodes of non-specified URI, the prescribing rate decreased from 44.6 percent of patients receiving antibiotic prescriptions in the baseline year to 37.3 percent in the performance year, with the trend continuing to decrease to 34.1 percent in This decrease is an improvement toward the CDC recommendation that antibiotics should not be used to treat non-specific URIs in adults, since antibiotics do not improve URI. 14 Sinusitis URI: Of the valid episodes of sinusitis URI, the antibiotic prescribing rate decreased from 90.1 percent in the baseline year to 88.9 percent in Pharyngitis URI: Among the valid episodes of pharyngitis URI, the antibiotic prescribing rate improved from 70.1 percent in 2013 to 69.2 percent in Figure 29: Non-specific URI Antibiotic Prescribing Rate (Medicaid) 60.0% 40.0% 44.6% 37.3% 34.1% % 3.2% 2.4% 2.1% % At Least One Antibiotic Filled Multiple courses of antibiotic filled Figure 30: Sinusitis URI Antibiotic Prescribing Rate (Medicaid) 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 90.1% 89.6% At Least One Antibiotic Filled 88.9% 7.2% 6.8% Multiple Courses of Antibiotic Filled 6.3% j Medicaid s baseline period was 10/1/2011 through 9/30/2012, while the performance period (initial period for payment) was 10/1/2012 through 9/30/2013. k Having consistent start and end dates for baseline and performance effectively removes seasonality associated with URI rates. Page 18

55 2013 PAP Baseline Range 2013 PAP Baseline Range Figure 31: Pharyngitis URI Antibiotic Prescribing Rate (Medicaid) 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 70.1% 69.2% At Least One Antibiotic Filled 4.6% 4.3% Multiple Courses of Antibiotic Filled Provider Cost Range Movement: PAP URI Performance (Medicaid): The following section contains information about provider movement across cost thresholds for the three different URI episode types: Non specific URI, pharyngitis, and sinusitis. Non-Specific URI: Figure 32 illustrates PAP movement for Medicaid non-specific URI episodes across cost categories from the baseline year to the performance year. There were a total of 442 PAPs who had 50,764 valid episodes of care in 2013 and 41,045 valid episodes in the 2014 performance period. Of the 94 PAPs who experienced costs within the commendable range, three Figure 32: 2014 Provider Cost Movement: Non-Specific URI Commendable: 94 PAPs Acceptable: 255 PAPs Unacceptable: 93 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable moved to the unacceptable range, 37 moved to the acceptable range, and 54 remained in the commendable range in Of the 255 PAPS who experienced costs in the acceptable range in their baseline year,, 198 remained in the acceptable category, and 26 improved to the commendable category. Of the 93 PAPs who experienced average non-specific URI episode costs in the unacceptable range in the baseline year, 45 remained in the unacceptable category, 44 improved to the acceptable category, and four improved to the commendable category in the performance year. Sinusitis URI: Figure 33 displays PAP movement for Medicaid sinusitis URI episodes across cost categories from the baseline year to the performance year. There were a Figure 33: 2014 Provider Cost Movement: Sinusitis URI total of 328 PAPs who had 22,643 valid episodes of care in 2013 and Commendable: 164 PAPs ,890 valid episodes of care in the 2014 performance period. Of the 164 PAPs who experienced costs Acceptable: 111 PAPs within the commendable range, two moved to the unacceptable Unacceptable: 53 PAPs range, 37 moved to the acceptable range, and 125 remained in the commendable range in the PAP Movement Range Distribution Unacceptable Acceptable Commendable 26 Page 19

56 2013 PAP Baseline Range performance year. Of the 111 PAPS who experienced costs in the acceptable range in 2013, 16 moved to the unacceptable category, 53 remained in the acceptable category, and 42 improved to the commendable category. Of the 53 PAPS who experienced average sinusitis URI episode costs in the unacceptable range in the baseline year, 22 remained in the unacceptable category, while 21 improved to the acceptable category and 10 improved to the commendable category in the 2014 performance year. Pharyngitis URI: Figure 34 displays PAP movement for Medicaid pharyngitis URI episodes across cost categories from the baseline year to the performance year. There were a total of 498 PAPs who had 51,739 valid episodes of care in 2013 and 49,646 valid episodes of care in the 2014 performance period. Of the 43 PAPs who experienced costs within the commendable range, one moved to the unacceptable range, 21 moved to the acceptable range, and 21 remained in the commendable range in the performance year. Of the 345 PAPs who experienced costs in the acceptable range in their baseline year, 42 moved to the Figure 34: 2014 Provider Cost Movement: Pharyngitis URI Commendable: 43 PAPs Acceptable:345 PAPs Unacceptable: 110 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable unacceptable category, 276 remained in the acceptable category, and 27 improved to the commendable category. Of the 110 PAPs who experienced average pharyngitis URI episode costs in the unacceptable range in the baseline year, 65 remained in the unacceptable category, while 45 PAPs improved to the acceptable category in the 2014 performance year. Attention Deficit Hyperactivity Disorder (ADHD) Episode The American Psychiatric Association states in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) that 5 percent of children have ADHD 15. In 2011, Arkansas ranked 2 nd nationally in parent-reported diagnoses of ADHD at 14.6 percent of children in the state. 16 Because ADHD can occur in conjunction with other behavioral health conditions and often includes a number of different medical providers, the ADHD Figure 35: ADHD Episode Volume (Medicaid) episode encourages strong evidence-based care and communication among providers. Level 1 3,046 3,768 Episode Definition: The episode includes all ADHDrelated care provided during the 12-month duration Level of the episode, excluding initial assessment. This includes the full range of services provided (e.g., physician visits, psychosocial therapy) as well as all medication used to treat ADHD. If a patient continues treatment after the end of the initial 12-month episode, a new episode is triggered. The ADHD episode consists of Level 1 and Level 2 patients. Level 1 patients who do not respond adequately to medication and other primary treatments will begin a level 2 episode once their provider certifies the severity and rational for Level 2 designation. Page 20

57 Designated PAP: The Principal Accountable Provider (PAP) for the ADHD episode is the provider who delivers the majority of care, determined by number of visits and cost of services delivered. When physicians or Rehabilitative Services for Persons with Mental Illness (RSPMI) provider organizations deliver the majority of care, they will be the sole PAP. When a licensed clinical psychologist not associated with an RSPMI delivers the majority of care, he or she will require a co-pap with the ability to write a prescription for medication. Participating Payers: Medicaid Medicaid Quality Metric Summary: l Figure 36 displays Level 1 ADHD quality measure outcomes. The percent of episodes with a completed certification decreased slightly from 46.4 percent in 2013 to 43.5 percent in The percent of episodes with medication improved from 97.1 percent in 2013 to 98.9 percent in The percent of non-guideline concordant care with no rationale slightly worsened from 3.4 percent in 2013 to 4.9 percent in the 2014 performance year. Figure 36: Level 1 ADHD Quality Metric Summary 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% 46.4% % Completed Certification 43.5% 97.1% 98.9% % Episodes with Medication 0.4% 0.5% 3.4% 4.9% % Non- Guideline Concordant Care % Non- Guideline Concordant Care with No Rationale Figure 37 displays ADHD Level 1 episode quality and utilization outcomes. The average number of physician visits per episode was reduced from 3.5 in 2013 to 3.3 in The average number of behavioral therapy visits per episode improved from 3.3 in 2013 to 1.2 in Figure 37: Level 1 ADHD Utilization Summary Average Number of Physician Visits per Episode Average Number of Behavioral Visits per Episode Average Number of Medication Fills per Episode l Provider cost movement and quality measure year-on-year comparisons are only available for ADHD Level 1 episodes at this time. ADHD Level 2 episode provider cost movement and quality measure outcome comparisons from are not available due to low volume and no PAPs having at least five valid ADHD Level 2 episodes in ADHD Level 2 episode outcomes for are anticipated to be reported in the next annual Statewide Tracking Report. Page 21

58 2013 PAP Baseline Range Provider Cost Range Movement: PAP ADHD Performance (Medicaid) m : For ADHD Level 1, the average episode cost fell from $1,808 in 2013 to $1,523 in 2014 for a projected overall savings of $1,075,746. Figure 38 displays PAP movement for Medicaid ADHD Level 1 episodes across cost categories from the baseline year to the performance year. There were a total of 125 PAPs who had 3,046 valid Figure 38: 2014 Provider Cost Movement: ADHD Level 1 (Medicaid) Commendable: 63 PAPs Acceptable: 55 PAPs Unacceptable: 7 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable episodes of care in 2013 and 3,768 valid episodes of care in the 2014 performance period. Of the 63 PAPs who experienced costs within the commendable range in 2013, 53 moved to the acceptable range, and 10 remained in the commendable range in the 2014 performance year. Of the 55 PAPs who experienced costs in the acceptable range in their baseline year, one moved to the unacceptable category, 48 remained in the acceptable category, and six improved to the commendable category. Of the seven PAPs who experienced average episode costs in the unacceptable range in 2013, five remained in the unacceptable category, while two PAPs improved to the acceptable category in the Coronary Artery Bypass Graft (CABG) Episode Coronary artery bypass graft (CABG) is the re-routing of blood vessels around blockages using arteries or veins from other parts of the body. It is an open-chest surgery and is performed when less invasive methods are not sufficient to Figure 39: CABG Episode Volume restore blood flow through the blocked vessels Episode Definition: CABG episodes begin on the first day of the procedure and end 30-days after discharge from the facility in Medicaid which the procedure occurred, or at the end of a readmission where the patient entered the hospital within the 30 day post-discharge period. All inpatient, outpatient, professional, and pharmacy services that are related to the CABG and are delivered within the episode timeframe are included in the episode. Designated PAP: The physician entity that performs the CABG is the designated. Participating Payers: Medicaid 6 10 m Provider cost movement is only available for ADHD Level 1 episodes. ADHD Level 2 episode provider cost movement is not available because there were no PAPs with at least five valid ADHD Level 2 episodes in Page 22

59 Performance and Results: The CABG episode includes three quality metrics that PAPs must pass in order to qualify for gain-share payments. These include percent of patients with stroke in 30 days post-procedure, percent of patients with deep sternal wound infection in 30 days post-procedure, and percent of patients with postoperative renal failure in 30 days post-procedure. For two of these three metrics PAPs must meet a maximum threshold of 0 percent. Additional quality metrics include percent of episodes during which at least one adverse outcome occurs (with adverse outcome defined as patients with either stroke, deep sternal wound infection, or postoperative renal failure in 30 days post-procedure), percent of patients on a ventilator for longer than 24 hours after surgery, average length of preoperative inpatient stay, percent of patients admitted on day of surgery, and percent of patients for whom an internal mammary artery is used. Medicaid Quality Metric Summary: The proportion of CABG episodes with an adverse outcome was decreased from 3.1 percent in 2013 to 2.6 percent in Additional quality measure outcomes for CABG are displayed in figure 43. Figure 40: CABG Quality Metric Summary 100.0% 78.1% 79.5% 50.0% 0.0% 3.1% 0.0% 0.0% 2.6% 3.1% 2.6% % of Episodes with Stroke in 30 Days % of Episodes with Deep Sternal Wound in 30 days % of "Adverse Outcome" Episodes 31.3% 33.3% % of Patients Admitted on Day of Surgery % for Whom an Internal Mammary Artery was Used Figure 41 displays average preoperative inpatient length of stay for CABG episodes, which was reduced from 2 days in 2013 to 1.6 days on average in Figure 41: CABG Inpatient Utilization (Medicaid) Average length of pre-operative inpatient stay (days) Page 23