EmblemHealth Medical Home High Value Network Project William Rollow, MD MPH PCPCC Presentation December 2, 2008

Project Objectives To create a subnetwork of high performing FFS adult PCPs To position EmblemHealth as an innovative force with providers, purchasers, and the community To test ability of physician practices to become medical homes and resulting impact on quality, efficiency, and patient experience

Project Design $460,000 Commonwealth Fund grant to Ethel Donaghue Center for Translating Research Into Practice (TRIPP) at the University of Connecticut Evaluation questions – Can supported practices achieve medical homeness? – Does medical homeness result in high performance on quality, efficiency, and patient experience measures? Practices signing letter of commitment were randomly assigned to Supported or Comparison Group Groups will be compared at baseline, end of 2008, and end of 2009 on medical homeness and at end of 2009 on quality, efficiency, and patient experience measures

Supported v. Comparison Groups Both groups – Complete NCQA PPC-PCMH survey and supplementary questions to assess medical homeness – Report blood pressure values for diabetics and hypertensives using CPT codes on claims – Provide contact information on patients receiving services for purposes of telephonic and web-based patient experience survey Supported Group – Receives revised payment methodology (potential for 15% additional earning beyond FFS base payment) – Receives technical support for redesign and onsite care manager Comparison Group – Receives participation payment of $5000/year

Revised Payment Methodology FFS – no change in underlying payment P4P – opportunity for $2.50 pmpm award based on performance on: – Quality measures – Patient experience measures – Efficiency measure Care management fee – opportunity for $2.50 pmpm based on: – Medical homeness (three levels) – Risk level of patient population (three levels)

Quality Measures (HEDIS ) Process – Cervical cancer screening – Chlamydia screening – Mammography – Diabetic HbA1c testing – Diabetic lipid testing – Appropriate use of antibiotics for patients with bronchitis Outcomes – Diabetic HbA1c control – Diabetic lipid control – Diabetic blood pressure control – Hypertensive blood pressure control – CAD LDL control

Efficiency Measure Based on the percentage of savings that is achieved when actual costs for members are compared against projected costs based on prior year results, using either an episode- or population- based methodology Outlier patients will be removed, and hospital costs may also be excluded from individual scoring and included on the basis of performance for the entire Supported Group

Patient Experience Measures (CAHPS – Clinician) Overall satisfaction Accessibility Physician communication Self-care ability Measurement using telephonic and web-based surveys conducted by DocInsight

Medical Homeness PPC-PCMH used for study purposes For payment purposes – Must have EHR to get to payment level 2 or 3 – Can meet care management requirements for care management related to EmblemHealth-only patients

Redesign and Care Management Support Enhanced Care Initiatives (ECI) provides – Redesign facilitator who works with the practice on EHR adoption and redesign of appointment systems, electronic clinical information, e-prescribing, lab results and referrals tracking, etc – Onsite care manager who coordinates hospital and specialist care, arranges services needed for quality measures, develops care plans and supports patient self- management, etc

Current Project Status 38 practices recruited; 35 currently participating 8 NYC and surrounding counties Average size 3 physicians; average HIP/GHI membership 500 Supported group has largely met initial requirements; comparison group still has stragglers First performance measure results (quality, efficiency, patient experience) will be provided to practices in November to February

Challenges Recruitment PPC-PCMH submission Performance measurement Practice transformation Care management