The Rhode Island Chronic Care Sustainability Initiative: Translating the Medical Home Principles into a Payment Pilot Deidre Spelliscy Gifford, MD, MPH Lynn Pezzullo, RPh Quality Partners of Rhode Island

Rhode Island Health Care Landscape 1 million population 200,000 Medicaid beneficiaries 10% (100,000) uninsured 20 Community Health Centers serving 10% of the population Two dominant commercial Health Plans – Blue Cross Blue Shield of Rhode Island – United HealthCare of New England One Medicaid-only plan – Neighborhood Health Plan of RI

Rhode Island Health Care Landscape State Government is largest employer Few large, self-insured employers Market dominated by many small business purchasers Employer-based insurance coverage eroding

Genesis of Program: National Issues Data on rising costs of care and gaps/variations in quality Need to offer alternatives to the SGR Pay for Performance limitations & consequences Workforce trends showing a marked decline in physicians going into general IM and primary care Increase in numbers of patients with chronic diseases Evidence that care coordinated by a personal physician is associated with better outcomes, especially for chronic disease Purchasers’ demands for accountability and transparency (Courtesy of Michael Barr, MD, MBA and ACP)

Genesis of Program: Local factors State interest in primary care sustainability: – Governor’s initiative in “balanced healthcare” – Medicaid interest in developing primary care infrastructure and reducing costs for chronic disease Provider/consumer “dissatisfaction” Existing multi-stakeholder collaboration Existing practice assistance infrastructure Funding Opportunity: Center for Healthcare Strategies’ “Regional Quality Initiative”

What is CSI Rhode Island? A statewide, multi-stakeholder collaborative effort designed to: – Align quality improvement goals and financial incentives among Rhode Island’s health plans, purchasers and providers, in order to develop and support a sustainable model for the delivery of chronic illness care in primary care settings. – Enhance payment to primary care providers for the delivery of high quality chronic illness care.

CSI Rhode Island – Underlying Principles Improving chronic illness care requires re-design of the delivery system (i.e., the Patient-Centered Medical Home) Delivery systems (i.e., CHCs, physician offices, hospital clinics, etc.) are subject to incentives and disincentives from multiple different sources For successful delivery system change, incentives and disincentives aimed at the provider must be aligned

Why An All-Payer Initiative? Improved Quality, Reduced Costs, Stronger Primary Care Fundamental Changes in Care Delivery (The PCMH) Investment in New Delivery Systems at the Practice Level (not at Health plan or Provider level)

Building the Payment Pilot: Process and Timeline Agree to terms of contract amendments Agree on Payment Identify Costs to Providers and Payers Identify Services, Conditions and Measures Convene Stakeholders July 2006 Sept. 2008

Participants in CSI Rhode Island Payers (representing 67% of insured residents) Medicaid; all RI-based commercial payers (Blue Cross & Blue Shield of Rhode Island, Neighborhood Health Plan of Rhode Island, United HealthCare – New England) Purchasers (including 70,000 self-insured residents) The two largest private sector employers (Care New England, Lifespan) Rhode Island Medicaid, State Employees - health benefits program, Rhode Island Business Group on Health Providers Largest primary care provider organizations (including Community Health Centers and hospital based clinics), Rhode Island Medical Society, RI AAFP, RI ACP State Office of the Health Insurance Commissioner, Department of Human Services, Department of Health, Economic Development Corporation Technical Experts Department of Health; Quality Improvement Organization

Convening Stakeholders: Barriers and Opportunities Barriers – Large national payers have little incentive to participate in regional or state-level programs – Payers fear losing competitive advantage – Payers not accustomed to collaborating with other plans – Anti-trust concerns – Medicaid and commercial plans often not aligned – Lack of trust between payers and providers – Competing programs and priorities

Convening Stakeholders: Barriers and Opportunities Opportunities: – Engage major purchasers as advocates – Engage regulatory/government entities – Involve consumers as advocates – Educate stakeholders regarding need for delivery system-level reform – Participate in national PCMH efforts – Focus on common goals:  reduce overall costs of care;  improve quality and access;  strengthen primary care

How do you build an All-Payer Initiative? Elements of the CSI RI Pilot Common Practice Sites All payers will select the same core group of practice sites in which to administer their pilot. Requires common set of practice qualifications. Common Measures All payers will agree to assess practices using the same measures, drawn from national measurement sets. Common Services All payers will agree to ask the pilot sites to implement the same set of new clinical services, drawn from the PCMH Principles. Common Conditions Pilot sites will not be asked by payers to focus improvement efforts on different chronic conditions Consistent Payment Method and intent of incentive payments will be consistent across all payers

Principles of the Patient Centered Medical Home - AAP, AAFP, ACP, AOA March 2007 Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated Quality and safety Enhanced access to care Payment to support the PC-MH

Implementing the PCMH: Where to start? The CSI “Key Services” 1.Ability to identify patients belonging to a particular PCP 2.Care Coordination/ Case Management Planned visits Care coordination agreements with specialist providers outside the office Care from practice team in the office Integrate specialist expertise and primary care (i.e., integrated behavioral health) Form partnerships with community organizations to support gaps in care and encourage patients to use their services

Implementing the PCMH: Where to start? The CSI “Key Services” 3.Self-management support Group visits 4.EHR or registry that provides: Prompts to providers on indicated care Ability to generate follow-up reminders to patients Identify relevant sub-populations for proactive care (exception reporting) Ability to monitor practices performance on (CSI) quality measures E-prescribing Remote access to problem/med list for covering doctors

Implementing the PCMH: Where to start? The CSI “Key Services” 5.Care based on evidence-based guidelines embedded into daily clinical practice Share evidence based guidelines and information with patients to encourage participation 6.Enhanced Access to Care (two of the following): Evening, weekend, holiday appointments Open access scheduling visit/consult with provider Telephone follow up for patients with chronic illness regarding results, self-management, etc. Answering machine/service after hours to non- ER options

Care Management Activities: CSI Nurse Care Manager Located within practices: Provides services to ALL patients, regardless of payer Provided through cash payments from health plans Care Manager “college:” Collaboration of NCMs across sites and with Medicaid NCMs Activities: Initial patient assessment Risk stratify severity of chronic illnesses Maintain registry/generate reports Gather and maintain educational information Education of patient on disease and treatment Monitor quality measures Access health plan resources

Identification of Conditions: Prevalence, Cost, Ability to Impact  Coronary artery disease  Diabetes mellitus  Depression  (Pediatric asthma)

Clinical Measures: Consistent with existing programs and drawn from national measure sets Coronary Artery Disease β-blocker therapy  % of patients >35 y.o. with prior MI who were prescribed β- blocker in previous year Depression Depression screening  % of patients > 18 y.o. screened annually for depression Antidepressant medication  % of patients > 18 y.o. with new dx of MDD with documentation of tx for full 84 days

Clinical Measures (cont.) Diabetes A1c control  % of diabetics with most recent Hgb A1c < 9.0% BP control  % of diabetics with most recent BP < 140/80 LDL control  % of diabetics with most recent LDL < 100 Eye exam  % of diabetics with dilated eye exam in past year All Smoking cessation  % of smokers who received advice in the past year

Structural Measures: NCQA’s “Physician Practice Connections: (PPC – PCMH) Tool At the beginning and end of the pilot, practices will take the PPC PCMH assessment to judge progress on adoption of Key Services PPC Recognition process funded by outside evaluators PPC Recognition NOT required prior to dollars flowing (LI recognition required by 9 months into pilot)

CSI-RI Evaluation – Overview 1.Conducted by 3 rd party: Harvard School of Public Health 2.Funded by Commonwealth 3.Will look for: Evidence that the organizations providing care adopt components of the patient-centered medical home model Evidence that the intervention has an impact on patients, including changes in care processes, outcomes and experiences of care Evidence that the intervention is associated with changes in the cost of care Qualitative information on experience of PCMH adoption

Scope of the CSI Program  5 pilot practices  29,000 patients  28 physician FTE’s  Private practices, University faculty practice, community health center  All patients except FFS Medicare  Training for participating practices and care management teams through RI Chronic Care Collaborative  Duration – 2 years

Payment Methodology  Current FFS model remains in place  Monthly $3 per member per month fee to each practice for enhanced PCMH services, plus cash to support Care Managers  Plans and providers agree to attribution methodology  No clinical performance incentives

CSI RI Approach to Payment Be transparent Share as much information as possible across stakeholders Put objective assessment of costs on the table (developed by CSI members based on local market conditions) Develop Key Services “roll out” consistent with $ being offered by payers Focus on non-monetary benefits to providers (training, enhanced efficiency, etc.)

CSI Major “Reconciliation” Issues $$ being offered by plans lower than cost estimates by providers, but still significant investment in practices Need to develop a consistent patient-PCP attribution methodology across payers (low managed care penetration in RI) How to organize non-monetary practice supports (i.e., care management) across payers Agreement on consistent measures of PCMH implementation (e.g., Physician Practice Connection measures from NCQA)

Deidre S. Gifford, MD, MPH

CSI Key Services: How do they compare? PCMH PrinciplesPPC “Must Pass” Elements CSI Key Services Personal PhysicianIdentify provider panels; regularly reconcile with plans Physician-directed care Care coordination/integrationTest/referral tracking follow- up Provide care management services: co-location, planned visits, community resources, group visits Whole person orientation Actively support patient self-management Provide self-management support Share guidelines with patients

CSI Key Services: How do they compare? PCMH PrinciplesPPC “Must Pass” Elements CSI Key Services Quality and safetyAdopt and implement guidelines for 3 conditions Organize clinical data Use data to identify important conditions Measure performance and report Use EHR/registry to integrate guidelines, identify patients out of compliance, prompt care Generate reports eRx Remote access Enhanced access Written standards for access and Communication Access and Communication results Select one of 4 options for enhancing access Payment FFS plus PMPM fee

Engaging Consumers Public disclosure Consumer Education Shared Data & Performance Measurement Aligning Financing/ Insurance Benefits promote cost/effectiveness Performance Incentives Leadership Improved Quality & Reduced Costs McColl Institute at Group Health Informed, Activated Consumers Motivated, Prepared Practices Improving Healthcare Delivery IT Connectivity & Support QI Models & Activities Consensus Guidelines Care Management Provider Networks Supportive Insurance & Payment Transformed Healthcare Delivery STAKEHOLDER COLLABORATION

Common Services: The CSI RI “Key Services” 4.EHR or Electronic Disease Registry Specified functionality to support care management 5.Evidence-based guidelines embedded in clinical practice 6.Enhanced Access to Care Choice of several methods

Common Services: The CSI RI “Key Services” 1.Link patients to providers Mutual agreement between providers and payers 2.Care Coordination/Case Management Planned visits, co-location or coordination with specialists, links to community resources, enhanced care team 3.Self-Management Support Group Visits

What’s the “Right” PMPM? It Depends Variables: Cover all costs, plus some increased income for providers? Pay all practices the same, despite differences in prior investments? What about FFS Medicare? What about differences in case mix by provider? Account for practice assistance provided by payers? What is projected ROI for payers?

CSI Next Steps: Each plan developing contract amendments based on CSI Key Services and Measures, national PCMH model, and local factors Contract amendments to be shared with group?????? “Reconciliation” of each payer’s proposal to form a consistent CSI pilot Start date: Early 2008