Transcript Title
PRELIMINARY DRAFT
Payment Improvement Initiative Webinar
Patient-centered medical home March 11, 2013
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Objectives
▪
Welcome, overview of initiative timeline and SIM update – Dr. Joe Thompson
▪ Introduction to patient centered medical homes (PCMH) ▪ Q&A 1
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Overview of initiative aspirations
Retrospective Episodes (e.g. URI, Perinatal, ADHD) Patient Centered Medical Homes Health Homes (Behavioral Health and Developmental Disability) Prospective Episodes (Long Term Services and Support, Developmental Disability)
2013 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4 Launch 75 – 100 episodes through mid 2016 2015 Q1 Enroll most Arkansas practices starting in mid 2014 Behavioral Health and DD Health Homes starting in 2014 Reach all Adults in this population by end of 2014; Children to follow in 6-12 months
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Arkansas is one of six states CMS awarded model-testing grant
SIM Awardees to implement healthcare innovation plans ▪ The
CMS State Innovation Models
(SIM) Initiative is providing funding to the State of Arkansas –
$42 million
to implement and test the initiatives over the next 42 months –
Funding covers
episode-based care delivery, patient-centered medical homes, and health homes ▪ The State sees this grant as an
indication of CMS’ engagement
with the initiative and belief that it could be a model more broadly applied in the country 3
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Objectives
▪ Welcome, overview of initiative timeline and SIM update ▪
Introduction to patient centered medical homes (PCMH)
–
Payment Initiative context and role for PCMH – Dr. Andy Alison
– – Overview of PCMH approach Path forward ▪ Q&A 4
There are major health care challenges in Arkansas
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▪
Health status in Arkansas is poor
, with the state ranked at or near the bottom of all states on national health indicators, such as heart disease and diabetes.
▪
The health care system is hard to navigate
, and it does not encourage doctors and other providers to work as a team when caring for patients.
▪ Health care
spending is growing unsustainably:
– Insurance premiums doubled for Arkansas employers and families in past 10 years (adding to uninsured population) – Budget shortfalls projected for Medicaid.
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Medicaid and private insurers believe paying for patient results, rather than just individual patient services, is the best option to control costs and improve quality
▪ Transition to system that
financially rewards value
and
patient outcomes
and
encourages coordinated care
Reduce payment levels for all providers
regardless of their quality of care or efficiency in managing costs
Pass growing costs on to consumers
through higher premiums, deductibles and co-pays (private payers), or higher taxes (Medicaid)
Intensify payer intervention in clinical decisions
to manage use of expensive services (e.g. through prior authorizations) based on prescriptive clinical guidelines
Eliminate coverage of
expensive services, or eligibility 6
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Patient-centered medical homes are a core component of this shift to paying for results and part of a broader statewide effort Enable and reward providers for
▪ Improving the
health
of the population ▪ Enhancing the
patient experience
of care ▪ Reducing or control the
cost of care
How care is delivered Medical homes + Health homes Episode-based care delivery Five aspects of broader program
Results-based payment and reporting
Health care workforce development Health information technology adoption Consumer engagement and personal responsibility Expanded coverage for health care services
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Principles of patient-centered medical home design for Arkansas Patient centered
Focus on improving quality, patient experience and cost efficiency
Empowering
Provide support to enable clinical leadership
Balanced
Provide autonomy as well as guidance
Practical
Minimize requirements and administrative burden 8
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What is PCMH?
Journey to PCMH
A team-based care delivery model led by a primary care provider that comprehensively manages a patient’s health needs
Aspirations
▪ Providers are responsible for managing health across their patient panel ▪ Coordinated and integrated care across multidisciplinary provider teams ▪ Focus on prevention and management of chronic disease ▪ ▪ Expanded access Referrals to high-value providers (e.g., specialists) ▪ ▪ Improved wellness and preventative care Use of evidence-informed care 9
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Why primary care and PCMH?
Most medical costs occur outside of the office of a primary care physician (PCP) , but PCPs can guide many decisions that impact those broader costs, improving cost efficiency and care quality
Ancillaries (e.g., outpatient imaging, labs) Specialists Patients & families PCP Community supports Hospitals, ERs 10
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Several developments in primary care payment aim to more appropriately compensate PCPs for playing this essential role Medicaid rate bump
– increase in primary care rates paid by Medicaid starting in April Outside of PCMH
Coverage expansion
– decrease in uncompensated care with increase in coverage on exchanges Part of PCMH
Gain-sharing
– significant upside only opportunity to share in savings from effectively patient panels’ total cost of care
Support payments for PCMH
– per member per month (PMPM) payments to support investment in care coordination and practice transformation activities 11
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Goals of episode-based and PCMH components of the Payment Initiative are aligned
Reward high-quality care and outcomes
Encourage clinical effectiveness
Promote early intervention and coordination to reduce complications and associated costs
Encourage referral to higher-value downstream providers
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Objectives
▪ Welcome, overview of initiative timeline and SIM update ▪ Introduction to patient centered medical homes (PCMH) – Payment Initiative context and role for PCMH – –
Overview of PCMH approach – Dr. Bill Golden
Path forward ▪ Q&A 13
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Arkansas PCMH strategy centers on three core elements: Incentives
▪ ▪ ▪ Gain-sharing Payments tied to meeting quality metrics No downside risk
Support for providers
▪ ▪ ▪ Monthly payments to support care coordination and practice transformation Pre-qualified vendors that providers can contract with for ▪ Care coordination support ▪ Practice transformation support Performance reports and information
Clinical leadership
▪ ▪ Physician “champions” role model change Practice leaders (clinical and office) support and enable improvement 14
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INCENTIVES
PCMH model has two ways for PCPs to receive upside only gain-sharing 1 Receive gain sharing based on your own performance improvement
Your year 1 performance
or … 2 Receive gain sharing based on being a high performer in the state
State-wide performance Your year 2 performance Your performance Similar to episodes approach,
but no down-side risk
in PCMH For both options: ▪ Quality metrics must be met for gain-sharing ▪ Costs to calculate gain-sharing are risk-adjusted and exclude high-cost outliers 15
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INCENTIVES
PMCH model provides options to pool patients across practices to enable gain-sharing
▪ ▪ ▪ To safeguard provider performance measurement from random variation, need to measure costs across a group of at least 5000 Pooling enables smaller practices to reach this panel size and participate in gain-sharing Costs are calculated and gain-sharing allocated based on all patients in a pool
PCPs can choose from 3 pooling options Considerations 1
Everyone starts in a “default pool”
2
Opt out of default if practice or health system has more than 5000 patients for a payer on its own
3
Opt out of default to form a voluntary pool by virtually affiliating with a few other practices Simplest option to sign up and start participating in PCMH, especially for smaller practices ▪ ▪ ▪ Smaller groups may provide Greater opportunity for impact Scale for practice transformation Support network 16
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SUPPORT FOR PCMH ACTIVITIES
Practices will have the option to contract with pre-qualified vendors to support for care coordination and practice transformation activities Care coordination (on-going activities) State has released two requests for qualifications (RFQs) for vendors to support your practices Practice transformation (up-front activities)
Support to ensure that all patients – especially high-risk patients – receive holistic, wrap around, coordinated care across providers and settings Support to train practices on approaches, tools, and infrastructure needed to achieve a population health approach and improve performance
▪ ▪ Use of pre-qualified vendors is optional Vendor model developed based on provider input that: – – – An easy process to identify vendors is important Support is needed Providers need flexibility to tailor support to their own practices 17
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SUPPORT FOR PCMH ACTIVITIES
Practices will receive monthly payments to support these activities
Payment amount
Care coordination and general practice investment Practice transformation
▪ ▪ Average of $4 per member per month (PMPM) Actual amount paid to be adjusted based on risk and complexity of patient panel ▪ ▪ $1 per member per month (PMPM) Flat amount per patient – not risk adjusted A PCP with 2000 attributed patients could receive up to $120,000 a year in support Purpose and uses ▪ ▪ ▪ Fund on-going care coordination activities Fund PCP and staff time invested in new care model PCPs choose how to use funds (e.g., pre-qualified vendor, other external support, internal practice investment) ▪ ▪ Fund costs to transition practice model to PCMH PCPs only receive $1 PMPM payment if they contract with a pre-qualified vendor 18
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CLINICAL LEADERSHIP
Clinical leadership is essential to success Success for PCMH requires physician leaders
▪
In their practices
to change mindsets, role model change and empower office leaders ▪
In their communities
to be proponents and early adopters of the model
Feedback from providers
▪ Critical for physicians to set the vision for how their practices will change ▪ PCMH is a team effort – PCPs, clinical staff, office staff must all be engaged
Provider input & guidance through the PCMH Provider Advisory Group has been a critical part of PCMH development to date
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Objectives
▪ Welcome, overview of initiative timeline and SIM update ▪ Introduction to patient centered medical homes (PCMH) – Payment Initiative context and role for PCMH – – Overview of PCMH approach
Path forward – Sheena Olsen
▪ Q&A 20
Anticipated PCMH rollout
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ILLUSTRATIVE
Potential PCMH coverage over next several years
Wave 3 Wave 2
All Arkansas practices
Wave 1
Early adopters (up to 30%) Start of wave CPCI (69 practices)
October 2012 Mid 2013 ▪ ▪ Wave 2a - pediatrics Wave 2b –adults Mid 2014 21
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How we hope to continue this engagement Medical societies
▪ ▪ ▪ AAP, AAFP, AHA, AMS Updates and engagement in design process Collaborate to engage membership as PCMH model is implemented
Clinical leaders
▪ ▪ Regular meetings with provider advisory group to input on design Planning sub-groups of pediatricians / family practitioners to input on specific clinical elements (e.g. ,quality metrics)
Broader public awareness
▪ ▪ ▪ Today’s intro webinar Regional town halls and Little Rock forum to raise broader awareness starting in late April in advance of initial (pediatric) enrollment period Email, social media, other media updates 22
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Objectives
▪ Welcome, overview of initiative timeline and SIM update ▪ Introduction to patient centered medical homes (PCMH) ▪
Q&A
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Questions
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For more information talk with provider support representatives…
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Online
▪
More information on the Payment Improvement Initiative can be found at www.paymentinitiative.org
– – – – – Further detailed information Printable flyers for bulletin boards, staff offices, etc. Specific details on PCMH Contact information for each payer’s support staff All previous workgroup materials
Phone/ email
▪
Medicaid :
1-866-322-4696 (in-state) or 1-501-301-8311 (local and out-of state) or
▪
Blue Cross Blue Shield:
Providers 1-800-827- 4814, direct to EBI 1-888-800-3283, [email protected]
▪
QualChoice :
1-501-228-7111, [email protected]
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