Enhancing Self-Insured Employer Participation in Provider Quality Programs

1. Provider Network Advisory Group Self-Insured Employers and Provider Quality Programs April 25, 2013

2. SIE and Quality Programs Goals of Discussion • Share current experiences with Self-Insured Employers (SIE) and quality programs • Identify barriers to SIE participation • Develop a shared vision for SIE involvement in quality programs • Create a plan or recommendation(s) to remove barriers

3. SIE and Quality Programs

4. SIE and Quality Programs What have we learned…COHE • L&I has done outreach to encourage Self-Insured Employer participation in COHE. Those who were interested, but chose not to participate, had questions about the benefits of participation. • Renton COHE and King County • Agreed to pilot in 2011 • Began working together in 2012 • Challenges: • Identifying COHE providers • Identifying COHE claims • Sharing data and medical records • Had to create unique measures to evaluate effectiveness • Some SIE want to wait and see the results of this pilot before making arrangements of their own

5. SIE and Quality Programs What have we learned…COHE Eastern Washington COHE • Several SIE were initially interested in piloting but: • One had participated as a state-fund employer but couldn’t take on the support that is neededfrom a self-insured employer. • Another had turnover among key executives who supported a pilot. • One couldn’t afford the expense of providing access to the records and data held by their third party administrator (TPA).

6. SIE and Quality Programs What have we learned…Orthopedic & Neurological Surgeon Quality Pilot • Seventeen SIE are participating in this pilot • SIE data not included in assessment of provider performance • No viable solutions for data-sharing have been identified. • Some SIEs have said they won’t participate unless/until an outcome evaluation shows positive findings.

7. SIE and Quality Programs What have we learned…Activity Coaching • Some self insured employers are using Progressive Goal Attainment Program (PGAP) by referring on their own to trained coaches • No SIE data is available to include in pilot evaluations

8. SIE and Quality Programs What have we learned…Future Pilots • Expect similar barriers/challenges for future pilots

9. SIE and Quality Pilots Summary of Barriers & What We Have Learned • Questions about outcomes: SIE want proof of positive results before participating, but state-fund experience is not directly transferrable. • Data issues: L&I has extensive claim-specific data for measurement and evaluation purposes, whereas each SIE/TPA has unique data resources. • Resource intensive: Developing and maintaining quality programs requires significant planning and coordination. • Hassle factor for providers: It is difficult for providers when SIE and state-fund do things differently.

10. SIE and Quality Programs Moving forward: What is our vision for SIE involvement? • Issue 1: Participation • Is SIE participation mandatory or voluntary? • Does participation apply to all best practice pilots or can it be pilot specific? • How likely is it that we can design pilots that will be feasible for a wide range of diverse SIE? • Issue 2: Technology • Can we obtain the data needed for care coordination, provider measurement, and pilot evaluation from SIE? • Can we include SI claims data in OHMS? • We would need: • Providers’ medical and billing records • Claim information from SIE and TPA • Consistent data from all participants (all the same data fields) • Standard format for data transmission / single interface from SIEs to OHMS

11. SIE and Quality Programs How can we get there? • SIE involved in planning for quality initiatives • Diverse representation of SIEs and TPAs