Implementation Update on OHIC Affordability Standards Clinical practice champion quarterly learning session December 9th 2016 Cory King - Office of the Health Insurance Commissioner

Office of the Health Insurance Commissioner Agenda Overview of OHIC Affordability Standards Initiatives + Opportunities for Collaboration in 2017 Results of Year 1 PCMH Reporting Discussion & Questions Office of the Health Insurance Commissioner

OHIC Theory of Action Smarter Spending Setting Rates for Commercial Insurers Innovative Regulatory Approaches to Healthcare Reform Better Care Healthier Population Affordability Standards Compliance with State & Federal Statute & Regulation Overview of OHIC’s tools for bringing about affordable health coverage OHIC sets commercial health insurance rates each year through a process called Rate Review. In addition to ensuring rate increases are as low as possible and justified by actuarial data, OHIC oversees compliance with federal and state law. Coupled with the innovative regulatory approaches OHIC has taken to reform the healthcare delivery system, thanks to the Office’s forward thinking legislative charge, this rate setting process gives Rhode Island a one of a kind regulatory lever to bring about smarter spending – for individuals, businesses, and the system – better quality of care, and better health outcomes. Care Transformation Payment Reform Cost Growth Containment

Affordability Standards Highlights to Date Care transformation Payment reform Value-based PCMH definition that relies on NCQA recognition, clinical quality performance, and implementation of a standard set of cost management processes. By 2019 health insurers must have 80% of contracted primary care clinicians practicing in PCMHs. Practices that meet the 3-part PCMH definition qualify for a “sustainability” payment when included in insurer PCMH count. Annual targets for the percentage of medical payments that must be paid under an Alternative Payment Model (APM) - 40% by 2017 and 50% by 2018 Concerted effort to have total cost of care contracts migrate to greater risk sharing. Concerted effort to figure out the place of specialist providers in the world of population- based care. Office of the Health Insurance Commissioner

Office of the Health Insurance Commissioner 2017 Care Transformation & APM Initiatives – Opportunities for Collaboration Identification and Outreach Strategy to Non-PCMH Small Primary Care Practices Primary Care Alternative Payment Model & Clinical Processes Under APMs Evidenced-based Approaches for High Risk Patient Identification Pilot Cost Management Strategy Data Audit Specialist Engagement – Commonly Defined Episodes of Care Office of the Health Insurance Commissioner

Small Practice Engagement Identification and Outreach Strategy to Non-PCMH Small Primary Care Practices Identify non-participating practices and to the extent possible, confirm their specific reason(s) for non-engagement. Among the identified practices, prioritize practices for transformation based on reason(s) for non- participation, and develop and implement a cooperative outreach strategy for engaging and supporting their practice transformation. Consider redrafting PCMH standards for non-participating small practices and develop eligibility criteria for the revised standards and develop strategies with CTC-RI and RIQI for supporting practices through this transformation.

Office of the Health Insurance Commissioner Primary Care APM Primary Care Alternative Payment Model & Clinical Processes Under Alternative Payment OHIC will convene a work group of insurers and interested primary care organizations in January 2017. The work group will begin by defining the principles and objectives for the payment model. The payment model design work will begin with service-based definitions of primary care and will include study of the CPC+ Track 2 Hybrid Model. Work to be completed by June 30th, 2017. Office of the Health Insurance Commissioner

Results of Year 1 PCMH Reporting Cost management strategies & clinical quality performance Office of the Health Insurance Commissioner

Office of the Health Insurance Commissioner Review of Data on Cost Management Strategies and Clinical Quality Performance Submission results: Cost strategy survey: 126 practices Quality data submission: 125 practices In comparison… CTC-RI: 81 practices RI primary care practice total (est.): 400-450 Office of the Health Insurance Commissioner

Attainment of 3-Part PCMH Definition Transformation Experience n Yes No None reported 4 Less than one year (Year 1) practice joined CTC on January 1, 2016; joined TCPI in 2016; or practice is not participating in any transformation initiative 16 10 6 One to two years (Year 2): practice joined CTC on January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition during 2015 30 Three or more years (Year 3): practice joined CTC prior to January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition prior to January 1, 2015 76 72 Total 126 116 Office of the Health Insurance Commissioner

Attainment of 80% Cost Management Strategy Threshold Transformation Experience n Yes No None reported 4 Less than one year (Year 1 ) practice joined CTC on January 1, 2016; joined TCPI in 2016; or practice is not participating in any transformation initiative 16 6 10 One to two years (Year 2): practice joined CTC on January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition during 2015 30 21 9 Three or more years (Year 3): practice joined CTC prior to January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition prior to January 1, 2015 76 73 3 Total 126 104 22 Note that only practices with three or more years of transformation experience were required to meet 80% threshold. Office of the Health Insurance Commissioner

Cost Management Strategy Data – Digging Deeper Office of the Health Insurance Commissioner

Cost Management Strategy Data – Digging Deeper Office of the Health Insurance Commissioner

Clinical Quality Performance Measures Adult practices required to submit the following 5 measures using clinical data specifications developed with CTC-RI: Adult BMI, Screening for Clinical Depression and Follow-up Plan, HbA1c Control (<8), Controlling High Blood Pressure, Tobacco Cessation Intervention Pediatric practices required to submit the following 4 measures using clinical data specifications developed with CTC-RI: Weight Assessment and Counseling for Nutrition and Physical Activity (3 sub measures), Developmental Screening All measures generally align with the SIM Aligned Measure Set, but are not identical. Office of the Health Insurance Commissioner

Clinical Quality Performance Improvement Requirement Beginning in 2017 The following methodology was finalized by a work group of the Care Transformation Advisory Group in April 2016: 3 percentage point improvement over one or two years or Performance at or above the national 66th percentile (average of HEDIS Medicaid (HMO) and commercial (PPO) values) or the state median (for non-HEDIS measures) The work group also recommended: Assessment of practical implications after a year of reporting Sub-analysis of FQHC performance with baseline data Office of the Health Insurance Commissioner

Clinical Quality Performance Measures: Baseline Data Analytical Plan Compare baseline rates to non-Rhode Island benchmarks: NCQA for HEDIS measures Rates from other states for non-HEDIS measures Compare CTC-RI and non-CTC-RI practices. Conduct a focused analysis of FQHC rates as recommended by the work group in April. Identify any potential data integrity concerns. Office of the Health Insurance Commissioner

Non-RI Benchmarks: HEDIS For the following HEDIS measures, we used an average of the National Commercial (PPO) and Medicaid (HMO) 66th percentile from NCQA’s 2016 Quality Compass product (CY2015 service period): Adult BMI Assessment Comprehensive Diabetes Care: HbA1c Control (<8.0) Controlling High Blood Pressure Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity (avg. of 3 components) Office of the Health Insurance Commissioner

Non-RI Benchmarks: Non-HEDIS For the non-HEDIS measures, we used the following: Developmental Screening in the First Three Years of Life Median rate of 9 states reporting using the Medicaid Child Core Set specifications (FFY 2014) Screening for Clinical Depression and Follow-Up Plan Oregon Medicaid Coordinated Care Organization (CCO) rate (CY 2015) Tobacco Use: Screening and Cessation Intervention Vermont commercial ACO rate (CY 2015) Office of the Health Insurance Commissioner

Non-RI Benchmark Rates Measure Category Measure Non-RI Benchmark Rate Adult Measures Adult BMI Assessment 81% Comprehensive Diabetes Care: HbA1c Control (<8.0) 53% Controlling High Blood Pressure 58% Screening for Clinical Depression and Follow-Up Plan* 37% Tobacco Use: Screening and Cessation Intervention* 89% Pediatric Measures Developmental Screening in the First Three Years of Life* 16% Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity 62% *Indicates a Non-HEDIS measure. Office of the Health Insurance Commissioner

Performance of Practices Submitting Data to OHIC Measure Category Measure Number of Practices Reporting (N) Practices Performing at or above Non-RI Benchmark Adult Measures Adult BMI Assessment 105 97% (n=102) Comprehensive Diabetes Care: HbA1c Control (<8.0) 89% (n=93) Controlling High Blood Pressure Screening for Clinical Depression and Follow-Up Plan 104 88% (n=91) Tobacco Use: Screening and Cessation Intervention 72% (n=75) Pediatric Measures Developmental Screening in the First Three Years of Life 21 90% (n=19) Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity 81% (n=17) Office of the Health Insurance Commissioner

CTC-RI Practice Performance Measure Category Measure CTC-RI Practices Non-CTC-RI Practices N Median Rate Adult Measures Adult BMI Assessment 68 99% 37 Comprehensive Diabetes Care: HbA1c Control (<8.0) 69% 66% Controlling High Blood Pressure 84% 88% Screening for Clinical Depression and Follow-Up Plan 80% 36 82% Tobacco Use: Screening and Cessation Intervention 95% 94% Pediatric Measures Developmental Screening in the First Three Years of Life 8 58% 13 83% Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity 92% Office of the Health Insurance Commissioner

Office of the Health Insurance Commissioner FQHC Performance Measure Category Measure FQHC Non-FQHC N Median Rate Adult Measures Adult BMI Assessment 22 98% 83 99% Comprehensive Diabetes Care: HbA1c Control (<8.0) 66% 71% Controlling High Blood Pressure 77% 87% Screening for Clinical Depression and Follow-Up Plan 83% 82 81% Tobacco Use: Screening and Cessation Intervention 92% 96% Note: Pediatric measures were excluded from this analysis because there were only two FHQCs that reported on the measures. Office of the Health Insurance Commissioner

Data Integrity Concerns Type of Concern Detail Aberrant Rates 1 practice submitted a rate that was greater than 100%. 9 practices submitted rates for a measure that were at or close to 0%. 27 practices submitted rates that were noticeably lower than the median rate for that measure. Aberrant Denominators 3 practices submitted data for a measure where the denominator was less than 30. 17 practices reported a denominator for “Adult BMI Assessment” that was noticeably different than that of “Tobacco Use: Screening and Cessation Intervention.” This is notable because the denominators for both of these measures should be similar. Other 2 practices submitted rates for both Adult and Pediatric measures, whereas 1 practice did not submit rates for any measures. Aberrant rates could be a result of a practice’s lack of familiarity with using an EHR to report on these measures, or with reporting on these measures entirely. There is no correlation between aberrant rates and a practice’s inclusion in CTC-RI. These rates will complicate OHIC’s ability to designate performance improvements in the next year. Office of the Health Insurance Commissioner

Questions & Discussion Office of the Health Insurance Commissioner