Arkansas Payment Improvement Initiative (APII) Tonsillectomy Episode Statewide Webinar

1. Arkansas Payment Improvement Initiative (APII) Tonsillectomy Episode Statewide Webinar August 12, 2013 0

2. Contents • Lee Clark, Medicaid Health Innovation Unit Episodes Manager - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Dr. William Golden, Medicaid Medical Director – Tonsillectomy Episode of Care • Paula Miller – HP APII Analyst - Episode Reports

3. The health status of Arkansans is poor: the state is 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 for patients to navigate, and it does not reward providers who work as a team to coordinate care for patients Health care spending is growing unsustainably: Insurance premiums doubled for employers and families in past 10 years (adding to uninsured population) Today, we face major health care challenges in Arkansas

4. Episode-based care Acute, post-acute, or select chronic conditions How care is delivered Population-based care Medical homes Health homes Objectives Improve the health of the population Enhance the patient experience of care Enable patients to take an active role in their care Four aspects of broader program Results-based payment and reporting Health care workforce development Health information technology (HIT) adoption Consumer engagement and personal responsibility For patients For providers Focus today Reward providers for high quality, efficient care Reduce or control the cost of care Our vision to improve care for Arkansas is a comprehensive, patient-centered delivery system

5.   Transition to a payment system that rewards value and patient health outcomes by aligning financial incentives Eliminate coverage of expensive services or eligibility Pass growing costs on to consumers through higher premiums, deductibles and co-pays (private payers), or higher taxes (Medicaid) Intensify payer intervention in decisions though managed care or elimination of expensive services (e.g. through prior authorizations) based on restrictive guidelines Reduce payment levels for all providers regardlessof their quality of care or efficiency in managing costs    This initiative aims to… This initiative DOES NOT aim to Medicaid and private insurers believe paying for results, not just individual services, is the best option to improve quality and control costs

6. Patient-centered Focus on improving quality, patient experience and cost efficiency Clinically appropriate Design based on evidence, with close input from Arkansas patients and providers Practical Consider scope and complexity of implementation Data-based Make design decisions based on facts and data Principles of payment design for Arkansas

7. Contents • Lee Clark, Medicaid Health Innovation Unit Episodes Manager - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Dr. William Golden, Medicaid Medical Director –Tonsillectomy Episode of Care • Paula Miller – HP APII Analyst - Episode Descriptions & Reports

9. Contents • Lee Clark, Medicaid Health Innovation Unit Episodes Manager - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Dr. William Golden, Medicaid Medical Director – Tonsillectomy Providers, Patients & Quality • Paula Miller – HP APII Analyst - Episode Descriptions & Reports

10. Tonsillectomy: key facts What is a tonsillectomy? • Surgical removal of the tonsils • Commonly performed on children due to repeated infections of the tonsils • Typically done as a same day surgery Goals of episode • Reduce multiple pre-op visits • Drive appropriate post-surgery observation period • Reduce inappropriate sleep study, antibiotic and pathology usage • Reduce readmissions • Create a model for ENTs to share practices and design even more effective care

11. Patient journey for tonsillectomy/adenoidectomy post-procedure admission Procedure Post-procedure – 30 days Pre-procedure – (up to 90 days) • Same-day recovery unit • Follow-up care • Presents to ENT specialist Pre-procedural work-up in hospital/outpatient setting • Operating room2 • Inpatient Care and Recovery Unit • Post-procedure admission3 Tonsillectomy/adenoidec-tomy performed This episode excludes cases that present through inpatient/emergency department setting • Inpatient care and recovery unit1 • Follow-up care 1 Conditions for inpatient observation include Down syndrome, congenital heart defects, coagulopathies, platelet storage deficiency, or coagulation defects 2 Complications resulting in return to operating room include excessive bleeding, severe vomiting, or low oxygen saturation 3 Major causes for post-procedure admission include dehydration and excessive bleeding SOURCE: American Academy of Otorhinolaryngology, Expert interviews

12. Episode summary: Number of adenoidectomy, tonsillectomy, and adeno-tonsillectomy in Arkansas Medicaid BCBS • Total number of procedures • Total number of procedures 3,498 1,311 • Adenoidectomy • Adenoidectomy 569 176 • Tonsillectomy • Tonsillectomy 269 361 • Adeno-tonsillectomy • Adeno-tonsillectomy 2,660 774 • Number of performing providers • Number of performing providers 61 74 SOURCE: Arkansas Medicaid claims for patients with tonsillectomy/adenoidectomy between January 1, 2010 – December 31, 2010 Arkansas Blue Cross Blue Shield claims for patients with tonsillectomy/adenoidectomy between July 1, 2011 – June 30, 2012

13. Tonsillectomy/adenoidectomy episode design (1/2) • Episode definition/ scope of services • Episode is triggered by select types of tonsillectomy/adenoidectomy procedures, including: • All outpatient tonsillectomy, adenoidectomy, and adeno-tonsillectomy procedures(i.e. ED and inpatient tonsillectomies/adenoidectomies are excluded) • Primary or second diagnosis (Dx1 and Dx2) indicating conditions that require tonsillectomy/adenoidectomy (e.g. chronic tonsillitis, chronic adenoiditis, chronic pharyngitis, hypertrophy of tonsils and adenoids, obstructive sleep apnea, insomnia, peritonsillarabscess) • Episode time frame: • Related services (including sleep studies, head and neck x-rays, laryngoscopy) within 90 days prior to procedure after and including initial consult with performing provider • Related services within 30 days after procedure (i.e., inpatient and outpatient facility services, professional services, related medications, treatment for post-procedure complications) • Post-procedure admissions within 30 days after procedure1 1 • Patient/ episode exclusions • Certain patients are excluded from this episode design, patients with: • Select co-morbid conditions (e.g., Down syndrome, cancer, severe asthma, cerebral palsy, muscular dystrophy, myopathies) • Uvulopalatopharyngoplasty (UPPP) on date of procedure • Patients with BMI>502 • Age younger than 3 or older than 21 • Dual enrollment in Medicare/Medicaid (i.e., dual eligibles) • Inconsistent enrollment (i.e., not continuously enrolled) during the episode • Death in hospital during episode • Patient status of “left against medical advice” during episode 2 Parameters and codes may vary across different payers; the following algorithm and associated codes sheet applies to Medicaid 1 Excludes post procedure admissions that are not related to the episode as determined by Bundled Payment for Care Improvement (BPCI). Covers entire length of readmission if it occurs within 30 days after trigger (i.e. entire 3-day stay admitted on the 29th day post discharge would be included in episode) 2 Reported through provider portal

14. Tonsillectomy/adenoidectomy episode design (2/2) • Episode adjustments • Episode cost is adjusted based on: • Risk factors (e.g. COPD, asthma) • Episode types: (1) adenoidectomy (2) tonsillectomy/adeno-tonsillectomy • Only providers with at least 5 episodes per year are eligible for gain sharing/risk sharing 3 • Quality/ utilization metrics • Quality metrics required for gain sharing payment: • Percent of episodes with administration of intra-operative steroids1 • Metrics for reporting only: • Quality: Post-operative primary bleed rate (i.e., post-procedure admissions or unplanned return to OR due to bleeding within 24 hours of surgery) • Quality: Post-operative secondary bleed rate • Utilization: Rate of antibiotic prescription post-surgery2 4 • Principal Accountable Provider • For Medicaid, the Principal Accountable Provider (PAP) will be the primary provider performing the tonsillectomy/adenoidectomy. Other payers independently determine the PAP by considering the following factors: • Decision making responsibilities • Influence over other providers • Portion of episode cost 5 1 Reported through provider portal as an aggregate percentage across all of a PAP’s episode for a specific payor 2 American Academy of Otolaryngology – Head and Neck Surgery Tonsillectomy Guidelines for 2011 recommend against prescription of antibiotics post-procedure

15. 1 Design rationale: Episode definition / scope of services (1/4) Episode begins Trigger Episode ends 90 days pre- procedure Tonsillectomy/adenoidec-tomy procedure 30 days post-procedure • Episode definition: • All related services up to 90 days prior to (after and including initial consult) and 30 days after tonsillectomy/ad-enoidectomy procedure, including inpatient and outpatient facility services, professional services, and related medications • Complications that occur after the procedure The episode includes the following services Preparatory visits (office/clinic, or specialist consultation) • All claims within 90 days prior to procedure with a diagnosis related to adenoidectomy/tonsillectomy • Claims must occur after initial consult with performing provider (initial consult is included) • All claims on day of procedure or within 30 days post-procedure window with a diagnosis related to tonsillectomy/adenoidectomy • Complications are included in the 30 day post-procedure window Labs, imaging, and diagnostic tests Professional claimfor procedure Inpatient or outpatient facility care Medication • All antibiotics, anti-emetics, narcotics, and steroids prescribed in the 30 day post-procedure window 30-day post-procedure admission1 • Inpatient admission within 30 day post-procedure window as defined by Bundled Payment for Care Improvement (BPCI) 1 Covers entire length of readmission if it occurs within 30 days after trigger (i.e. entire 3-day stay admitted on the 29th day post discharge would be included in episode)

16. 1 Detailed in following pages Design rationale: Episode definition / scope of services (2/4) Episode design decisions Rationale • Trigger identification: • Only outpatient tonsillectomies/adenoidectomies can be potential triggers (i.e., tonsillectomies/adenoidectomies which occur in the ER or inpatient are automatically excluded as potential triggers) • Episode is triggered by tonsillectomy/adenoidectomy procedure and appropriate primary or secondary diagnosis • Tonsillectomies/adenoidectomies which occur in the ER or inpatient often have high variability in patient conditions, outcomes, and episode costs (i.e., variability beyond the control of the PAP), and are therefore excluded • A list of CPT and ICD-9 Px codes for tonsillectomy, adenoidectomy, and adeno-tonsillectomy are identified as triggers for an episode • An appropriate ICD-9 diagnosis code (Dx fields 1 and 2) must also accompany a procedure code for the procedure to be considered a valid trigger for an episode • Pre-procedure window: • Episode begins the day of the first PAP visit within a 90-day window prior to procedure • Any ER/Inpatient cost in pre-procedure window will be excluded • Any medications in pre-procedure window will be excluded • Pre-procedure window is a maximum of 90 days prior to the procedure to allow for capture of the first ENT consult with patient • ER/Inpatient and medication costs are not captured in pre-procedure window since the tonsillectomy/adenoidectomy procedure is often scheduled based on patient convenience, therefore giving some PAPs a greater risk for higher ER/inpatient and medication cost that is beyond PAP’s control • Post-procedure window: • Related services within 30 days after procedure (i.e., inpatient and outpatient facility services, professional services, related medications, treatment for post-procedure complications) • Inpatient post-procedure admission within 30 days after procedure as defined by Bundled Payment for Care Improvement (BPCI) • Post procedure admissions due to complications, etc. are included in episode cost calculations since reducing complications and treating them effectively and efficiently is an identified value driver • Bundled Payment for Care Improvement (BPCI) provides a list of procedure codes which are not relevant to tonsillectomy/adenoidectomy and these procedures would not be included in episode costs (i.e., if a patient is treated for a condition that is not a complication or relevant to the tonsillectomy/adenoidectomy procedure within 30 days after the procedure, it will not be included in the episode cost calculations)

17. 2 Detailed in following pages Design rationale: Patient exclusions (1/5) Patient exclusion design decision Rationale • Select co-morbid conditions within 365 days prior to procedure or during episode • Patients with certain co-morbidities which may unfairly increase a PAP’s average episode cost due to their inherent medical condition(s) within a year prior to procedure or during the episode are excluded (i.e., co-morbidities are factors beyond the PAP’s control/influence) • Pregnant during episode • Tonsillectomies/adenoidectomies performed on women who are known to be pregnant during an episode window are excluded due to their potentially complex condition • Age younger than 3 or older than 21 • Patients under 3 and older than 21 tend to be more complicated procedures and are therefore excluded • Dual enrollment in Medicare/Medicaid (i.e., dual eligibles) • In order to reduce the possibility that costs within an episode are not accurately and fully captured (i.e., costs partially covered by another program), patients who have dual enrollment are excluded • Inconsistent enrollment with payer during episode • Consistent enrollment ensures that all costs associated with an episode are accurately and fully captured

18. 2 Design rationale: Patient exclusions (2/5) Patient exclusion design decision Rationale • Uvulopalatopharyngoplasty (UPPP) on date of procedure • Patients with UPPP on date of procedure have a different clinical pathology than relevant tonsillectomy/adeno-tonsillectomy • As a result, the severity of care and episode cost is extremely different and variable as compared to relevant episodes • Patients with BMI>50 • Patients with BMI over 50 are higher risk and more complicated to operate on • The PAP cannot control this risk or the variability in outcomes due to this patient condition • Death in hospital during episode • Patients with death in hospital are clinical outliers • Patient status of “left against medical advice” during episode • A PAP cannot be held responsible for outcomes and resulting cost of care if patient leaves AMA

19. LIST OF EXCLUSION CO-MORBIDITIES 2 Design rationale: Patient exclusions (3/5) • Age on date of procedure • Care setting1 • Severe/chronic diseases and procedures • (Exclusion period: 365 days pre-procedure and during episode window) • Younger than 3 • Older than 21 • ED tonsillectomy/ adenoidectomy • Inpatient tonsillectomy/ adenoidectomy • Sickle cell disease • Cystic fibrosis • Coagulopathies • Severe asthma • Down syndrome • Congenital defects of the circulatory system • Post obstructive pulmonary edema • Muscular dystrophy • Myopathies • Degenerative diseases of CNS • Severe mental retardation • Blood disorders • Congenital anomalies • Malignant hypothermia • ESRD (end-stage renal disease) • Uvulopalatopharyngoplasty (UPPP)2 1 Setting where patient presented with symptoms and received treatment 2 Exclusion applies only if performed on date of procedure

20. LIST OF EXCLUSION CO-MORBIDITIES 2 Design rationale: Patient exclusions (4/5) • Cancers • (Exclusion period: 365 days pre-procedure and during episode window) • Other • (during episode window) • Bone cancer • Brain cancer • Bronchial/lung cancer • Colon cancer • Esophageal cancer • GI/peritoneum cancer • Liver cancer • Malignant neoplasm • Neoplasm unspecified • Female genital cancer • Male genital cancer • Ovarian cancer • Pancreas cancer • Rectum/anus cancer • Kidney/renal cancer • Stomach cancer • Urinary organ cancer • Gallbladder cancer • Secondary malignancy • Other respiratory cancer • Other primary cancer • Pneumonia • Fetal disturbances • Forceps or vacuum extractor delivery • Malposition • Other perinatal diagnosis • Umbilical cord complications • Spontaneous abortion • Suicide and intentional self-inflicted injury

21. TOP-20 EXCLUSION CO-MORBIDITIES FROM 2010 2 Design rationale: Patient exclusions (5/5) INDIVIDUAL PATIENT MAY HAVEMORE THAN ONE CO-MORBIDITY ICD9-Dx Description 486 Pneumonia, organism unspecified Asthma, unspecified type, with (acute) exacerbation 493.92 Lymphadenitis, unspecified, except mesenteric 289.3 758.0 Down's syndrome 343.9 Infantile cerebral palsy, unspecified 745.4 Ventricular septal defect 331.4 Obstructive hydrocephalus 759.7 Multiple congenital anomalies Extrinsic asthma with (acute) exacerbation 493.02 Ostium secundum type atrial septal defect 745.5 750.29 Other specified anomalies of pharynx 239.2 Neoplasm of unspecified nature of bone, soft tissue 482.9 Bacterial pneumonia, unspecified 519.11 Acute bronchospasm 282.5 Sickle-cell trait Neoplasm of uncertain behavior of skin 2382 3181 Severe mental retardation 74100 Spina bifida with hydrocephalus, unspecified region 7423 Congenital hydrocephalus 2875 Thrombocytopenia, unspecified SOURCE: Arkansas Medicaid claims for patients with tonsillectomy/adenoidectomy between January 1, 2010 – December 31, 2010

22. 4 Design rationale: Quality metrics Quality metrics design decision Rationale • Quality metrics required for gain sharing payment: • Rate of administration of inta-operative steroids • To qualify for gain sharing, providers or their staff must report quality metrics through an online provider portal since some quality metrics cannot be extracted from claims data • Providers must meet minimum quality standards agreed upon by a clinical advisory board • Example: • Average rate of intra-operative steroid administration A • Quality/utilization metrics for reporting only: • Post-operative primary bleed rate (i.e., post-procedure admissions or unplanned return to OR due to bleeding within 24 hours of surgery) • Post-operative secondary bleed rate • Utilization: Rate of antibiotic prescription post-surgery • A bleed within 24-hours post-surgery (primary bleed) is related to surgeon technical skill and can drive post-procedure admissions as well as unplanned return to the operation room • A bleed within 2-14 days post-procedure is less related to physician efficiency but should still be monitored as it can drive post-procedure admissions • The Academy of Otolaryngology has recommended against post procedure antibiotic prescription in the revised tonsillectomy guidelines from 2011 B

23. 5 Design rationale: Principal Accountable Provider (PAP) PAP design decision Rationale • Payers independently determine the PAP by considering the following factors: • Decision making responsibilities • Influence over other providers • Portion of episode cost • Medicaid has publicly announced that the Principal Accountable Provider (PAP) will be the primary provider performing the tonsillectomy/adenoidectomy since they are in the position to influence the most decisions and costs • Medicaid’s PAP will be the provider performing the tonsillectomy/adenoidectomy

24. Contents • Lee Clark, Medicaid Health Innovation Unit Episodes Manager - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Dr. William Golden, Medicaid Medical Director – Tonsillectomy Episode of Care • Paula Miller –HP APII Analyst - Episode Descriptions & Reports

25. Medicaid Little Rock Clinic 123456789 April 2013 Arkansas Health Care Payment Improvement Initiative Provider Report Medicaid Report date: April 2013 Historical performance: January 1, 2012 – December 31, 2012 DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports is neither intended nor suitable for other uses, including the selection of a health care provider. The figures in this report are preliminary and are subject to revision. For more information, please visit www.paymentinitiative.org

26. Division of Medical Services P.O. Box 1437, Slot S-415 · Little Rock, AR 72203-1437 501-683-4120 · Fax: 501-683-4124 Dear Medicaid provider, This is an update on the Arkansas Health Care Payment Improvement Initiative (APII) – a payment system developed with input from hundreds of health care providers, patients and family members. Our goal is to support and reward providers who consistently deliver high-quality, coordinated, and cost-effective care. As a reminder, a core component of this multi-payer initiative is episodes of care. An episode is the collection of care provided to treat a particular condition over a given length of time. Since July of 2012, Arkansas Medicaid has introduced new episodes, including Upper Respiratory Infection (URI), Perinatal (colloquially, called “pregnancy”), Attention Deficit/Hyperactivity Disorder (ADHD), and more. To see the most up to date list of episodes visit the APII website at www.paymentinitiative.org. For each episode, the provider that holds the main responsibility for ensuring that care is delivered at appropriate cost and quality will be designated as the Principal Accountable Provider (PAPs). For some episodes in the period covered in the attached report, you were identified as the PAP. After appropriate risk-adjustments and exclusions, your average quality and cost was compared with previously announced thresholds. This determines any potential sharing of savings or excess cost indicated in the report. Note that all information described throughout your report is based on claims already submitted and all providers should continue to submit and receive reimbursement for claims as they do today. This report contains episodes currently in the ‘preparatory phase’ and so the data and analyses for these reports are historical only (i.e. they are not data from the time period that you will be measured against). To see “performance” reports (i.e., containing episodes eligible for gain or risk sharing) for episodes launched earlier, log onto the provider portal at www.paymentinitiative.org to download a separate report. To aid you in your role as a PAP for future episodes, we have been working hard with providers and other payers to design a set of reports that give you detailed data about the quality and cost of your care as well as how this compares with previously announced thresholds and the range of performance of other providers. As each payer will send a report covering their patients, you may receive similar reports from Arkansas Blue Cross Blue Shield and / or QualChoice. We encourage you to log onto the provider portal to access your current and previous ‘preparatory period’ and ‘performance period’ reports. As a PAP for select episodes, you should begin using this portal to enter selected quality metrics for each patient with an episode of care starting. To see which episodes have quality metrics linked to gain sharing visit the APII website. We have been working diligently to solicit feedback from the provider community and will continue in our efforts to respond to all questions, comments and concerns raised in a timely and consistent manner. For answers to frequently asked questions regarding the initiative and episodes, please refer to the payment initiative website (www.paymentinitiative.org) You can also call us at 1-866-322-4696 or locally at 501-301-8311 with questions or email ARKPII@hp.com. Additionally, be sure to check the website regularly for updates on upcoming informational WebEx sessions, other resources, or to sign up for alerts. Sincerely, Andy Allison, PhDMedicaid Director DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports is neither intended nor suitable for other uses, including the selection of a health care provider. These figures are preliminary and are subject to revision. For more information, please visit www.paymentinitiative.org. 25

27. Medicaid Little Rock Clinic 123456789 April 2013 Table of contents Performance summary Attention Deficit/Hyperactivity Disorder (ADHD) – Level I Attention Deficit/Hyperactivity Disorder (ADHD) – Level II Cholecystectomy Colonoscopy Congestive Heart Failure Oppositional Defiance Disorder Perinatal Tonsillectomy Total Joint Replacement Upper Respiratory Infection – Non-specific URI Upper Respiratory Infection – Pharyngitis Upper Respiratory Infection – Sinusitis Glossary Appendix: Episode level detail

28. Medicaid Little Rock Clinic 123456789 April 2013 Attention Deficit / Hyperactivity Disorder (ADHD) – Level II Not eligible for gain sharing Upper Respiratory Infection – Sinusitis Will receive gain sharing Met Acceptable $0.00 N/A Commendable $349.50 Not eligible for gain sharing Not eligible for gain sharing Cholecystectomy Congestive Heart Failure Not met Met Acceptable Acceptable $0.00 $0.00 Not eligible for gain sharing Not eligible for gain sharing Colonoscopy Perinatal Met Met Acceptable Acceptable $0.00 $0.00 Not eligible for gain sharing Met Acceptable $0.00 Oppositional Defiance Disorder Not eligible for gain sharing Total Joint Replacement N/A Acceptable $0.00 Not eligible for gain sharing Tonsillectomy Met Acceptable $0.00 Upper Respiratory Infection – Non-specific URI Subject to risk sharing -$3,844.50 N/A Not acceptable Upper Respiratory Infection – Pharyngitis Not eligible for gain sharing Not met Acceptable $0.00 Performance summary 1 Quality of services and cost summary Quality of Service Average Episode Cost Share Amount Episode of Care Your Gain/Risk Share Not eligible for gain sharing Attention Deficit / Hyperactivity Disorder (ADHD) – Level I Not met Acceptable $0.00 Across these Episodes of Care You are Subject to Risk Sharing: Stop-loss was applied -$3,000.00 The figures in this report are preliminary and are subject to revision

29. Medicaid Little Rock Clinic 123456789 April 2013 $974 to $1,003 < $974 > $1,003 Post-op Abx Rx rate ü ü Surgical pathology utilization rate Acceptable Not acceptable You Commendable Summary – Tonsillectomy 1 Overview Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29 2 Cost of care compared to other providers Gain/Risk share $0 Commendable Acceptable Not acceptable You > $4000 All providers You will not receive gain or risk sharing • Selected quality metrics: N/A • Average episode cost: Acceptable 3 Quality summary 4 Cost summary You achieved selected quality metrics Your average cost is acceptable Linked to gain sharing Average cost overview, $ Your total cost overview, $ There are no quality metrics linked to gain sharing generated from claims data. Selected quality data submitted on the Provider Portal will generate additional quality metrics for future reports. Intra-op steroid Rx rate Post-procedure primary bleed rate 512,000 2,000 466,000 1,750 100% 100% Standard for gain sharing 50% You (non-adjusted) You (adjusted) You All providers 50% 0% 0% Your episode cost distribution You Avg You Avg Post-procedure secondary bleed # episodes 100 100% 50 >$1,542 <$899 $899-$974 $974-$984 $984-$993 $993-$1003 $1,003-$1,542 50% Series Distributionof provider average episode cost 0% You Avg 7500 Cost, $ 100% 5000 2500 50% Percentile 0% You Avg 5 Key utilization metrics All providers You 30% 17%

30. Medicaid Little Rock Clinic 123456789 April 2013 Quality and utilization detail – Tonsillectomy You Metric linked to gain sharing Minimum standard for gain sharing 1 Quality metrics: Performance compared to provider distribution Percentile Percentile Metric You 25th 50th 75th 0 25 50 75 100 - Post-procedure primary bleed rate 1% 0% 1% 2% - Post-procedure secondary bleed 0% 1% 2% 4% - Post-procedure Abx Rx 25% 20% 30% 40% You achieved selected quality metrics û 2 Utilization metrics: Performance compared to provider distribution Percentile Percentile Metric You 25th 50th 75th 0 25 50 75 100 -

31. Medicaid Little Rock Clinic 123456789 April 2013 Cost detail – Tonsillectomy Total episodes included = 233 You All provider average # and % of episodes with claims in care category Total vs. expected cost in care category, $ Average cost per episode when care category utilized, $ Care category 233 Outpatient professional 100% 550 128,150 100% 500 116,500 230 99% 2,415 555,450 Pharmacy 99% 2,400 552,000 221 Emergency department 95% 76 16,796 97% 76 16,796 184 79% 81 14,904 Outpatient lab 77% 81 14,904 Outpatient radiology / procedures 21 75% 117 2,457 80% 95 1,995 16 78% 70 1,120 Inpatient professional 75% 75 1,200 12 5% 69 828 Inpatient facility 3% 62 744 1 Outpatient surgery <1% 97 97 <1% 84 84 7 3% 25 175 Other 4% 27 189

32. Questions

33. For more information talk with provider support representatives… Online • More information on the Payment Improvement Initiative can be found atwww.paymentinitiative.org • Further detail on the initiative, PAP and portal • Printable flyers for bulletin boards, staff offices, etc. • Specific details on all episodes • 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) orARKPII@hp.com • Blue Cross Blue Shield: Providers 1-800-827- 4814, direct to EBI 1-888-800-3283, APIICustomerSupport@arkbluecross.com • QualChoice: 1-501-228-7111, providerrelations@qualchoice.com