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Payment Reform for Primary Care

Payment Reform for Primary Care. HFMA of SW Ohio 2013 Winter Education Day December 13, 2013 Richard Shonk, MD Chief Medical Officer. CPCi Overview.

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Payment Reform for Primary Care

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  1. Payment Reform for Primary Care HFMA of SW Ohio 2013 Winter Education Day December 13, 2013 Richard Shonk, MD Chief Medical Officer

  2. CPCi Overview The Comprehensive Primary Care (CPC) initiative is a multi-payer initiativefostering collaboration between public and private health care payers to strengthen primary care. Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients.

  3. CPCi Markets

  4. Greater Cincinnati Region:The Investment Made The ONLY community in America with all these programs: • 1 of 7 Comprehensive Primary Care Initiative communities, • 1 of 16 Aligning Forces for Quality (AF4Q) communities, • 1 of 17 Beacon Communities, • 1 of 62 Health IT Regional Extension Centers, • 110+ Patient-Centered Medical Homes • >80% of physicians and hospitals exchanging data through HealthBridge • 500 Physicians, 20+ Hospitals publically reporting on YourHealthMatters.org • 1 of 7 Organizations Designated as Qualified Entity

  5. How we got there? Health Information Exchange 1997 PCMH CPCI MPCD APCD CPCDA QE 2009 2011 2013 2008 2015 2010 2012 Bethesda Grant REC Beacon Grant Aligning Forces for Quality

  6. Leveraging the Investmentfor CPCi; for SIM A way of expanding this methodology • Transformation expertise • Coordination of resources • Multi-stakeholder relationships • HIE Connectivity • Tracking quality, cost satisfaction, utilization • Public Reporting of results Triple Aim Vision: provide multi-stakeholder incentives for what produces value in Health Care • Improves Outcomes, • Engages Consumers, • Reduces or Slows Cost Primary Care transformation (PCMH) has been recognized as a method for doing this. WHAT IS NEEDED WHAT IS THE GOAL

  7. Cincinnati/Dayton/Northern KY Market • 75 practices • 261 Providers • 10 Payers • Aetna • CareSource(Ohio only) • Buckeye Community Health Plan (Ohio only) • Anthem Blue Cross Blue Shield of Ohio • Humana • HealthSpan • Medical Mutual • Medicare • Ohio Medicaid • UnitedHealthcare • Estimated 44,500 Medicare beneficiaries • Estimated 250,000 Commercial, Medicaid, and Medicare Advantage

  8. Cincinnati/Dayton/Northern Kentucky Market • 75 Practices: • ~2/3 System affiliated • ~1/3 Independent • Quality & Data Transparency: • ~ 3/4 Public Reporting Initiative • 63% NCQA PCMH recognition • 95% attested for MU Stage 1 • EHRs: • Epic-59% • AllScripts-23% • Athena-13% • McKesson-3% • NextGen-1% • Amazing Charts-1%

  9. Payment Model Fee for Service + PMPM + Shared Savings = Total Reimbursement

  10. CPC Year One Milestones • Annual Budget • Care Management of High-Risk Patients • 24/7 patient access guided by the medical record • Assess and improve patient experience of care • Use data to guide improvement • Care coordination across the medical neighborhood • Improve patients shared decision-making • Participate in market based learning collaborative • Meaningful Use Stage 1

  11. Milestone Progress:

  12. Quality Measures • Quality Metrics: • 21 NQF endorsed measures • 2 patient experience (CG-CAHPS) • 3 care utilization (Claims) • 6 preventive health/ screenings (EHR) • 10 chronic disease/ at-risk population (EHR) • ( 2 metrics are deferred until 2015) • Meeting Targets (TBD) required to be eligible for shared savings and continued participation • Begin tracking one utilization and one quality metric in 2013 • Begin reporting all 19 measures to CMS in 2014 (CY 2013 as baseline)

  13. 5-Year Goal for Payment Innovation • 80-90 percent of Ohio’s population in some value-based payment model (combination of episodes- and population-based payment) within five years • Goal • Shift rapidly to PCMH and episode model in Medicaid fee-for-service • Require Medicaid MCO partners to participate and implement • Incorporate into contracts of MCOs for state employee benefit program • State’s Role Patient-centered medical homes Episode-based payments • Year 1 • In 2014 focus on Comprehensive Primary Care Initiative (CPCi) • Payers agree to participate in design for elements where standardization and/or alignment is critical • Multi-payer group begins enrollment strategy for one additional market • State leads design of five episodes: asthma (acute exacerbation), perinatal, COPD exacerbation, PCI, and joint replacement • Payers agree to participate in design process, launch reporting on at least 3 of 5 episodes in 2014 and tie to payment within year • Year 3 • Model rolled out to all major markets • 50% of patients are enrolled • 20 episodes definedand launched across payers • 50+ episodes defined and launched across payers • Year 5 • Scale achieved state-wide • 80% of patients are enrolled

  14. Enabling Infrastructure; under construction • Electronic Health Record EHR • Meaningful Use • Critical Mass • Health Information Exchanges • PCMH/MU Practice Transformation Expertise • Standardization of processes across payers • Convening Support • Outcomes Reporting/ Transparency

  15. Visit YourHealthMatters.org

  16. Enabling Infrastructure:or “shovel ready”? • Measurement of Value • Clinical Outcomes • Cost Savings • Attribution Methodology • Risk Adjustment Methodology • Data aggregation • Outcome targets

  17. Measurement of Value What gets measured gets managed Need for recognized source of truth • No one payorhas the whole picture • No one providor organization as data outside of their walls • Payment is proceeding to “payment for value” from “fee for service” • A high degree of statistical credibility is needed to demonstrate value (quality/cost) if economic decisions are to be made by stake-holders • Without aggregation of data, practice level measurement will always have a “n” problem • A consistent and continuous methodology is needed to monitor year over year progress

  18. The Cincinnati Health Collaborative with HealthBridge Infrastructure Readily Scale-able across the state: • Contracts with Health Plans are in place in SW Ohio; could include rest of state • Data aggregation for CPC could provide model for rest of state • Data Governance Committee has Health Plan representation from across the state • Qualified Entity (QE) status provides fee-for-service medicare data • QE as a foundation for All Payor Claims Data (APCD) in Ohio • Support of concept from “Collaboratives” in Columbus and Cleveland • EHR Meaningful Use allows addition of clinical data to claims data; creating an All Claims/Clinical Data (APPD) base

  19. Qualified Entity

  20. A word about Qualified Entity • The Collaborative with HealthBridge infrastructure qualified as one of the first three in the country, presently there are a total of seven • The main goal of the program is to allow the sharing of Medicare claims data with regional data organizations for the purpose of driving health care transformation • Our program qualifies for data from three states: Ohio, Kentucky, and Indiana; making it the largest QE in the country • We have already engaged three other payors to submit their data and discussions are ongoing with others plans that are active in the region • The program requires the highest level of data security to protect PHI and cost data; we have recently achieved that level. • Having done so we are in the position of receiving data in the third quarter of 2013

  21. Efficiencies of a RegionalAll Payers Claims Data base • Data and methodology is managed by a neutral entity • Provides a more robust picture of a providors performance • Allows a providor or health plan to study utilization for their patients/members with local de-identified control groups • APCD can be used for multiple projects and stakeholder research • Avoids a redundant submission of data for the CPCiproject • Supervision by one Data Governance authority avoids repetitive committees for stakeholders • Standard master service and data use agreements for various scopes of work streamlines legal processes.

  22. Why it is Important to CPC • Allow better comparative groups by having multi payer all claims data for the territory rather than just for those members attributed to CPC practices • By expanding data to all payers can now capture at least 60% of a practice’s performance thus adding credibility and accuracy necessary for payment for outcome • For a practice as small as a 3 physician group all payer data assuming 60% of practice capture approaches the actuarial cut off (5000 lives) necessary for credible measurement of cost and quality. • Credible and accurate data makes the case more credible to ASO customers • CPC allows for test phase in limited geography before expanding to 3 state regional data base

  23. Questions?

  24. Aligned Quality Measures Survey-based Quality Measures Claims-based Quality Measures

  25. Aligned Quality Measures EHR-based Quality Measures *Stage 1 Meaningful Use Only #measure to be incorporated with 2015 reporting

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