1 Pennsylvania's Chronic Care Initiative: Improving Diabetes Care through Physician Practice Transformation Carey Vinson, MD Vice President Quality & Medical Performance Management Highmark Inc. 1

Pennsylvania's Chronic Care Initiative Description of the Governor’s Office for Health Care Reform Chronic Care Initiative Preliminary results Implications for the care of patients with diabetes mellitus

3 The Governor’s Chronic Care Initiative The Pennsylvania Chronic Care Management, Reimbursement and Cost Reduction Commission May 2007 Purpose: Design infrastructure needed to implement and support widespread dissemination of the Chronic Care Model throughout Pennsylvania The Plan provides a business case and framework for implementing the Chronic Care Model across the Commonwealth Incremental implementation Diabetes and pediatric asthma focus of the initial rollout

4 Implementation of the Chronic Care Model in Pennsylvania Southeastern PA was the first regional rollout May 2008  32 Practices  149 Clinical FTEs  230,000 patients Current pilots  South Central PA – February 11-12, 2009  South Western PA – March 3-4, 2009  Limited payment pilots: North East PA – June 2009 North West PA – June 2009

5 Implementation of the Chronic Care Model in Pennsylvania Total impact of this first phase includes over 400 physicians/CRNP’s representing nearly 600,000 patients. Rollout framework has flexibility by region as determined by regional steering committee At eighteen and thirty-six months a formal evaluation will assess whether the rollouts are achieving desired quality and cost containment goals, and whether to continue.

Partner Organizations in Collaborative Payers  Independence Blue Cross  Aetna  Keystone Mercy  Health Partners  Cigna  Highmark Inc.  Capital Blue Cross  Gateway Health Plan  Health America Provider Organizations  Temple University Health System  Jefferson Health System  University of Pennsylvania  Wellspan  Hershey Medical Center  UPMC Medical Center Professional Organizations/Societies  Improving Performance in Practice (IPIP), PA  ABIM  ACP  PAFP

7 The Chronic Care Model Developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound Identifies fundamental areas making up a system that encourages high-quality chronic disease management.

8 The Chronic Care Model Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Info Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Improved Outcomes

9 The Learning Collaborative One-year process with 3 two-day in person sessions and a one day Outcomes Congress Facilitated by IPIP Teams supported by expert faculty in diabetes and asthma care, QI, IT, self-management support, co- morbid care, and topics related to the overall framework. Sharing across teams facilitated by conference calls between sessions, websites for materials

10 Integration of the Patient Centered Medical Home NCQA Patient Centered Medical Home Certification Standardized tool for qualifying practices for demonstration projects evaluating the patient-centered medical home model 3 Achievement Levels Used as validation tool to confirm practice transformation Incorporate additional requirements beyond NCQA scoring levels Recognition triggers incentive payments to practices

11 Expected Results From Practices Provide leadership, coordination and partial funding for three, two- day Collaborative learning sessions and a one-day Outcomes Congress, a reporting structure, data analysis, marketing and promotion, technical support to teams and communication methodologies Create a framework that will permit payors to help practices defray the cost of transforming to the Chronic Care Model Provide a web-based patient registry to track a number of interventions and clinical parameters important in chronic disease management and provide alerts if there are problems Work with other organizations to arrange for practice coaches to assist with implementing the action steps required in practice settings

12 Physician Responsibilities Sign a Participation Agreement with GOHCR with a three year minimum commitment Apply for Patient-Centered Medical Home (PCMH) recognition from NCQA and give results to GOHCR Select a team of at least three people: a physician or nurse practitioner, nurse, office manager and other office staff As a team, participate in each of three, two-day learning sessions and a one-day Outcomes Congress Commit to attaining PCMH Level 1 certification along with the High Value Elements identified by GOHCR (PCMH Level 1 PLUS) at eighteen months from the start date Report on the required outcome measures of the Collaborative

13 Financial Incentives Financial incentives totaling $4 pmpm to include:  Payment for technical infrastructure and related costs  Payment for resources required for care management functions  Payment to achieve NCQA PCMH Level 1  Payment for NCQA PCMCH Level 3 recognition Payments to practices will be proportionate from participating payers

14 Evaluation Learning Collaborative Evaluation  Practices report monthly Data Narrative  IPIP aggregates data and provides dashboard report to collaborative members Initiative Evaluation  Outside firm will evaluate each learning collaborative and entire initiative

15 Progress As of February 1, 2009 twelve SEPA practices have NCQA Patient Centered Medical Home Certification Generally improved clinical results for diabetes mellitus

IPIP Early Results Population Comparison by PA Regions SE PA Total Population  10,000 diabetes patients in 25 practices  5,000 pediatric asthma patients in 8 practices SC PA Total Population  7,500 diabetes patients in 24 practices  500 pediatric asthma patients in 2 practices SW PA Total Population  6,500 diabetes patients in 22 practices

Aggregate Average % DM Patients A1C>9.0 by Pennsylvania Region

Aggregate Average % DM Patients BP<130/80 by PA Region

Aggregate Average % DM Patients BP<140/90 by Pennsylvania Region

Aggregate Average % DM Patients LDL<100 by Pennsylvania Region

Aggregate Average % DM Patients LDL<130 by Pennsylvania Region

Aggregate Average % DM Patients Kidney Assessment by Pennsylvania Region

Aggregate Average % DM Patients Eye Exam by Pennsylvania Region

Aggregate Average % DM Patients Foot Exam by Pennsylvania Region

Aggregate Average % DM Patients Self Mgmt Goal by Pennsylvania Region

Implications Prove worth of the Wagner Model for care of patients with diabetes Define a patient centered medical home type of primary care practice Transform practices for better care of diabetics Determine if financial incentives make a difference Improve clinical results for diabetics

Implications Build on current clinical quality improvement activities Enhance pay-for-performance results Expand practice support efforts

Summary The Governor’s Office for Health Care Reform Chronic Care Initiative attempts to improve the care of patients with diabetes  Practice transformation  Patient centered medical home  Application of the Wagner Chronic Care Model  Financial incentives Positive early results May be a prototype for the care of patients with diabetes mellitus

29 Pennsylvania's Chronic Care Initiative: Improving Diabetes Care through Physician Practice Transformation Carey Vinson, MD 29