The Payer Perspective Richard Snyder, M.D.

Agenda The National Landscape Profiles of Single and Multi-Stakeholder Pilots –North Dakota –New Jersey –Pennsylvania Chronic Care Management, Reimbursement & Cost Reduction Commission

The National Landscape 24 Pilots / 10 Active Single and Multi-Stakeholder –Public/Private –Commercial, Medicare Advantage, Managed Medicaid Practices –13 – 6,471 Practitioners –850 – 1.7M Patients Diverse reimbursement strategies Variable degrees of clinical outcomes

BCBS of North Dakota & Meritcare Health System Payer and Integrated Multi-specialty Medical Group Focus on diabetes – started 2005 –Use of integrated RN – CDM –Emphasis on self-management, goals, education, follow-up Outcomes –Improved satisfaction of patients and practices –Improved results of comprehensive diabetes care –Savings shared 50:50 with practices $531 per patient with diabetes $1,213 per patient with diabetes Expanded to 4 practices, added HTN and CAD, added management fee and generic prescribing incentives

Horizon BCBS & Partners in Care Payer and Physician Owned MSO –Offered to New Jersey State Health Benefits Program –Initially 1,300 patients Focus on diabetes – started 2007 –Emphasis on care coordination and information sharing –Complemented with Payer disease management program Outcomes between January and November 2007 –HgbA1c testing increased 43% to 91% –HgbA1c result between 7 and 9 increased from 15% to 36% –PMPM medical spend dropped from $1,049 to $870 Expanded to over 400 practices and 30,000 patients

Chronic Care Management, Reimbursement & Cost Reduction Commission Part of Prescription for Pennsylvania Goal - Improve chronic care delivery in PA –$1.7 billion in avoidable admissions –Missed opportunities in process/outcomes measures 45 Provider, insurer, cabinet, organized labor, academic and consumer representatives Blend of Wagner Chronic Care Model and Patient Centered Medical Home Model –Lead by Governor’s Office on Health Care Reform –Learning sessions –Practice coaches to support transformation –NCQA PPC-PCMH recognition levels drive reimbursement

SE Pennsylvania Rollout 32 PCP (Ped, IM, FP, CRNP) Practices with 166 PCPs –220,000 patients Multiple Payers (IBC, KMHP, Aetna, CIGNA, Health Partners, AmeriChoice) Primary Care Coalition (PAFP, ACP, AAP) Goals are to improve: –Access to care and communication with PCP –Team based care coordination, health education and self- management skills –Use of registry/EMR to report data –Member and provider satisfaction –Aggregation of payer and practice level data for reporting –Improved quality, utilization and cost outcomes

Role of GOHCR Staffing –Project management Funding –Consultants –Faculty and expenses for a year-long learning collaborative for participating primary care practices –Cost of registry –Data collection, evaluation and reporting activities through a 3 rd party, including surveys Coordinating –Flow of data between practices and payers –Flow of funds from payers to practices; and IPIP (Improving Performance in Practice) a PAFP 501c3 –Baseline and subsequent satisfaction surveys

Requirements of PCP Practices Three year commitment Attend “Learning Collaborative” meetings Work with assigned practice coach to transform practice –Enhanced access to care –Team based coordinated care –Enhanced communication –Self-management support Use a patient registry (or EMR) to track patients Report data from the patient registry and other sources required for evaluation purposes Achieve Level 1 NCQA PPC-PCMH Recognition in year 1 Reinvest funds into staff and technology at practice site

Requirements of Payers Three year commitment to fund and support Methodology – payments proportionate to revenue from all sources as validated and coordinated through GOHCR Payment to IPIP for Practice Coaches Payment to PCP Practices are intended to offset costs –Infrastructure development NCQA PPC-PCMH survey tool$80/practice Data entry to registry$800/practice Office assistant $8,000/practice NCQA application fee $360/clinician Registry license fee$275/clinician –Time for practice team to attend learning collaborative are paid after attendance Seven days during 1 st year$11,655/team Consist of quarterly 2 day learning meetings and final outcome meeting

Requirements of Payers Enhancement to current payer contractual payments –Annual lump sum payments upon NCQA PPC-PCMH recognition yield up to $4PMPM Prorated for portion of year at each level of recognition Prorated based on PCP/CRNP FTEs in practice Discounted by % of revenue from Medicare FFS and non-par payers Pay-for-performance – standard process post first 3 years based on clinical, utilization, satisfaction and financial outcomes NCQA PCMH Recognition Level Practice 1 FTE Practice 2-4 FTEs Practice 5-9 FTEs Practice FTEs Level 1$40,000$36,000$32,000$28,000 Level 2$60,000$54,000$48,000$42,000 Level 3$95,000$85,500$76,000$66,500

Requirements of IPIP Provide Practice Coaches to assist –With transforming the practice –With data collection and reporting –Linking practices to community resources –With completing the NCQA PPC-PCMH recognition process Contribute to Consumer Engagement Strategy –Community Registry of resources available to practices –Building public-private partnerships to support self-management –IPIP practice coach resource for training on self-management –Reimburse self-management education services –Contribute to community sponsored lay support services –Contribute to standardized incentive program Consumer Engagement

Evaluation The Commission has approved a methodology –Data from payers, providers, and surveys to be aggregated by 3 rd party –Rollout “intervention” groups to be compared to control groups –Metrics are based on nationally endorsed measures where possible (NCQA, AQA, etc.) The initiative will be evaluated using the following measurement domains: –Engaged providers –Patient self-care knowledge and skills –Patient function and health status –Primary care practice satisfaction –Appropriate and efficient utilization of services –Clinical care quality –Cost

Anticipated Gains Improved quality of care within 1 year Reduced admissions and cost in 3 years Improved access to care and member satisfaction Support for the vulnerable and essential primary care professional community A robust demonstration of the impact of a far-reaching, multi-payer strategy to transform care delivery Lessons learned to hopefully apply to a broader system- wide model application