CTC-Clinical Strategy Committee April 15, 2016 Defining and Measuring Primary Care Access Goals for Integra-BCBSRI Commercial Contract CTC-Clinical Strategy Committee April 15, 2016

BCBSRI/Integra Access Improvement Initiative Primary Care Access Improvement proposed as performance requirement for commercial contract Proposed baseline measure in YR1 with % improvement in years 2 & 3. Agreement not reached on specific measure Consultant engaged to mediate and obtain agreement Primary Care access measurement approaches document delivered by consultant Parties met, reviewed document and rapidly reached consensus Measurement definition & specifications written Implementation pending

Defining Primary Care Accessible first‐contact care: Primary care clinicians make their services available and easily accessible to patients with new medical needs or ongoing health concerns. This includes: Shorter waiting times for urgent needs, Enhanced in‐person hours, Around‐the‐clock telephone or electronic access to a member of the care team who has access to the patient’s medical record, and Alternative methods of communication including patient portals. This also includes providers who speak the language of the population served.   Continuous care: Primary care clinicians have a personal and uninterrupted caring relationship with their patients, with continuous exchange of relevant information about health care and health needs. Comprehensiveness of care: Primary care clinicians, working with the interprofessional primary care team, meet the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, chronic and comorbid care, to include discussing end‐of‐life care. Coordinated care: Primary care practices coordinate care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and support. Accountable whole‐person care: Primary care clinician/team is knowledgeable about and oriented toward the whole person, understanding and respecting each patient’s unique needs, culture, values, and preferences in the context of their family and community. “Accountability” refers to caring for the whole person, not just an isolated body system. Source: material prepared by Commonwealth Medicine for Integra-BCBSRI

Defining Access The Institute of Medicine (IOM) notably defined access to health care as "the timely use of personal health services to achieve the best possible health outcomes."3   The 2011 National Healthcare Quality Report, prepared by the Agency for Healthcare Research and Quality (AHRQ) identified three essential steps, all necessary to achieve access: 4 Gaining entry into the health care system. Getting access to sites of care where services can be delivered; and Finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust. Source: material prepared by Commonwealth Medicine for Integra-BCBSRI

Measuring Primary Care Access It is helpful to consider primary care access from three perspectives: population, provider/practice, and patient. For the purposes of this report, we define these three perspectives as follows:   Population – all BCBS‐RI members under the care of the Integra ACO (approximately 60,000 members). Practice – the network of medical practices in the Integra Community Care Network, and the eight new primary/urgent care access centers being set up by Integra. Patient – the population as defined above, but understood as 60,000 unique individuals, each with her/his own viewpoint. Each of these three perspectives will align best with certain types of access measures: Population – aggregated measures (HEDIS), typically derived from administrative (claims) data. Practice ‐ measures derived from practice management software/data, and used for internal benchmarking and improvement. There may be preferred measures for different types of practices – urgent vs. primary care, pediatric vs. adult. Patient – primarily survey data (such as CAHPS), but perhaps also patient‐reported outcomes data. Source: material prepared by Commonwealth Medicine for Integra-BCBSRI

Considerations The measures considered included a wide array of approaches to assessing primary care access at the ACO level. The group considered the following issues when selecting the final measure:   For what purpose will the measure results be used? Measures selected may differ if the end goal is monitoring contract compliance, or performance improvement. Variability: Measures with high variability should be avoided. In other words, measures selected for contract monitoring should be fairly stable over time. (This applies in both the contract monitoring and performance improvement contexts.) Ability to make improvements/sensitivity to change: If the goal of measurement is to improve performance, then it is critical to pick measures that have some room for improvement (i.e., scores are not already near the highest possible level). What is the level of accountability? Measures selected may differ if accountability is at the practice level, or at the level of the ACO. Appropriateness of measures for practice types: If accountability is at the practice level, then some measures will be appropriate for primary care sites, but not urgent care sites, and vice versa. What relative importance is placed on patient voice? Survey‐based methods, while an important tool for giving patients input, may not always be the best measures of access due to methodological issues (sample size, accuracy issues with patient report). How important is use of leading‐edge indicators? Measures of dimensions like enhanced (electronic) access or cultural competency are meaningful, but such newer measures remain in early stages of development, and may have reliability issues. Source: material prepared by Commonwealth Medicine for Integra-BCBSRI

Measure : Percentage of new patients getting access to primary care team within 30 days Description:   The percentage of new BCBSRI commercial members who have not yet selected a primary care practitioner (PCP) who receive an initial non‐urgent appointment with a member of a primary care team (either a physician, physician assistant, or nurse practitioner) within 30 days of requesting an appointment. Target Population: All new BCBSRI commercial members seeking primary (non‐urgent) care as a new patient from Integra (practices currently on Epic EHR). Seeking care is defined as calling either the BCBSRI/Integra member services call center or a medical practice that is part of the Integra Community Care network and currently on Epic EHR to request a non‐urgent primary care appointment. New patient is defined as an ACO member who reports not having an assigned/enrolled PCP upon calling to request an initial visit. Denominator: All new BCBSRI commercial patient non‐urgent visit requests made by prospective Integra ACO(Epic EHR practices) members during the measurement period. Numerator: Number of new BCBSRI commercial patient non‐urgent visit requests scheduled for an initial appointment with a member of a primary care team within 30 days of the request. (Patient cancellations or no‐shows should count towards the numerator compliance, i.e., appointments do not have to be completed to qualify for the numerator, just scheduled.)

Measure : Percentage of new patients getting access to primary care team within 30 days Data Collection Methods:   The following data collection methods may be used: Call logs at BCBSRI/Integra Call Center and/or Integra ACO practices Epic Electronic Health Record System Audit method – using either manual calculation by office staff or practice management software, simulate a new patient non‐urgent visit request on a regular schedule (same day/time each week). Measurement Frequency: We propose quarterly measurement for process improvement purposes. Quarterly data can be rolled up to the annual level for performance assessment.

Questions?