September 19, 2012

Oregon Health Leadership Council: High Value Patient Centered Care Model The Clinical Performance Improvement Network

Denise L. Honzel Executive Director

Oregon Health Leadership Council--History

• Commissioned by the business community in the summer of 2008 • Purpose—Develop solutions and actions to keep health care costs and premium increases closer to the CPI • Incorporated as a 501(c) 6, statewide membership organization in 2010 • 14 member Board of Directors • 29 Council members: 7 major medical groups; 8 hospitals/health systems; 12 local/national health plans; Oregon Assoc. of Hospitals and Health System and Oregon Medical Assoc.

• Director of Oregon Health Authority (ex-officio) • Quarterly reporting back to the business community 2 | OHLC-- HVPCCM

Areas of focus for the Council

• Initially, four committees to oversee work  Value Based Benefits   Evidence Based Best Practice —high cost imaging; low back pain; elective deliveries before 39 weeks Administration Simplification —single sign on; standardized EDI for claims, eligibility; best practices — plan websites, pre-authorization, credentialing Reimbursement and Payment Reform —medical home  • In 2011 began work on a major effort focused on re designing care delivery and financing for the Medicaid and uninsured populations--now moving forward as Community Care Organizations (CCO’s) 3 | OHLC-- HVPCCM

High Value Patient Centered Care Demonstration--Timeline

• In early 2009, the Payment Reform group recommends a multi payer “medical home” initiative focused on high risk adult population • Reviewed the successful model of Boeing that delivered lower costs (up to 20%), higher quality and patient satisfaction, improved employee productivity with results beginning within 12 months • In fall of 2009, hired Dr. Pranav Kothari, Renaissance Health with a goal to launch the initiative within a year, learn along the way • Convened medical group and health plan advisory committees to develop the care and financing models 4 | OHLC-- HVPCCM

Hypothesis: Care Model and Outcomes

• Focus on the to ~10% highest risk patients • Intensive care management with RN Care Manager in the medical office, following a defined care model would produce the greatest impact on care/costs • At the end of the 2 year demonstration, results would show  Lower overall costs compared to a matched control group with reduced ED visits, reduced inpatient admits/days and initial increase in PCP visits  High quality health outcomes, high levels or member and provider experience 5 | OHLC-- HVPCCM

Hypothesis: Process Needs

• Multiple payers to get the size • Common model of care • Common payment model and standard contract for all plans to use • Committed medical groups • Scientific approach to the evaluation • Collective funding to support infrastructure • Common set of health plans policies and practices to implement 6 | OHLC-- HVPCCM

Common Care Model Components

• Access  Dedicated care manager for each patient   24/7 access for urgent care Access to care team via email/phone  Facilitate access for non-MD services, integrated w/PCP • Care Delivery Elements  Rules-based, care planning and management  Intentional, integrated care coordination  Recognition of social and behavioral health needs • Information   EHR, registries, quarterly feedback for the team Movement towards broader data transparency 7 | OHLC-- HVPCCM

Common Care Model Components

• Coordination  Care transition management (post ED, hospital)  Medical neighborhood of specialists, service agreements  Care giver and social support systems • Intensive Care Management   Motivational interviewing, readiness assessment Team based pre-visit planning, systematic Rx review  Team huddles, group visits  Advanced directives, end-of-life care programs • Staffing—RN as a team lead with support from the care team; one RN for 200 patients enrolled 8 | OHLC-- HVPCCM

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Consistent Payment Approach

• All payers use the same methodology; same contract • Upfront PMPM for participating patients to pay for the RN care coordinator • • Standard fee-for-service for medical care provided Shared savings between the medical groups and payers for achieving savings

and

quality metrics, paid at the end of the demonstration • Quality measures—maintain or improve and achieve Quality Compass at 50 th percentile for diabetes, hypertension, cholesterol management measures; patient satisfaction administer pre, post • Cost savings—50% share up to specified limit; based on difference over difference of intervention group vs. tightly matched control group OHLC-- HVPCCM

Rolling Out the Demonstration

• Early 2010, 8 health plans and state expressed interest • Plans identified 25 medical groups statewide that they felt could deliver on the model • OHLC issued an RFP • Staff interviewed each group • Fourteen medical groups selected; a 15 th group met qualifications except not the volume needed • Due to volume or challenges with data, 5 health plans and state agree to move forward 10 | OHLC-- HVPCCM

Medical Groups Selected

A

Adventist (Portland) Legacy (NW Port./Tualatin NW Primary Care (Portland) OHSU (Portland) PeaceHealth (Eugene) Portland Family Practice (Portland) Tuality (Hillsboro) High Lakes (Bend) Medford Medical (Medford) No. Bend Med. Ctr. (Coos Bay) Oregon Med. Group (Eugene) Portland Clinic (Portland) Providence (Portland/Newberg) Westside Internal Medicine (Beaverton) 11 | OHLC-- HVPCCM

Health Plans and State Groups

Health Net PacificSource ODS Providence Regence OEBB (School employees) DMAP (Medicaid FFS) PEBB (State employees) OMIP (High risk pool) 12 | OHLC-- HVPCCM

Implementation

• July 2010, each health plan began negotiating with each medical group —30 day target, finished within 45 days • During that time, plans began identifying patients to be invited into the demonstration, using plan predictive risk models • Top 10-15% highest risk adult patients • All complex and chronic included • Asked plans to exclude patients with ESRD, transplants, OB, Trauma with no other co-mordity • In September 2010, medical groups hired 23 RN’s • In October 2010, 23 RN’s participate in a four day training 13 | OHLC-- HVPCCM

Implementation

• Beginning October 1, 2010, using the lists provided by the plan, nurses start to invite patients to participate-- original goal to have all enrolled by end of December, extended until early March 2011 • Intake visits and care plans completed early in 2011 • Baseline quality measures for each patient • LDL’s, A1c and blood pressure reported • Patient satisfaction surveys (modified national survey) completed • Early 2011, began quarterly meetings on the medical group and health plan project managers and care managers 14 | OHLC-- HVPCCM

Where we are now

• 3,600 patients voluntarily enrolled • In July 2011 began, reporting quarterly utilization reports to medical groups, from claims data • ED: # of visits, avoidable rates, diagnosis, by day of week, by member • Inpatient: # of admissions, by DRG, discharge/admission day of week, by member, LOS • Rx Drugs filled, Imaging, Lab • Working with Oregon HealthCare Quality Corp and Milliman to refine the medical group reporting • Producing summary utilization reports for OHLC and demonstration participants 15 | OHLC-- HVPCCM

Where we are now

• Additional 1.5 day training for the care managers in Sept. 2011 • Agreed to extend the program through Feb. 2013 to allow for input from physicians on patient selection; minimize churning • Second enrollment period occurred Jan.-March 2012 to address attrition • Plans provided new lists; nurses more selective in choosing those to invite • Contracted with Dr. John McConnell, OHSU for the shared cost savings evaluation; Dr. Meredith Rosenthal, Harvard University, Dr. Kothari, Renaissance Health will be advisors.

• In February 2012, weekly “Office Hours” with care managers • Working on a sustainable model, post demonstration 16 | OHLC-- HVPCCM

Results to date

• While promising, it’s too early to make conclusions; not comparing to a control group, some enrollment data need reconciliation • Looking at utilization data through March 2012, compared to the pre-intervention time period, we are seeing  Downward trends in emergency room visits, inpatient admits and inpatient days/1000  Office visits for primary and specialty care initially stayed flat or increased slightly; then decreased (phone/email not included   Reduced use of RX for chronic conditions Slight downward trends in imaging • Final cost savings won’t be available until the end of the demonstration and analysis —fall 2013 17 | OHLC-- HVPCCM

Learnings: Medical Group-Plan Partnership

• Medical groups and Plans able to move beyond contracts and work creatively together —for data, care delivery • Medical groups and Plans appreciate personal interactions, in person meetings • Medical groups appreciate requests for input • Communication beyond direct participants involved has been uneven for all parties sometimes leading to confusion, complications and eroding partnerships • Medical groups and Plans challenged to manage new billing processes • Study design (control group, enrollment, etc) limits real-time adjustments to care model and patient selection 18 | OHLC-- HVPCCM

Learnings: Data Transparency/Exchange

• Exchanging accurate, timely data between plans and medical groups can impact care decisions —need timely ED and hospital admit/discharge data • Challenge in the data exchange: accuracy, timing, capabilities to manage/use data • Risk models are a good starting point to identifying risk; need mechanisms to include clinical intelligence; not all the “right” patients • Attribution capabilities uneven • Need for more real-time assessment of progress—claims lag not suited for dynamic interpretation 19 | OHLC-- HVPCCM

Learnings: Medical Group Culture/Readiness

• Some medical groups fully engaged others less so; difference in readiness not small vs. large group, but cultural • Front-line MD compensations still almost entirely productivity based; these efforts largely perceived as noise by physicians • Physicians appreciate care manager support, especially after seeing patient improvement • Support for care managers varies, depending on clinic buy in 20 | OHLC-- HVPCCM

Learnings: Care Model

• Patients appreciate care management from their MD team; very high engagement when advocated by PCP, well accepted by clinic • Non-visit based care (especially email) critical to serving this population needs; and for care manager panel management • Early, regular communication with patients surface unique needs • Initial intake assessments yielded deep patient discussions, revelations around barriers; although difficult to schedule • Workforce needs skill building to engage patients • Health Plan disease management can be helpful partner with medical group care management • Gap around education resources for patients, behavioral health, pharmacy, community resources 21 | OHLC-- HVPCCM

Next Steps

• As demonstration continues, further work on the processes to support the model of care • Continue collaboratives to share best practices and learning's • Complete work on a sustainable model for the long term care model, roles/responsibilities, reimbursement models • Measure results 22 | OHLC-- HVPCCM

For further information

Denise Honzel, Oregon Health Leadership Council [email protected]

Dr. Pranav Kothari, Renaissance Health [email protected]

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