Purchaser and Health Plan Initiatives to Support Medical Home Development Don Liss, MD Regional Medical Director Aetna

Don Liss, MD 2 Why are Payers Involved? Frustrated by well established problems with our current delivery system –Cost, quality, access, satisfaction, … –Disorganized, uncoordinated, … Impending shortage of physicians in primary care specialties Appreciation that primary care is good Responsive to Customers

Don Liss, MD 3 How Health Plans and Purchasers are Getting Involved? Individual Health Plan Programs –Network wide efforts –Single practice or medical group efforts Multi-Stakeholder Programs –More complicated; require compromises Purchasers (Large Employers) –Asking about their health plan’s involvement –Demanding involvement

Don Liss, MD 4 Challenges for Health Plans There is no direct, compelling evidence demonstrating that PCMH will result in lower net medical costs –There is a body of literature supporting this conclusion, but it is indirect Collaborating in multi-stakeholder pilots surrenders a competitive advantage Customers differ in their interest Operational complexities in mechanics and accounting

Don Liss, MD 5 Patient Centered Medical Home Demonstration in Philadelphia Convened by the Pennsylvania Governor’s Office of Health Care Reform through the Chronic Care Commission as part of Gov. Rendell’s Rx for Pennsylvania Supported by all of the major health plans in Southeastern Pennsylvania –Aetna, Independence Blue Cross, Cigna –All 3 Medicaid plans Promoted by the primary care professional organizations (ACP, AAFP, AAP) and their PA affiliates

Don Liss, MD 6 How it works 32 Practices agree to transform into Patient Centered Medical Home practices –Participate in 4 Learning Collaborative sessions over 7 days Delivered by MacColl Institute under contract to GOHCR Learn to implement the Wagner Chronic Care Model –Use a patient registry for diabetes (adults) and asthma (peds) Intent is to expand to more conditions in the future –Engage with practice coaches from PA Improving Performance in Practice –Assistance with nuts-and-bolts of transformation to PCMH –Assistance with application for NCQA designation as PCMH –Achieve NCQA PPC PCMH designation at Level 1 by the end of first year

Don Liss, MD 7 What practices get Health Plans make enhanced payments to practices in addition to existing compensation –$20,095 (in the aggregate) per practice in year 1 for participating in Learning Collaborative, using registry and applying for NCQA designation –$35,000 to $80,000 per FTE physician (or NP) per year upon achievement of NCQA designation through year 3 Varies by practice size and PCMH Level achieved

Don Liss, MD 8 Some details GOHCR is the organizing entity –Establishes the schedule for enhanced payments –Monitors performance –Organizes/staffs Learning Collaborative –“invoices” health plans for enhanced payments due to practices Enhanced payments are allocated to participating health plans in direct proportion to their penetration in a given primary care practice 3 Year Commitment with intent to establish a common set of outcome measures to be used in a payment model in the future Formal evaluation to be conducted to assess clinical, financial, patient satisfaction/engagement and professional acceptance outcomes.