Alternative Payment Models- Recipes For Success Elizabeth Lange, MD, PCMH-Kids Michael Magill, MD, Department of Family and Preventative Medicine-University of Utah Kevin Schendel, MD Timothy Willox, MD, MBA, Bon Secours Medical Group Len Nichols, PhD (Moderator), Center for Health Policy Research and Ethics- George Mason University
Co-Directors: Elizabeth B. Lange, MD FAAP and Patricia Flanagan, MD FAAP elizlange@cox.net pflanagan@lifespan.org
What is PCMH-Kids? PCMH-Kids was formed to extend the transformation of primary care to pediatrics, allowing for multi-payer payment reform and data-driven quality improvement Convened by the Office of the Health Insurance Commissioner and the Executive Office of the Health and Human Services (the state Medicaid agency) in Fall 2012 Grant from the Rhode Island Foundation and federal match for first year Modeled after the Care Transformation Collaborative (CTC) which began in 2008 and now includes 73 practice sites, 433 providers and approximately 330,00 adults in Rhode Island (www.pcmhri.org)
Mission and Vision Mission: PCMH-Kids will engage providers, payers, patients, parents, purchasers and policy makers to develop high quality family and patient-centered medical homes for children and youth that will assure optimal health and development, a commitment to quality measurement, accountability for costs and outcomes, a focus on population health, and dedication to data-driven system improvement. PCMHs for children will be cost effective and sustainability resourced. Vision: All children and youth in RI will be cared for in high quality family and patient-centered medical homes. RI s children and youth will grow up healthy and reach their optimal potential.
Timeline Fall 2012 - officially convened by OHIC and EOHHS February 2013 Kick off event for Stakeholders September 2013 Monthly Stakeholder meetings begin January 2014 Measures committee and Application committee begin December 2014 Open call for Applications April 2015 Ten pilot practice sites are announced April 2015 - Contracting committee begins Late fall 2015 Contracts finalized and signed, practice facilitation begins January 2016 PMPM payments to practices begin
Who are the Pilot Practices? 15 pediatric and family medicine practices applied representing 20 sites and almost 75,000 patients. 10 pilot practice sites selected: Serve 30,000 attributed patients, 43% of whom are insured by Medicaid 3 practices are beginner practices, as defined by no NCQA PCMH recognition 7 practices have NCQA PCMH Level 3 recognition 3 are family medicine offices, 7 are pediatric offices 4 practices are affiliated with CTC for their adult patients
Common Contract A three year contract between each pilot practice site and all the major RI health plans (Blue Cross Blue Shield of RI, Neighborhood Health Plan, Tufts Health Plan and United Healthcare (both commercial and Medicaid products) At the end of three years (2019), pilot practice sites will be ready for successful participation in advanced payment contracts Built on a foundation of the CTC contract with the goal of supplemental per-member, per-month (PMPM) payments to support NCQA recognition, care coordination, team-based care, data reporting and quality improvement activities and expanded access CTC base payments are $5.50 PMPM
PCMH-Kids Proposed Contract Year 1 - $2.50 PMPM for care coordination and $1 PMPM for transformation costs Year 2 - $2.50 PMPM for care coordination and $0.50 PMPM incentive opportunity for reduced ED utilization, with quality gate Measures: Clinical Quality 1) BMI assessment and counseling (HEDIS) and 2) Developmental Screening (NQF) Patient Experience Quality CAHPS-PCMH Child Survey Utilization Emergency Room visits
Learning Curve Lessons The emotional attachment to the goal of healthy children and families is easy, until the lens of short term investment return is applied Funding for quality integrated pediatric medical homes initiative needs to be creative and from multiple sources (Race to the Top Early Learning Challenge Grant, State Innovation Model Grant, CEDAAR comprehensive evaluation diagnosis assessment referral re-evaluation) Be patient, be persuasive and be persistent Work with energizing, passionate, intelligent people who are dedicated advocates for children and their families
Alternative Payment Models- Recipes For Success Elizabeth Lange, MD, PCMH-Kids Michael Magill, MD, Department of Family and Preventative Medicine-University of Utah Kevin Schendel, MD Robert Fortini, PNP, Bon Secours Medical Group Len Nichols, PhD (Moderator), Center for Health Policy Research and Ethics- Geroge Mason University
Cost of Sustaining the Patient Centered Medical Home Michael K. Magill, MD; David Ehrenberger, MD; Debra Scammon, PhD; Jaewhan Kim, PhD; Julie Day, MD; Lisa H Gren, PhD; Rhonda Sides, CPA Study supported by the Agency for Healthcare Research and Quality, Grant Number 1R03HS22620. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality
Colorado Study Groups Utah 5 FQHC Sites 8 Multispecialty Primary Care Practices 7 Family Practices
PCMH Cost Dimensions Tool Modeled on NCQA PCMH 2011 Standards: Ongoing personnel costs associated with each NCQA PCMH element
PCMH Cost Dimensions Tool: Cost Worksheet
PCMH Cost Dimensions Tool Exclusions: Basic Primary Care and EMR Functions Culturally and Linguistically Appropriate Services Electronic system for Patient Information Electronic system for Structured Clinical Data Comprehensive Health Assessment Electronic Prescribing Urgent Care Centers (Utah)
Total Cost Summary: Per Encounter & PMPM* $40.00 $30.00 36.68 Colorado 35.0597 32.3018 Utah All Practices $20.00 $10.00 4.83 3.85 4.37 $- Cost per Encounter (Average/Pt) Cost Per "Member" Per Month *PMPM normalized to 2000 panel
Clinician FTE/Year Clinician/Year =
$10,000 $7,500 $5,000 Cost per Month per FTE Provider 9657.7954 8733.2319 7691.0999 Colorado Utah All Practices $2,500 $- Colorado Utah All Practices Data not adjusted for Consumer Price Index, practice characteristics, patient population.
$1,800 3. Plan & Manage Care Staff Costs per Clinician per Month 1786 $1,350 1213.5 Utah Practices Colorado Practices $900 $450 $0 1001.5 586.5 425 232 32 110 Physician Costs PA-NP Costs MA Costs Care Mgr Costs
$1,000 1. Enhance Access & Continuity Staff Costs Per Clinician Per Month 979 $750 785 608.5 Utah Practices Colorado Practices $500 $250 316.5 300 257 $0 35 120.5 Physician Costs PA-NP Costs MA Costs Care Mgr Costs
Main Findings Marginal costs to maintain PCMH are consistent across various practice settings: ~$35/encounter, ~100,000/FTE Clinician/Year Staffing models in the Utah and Colorado practices differ This study s cost data do not reflect the cost of full PCMH implementation or those of future PCMH constructs (2014 and beyond)
Future research should examine Cost variation by practice type and by staffing model Revenue and opportunity costs of PCMH Relationship of PCMH costs to quality, total cost of care, provider, staff, and patient experience Value for cost: basis for payment
Finis Thank you! Contact Info: michael.magill@hsc.utah.edu
Alternative Payment Models- Recipes For Success Elizabeth Lange, MD, PCMH-Kids Michael Magill, MD, Department of Family and Preventative Medicine-University of Utah Kevin Schendel, MD Robert Fortini, PNP, Bon Secours Medical Group Len Nichols, PhD (Moderator), Center for Health Policy Research and Ethics- Geroge Mason University
ALTERNATIVE PAYMENT MODELS RECEIPTS FOR SUCCESS Kevin Schendel, MD, Medical Advisor CareFirst PCMH Program 27 Not Intended for Distribution
Patient-Centered Medical Home (PCMH) Primary Care Providers are central to improving cost and quality. Total care of patients is to be provided, organized, coordinated and arranged through small Panels of PCPs. Panels, as a team, are accountable for aggregate quality and cost outcomes of their pooled population. Savings against the Panel s pooled global budget target are shared with the Panel Providers, creating a powerful incentive for PCPs as a team to control costs. All supports in TCCI are designed to assist Panels to get better results. Primary Care Provide rs CareFirs t Membe rs 28
PCP s Opportunity is with the Entire Healthcare System PCPs: Caring for the whole patient and influencing the entire medical dollar. OutpaUent 19.5% Pharmacy 28.8% Primary Care Physician 5.7% Distribution of Medical Spending is Changing Spending on prescription drugs has become InpaUent 19.7% Specialists 22.7% the largest share of the medical dollar (including spending in the Pharmacy and Medical benefits) This key change causes increased focus on pharmacy care coordination Source: CareFirst HealthCare Analytics Medical spending is based on claims paid in 2014 for the CareFirst Book of Business Excluding Medicare Primary Members. The Pharmacy % is adjusted to represent typical spend for members with CareFirst s pharmacy benefit. 29
Concentration of Costs in a Few A small percentage of CareFirst s Members consume approximately half of all of the Company s health care spending in the region. This mirrors the national experience. (Program Description & Guidelines, January 2014) 72% of admissions were for members in bands 1 & 2 Advanced/Critical Illness Band 1 Multiple Chronic Illnesses Band 2 At Risk Band 3 Stable Band 4 Healthy Band 5 Illness Burden (5.00 and Above) Percent of Population CareFirst Population Percent of Cost Cost PMPM Extremely heavy health care users with significant advanced / critical illness. 2.9% 32.9% $3,681 Illness Burden (2.00-4.99) Illness Heavy users of health care system, mostly for Burden more than one chronic disease. 8.6% 27.3% $999 Range Illness Burden (1.00-1.99) Fairly heavy users of health care system who are at risk of becoming more ill. 12.7% 18.2% info. for $457 2013 Illness Burden (0.25-0.99) Generally healthy, with light use of health care services. 26.9% 15.6% $191 Illness Burden (0-0.24) Generally healthy, often not using health system. 48.9% 6.0% $46 Source: CareFirst HealthCare Analytics incurred in 2014 and paid through March 2015 CareFirst Book of Business, excluding Medicare Primary Members 30
Differentiating Factors of the CareFirst PCMH Program 22 Program Consultants 120+ SearchLight Reports 12% point fee schedule increase Credible data and analytic support 300 Nurses Reimbursed $200/$100 for Care Plan Significant, meaningful financial incentives High touch with superior technical support icentric Outcome Incentive Award Service Request Hub 31
Every PCP is in a Panel. Panels have 5 to 15 PCPs. Every Panel has a Global Budget A Global Budget target is set for each Panel at the beginning of a performance year. The Global Budget, available in your Patient Care Account, includes historical Member Costs, Adjusted for Risk and Medical Inflation. Panels are financially rewarded with shared savings, when the actual costs of the Panel s patient population are lower than the expected costs and quality standards are met. 32
Panel Engagement and Panel Performance Shared savings are calculated at the Panel level Viable Panels must have 1,000 members or 12,000 member months annually 5 to 15 PCPs Panel size ensures statistical credibility and reliability in patterns and trends in care costs Panels that Work Together Win Together Who covers weekend hours? When does the Panel meet to discuss opportunities? Do you create a PCMH-friendly environment in your office? 33
HealthCheck 5 Focus Areas for Panels Cost Effectiveness of Referral Patterns Extent of Engagement in Care Coordination Programs and with various TCCI programs Effectiveness of Medication Management Reduction in Gaps in Care and Quality Deficits Consistency of PCP Engagement and Performance within the Panel 34
CareFirst PCMH Health Promotion, Wellness & Disease Management Services (WDM) Hospital Transition of Care Program (HTC) Complex Case Management Program (CCM) Chronic Care Coordination Program (CCC) Substance Abuse and Behavioral Health Programs (BHSA) Home Based Services Program (HBS) Pharmacy Coordination Program (RxP) Enhanced Monitoring Program (EMP) Comprehensive Medication Review Program (CMR) Patient Centered Medical Home Urgent and Convenience Care Access Program (UCA) Community-Based Programs (CBP) Expert Consult Program (ECP) Centers of Distinction Program (CDP) Pre-Authorization Program (PRE) Dental-Medical Health Program (DMH) Telemedicine Program (TMP) 35
Program Growth 2011 to Present The PCMH program continues to grow Increases in PCPs increases the number of attributed members and the global cost of care under management Year Panels PCPs* Attributed Members GlobalCost of Care 2011 180 2,152 530,000 $1.7B 2012 283 3,387 745,000 $2.5B 2013 402 3,703 991,000 $3.5B 2014 424 4,047 1,037,000 $4.5B 2015 438 4,052 1,079,190 $4.8B * PCPs include Physicians and Nurse Practitioners 36
Current and Projected State of Panels, Providers & Members CareFirst categorizes Panels into four types 75% of PCPs practice outside of a large health system Growth in PCPs, Panels and Attributed Members has been steady CareFirst regularly reconfigures non-viable Panels and culls Panels failing to meet minimum engagement requirements Panel Type Panels Practices Providers* Providers / Panel Members Members/ Panel Members/ Provider Single Panel Virtual Single Panel Independent Multi Panel Independent Multi Panel Health System 166 968 1,424 8.6 421,280 2,538 296 70 70 586 8.4 185,212 2,646 316 97 106 968 10.0 280,425 2,891 290 105 75 1,074 10.2 192,273 1,831 179 Total January 2015 438 1,219 4,052 9.3 1,079,190 2,464 266 Total January 2016 (Projected) * Primary Care Physicians and Nurse Practitioners are included in the Provider counts above. 427 1,300 4,359 10.2 1,160,000 2,717 266 37
Admission Rates are Dropping Total CareFirst admissions in the region have declined 22.8% from 2011 to 2015 YTD The admission rate per 1,000 Members is down 19% in the same period Low cost hospitals have declined less (19.0%) than high cost hospitals (24.6%) over the same period 70 Admissions/1,000 63.8 57.5 51.3 63.9 62 57.8 54.8 52 19% Decline 45 CY 2011 CY 2012 CY 2013 CY 2014 YTD 2015 Source: CareFirst Health Care Analytics. CareFirst Book of Business. Claims paid through March 2015. 38
Admissions are More Acute 100% % of Admissions by Illness Band 75% 50% Advanced % Chronic % At Risk % Stable % Healthy % 25% 0% Apr 2012 - Mar 2013 Sep 2012 - Aug 2013 Jan 2013 - Dec 2013 June 2013 - May 2014 Oct 2013 - Sep 2014 39
Cost Avoided by Bending the Curve 8.0% 7.5% CareFirst Book of Business and PCMH Trends Compared to Target OIA Trend 6.0% 6.8% 6.8% 6.5% 5.5% 4.8% 4.0% 4.4% 3.5% 3.7% 2.0% 2.4% 2.0% 0.0% 2010/2011 2011/2012 2012/2013 2013/2014 Source: CareFirst HealthCare Analytics - Updated May 2014 2014 Projected based on claims run out through December 2015 40
Wins More Impressive on Slower Growing Global Budget In spite of slowing / lower trend, savings have increased o o The number of panels achieving savings has continued to grow The size of the savings achieved have increased Panels who achieved savings in 2014 but were not sufficiently engaged to receive an OIA have shown advancements in engagement in 2015 Performance Year % of Panels with Savings Savings % (all Panels) 2011 60% 1.5% 2012 66% 2.7% 2013 69% 3.1% 2014 84% 7.6% 41
Questions? www.carefirst.com/pcmhinfo 42
Alternative Payment Models- Recipes For Success Elizabeth Lange, MD, PCMH-Kids Michael Magill, MD, Department of Family and Preventative Medicine-University of Utah Kevin Schendel, MD Robert Fortini, PNP, Bon Secours Medical Group Len Nichols, PhD (Moderator), Center for Health Policy Research and Ethics- Geroge Mason University