Statewide Tracking Report

Transcription

1 Statewide Tracking Report January 2015 Participating Payers: ACHI is a nonpartisan, independent, health policy center that serves as a catalyst to improve the health of Arkansans West Capitol Avenue Suite 300, Victory Building Little Rock, Arkansas Copyright January 2015 by the Arkansas Center for Health Improvement. All rights reserved.

2 Arkansas Health Care Payment Improvement Initiative: Statewide Tracking Report Executive Summary Arkansas s total health system transformation effort has broad goals that include improving quality, expanding access, and avoiding unnecessary costs. The Arkansas Health Care Payment Improvement Initiative (AHCPII) is a key component of this effort and is based on an innovative restructuring of the system to incentivize quality outcomes. This multi payer endeavor is being accomplished collaboratively by the largest public and private carriers in the state. The two main components of AHCPII are: Patient centered medical homes (PCMH), designed to improve quality and contain costs by supporting the delivery of better coordinated, team based care a An episodes of care model, designed to improve quality and reduce variation in common procedures and the treatment of acute conditions Arkansas has become a national leader in payment transformation activities and is on a path to deliver 70 percent of the state s health care under value based purchasing models. As one of only six states awarded an initial round one State Innovation Model Testing grant by the Centers for Medicare and Medicaid Services, Arkansas has pursued all of the proposed elements of the AHCPII, including PCMH and episodes of care. While the AHCPII has the strength of multiple payer participation, because of the nature of health care services provided to specific populations, some elements of AHCPII involve only Arkansas Medicaid. This includes development of health homes for those with complex or extensive needs. AHCPII implementation progress as well as quality and cost impacts based on currently available data are captured in the inaugural AHCPII Statewide Tracking Report. This is the first of three annual reports designed not only to track progress but also to help identify areas in need of adjustment. As the initiative progresses, we expect that more robust cost and quality information from the payers will be available for future reports. Patient Centered Medical Homes (PCMH) b Building on the success of the Comprehensive Primary Care (CPC) initiative, and with design and implementation being led by Medicaid, the state s PCMH program has exceeded initial enrollment expectations. Team based preventive care, chronic disease management, increased information, and responsibility for the total experience of patient care culminate to position the PCMH to optimize utilization of services by patients and guide referrals to the highest value specialty providers. Patient Centered Medical Home Highlights Approximately 780 primary care providers enrolled 309K Medicaid beneficiaries served representing 80% of eligible Medicaid beneficiaries The vast majority of PCMHs successfully completed 3 month and 6 month transformation milestones Anecdotal practice level successes and challenges identified throughout the state a To view a comprehensive video about AHCPII, visit b PCMH Enrollment data provided by Arkansas DHS, pulled from PCMH Q4 reporting as of December 10, Includes practices that enrolled for 1/1/14 and 7/1/14 start dates. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 1 of 11

3 Preliminary 2015 enrollment totals show increases in provider participation and beneficiaries served. Through the state s Health Care Independence Act, qualified health plans operating in the Health Insurance Marketplace will join Arkansas Medicaid in supporting PCMH practices in Episodes of Care During the first phase of the payment initiative, the state Medicaid program, Arkansas Blue Cross and Blue Shield (AR BCBS) and QualChoice of Arkansas (QCA) agreed on design parameters and initially introduced five episodes of care: Upper respiratory infections (URIs) Total hip and knee replacements Congestive heart failure (CHF) Attention deficit hyperactivity disorder (ADHD) Perinatal (pregnancy) Episodes of Care Highlights A 17% drop in unnecessary antibiotic prescribing for non specific URI Across the board improvements in perinatal screening rates AR BCBS hip/knee replacement costs were reduced by 1.4% (7% below projected costs) 73% of Medicaid and 60% of AR BCBS Principal Accountable Providers (PAPs) improved costs or remained in a commendable or acceptable cost range AHCPII System Infrastructure Development The episode and PCMH models have been enabled through development of advanced analytic infrastructure allowing the state to identify areas of improvement and support improved clinical outcomes. After agreeing on common performance measures and report designs, participating payers each conducted analysis of provider performance independently using either internal capabilities or independently contracted vendors. Medicaid, QCA, and other payers worked with AR BCBS to facilitate provider reporting through their Advanced Health Information Network (AHIN). This has enabled a multi payer provider portal on a common platform to support episode and PCMH data entry, and access to reports produced by each payer or their vendors. Providers now receive both historical and performance reports for each episode type (e.g., perinatal), including summarized and detailed cost and quality information, patient names, and patient level episode ID numbers for each individual episode. A large and increasing number of providers have accessed their reports: For the first wave of episodes, 15,600 quarterly performance reports distributed to nearly 2,000 PAPs PAPs Approximately 227 million claims were processed 2.8 million episodes were generated before exclusions Today, the state s Medicaid growth rate is reduced to 2 3 percent, private payers have reported 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. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 2 of 11

4 Introduction In 2011, facing an increasingly fragmented health care system with system costs exceeding available revenue, and growing concern regarding the value of health care expenditures in both the public and private sector, 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 of Arkansas (QCA) c to transform the Arkansas health care system to a value based purchasing model. From this convening, the collaborative effort known as the Arkansas Health Care Payment Improvement Initiative (AHCPII) was established. Arkansas Medicaid (Medicaid), AR BCBS, and QCA have worked collaboratively with hundreds of physicians, hospital executives, patients, families, and advocates in designing, building, and implementing Arkansas s new payment and delivery system. The result is a bold initiative 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 support to enable 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 patientcentered medical home (PCMH) model. Through team based preventive care and chronic disease management as well as increased information and responsibility for the total experience of care, the PCMH is positioned to optimize the patients appropriate 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 already exceeded enrollment expectations. Complementing the PCMH model is the second major component Arkansas s episode of care model for 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 the quality and minimize treatment variations. Through identified opportunities to improve quality and reduce complications for the entire episode, established performance expectations enable the PAP to benefit from system efficiencies. Improvements in Quality of Care Reduction in use of unnecessary antibiotics Improved prenatal screening rates Reduced infection rates in joint replacements Increased 24/7 access to care through medical homes A third component utilized by Arkansas DHS is that of a health home a client based support strategy for individuals with needs exceeding the traditional medical home model. The health home strategy optimizes coordination services to those individuals, including the frail elderly, the severe and persistently mentally ill, and the developmentally disabled. This AHCPII Statewide Tracking Report is the first of an anticipated series of updates on the progress and penetration of the state s system transformation effort. Included are reports on provider uptake in the PCMH model and on the first performance reports for initial episodes launched in Information contained in this report represents aggregate results provided by individual payers for descriptive purposes. More details and additional graphical representations of results can be found in Appendix B. The state s health system has already been impacted by the AHCPII in several ways. Enrollment in the state s PCMH model is widespread, having over half of all eligible Medicaid primary care providers enrolled, with the vast majority successfully completing practice transformation activities. Approximately 82 percent of eligible c QCA is committed to reporting their two initial episodes progress after the end of their performance period (12/31/2014); results will be included in the second year report in Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 3 of 11

5 beneficiaries are now receiving care under the state s program, far exceeding the initial year one goal of 40 percent. For the episode of care model, we have seen meaningful impacts on quality and efficiency, and providers either have received enhanced payments for commendable performance or have been subject to required payments for not achieving acceptable performance. For example, AR BCBS results showed that quality of perinatal (pregnancy) care was improved, and 58 percent of PAPs had decreased perinatal costs compared to projected estimates. For total knee or hip replacements, costs were 1.4 percent below previous year costs. Across all AR BCBS PAPs, 60 percent either improved to a lower cost range or remained in an acceptable or commendable cost range, while 40 percent of PAPs shifted to a higher cost range or remained in an unacceptable cost category. For Medicaid, just one of several areas that showed improvement was in antibiotic prescribing rates, which were reduced by approximately 17 percent. Across all Medicaid PAPs, 73 percent either improved to a Financial Impact and Cost Containment Medicaid growth rate reduced to 2 3% AR BCBS hip/knee replacement costs were reduced by 1.4% (7% below projected) 73% of Medicaid and 60% of AR BCBS PAPs improved costs or remained in a commendable or acceptable cost range lower cost range or remained in an acceptable or commendable cost range, with 296 PAPs receiving gainsharing payments, while 27 percent of PAPs shifted to a higher cost range or remained in an unacceptable cost category, with 231 PAPs owing risk sharing payments. 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 will be a requirement in In addition, some commercial carriers are extending the PCMH model to their fully insured, non exchange 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 the AHCPII remains the lack of full participation of Medicare with the care needs of its eligible participants and their volume of care consumed. Continued demonstration of progress will be utilized to solicit the Centers for Medicaid and Medicare Services full participation. The 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 System Infrastructure Development One of the greatest areas of success in the first operational year has been the progress made in establishing the system infrastructure, which has allowed Arkansas to identify areas of improvement within the AHCPII, and support the clinical outcomes reached by providers. After agreeing on common performance measures and report designs, participating payers each conducted analysis of provider performance independently using either internal capabilities or independently contracted vendors. Medicaid, QCA, and other payers worked with AR BCBS to facilitate provider reporting through their Advanced Health Information Network (AHIN), enabling a multi payer provider portal on a common platform to support episode and PCMH data entry and access to payers' reports. The analyses contained in this report were produced and made possible in part by GDIT, Medicaid, and AR BCBS. Providers now receive both historical and informational reports for each episode type (e.g., perinatal), including summarized and detailed cost and quality information, patient names, and patient level episode ID numbers for each individual episode. A large and increasing number of providers have accessed their reports. In order to generate and report on the first wave of episodes, approximately million claims have been processed Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 4 of 11

6 through the episode engine, resulting in just fewer than 2.67 million episodes before exclusions. More than 15,600 quarterly performance reports have been distributed to nearly 2,000 distinct PAPs. d Patient-Centered Medical Home e The PCMH model is best described as a model of primary care that is patient centered, comprehensive, teambased, coordinated, accessible, and focused on quality. Through improved care coordination and communication, the goal of the medical home is 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 Wavetwo expansion of the PCMH model began in January 2013, and builds upon the efforts of the CPC initiative. For this expansion, Medicaid developed a medical transformation model with particular attention given to the pediatric population. Arkansas s long term goal is for most primary care practices in the state to transition to the PCMH model. Provider Spotlight: Dr. Stacy Zimmerman e Our numbers have gotten better every year since we started the program, but there is always room to improve. Dr. Stacy Zimmerman of Ozark Internal Medicine and Pediatrics Currently, detailed information about system wide cost and quality impacts of the PCMH model and the Medicare led CPC initiative is not readily available. Inclusion of this information is anticipated in subsequent reports. Information is available regarding provider and beneficiary enrollment and practice transformation progress. 44% Reduction in Hospital Admissions 25% Reduction in ER Costs 29% Decrease in Total Costs of Care 9% Increase in Prescribing of Generic Drugs 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 gain sharing based on performance improvements, or based on high performance compared to statewide averages. Quality metrics must be met in both options. Unlike episodes, there is no downside financial risk to the current PCMH models operating in Arkansas. The Arkansas PCMH model has exceeded initial expectations for both provider enrollment and number of beneficiaries served under the model at this stage of implementation. Key findings on current enrollment and participation include: 123 PCMHs enrolled f in the state s Medicaid led, multi payer PCMH program. Nine of these practices are also enrolled in the CPC initiative; 61 practices g enrolled in the Medicare led CPC initiative; d Arkansas has 6,340 active, licensed physicians and 93 hospitals e For a full PCMH case study on Ozark Internal Medicine and Pediatrics (OIMP), please see Appendix B. An early adopter of the PCMH model in Arkansas, OIMP is located in Clinton, AR, in Van Buren County, and serves a panel of approximately 5,700 active patients. f Data provided by Arkansas DHS, pulled from PCMH Q4 reporting as of December 10, Includes practices that enrolled for 1/1/14 and 7/1/14 start dates. g Practices are enrolled individually in the CPC initiative, and current enrollment numbers are tracked by the Centers for Medicaid and Medicare Services: Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 5 of 11

7 Approximately 780 primary care providers are participating, representing 73 percent of all eligible providers; c Approximately 309K Medicaid beneficiaries are covered, representing 80 percent of all eligible Medicaid beneficiaries; c Multi payer participation in either the CPC initiative or the Arkansas PCMH program includes Medicaid, Medicare, AR BCBS, QCA, Humana, Arkansas Public School Employees Plan, Arkansas State Employees Plan, Federal Employees Plan, Walmart, and Fort Smith Physicians Alliance (Medicare shared savings program accountable care organization (ACO) in alignment with PCMH); Table 1: Patient Centered Medical Homes Milestones The first wave of PCMHs enrolled in the Medicaid led PCMH program started in January For those practices, the six month practice transformation milestones have required attestation most recently. Currently, milestone attestation is available for 105 PCMHs that began their enrollment on January 1, 2014; and Through the state s Health Care Independence Act, known as the Private Option, QHPs operating on the Health Insurance Marketplace will join Medicaid in supporting PCMH practices in Table 2: Attestation to PCMH Practice Transformation Milestones h PCMHs that should have attested (Total = 105) Episodes of Care PCMH 3 Month Activities Identify team lead(s) for care coordination Identify the top 10% of high priority patients Assess operations of practice and opportunities to improve Develop and record strategies to implement care coordination and practice transformation PCMH 6 Month Activities Identify and reduce medical neighborhood barriers to coordinated care at the practice level Make available 24/7 access to care Track sameday appointment requests Number Percent 100% 100% 84% 83% 80% 82% 69% An episode of care is the collection of care provided to treat a particular condition for a given length of time. 2 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. PAPs are given quarterly reports that outline their overall performance across the entire episode, including quality targets, utilization variation, and aggregate costs. Upon completion of a performance period (usually one year), each PAP may be eligible for gain sharing if their overall performance has achieved commendable status. If the overall performance is not acceptable and exceeds the acceptable threshold, the PAP may be required to refund a portion of his payments. h Data provided by Arkansas DHS on 11/6/2014. The PCMH attestation validation process is underway to ensure attestation is accurate. Any PCMHs that do not meet attestation validation must complete remediation in a timely manner or will be subject to termination from the PCMH program. Validation of milestones will be provided in subsequent statewide tracking reports. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 6 of 11

8 During the first phase of the payment initiative, Medicaid and the private insurers selectively introduced five episodes of care: upper respiratory infections (URI), total hip and knee replacements, congestive heart failure (CHF), attention deficit hyperactivity disorder (ADHD), i and perinatal. 2 For these episodes, payers agreed upon the following strategies to align financial incentive to improve care: Upper Respiratory Infections (URI) the trigger is the first diagnosis of a URI; the PAP is the diagnosing clinician; the time period is 21 days; quality targets include appropriate testing prior to antibiotic use; costs include all associated therapeutic costs. Currently, Medicaid is the only participating payer. Perinatal the episode trigger is the delivery of a live infant; the PAP is the delivering provider; the time period is the prenatal period and 60 days postpartum; quality targets 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 preoperatively to 90 days postoperatively; quality targets 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 index hospital for the admission; the time period is the admission day plus 30 days; quality targets include appropriate cardiac medication management and follow up; all facility services, inpatient professional services, emergency department visits, observation, and post acute care; any CHF related outpatient labs and diagnostics, outpatient costs, and medications are 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 is 12 months; complexity and quality assessments are through provider attestation; costs include all ADHDrelated charges (ADHD results are not reflected in this year s report due to length of performance period and ongoing analyses of results). Currently, Medicaid is the only participating payer. In the multi payer effort, payers in collaboration with practicing providers jointly developed the definitions above. j 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 performance year are reported below for Medicaid and AR BCBS. QCA will report their two initial episodes progress after the end of their performance period (December 31, 2014). 1. Perinatal The perinatal episode aims to ensure healthy pregnancy and follow up care for the mother and new baby, which requires months of care provided by many different providers ranging from obstetricians, family practice physicians, and nurse midwives to hospitals, emergency departments, obstetric specialists, and others. 3 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. 4 There are five additional quality metrics that PAPs are tracked on in the perinatal episode i This report does not include ADHD episode data due to significant changes in the algorithm and this episode had a short performance period of only one quarter (any comparison would be flawed). j Specific details are available at Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 7 of 11

9 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 QCA are participating in the perinatal episode. Key findings from this episode include the following: Screening rates improved across the board for both AR BCBS and Medicaid. The Chlamydia screening rate showed the most improvement for both payers. Medicaid s C section rate improved from 38.6 percent in the baseline year to 33.8 percent in the performance year. However, the C section s average length of inpatient stay increased from 2.2 days in the baseline year to 2.6 days in the performance year, which may signify a shift to more appropriate C sections. AR BCBS s C section rate increased from 38.0 percent in the baseline year to 38.5 percent in the performance year. 2. Total Joint Replacement (TJR): Hip and Knee Previously, multiple providers have been involved at each stage of total hip and knee replacements without optimal care coordination. This leads to duplication of efforts, increased costs, and 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. 5 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. 6 TJR includes all care related to the procedure in the period 30 days prior to the surgery to 90 days after. 5 This episode has four metrics in place to track quality of care and improvement opportunities: 30 day all cause readmission rate; k 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. Medicaid, AR BCBS, and QCA are participating in the TJR episode. Key findings for the episode include: For AR BCBS, all TJR quality metrics from baseline period to performance period showed improvement, with wound infection rates decreasing by nearly eight fold from 8.5 per 1,000 in the baseline year to 1.1 per 1,000 in the performance year. The 30 day all cause readmission rate improved from 2.55 percent in the baseline year to 2.09 percent in the following performance year. The 90 day post op complication rate improved from 3.40 percent in the baseline year to 2.63 percent in the performance year. For Medicaid, the TJR episode is the single most costly episode, with procedures for the knee being more costly than hip. For TJR, there was improvement in the 30 day all cause readmission rate. While costly, Medicaid s limited adult coverage is reflected in the limited number of episodes, thus limiting the interpretation of results. 3. Upper Respiratory Infection (URI) Upper Respiratory Infections (URIs) are one of the most common illnesses suffered by Arkansans, leading to more doctor visits than any other ailment each year. 7 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 retrospective 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. Key results from the URI episodes include: k The 30 day all cause readmission rate is for patient readmissions occurring between days post surgery o related only to the TJR procedure count toward the episode. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 8 of 11

10 All three of the URI (pharyngitis, sinusitis and non specified URI) episode metrics for antibiotic prescribing rates improved from the baseline to performance period. l,m 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 37.1 percent in the performance year. This decrease is an improvement toward the CDC recommendation that antibiotics should not be used to treat non specific URI in adults since antibiotics do not improve URI. 8 Across all three URI episode types, there were more PAPs with performance year costs in either the commendable and acceptable range than the unacceptable cost range. 4. Congestive Heart Failure (CHF) In Arkansas, 24 percent of hospitalized Medicare patients with congestive heart failure (CHF) will be re admitted within 30 days annually. 9 CHF affects a significant number of older 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, with a focus 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. 9 The 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 7 and 14 days after discharge; proportion of patients matching hyper dynamic, normal, mild dysfunction, moderate dysfunction, 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). 10 Medicaid and AR BCBS are participating in the CHF episode. Key findings include: For Medicaid, the CHF episode saw a decrease in the 14 day observation rate, improving from percent in the baseline period to percent in the performance period. Medicaid excludes dualeligible from it's episodes. For this reason, the number of cases is low. With only thirteen valid PAPs and the low volume of valid episodes in the analysis, the results for this episode must be cautiously observed. For AR BCBS, the 30 day all cause readmission rate worsened from percent in the baseline year to percent in the performance year. However, the CHF episode s volume was so low that any statistical significance is questionable. Additional Episodes Additional episodes deployed or under development are increasing the proportion of surgical, specialty, or intensive care under value based purchasing strategies. The consistent definition of the episode, identification of the PAP, and articulation of quality expectations across payers will 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 quality improvement and practice variation. Table 3 below illustrates the additional episodes deployed or under development. l 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. m Having consistent start and end dates for baseline and performance effectively removes seasonality associated with URI rates. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 9 of 11

11 Table 3: Episodes Deployed or Under Development Episode Upper Respiratory Infection (URI) Perinatal Congestive Heart Failure (CHF) Total Joint Replacement (TJR) Attention Deficit Hyperactivity Disorder (ADHD) Cholecystectomy (Gall Bladder Removal) Colonoscopy Tonsillectomy Oppositional Defiant Disorder (ODD) Coronary Artery Bypass Grafting (CABG) Asthma Chronic Obstructive Pulmonary Disease (COPD) Percutaneous Coronary Intervention (PCI) Neonatal ADHD/ODD Comorbidity Payer Participation Medicaid Medicaid, AR BCBS, QCA Medicaid, AR BCBS Medicaid, AR BCBS, QCA Medicaid Medicaid, AR BCBS, QCA Medicaid, AR BCBS, QCA Medicaid, AR BCBS Medicaid Medicaid, AR BCBS Medicaid, AR BCBS Medicaid, AR BCBS Medicaid, AR BCBS, QCA Medicaid Medicaid Conclusion The AHCPII is a statewide, permanent initiative, not a small scale or short term demonstration project. Enhanced multi payer participation is anticipated, and some of the state s largest self insured employers are already participating, having seen the potential opportunities for better, and more efficient health care for their employees. The total transformation of Arkansas s health system will be strengthened if every payer in the state operates under the new system. 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 As Arkansas moves forward with an increasing proportion of care being delivered under the value based models of the AHCPII, subsequent annual statewide tracking reports will capture future system impacts, including more detailed information on PCMHs, episodes of care, and health homes. REFERENCES 1 Patient Centered Medical Home. Arkansas Health Care Payment Improvement Initiative. [Online] Last Updated April Accessed on November 4, 2014 at 2 Episodes of Care. Arkansas Health Care Payment Improvement Initiative. [Online] Accessed on November 4, 2014 at 3 Episode Summary: Perinatal. Arkansas Health Care Payment Improvement Initiative. [Online] Accessed on November 4, 2014 at 4 Perinatal Care Algorithm Summary. Arkansas Health Care Payment Improvement Initiative. [Online] [Cited: November 17, 2014.]. 5 Episode Summary: Total Hip and Knee Replacement. Arkansas Health Care Payment Improvement Initiative. [Online] Accessed on November 4, 2014 at Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 10 of 11

12 6 Arkansas Blue Cross Blue Shield. Provider Manual: Arkansas Health Care Payment Improvement Initiative Hip and Knee Replacement Episode Reimbursement Program. Little Rock, AR: Arkansas Blue Cross and Blue Shield. Accessed on December 15, 2014 at 7 Episode Summary: Ambulatory Upper Respiratory Infection (URI). Arkansas Health Care Payment Improvement Initiative. [Online] Accessed on December 15, 2014 at 8 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): Episode Summary: Acute/Post acute Congestive Heart Failure. Arkansas Health Care Payment Improvement Initiative. [Online] Accessed on December 11, 2014 at pdf. 10 Congestive Heart Failure Algorithm Summary. Arkansas Health Care Payment Improvement Initiative. [Online] [Cited: November 24, 2014]. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015) Page 11 of 11

13 Appendix A Case Study Patient-Centered Medical Homes: Improving Quality in a Fragmented System

14 Case Study Patient-Centered Medical Homes: Improving Quality in a Fragmented System ACHI is a nonpartisan, independent, health policy center that serves as a catalyst to improve the health of Arkansans. Ozark Internal Medicine and Pediatrics October 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 primary focus of the initiative has been payment innovation and restructuring the system to incentivize quality outcomes. The three main strategies are episodes of care, which focus on improving quality and reducing waste and inefficiencies in common procedures and the treatment of acute conditions; behavioral health and long-term services and support; and patient-centered medical homes. This study is part of a series of case studies spotlighting practice transformation to patient-centered medical homes, 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 This case study was produced in partnership with the Arkansas Department of Human Services. Our numbers have gotten better every year since we started the program, but there is always room to improve. Dr. Stacy Zimmerman of Ozark Internal Medicine and Pediatrics An early adopter of the patient-centered medical home (PCMH) model in Arkansas, Ozark Internal Medicine and Pediatrics (OIMP), is located in Clinton, AR, in Van Buren County, and serves a panel of approximately 5,700 active patients. Led by Dr. Stacy Zimmerman, OIMP employs a staff of nine, with one advanced practice nurse (APN), two licensed practical nurses (LPNs), two administrative personnel, two X-ray technicians, and one full-time information technology (IT) specialist. OIMP began the PCMH transformation process in 2010 first as one of five practices in the PCMH Pilot Project sponsored by Arkansas Blue Cross and Blue Shield, then by being one of 69 Arkansas practices originally selected to participate in the Centers for Medicare and Medicaid Services Innovation Improvements Reported By Dr. Zimmerman Since OIMP Became a PCMH 44% Reduction in Hospital Admissions 25% Reduction in ER Costs 29% Decrease in Total Costs of Care 9% Increase in Prescribing of Generic Drugs Center s Comprehensive Primary Care (CPC) initiative, followed by their enrollment in the Arkansas PCMH program. Implementing a team-based approach to patient care is a primary goal of the PCMH model. By involving the entire staff in care coordination activities, OIMP has been able to provide more efficient, higher quality care. According to Zimmerman, Everybody contributes to care coordination, from the time the front office checks in the patient. We do a lot of team huddles before we see patients and throughout the day so the nurses anticipate any lab tests, shots, or other things that need 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)

15 VAN BUREN COUNTY PROFILE Overall County Health Ranking: 25 (of 75) Social & Economic Factor Ranking: 43 (of 75) Uninsured: 22% (AR: 20%) Poor or Fair Health: 23% (AR: 19%) Primary Care Physicians: 8,542:1 (AR: 1,586:1) Mental Health Providers: 1,548:1 (AR: 696:1) Diabetic Screening: 84% (AR: 82%) Low Birth Weight: 8.6% (AR: 9.0%) Mammography Screening: 55% (AR: 58%) Unemployed: 8.9% (AR: 7.3%) * to be done this helps us save time. The PCMH program also provides resources and incentivizes practices to adopt an electronic medical record (EMR) system. By using their own customized EMR system, the OIMP team has been able to greatly reduce or eliminate care gaps for their patients. Zimmerman researched which EMR system would suit her clinic s needs before deciding on a platform that now allows her to run automated reminders and care-gap analyses. These tools help OIMP proactively manage chronic conditions. Our EMR reminders tell the staff where the needs are for each of our patients. We design the rules in our system to track things like hemoglobin A1C checks for all of our diabetic patients, said Zimmerman. The EMR system also supports a patient portal where OIMP staff can share lab results, prescription details, or follow-up reminders directly with patients. Zimmerman said, When I get results, I can immediately send the patient a portal message indicating lab results and appropriate follow-up. I get confirmation when they receive the message, and then we have a perfect circle with no care gaps. In addition to the patient portal, the OIMP team has improved other aspects of patient engagement and experience of care. Patients at OIMP now benefit from improved access and an after-hours call line features that Zimmerman credits in helping reduce unnecessary emergency room (ER) admissions for her patients. Zimmerman said, Patients love timely turnaround and professional service. Having that, they are more apt to lean on us before they go to the ER. For OIMP, the PCMH model has facilitated and reinforced a shift towards greater patient responsibility. It builds confidence and trust and guides patients to use the system in the right way. The PCMH is outside of our walls, it s a change in the culture of our practice, in the methodology, said Zimmerman. It comes down to care management. Before patients leave, we go through their care gaps with them. They have a follow-up date, and all of their medicines are taken care of. We are reducing the chance of problems before followup. We re keeping our patients healthy. --Stacy Zimmerman, MD, OIMP The staff and patients at OIMP have benefited from the PCMH program in numerous ways. However, Dr. Zimmerman s team is still challenged with issues such as managing transitions of care for their patients who visit hospitals or other providers. OIMP is participating in the state s health information exchange the State Health Alliance for Records Exchange (SHARE) and the team is capable of securely exporting information to other providers. However, obtaining bi-directional communication from hospitals either using a different EMR platform or not connected to SHARE has been difficult. It s so hard to track inpatient admissions and ER discharges; my patients may go to three or four different hospitals. Right now, I m dependent on discharge summaries, faxes, or patient s. Receiving results from the SHARE interface will fulfill so many of our transitions of care goals and milestones that we have to meet for the PCMH program, said Zimmerman. Like all PCMH practices in Arkansas, OIMP receives up-front financial support from participating payers. These funds have helped Dr. Zimmerman transform her practice and maintain care-coordination activities. While there is a requirement for qualified health plans to offer financial support to PCMH practices beginning in 2015, it is unclear to what extent all payers will support Arkansas s PCMH program in the future. I would like to see Medicare come to the table. Trying to stretch the $3 permember per-month payment from Medicaid doesn t go very far, said Zimmerman. The goal of improved quality is one shared by OIMP and all PCMH practices in the state. While OIMP has made improvements in areas such as care coordination and EMR implementation that have impacted key quality and cost indicators, Dr. Zimmerman still acknowledges, It s a work in progress. This report was composed using information obtained during an in-person interview and discussion with Dr. Stacy Zimmerman of Ozark Internal Medicine and Pediatrics. The Arkansas Center for Health Improvement was granted written permission to use this information. Additional information included 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 October 2014 by the Arkansas Center for Health Improvement. All rights reserved. Case Study Patient-Centered Medical Homes: Improving Quality in a Fragmented System Page 2

16 Appendix B Arkansas Health Care Payment Improvement Initiative: Detailed Statewide Tracking Report

17 APPENDIX B TABLE OF CONTENTS Background & Purpose... 2 Report Overview... 3 PATIENT CENTERED MEDICAL HOME (PCMH)... 3 PCMH Implementation Update... 4 EPISODES OF CARE... 6 Perinatal... 7 Total Joint Replacement (TJR): Hip and Knee... 9 Upper Respiratory Infection (URI) Congestive Heart Failure (CHF): Additional Episodes Conclusion Appendix B: AHCPII Detailed Statewide Tracking Report 1

18 Background & Purpose In 2011, facing an increasingly fragmented health care system with system costs exceeding available revenue, and growing concern regarding the value of health care expenditures in both the public and private sector, 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 of Arkansas (QCA) a to transform the Arkansas health care system to a value based purchasing model. From this convening, the collaborative effort known as the Arkansas Health Care Payment Improvement Initiative (AHCPII) was established. Together, Arkansas Medicaid (Medicaid), AR BCBS, and QCA have worked collaboratively with hundreds of physicians, hospital executives, patients, families, and advocates in designing, building, and implementing Arkansas s new payment and delivery system. The result is a bold initiative 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 support to enable 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 chronic disease management as well as increased information and responsibility for the total experience of care, the PCMH is positioned to optimize the patients appropriate utilization of services and guide referrals to the highest value specialty providers. Complementing the PCMH model is the second major component Arkansas s episode of care model for 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 the quality and minimize treatment variations. Through identified opportunities to improve quality and reduce complications for the entire episode, established performance expectations enable the PAP to benefit from system efficiencies. A third component utilized by Arkansas DHS is that of a health home a client based support strategy for those individuals with needs exceeding the traditional medical home model. The health home strategy optimizes coordination services to those individuals, including the frail elderly, the severe and persistently mentally ill, and the developmentally disabled. This AHCPII Statewide Tracking Report is the first of an anticipated series of updates on the progress and penetration of the state s system transformation effort. Included are reports on provider uptake in the PCMH model and on the first performance reports for initial episodes launched in Information contained in this report represents aggregate results provided by individual payers for descriptive purposes. The state s health system has already been impacted by the AHCPII in several ways. Enrollment in the states PCMH model is widespread, having over half of all eligible primary care providers enrolled, with the vast majority successfully completing practice transformation activities. Approximately 76 percent of eligible beneficiaries are now receiving care under the state s program, far exceeding the initial year one goal of 40 percent. For the episode of care model, we have seen meaningful impacts on quality and efficiency, and providers either have received enhanced payments for commendable performance or have been subject to required payments for not achieving acceptable performance. For example, AR BCBS results showed that quality of perinatal (pregnancy) care was improved, and 58 percent of PAPs had decreased perinatal costs compared to projected estimates. For total knee or hip replacements, costs were 1.4 percent below previous year costs. Across all AR BCBS PAPs, 60 percent either improved to a lower cost range or remained in an acceptable or commendable cost range, while 40 percent of PAPs shifted to a higher cost range or remained in an unacceptable cost category. For Medicaid, just one of several areas that showed improvement was in antibiotic prescribing rates, which were reduced by approximately 17 percent. Across all Medicaid a QCA is committed to reporting their two initial episodes progress after the end of their performance period (12/31/2014); results will be included in the second year report in Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 2

19 PAPs, 73 percent either improved to a lower cost range or remained in an acceptable or commendable cost range, with 296 PAPs receiving gain sharing payments, while 27 percent of PAPs shifted to a higher cost range or remained in an unacceptable cost category, with 231 PAPs owing risk sharing payments. 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 will be a requirement in In addition, some commercial carriers are extending the PCMH model to their fully insured, non exchange products. Selfinsured interest continues to grow, with both public and private sector expansion 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 the AHCPII remains the lack of full participation of Medicare with the care needs of its eligible participants and their volume of care consumed. Continued demonstration of progress will be utilized to solicit the Centers for Medicaid and Medicare Services full participation. 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 This statewide, cross payer tracking report is funded in part through a grant to ACHI from Wal Mart Stores, Inc. (Walmart), a participant in and major supporter of the AHCPII. Through the state s Employer Advisory Council (EAC), leaders at Walmart have provided input on design and implementation of AHCPII alongside other participating public and private payers. Report Overview The following report contains an update on the PCMH model, which includes current enrollment status, as well as progress towards practice transformation milestones and quality indicators. In an effort to monitor the statewide diffusion of AHCPII and the overall amount of care that is being delivered under a value based system, this report also includes a section on overall penetration of AHCPII components across providers and beneficiaries. In addition, the report contains a section for the episodes of care model that includes a summary of how the model works and a description of each episode, including assignment of a PAP, episode timeframe, and patient journey for each type of episode. The section also contains key quality metrics for each episode, as well as summary information on episode providers cost impact as reflected in provider movement across episode specific cost thresholds. Here are some of the key highlights presented in this report: Approximately 76 percent of eligible Medicaid beneficiaries are receiving care under the Arkansas PCMH model, greatly exceeding the initial expectation of 40 percent of beneficiaries covered by the first year of the initiative. PCMH provider enrollment exceeded initial expectations, with encouraging reports of practice level improvements already underway. Approximately 659 primary care providers are enrolled in the Arkansas PCMH model. Medicaid saw an improvement in upper respiratory infection (URI) episodes, with a large reduction in antibiotic use. Both Medicaid and AR BCBS improved in the perinatal episode, with an increase in screening rates. The total joint replacement (TJR) episode s 30 day readmission rate for Medicaid and AR BCBS showed improvement with reductions in readmission rates. Both Medicaid and AR BCBS experienced some variation in the congestive heart failure (CHF) episode. Both payers did see an improvement with reductions in hospital readmissions. PATIENT CENTERED MEDICAL HOME (PCMH) The PCMH is best described as a model of primary care that is patient centered, comprehensive, team based, coordinated, accessible, and focused on quality. Through improved care coordination and communication, the goal of Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 3

20 the medical home is to help patients stay healthy, increase the quality of care they receive, and reduce costs. The patient is a part of a care team that is led by a designated primary care doctor who communicates with other clinical and administrative professionals to better coordinate responsibilities of the patient s care. 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 Wave two expansion of the PCMH model began in January 2013, and builds upon the efforts of the CPC initiative. Arkansas s long term goal is for most primary care practices in the state to transition to the PCMH model. Participating PCMH practices receive up front payments to enable them to more proactively meet patient needs and practice transformation milestones, including 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, there are two ways for a primary care physician to achieve gain sharing: 1. Gain sharing based on performance improvements 2. Gain sharing based on high performance compared to statewide averages Quality metrics must be met in both options. Unlike episodes of care, there is no downside financial risk to the current PCMH model operating in Arkansas. PCMH Implementation Update Beginning with the CPC initiative in 2012, the state embarked on a multi payer PCMH implementation, with participation from Medicare, Medicaid, AR BCBS, QCA, and Humana. Development of an EAC helped facilitate further self insured participation, including Walmart, Arkansas State Employees Plan, and Arkansas Public School Employees Plan. Currently, detailed information about system wide cost and quality impacts of the PCMH model and the Medicare led CPC initiative is not readily available. Inclusion of this information is anticipated in subsequent annual reports. However, information is available regarding provider Table 1: Patient Centered Medical Homes Milestones and beneficiary enrollment and practice transformation progress for PCMHs enrolled in the Medicaid led PCMH program, as well as anecdotal, practice level information. b The Arkansas PCMH model has exceeded initial expectations for both provider enrollment and number of beneficiaries served under the model at this stage of implementation. Arkansas s PCMH rollout is inclusive of the initial 69 practices selected for the CPC initiative, and the 143 practices now enrolled in the state s Medicaid led, multi payer PCMH program. Current PCMH Enrollment 123 PCMHs enrolled in the state s Medicaid led, multi payer PCMH program. Nine of these practices are also enrolled in the CPC initiative. 61 practices c enrolled in the Medicare led CPC initiative. b For a full PCMH case study on Ozark Internal Medicine and Pediatrics (OIMP), see Appendix A. An early adopter of the PCMH model in Arkansas, OIMP is located in Clinton, AR, in Van Buren County, and serves a panel of approximately 5,700 active patients. c Practices are enrolled individually in the CPC initiative, and current enrollment numbers are tracked by Centers for Medicaid and Medicare Services: Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 4

21 Approximately 780 primary care providers are participating, representing 73 percent of all eligible providers. c Approximately 309K Medicaid beneficiaries are covered, representing 80 percent of all eligible Medicaid beneficiaries. c Current Payer Participation Arkansas Medicaid Medicare Arkansas Blue Cross and Blue Shield QualChoice of Arkansas Humana Arkansas Public School Employees Plan (73K beneficiaries) Federal Employees Plan (approximately 50K employees in Arkansas) Arkansas State Employees Plan (55K beneficiaries) Walmart (approximately 50K employees in Arkansas) Fort Smith Physicians Alliance (Medicare shared savings program accountable care organization (ACO) in alignment with PCMH) Current PCMH Practice Transformation Progress The first wave of PCMHs enrolled in the Medicaid led PCMH program starting in January For those practices, the six month practice transformation milestones have required attestation most recently. Table 2 below illustrates the rate of attestation for the six month PCMH milestones for the first round of practices enrolled in the Medicaid led PCMH program. The table displays the rate of attestation among the practices that began the Medicaid led PCMH program on January 1, The PCMH attestation validation process is underway to ensure that attestation is accurate, and that any PCMHs that do not meet attestation validation must complete remediation in a timely manner, or will be subject to termination from the PCMH program. Validation of milestones will be provided in subsequent statewide tracking reports. Table 2: Attestation to PCMH Practice Transformation Milestones d PCMHs that should have attested (Total = 105) Milestone attestation is currently available for 105 PCMHs that began their enrollment on January 1, The 105 PCMHs whose transformation timeline began on January 1, 2014, are part of the 193 total PCMHs currently recognized in the state. 70 of 71 practices with deficiencies in six month milestones submitted quality improvement plans (QIPs). PCMHs have a calendar quarter following submission of QIPs to complete remediation. The PCMH quality assurance team is in the attestation validation process (e.g., site visits, phone calls, etc.) to confirm PCMH activity attestation. PCMHs that do not remediate any inaccurate attestations are subject to termination from the program. Future Payer Participation PCMH 3 Month Activities Identify team lead(s) for care coordination Identify the top 10% of highpriority patients Assess operations of practice and opportunities to improve Develop and record strategies to implement care coordination and practice transformation PCMH 6 Month Activities Identify and reduce medical neighborhood barriers to coordinated care at the practice level Make available 24/7 access to care Track sameday appointment requests Number Percent 100% 100% 84% 83% 80% 82% 69% d The PCMH attestation validation process is underway to ensure attestation is accurate. Any PCMHs that do not meet attestation validation must complete remediation in a timely manner or will be subject to termination from the PCMH program. Validation of milestones will be provided in subsequent state tracking reports. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 5

22 Through the state s Health Care Independence Act, known as the Private Option, qualified health plans (QHPs) operating on the Health Insurance Marketplace will join Medicaid in supporting PCMH practices in Additional payer participation is anticipated, and QHPs will be required to increase the incentives of the PCMH program for providers to transition to the PCMH model in To be implemented by Arkansas Insurance Department (AID) rule, new payer requirements include a minimum average of $5 PMPM care payment for care coordination and practice transformation. The payment is tied to performance on practice support activities and metrics. This additional financial support to participating practices will reinforce the value of practice transformation activities, which are aimed at things like achieving more coordinated care and increasing the use of health information technology and the State Health Alliance for Records Exchange (SHARE). The AID rule also requires payers to develop a shared savings model (to be implemented in future years of the PCMH program) for practices to achieve a per issuer enrollee cost of care that is below a benchmark cost. Finally, the rule requires that payers provide performance reports in a pre specified, standardized format, and share statistics in the form of analyzed claims data for potential multi payer use. Expanded Payer Participation Beginning January 1, 2015 Arkansas Blue Cross and Blue Shield** Blue Cross and Blue Shield Multi state Plan** QualChoice of Arkansas** Arkansas Health and Wellness (Ambetter)** United Healthcare Additional Self Insured Purchasers **Via QHP Requirements Upcoming Additional Support for PCMH PMPM payments will begin on April 1, 2015, for QHP beneficiaries attributed to Medicaid designated PCMHs that are in good standing. Attribution will be updated on a quarterly basis. QHP PCMH attribution will be based on marketplace enrollment. Excluding those deemed medically frail and enrolled in traditional Medicaid, there are 188K e individuals enrolled in the Private Option, and another45k f individuals enrolled in the Health Insurance Marketplace. Five carriers are offering plans for Dual Eligible Special Needs Plans (D SNPs) and must adhere to the same QHP requirements to support PCMHs for program eligible individuals. The first PCMH shared savings payments will be issued to providers beginning in July EPISODES OF CARE An integral component of the AHCPII is the creation and implementation of an episode based care delivery model. The episode of care model is designed to reduce or control costs, and improve quality of care. An episode is the collection of care provided to treat a particular condition for a given length of time. 2 For each episode of care identified, a principal accountable provider (PAP) is designated. 3 This 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 mid level provider. In others, it will be a hospital or facility. 4 Payers provide quarterly data reports to providers outlining quality, cost, and utilization patterns associated with specific episodes of care. These reports provide PAPs with information they have not had in the past, which allows them to better understand which areas they are excelling or may need improvement as compared to their peers. They also support PAPs operating in a PCMH model to better account for the entire continuum of care their patients encounter across the health care system. e Total number enrolled in private plans through the Health Care Independence Program (Private Option) per Arkansas DHS report run on December 3, f Total number of Health Insurance Marketplace enrollees actively covered, excluding enrollment cancellations, as reported by the Arkansas Insurance Department as of December 15, Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 6

23 During the first phase of the payment initiative, Medicaid and the private insurers initially introduced five episodes of care: upper respiratory infections (URI), total hip and knee replacements, congestive heart failure (CHF), attention deficit hyperactivity disorder (ADHD), g and perinatal. All payers do not participate in all types of episodes developed under the model. 2 Quality metrics are built into each episode in order for providers to qualify for gain sharing. There are two types of quality metrics for episodes: to pass and to track. The to pass metrics are linked to payment. 4 The provider must meet required threshold levels to be eligible for incentive payments, known as gain sharing. To track metrics are key to understanding overall quality of care and quality improvement opportunities. The tracking metrics are shared with providers, but are not linked to payment. 4 At the end of an episode s performance period, each PAP s average cost of care for each type of episode will be calculated by each payer. Only valid episodes, as determined by episode specific algorithms and inclusion criteria, will count towards a PAP s average. The PAP s average cost will be compiled and compared with other providers. Based on results, PAPs will fall into threshold categories that determine whether they qualify for risk or gain sharing. Episode cost thresholds are set separately by each participating payer, and are based on historical Arkansas cost data. Threshold categories are commendable, acceptable, and unacceptable. PAPs that meet quality targets with average episode costs below the commendable threshold, or green zone, will share half the savings up to a limit. To ensure that appropriate and high quality care is maintained, there is a threshold for maximum gain sharing for each episode, known as the gain sharing limit. PAPs that experience average costs within the acceptable, or grey zone, will not be subject to risk sharing, but will not receive any gain share payments. PAPs that have average costs above the unacceptable threshold, or red zone, will be responsible for a share of costs above this threshold. Perinatal The perinatal episode aims to ensure a healthy pregnancy and follow up care for the mother and new baby, which requires months of care provided by many different providers, ranging from obstetricians, family practice physicians, and nurse midwives to hospitals, emergency departments, obstetric specialists, and others. Episode Definition: The perinatal episode includes all pregnancyrelated care provided during the course of the pregnancy. 5 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. 9 It encompasses the full range of services provided during this time period (e.g., labs, imaging, specialist consultations, and inpatient care). 5 The initial episode design excludes neonatal care. Figure 2: Perinatal Care Screening Rates MEDICAID g This report does not include ADHD episode data due to significant changes in the algorithm and the short episode performance period of only one quarter; any comparison would be flawed. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 7

24 PAP: The PAP for the perinatal episode is the physician or nurse midwife (provider or provider group) who performs the delivery. 5 This provider must also perform the majority of the prenatal care for the patient identified by claims with the appropriate global OB bundle procedure, prenatal care bundle procedure, or office visit procedures. 6 Participating Payers: Medicaid, AR BCBS, and QCA. h Performance & 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. These measures are for HIV, Chlamydia, and Group B streptococcus (GBS) screenings. Each screening must meet the minimum threshold of 80 percent to pass. 7 There are additional quality metrics that are tracked in the perinatal episode for quality of care and improvement opportunities including the following screenings: asymptomatic bacteriuria, hepititis B specific antigen, ultrasound and gestational diabetes. Cesarean (C section) rate is also tracked in the perinatal episode. Payer Overall Performance (AR BCBS and Medicaid): Screening rates improved across the board for both AR BCBS and Medicaid. The Chlamydia screening rate showed the most improvement for both payers. (Please see individual findings below.) 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 sections. The C section rate improved from 38.6 percent in the baseline year to 33.8 percent in the performance year. However, the C section s average length of stay worsened, moving from 2.2 days in the baseline year to 2.6 days in the performance year. i PROVIDER COST MOVEMENT: PAP Perinatal Performance (Medicaid) At the start of 2012, PAPs began in one range, and may have shifted to another range in For example, in 2012, 13 PAPs were in the unacceptable category. In 2013, 9 of those PAPs moved to the acceptable category. Figure 3: 2013 Provider Cost Movement/Shift: Perinatal (Medicaid) 2012 PAP Baseline Range Commendable: 10 PAPs Acceptable: 73 PAPs Unacceptable: 13 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable Figure 3 displays PAP movement for Medicaid perinatal episodes across cost categories from the baseline year through the performance year. There were a total of 96 PAPs who had 5,845 valid episodes of care in the baseline year, and 5,712 valid episodes in the performance period. Of the 10 PAPs who experienced costs within the commendable range, 4 moved to the acceptable range, and 6 remained in the commendable range in the performance year. Of the 73 PAPs who experienced costs in the acceptable range in their baseline year, 2 moved to the unacceptable category, 57 remained in the acceptable category, and 14 improved to the commendable category. Of the 13 PAPs who experienced average perinatal episode costs in the unacceptable range in the baseline year, 4 remained in the unacceptable category, and 9 improved to the acceptable category in the performance year. h QCA is committed to reporting their two initial episodes progress after the ending of their performance period (12/31/2014); results will be included in the second year report in i Medicaid s baseline period was 3/1/2012 through 9/30/2012, while the performance period (initial for payment) was 3/1/2013 through 9/20/2013. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 8

25 Figure 4: Perinatal Care Screening Rates AR BCBS 2012 PAP Baseline Range Figure 5: 2013 Provider Cost Movement/Shift: Perinatal (AR BCBS) Commendable: 92 PAPs Acceptable: 30 PAPs Unacceptable: 12 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable 56 AR BCBS Summary: As mentioned above, all AR BCBS perinatal quality metrics (for screenings), from baseline period to performance period, showed improvement. The AR BCBS C section rate worsened, from 38.0 percent in the baseline year to 38.5 percent in the performance year. j PROVIDER COST MOVEMENT: PAP Perinatal Performance (AR BCBS) There were a total of 134 PAPs who had 2,871 valid episodes of care in the baseline year and 2,725 valid episodes in the performance period. Figure 5 displays PAP movement across cost categories from the baseline year to the performance year. Of the 92 PAPs who experienced costs within the commendable range, 6 moved to the unacceptable range, 30 moved to the acceptable range, and 56 remained in the commendable range in the performance year. Of the 30 PAPS who experienced costs in the acceptable range in their baseline year, 15 moved to the unacceptable category, 9 remained in the acceptable category, and 6 improved to the commendable category. Of the 12 PAPS who experienced average perinatal episode costs in the unacceptable range in the baseline year, 8 remained in the unacceptable category, 2 improved to the acceptable category, and 2 improved to the commendable category in the performance year. Total Joint Replacement (TJR): Hip and Knee Previously, multiple providers have been involved at each stage of total joint replacement procedures without optimal coordination. 8 This leads to duplication of efforts, increased costs and decreased quality of care. The hip and knee j AR BCBS baseline period was 1/1/2012 through 12/31/2012, while the performance period was 1/1/2013 through 12/31/2013. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 9

26 episode includes all services related to elective hip and knee replacement procedures, from the initial consultation to post surgery follow up care. 9 Hip and knee replacements resulting from joint degeneration and osteoarthritis are among the top five elective procedures performed. 10 Each operation involves pre surgery diagnostics and testing, hospitalization, the procedure itself, and post surgery rehabilitation. Episode Definition: The hip and knee TJR episode includes all care related to elective hip and knee replacements. 11 A hip or knee replacement episode includes all services in the period from 30 days prior to the surgery through 90 days after surgery, including all cause readmissions within 30 days of Figure 7: Total Joint Replacement: Hip and Knee AR BCBS 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. PAP: The PAP for the hip and knee TJR episode is the orthopedic surgeon who performs the surgical replacement procedure. 11 Participating Payers: Medicaid, AR BCBS, and QCA h Performance & Results: Post operative 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 pre operative 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. These improved outcomes are aimed at the overall goals of improving quality and lowering costs. No quality metrics that require PAPs to pass to participate in shared savings have been selected. 12 Yet, TJR has four quality metrics in place that PAPs are tracked on for quality of care and improvement opportunities. These are the following quality metrics: 30 day all cause readmission rate; k 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. Medicaid Summary: The TJR episode is the single most costly episode for Medicaid, with procedures for the knee being more costly than hip. For TJR, there was improvement in the 30 day all cause readmission rate. This is an episode particularly susceptible to having low volume for Medicaid. l 30 day wound infection: The infection rate increased from 1.42 percent in the baseline year to 1.98 percent in the performance year. 30 day all cause readmission rate: The hospital readmission rate decreased from 3.55 percent in the baseline year to 0.00 in the performance year; a lower rate is desired and indication of no readmissions in performance period. 90 day post op complication rate: The complication rate worsened from 6.38 percent in the baseline year to 7.92 percent in the performance year. k The 30 day all cause readmission rate is for patient readmissions only related to the TJR procedure, between days post surgery count toward the episode. l Medicaid s baseline period was 2/1/2012 through 12/31/2012, while performance period (initial for payment) was 2/1/2013 through 12/31/2013. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 10

27 PROVIDER COST MOVEMENT: PAP Total Joint Replacement Performance (Medicaid) There were a total of 3 separate PAPs for the TJR episode with 141 valid episodes of care in the baseline year and 101 valid episodes of care in the performance year. Two PAPs baseline year costs fell within the commendable green zone. Of the 2 PAPs, 1 PAP remained with commendable range, and the other PAP moved from commendable average cost to the acceptable range. One PAP had a baseline cost within the acceptable range, and remained in that range for the performance period. AR BCBS Summary: All total joint replacement quality metrics, from baseline period to performance period, showed improvement. m 30 day wound infection: The infection rate improved from 0.85 percent in the baseline year to 0.11 percent in the performance year. 30 day all cause readmission rate: The hospital readmission rate improved from 2.55 percent in the baseline year to 2.09 percent in the performance year. 90 day post op complication rate: The complication rate improved from 3.40 percent in the baseline year to 2.63 percent in the performance year. PROVIDER COST MOVEMENT: PAP Total Joint Replacement Performance (AR BCBS) There were a total of 27 PAPs who had a total of 823 valid episodes of care in the baseline year and 911 valid episodes in the performance period. Figure 8 displays PAP movement across cost categories from the baseline year through the performance year for the TJR episode. Of the 12 PAPs who experienced costs Figure 8: 2013 Provider Cost Movement/Shift: Total Joint Replacement AR BCBS 2012 PAP Baseline Range Commendable: 12 PAPs Acceptable: 13 PAPs Unacceptable: 2 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable within the commendable range, 2 moved to the unacceptable range, while the remaining 10 PAPs remained in the commendable range in the performance year. Of the 13 PAPS who experienced costs in the acceptable range in their baseline year, 1 moved to the unacceptable category, 5 remained in the acceptable category, and 7 improved to the commendable category. Of the 2 PAPS who experienced average TJR episode costs in the unacceptable range in the baseline year, both remained in the unacceptable range. 7 Upper Respiratory Infection (URI) 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. 13 Most URIs are viral infections that resolve m AR BCBS baseline period was 1/1/2012 through 12/31/2012, while the performance period was 1/1/2013 through 12/31/2013. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 11

28 themselves within 10 days. 14 These infections are typically unaffected by antibiotics; therefore, antibiotics are rarely needed to treat these infections, but are still regularly prescribed in Arkansas. This retrospective episode encourages efficient treatment and consultation with the physician, including follow up appointments, as well as urging physicians to better manage prescribing antibiotics. 13 Episode Definition: Three types of episodes are covered nonspecific URIs, acute pharyngitis, and acute sinusitis. These share common characteristics, but are treated as separate episode types. 14 PAP: The PAP for the URI episode is the first provider to see the patient in an in person setting, even if other providers see the patient during the episode. Figure 10: Antibiotic Prescribing Rate for URI Episodes MEDICAID Participating Payers: Medicaid Performance & 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 nonbacterial and therefore not URI (Non specific) (%) URI (Sinusitus) (%) URI (Pharyngitis) (%) Baseline Performance 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. 15 URI has one quality metric that PAPs must pass in order to participate in upside savings. 16 In the pharyngitis episode, providers must have carried out a strep test for patients for whom an antibiotic was prescribed at a minimum threshold of 47 percent. PAPs were tracked on two quality metrics for URI quality of care and improvement opportunities. The first tracked metric was the antibiotic prescribing rate for all URI episodes. The second metric was the multiple antibiotic prescribing rates for the URI episodes, sinusitis and non specific URI. Medicaid Summary: There are three types of episodes within the URI episode that are covered non specified URIs, acute sinusitis, and acute pharyngitis. All three of the URI (pharyngitis, sinusitis, and non specified) 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 37.1 percent in the performance year. 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. 17 Sinusitis URI: Of the valid episodes of sinusitis URI, the antibiotic prescribing rate decreased from 90.1 percent in the baseline year to 89.5 percent in the performance year. Pharyngitis URI: For pharyngitis patients, a strep test is necessary to indicate whether antibiotics should be prescribed. Among the valid episodes of pharyngitis URI, the strep test to prescribing rate improved from 49.3 percent in the baseline year to 57.7 percent in the performance year. 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. o Having consistent start and end dates for baseline and performance effectively removes seasonality associated with URI rates. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 12

29 PROVIDER COST 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. Figure 11 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 459 PAPs Figure 11: 2013 Provider Cost Movement/Shift: URI Non specific (Medicaid) 2012 PAP Baseline Range Commendable: 82 PAPs Acceptable: 286 PAPs Unacceptable: 91 PAPs PAP Movement Range Distribution Unacceptable Acceptable Commendable who had 55,069 valid episodes of care in the baseline year, and 51,198 valid episodes in the performance period. Of the 82 PAPs who experienced costs within the commendable range, 3 moved to the unacceptable range, 29 moved to the acceptable range, and 50 remained in the commendable range in the performance year. Of the 286 PAPS who experienced costs in the acceptable range in their baseline year, 41 moved to the unacceptable category, 204 remained in the acceptable category, and 41 improved to the commendable category. Of the 91 PAPs who experienced average non specific URI episode costs in the unacceptable range in the baseline year, 56 remained in the unacceptable category, 31 improved to the acceptable category, and 4 improved to the commendable category in the performance year. Figure 12 displays PAP movement for Medicaid Figure 12: 2013 Provider Cost Movement / Shift: URI Pharyngitis (Medicaid) pharyngitis URI episodes across cost categories from the baseline year to the performance year. There were a total of 505 PAPs who had 40,428 valid Commendable: 46 PAPs episodes of care in the baseline year and 36,481 valid episodes of care in the Acceptable: 357 PAPs performance period. Of the Unacceptable: 101 PAPs PAPs who experienced costs within the commendable range, moved to the unacceptable 2013 PAP Movement Range Distribution range, 24 moved to the Unacceptable Acceptable Commendable acceptable range, and 21 remained in the commendable range in the performance year. Of the 357 PAPS who experienced costs in the acceptable range in their baseline year, 52 moved to the unacceptable category, 272 remained in the acceptable category, and 33 improved to the commendable category. Of the 101 PAPS who experienced average pharyngitis URI episode costs in the unacceptable range in the baseline year, 63 remained in the unacceptable category, and 38 improved to the acceptable category in the performance year PAP Baseline Range 41 Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 13

30 Figure 13 displays PAP movement for Medicaid Figure 13: 2013 Provider Cost Movement / Shift: URI Sinusitis (Medicaid) sinusitis URI episodes across cost categories from the baseline year to the performance year. There were a total of 331 PAPs Commendable: 182 PAPs who had 22,696 valid episodes of care in the baseline year and 22,852 Acceptable: 113 PAPs valid episodes of care in the performance period. Of the 182 PAPs who Unacceptable: 36 PAPs experienced costs within the commendable range, 2013 PAP Movement Range Distribution 11 moved to the unacceptable range, 47 Unacceptable Acceptable Commendable moved to the acceptable range, and 124 remained in the commendable range in the performance year. Of the 113 PAPs who experienced costs in the acceptable range in their baseline year, 23 moved to the unacceptable category, 58 remained in the acceptable category, and 32 improved to the commendable category. Of the 36 PAPs who experienced average sinusitusuri episode costs in the unacceptable range in the baseline year, 20 remained in the unacceptable category, 12 improved to the acceptable category, and 4 improved to the commendable category in the performance year PAP Baseline Range Congestive Heart Failure (CHF): In Arkansas, 24 percent of hospitalized Medicare patients with congestive heart failure (CHF) will be re admitted within 30 days annually. 18 CHF affects a significant number of Arkansans and represents an opportunity to improve quality, patient experience, and efficiency. 19 Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 14