The Pennsylvania Chronic Care Initiative Richard L. Snyder, M.D. Senior Vice President Chief Medical Officer Independence Blue Cross William J. Warning II, M.D. Program Director Crozer-Keystone Family Medicine Residency Program 1
Pilot to Mainstream Pennsylvania s Multi-stakeholder Chronic Care Initiative Extending the Work with CMS IBC s Approach to Primary Care Transformation in SEPA Transforming the Role of the Plan 2
PA s Multi-stakeholder Chronic Care Initiative Distinguishing Features Government as Convener Multi-stakeholder participation Transformational care for all Transparent and adequate funding Practice support Scale to yield reliable outcomes Transferrable (regional and national) 3
Chronic Care Commission Goal - Improve chronic care delivery (access, quality, cost) Desired features of Pennsylvania model Regional Learning Collaborative rollouts Practice coach support Technology Registry/EMR, e-rx, open access scheduling Communication telephonic, encrypted e-mail Team health educators, case managers, CRNPs, PCPs Self-management skills Provider and consumer incentive alignment Third party assessment - NCQA PPC-PCMH Clinical, financial and satisfaction outcomes reporting 4
Role of GOHCR Convener Staffing Funding Consultants Faculty / expenses for year-long learning collaborative Registry Data collection, aggregation, evaluation and reporting activities through a 3 rd party, including surveys Coordinating Flow of data between practices and payers Flow of funds from payers to practices and IPIP Baseline and subsequent satisfaction surveys 5
Requirements of Primary Care Practices Attend Learning Collaborative meetings Team(s) from each practice Seven days in year 1, then less frequently Initial focus on diabetes and pediatric asthma Work with IPIP practice coach to transform practice Use a patient registry (or EMR) to track patients Report data from the patient registry and other sources required for evaluation purposes Achieve L1 NCQA PPC-PCMH Recognition* in year 1 Invest funds in staff and technology at practice site * Later rollouts have not required recognition in year 1; focusing on care mgmt. 6
Requirements of Payers Three year commitment to fund and support Payment to IPIP for Practice Coaches Payment to PCP Practices are intended to offset costs Infrastructure development Registry license /data entry NCQA recognition application / filing fee $9,515/practice Time for practice team to attend learning collaborative meetings Seven days during 1 st year $11,655/team Monthly or Quarterly payments that yield up to $4PMPM Support hiring care managers, health educators Support systems implementation (EMR, registry, e-rx, Addition of services that support self management Behavioral health integration 7
Requirements of IPIP Provide Practice Coaches to assist with Transforming the practice Data collection, aggregation, reporting and socializing Linking practices to community resources Completing the NCQA PPC-PCMH recognition process 8
Stakeholders in Collaboratives Participating Payers across 4 of 7 Regional Rollouts Commercial: Blues, Aetna, UPMC, Geisinger, CIGNA Medicaid: All Managed Medicaid Plans Medicare Advantage: Blues, Aetna Account for 75-80% of revenue Participating Practices Pediatric, Family Medicine, Internal Medicine, CRNP-led 1,000 FTEs (solo, small, medium and large) 1,200,000 Pennsylvanians Mix of independent, academic and FQHC practices The Primary Care Coalition (the RWJF IPIP grantee in PA) The PA Academy of Family Physicians The PA Chapter, American Academy of Pediatrics The PA Chapter, American College of Physicians 9
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SE PA NCQA PPC-PCMH Recognition Dates from NCQA according to survey completion date 11
Building a Quality Medical Home Transforming VISIT POPULATION Management Measure with DATA Educate Physicians and ENTIRE Staff Redesign Work Flow Tasks for Staff; Decisions for Physicians Empower Employees Function at the highest level of job description VISIT Management Working SMARTER, not HARDER! No extra $$ spent time/energy only! INWARD Focus = VISIT Management (Numerator Management) 12
DM Foot Monofilament Testing Pct of DM patients w ith foot exam 100 80 60 40 20 0 MAs Start Monofilaments Physicians Perform Monofilaments 13
DM Pneumovax Administration Pct of DM pts w ith pnuemo vacc 100 Pneumovax Lunch and Learn Session 80 60 40 20 0 Ju Ju A S O N D Ja Fe M A M Ju Ju A S O N 14
Building a Quality Medical Home Transforming VISIT POPULATION Management Measure with DATA Educate Physicians and ENTIRE Staff Redesign Work Flow Tasks for Staff; Decisions for Physicians Empower Employees Function at the highest level of job description Hire Key PCMH Employee Develop Informed and Activated Patients Build Multidisciplinary Teams Involve the Community 15
Hire Key PCMH Employee Hire (full or part-time) a Case Manager RN Case Manager Level 1 billing for visits NP/PA Case Manager Level 2+ billing for visits Social Worker with CM skills Nonbillable Clinical Pharmacist?Billable for visits Certified Health Educator?Billable for visits Nutritionist/Dietician?Billable for visits OUTWARD Focus = PRACTICE Management (Denominator Management) 16
DM Foot Monofilament Testing: Denominator Management Example Pct of DM patients w ith foot exam 100 80 60 40 20 0 MAs Start Monofilaments Physicians Perform Monofilaments Need Denominator Mgt 17
What Are The Practices Doing Focusing on planned visits to ensure patients get all needed care at visits Bringing patients in for overdue services Providing team-based care Establishing standing orders Overcoming clinical inertia with clinical guidelines Holding group visits Stratifying patients for care management and self-management support Setting goals with patients and following up on goals Producing patient report cards 18
Management of Diabetes % with A1C>9 % with A1C<7 S E P A 35% 30% 25% 20% 15% 10% 5% 0% 33% 27% 24% 2008 2009 2010 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 35% 43% 43% 2008 2009 2010 S T A T E 19
Management of Diabetes % with BP < 140/90 % with BP < 130/80 S E P A 80% 70% 60% 50% 40% 30% 20% 10% 0% 75% 69% 57% 2008 2009 2010 80% 70% 60% 50% 40% 30% 20% 10% 0% 45% 44% 47% 2008 2009 2010 S T A T E 20
Management of Diabetes % with LDL < 130 % with LDL < 100 S E P A 70% 60% 50% 40% 30% 20% 10% 0% 69% 62% 46% 2008 2009 2010 70% 60% 50% 40% 30% 20% 10% 0% 35% 43% 43% 2008 2009 2010 S T A T E 21
Management of Diabetes % with Statin Script % with ACE/ARB Script S E P A 80% 70% 60% 50% 40% 30% 20% 10% 0% 57% 75% 2008 2009 2010 80% 70% 60% 50% 40% 30% 20% 10% 0% 62% 77% 2008 2009 2010 S T A T E 22
Cost Savings of Diabetic Care 23
PCMH vs. Control Groups: Diabetes PCMH Groups Trends Members with Diabetes Control Groups Trends Members with Diabetes Care Gaps were about 50% fewer amongst members in PCMH practices 24
PCMH vs. Control Groups: Total Population PCMH Groups Trends Total Population Control Groups Trends Total Population 25
Evaluation IPIP reporting at practice and Collaborative level to support day to day practice level management Evaluation by UPMC and Rand Payer, provider, and survey data to be aggregated Collaborative practices to be compared to control practices both at a regional and a State-wide level Measurement domains: Engaged providers Patient self-care knowledge and skills Patient function and health status Primary care practice satisfaction Appropriate and efficient utilization of services Clinical care quality Cost 26
Quality Incentive Payment System Over 15 Years of Experience with focus on: Quality Measures (HEDIS, etc.) Generic Prescribing Access Provider Portal use Newly revised program rewards: Quality Measures (HEDIS, etc.) Generic Prescribing PCMH NCQA Recognition Level 1: $1.25PMPM Level 2: $2.00PMPM Level 3: $3.00 PMPM Medical Cost Management 27
Transforming the Role of the Plan Where should current Plan functions reside in a transformed PCMH world? Disease Management Decision Support Case Management What does the PCMH need from the Plan? Collaboration Accurate / Timely Information Tools / Support 28
National Health Care Transformation Demonstration Project Pennsylvania one of 8 States awarded by CMMI SEPA, NEPA and SCPA Chronic Care Initiatives $33M CMS infusion to PCMHs Commonwealth owns contract Extends the above CCIs for 3 additional years Will likely include IM and FM practices All Payers have committed to stay on with CMS Funding averages $4pmpm in a CM fee GOHCR seeking Shared Savings model 29
Transforming Primary Care Practice Questions? 30