Transforming Primary Care in the Adirondack Region of New York State

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1 Transforming Primary Care in the Adirondack Region of New York State 2013 Southwind Institute October 22, 2013 Karen Ashline, Director Northern Adirondack Medical Home A Division of the Champlain Valley Health Network Cliff Omstrom, Executive Director Empire Plan UnitedHealthcare National Accounts

2 Who are we and what have we accomplished? Payors meet with ADK provider leadership & DOH to address crisis in primary care in Northeastern NY (Clinton, Essex, Franklin & Hamilton Counties) Demonstration objective-improved access & quality outcomes at reduced cost. Recruit & retain primary care practitioners. Guidelines of participation developed. Attribution logic for non-hmo patients agreed upon. Payment level- $7PMPM targeted at practice transformation, care management & provider compensation. January 2010 Pilot implementation- Governance Committee formed to provide direction, evaluation & dispute resolution P4P considered after year 1.

3 The Partnership: New York State, Primary Care Providers, Hospitals, and Payors 3 Supervised by both New York Department of Health and Department of Insurance Partnering with Excellus, Empire BCBS, UHC The Empire Plan, BSNENY, MVP, CDPHP, Fidelis, NYS Medicaid and one of eight states chosen nationally to participate in the CMS Multi- Advanced Primary Care Pilot 105,000 covered lives 30 primary care sites across 50 NCQA recognized sites 201 primary care providers 111 physicians and 90 mid-levels 5 hospitals The demonstration includes seven rural counties in the Adirondacks of upstate New York spanning across 8,500 square miles with an approximate population of 430,000.

4 Adirondack Health Institute The Adirondack Health Institute (AHI) was established to expand regional collaboration among health care providers serving the Adirondack North Country of New York State, addressing rapid changes and challenges to the health care system by coordinating planning, recruiting, clinical activities, outreach, and by overseeing grant-supported programs. Provides overall governance structure and maintains NYS Anti-Trust Legislation Manage data warehouses claims and quality Reinforces regional value in health care

5 Committing to Substantial Practice Redesign Key Requirements to Join Pilot 5 Required to Achieve medical home recognition wtih Level 2 or Level 3 required Primary Care Practice with each patient assigned a personal provider Implement same day access with 24/7 telephone access for all patients Adopt e-prescribing system by month 6 with benchmark of 80% Implement evidence-based care with consistent approach to quality Create disease management with adult focus on diabetes, CAD and HTN and pediatric focus on obesity, asthma and prevention Coordinate care across continuum to include optimal transitions of care Join regional health information exchange that allows for data sharing that enhances patient care Participate in quality measurement and improvement activities to include reporting across the provider groups

6 Payor Perspectives Significant concern with structure of Pilot and the absence of P4P from inception. Could desired results be achieved in provider & practice transformation with no financial risk to practitioners? Could clinical & utilization goals be realized? Would providers be sufficiently committed w/o financial risk to the $7PMPM? Would the plans investment be returned?

7 Components of an Effective Program Needed Infrastructure to Support New Models of Care Integrated Physician Organization Clinical Transformation Capabilities Robust Technology Platform Effective (FFS) Payer Strategy Engage medical staff both independent and employed Establish physician governance and leadership Develop new and ongoing program initiatives Create and administer value based financial incentives Medical Home Care Transitions Establish ambitious standards for delivery system redesign Focus on chronic disease and prevention Analytics to ensure high quality, low cost care Management Infrastructure Provide visibility across full care continuum Monitor performance across key metrics and initiatives Address physician concerns about data integrity Demonstrate value proposition to payer partners Proactively solicit pay-for-performance incentives to augment fee-forservice payment Partner and negotiate with commercial payers on behalf of full physician network

8 Supports Designed to Encourage Provider Participation Build Robust Care Management Team Include RN Care Manager, Pharmacist, Social Worker Improve patient care that leads to enhanced outcomes Ensure that care coordination is linked to primary care Improve care across continuum and provide consistency for patient Seamless transition from one level of care to another Reduce gaps/barriers to health care Reduce health care costs

9 Care Management Supports Transitional Care Supports Includes Medication Reconciliation and Education with post hospital discharge support Practice Based Embedded Care Management Disease Management Diabetes/Nutrition Support/Education Resources to Reduce Barriers to Health Care Identify barriers and collaborate to find resources available in our communities

10 Building Community Collaboration Care Management Supports

11 How are we doing? Current Status Utilization Decrease Healthcare Cost Decrease preventable readmissions Decrease ER use Quality Improve Patient Outcomes Decreased HbA1c levels Patient/Physician Satisfaction Physician Engagement Collaboration Recognition for benefit of Care Management Team

12 Delivering ROI to Purchasers Pilot Yields Improvements in Total Cost of Care Risk-Adjusted and Trended Spending PMPM 1 12 Medicaid Commercial Inpatient Admission Per 1,000 Lives 2 Emergency Department Visits Per 1,000 Lives 2 1)Per-member, per-month. 2)Among commercial population. Source: Treo Solutions; Advisory Board Company interviews and analysis.

13 Improved Patient Satisfaction from Year to Year 13 Top box patient satisfaction scores have improved each year which is impressive given the limited resources available at many practices. Over 61% of patients said they had the best possible provider (10 of 10). 90% 85% 80% 75% 70% 76% 81% 82% 85% 69% 71% 75% 79% 65% 60% 55% 50% Overall Rating Communication Test Results Office Staff Pilot Average - CY2011 Pilot Average - CY2012

14 Results Payors-all of the concerns from previous slide have been eliminated. Outcomes trending in the right direction. P4P in place for Collaboration between all stakeholders has been the key. This has led to trust & co-dependence.

15 Future Challenges Accountable Care Organization

16 Questions? For more information contact: Karen Ashline, Director Northern Adirondack Medical Home Cliff Omstrom, Executive Director Empire Plan UnitedHealthcare National Accounts Adirondack Medical Home Website