1. Coordinated Care: What do Employers Want?

2. Agenda Lay of the Land: from the Purchaser Perspective Value-Based Purchasing Purchaser Expectations: the eValue8 Guide Patient Centered Medical Home

3. Pause for a simple question: What do all businesses want?

4. Purchaser: “A Day in the Life” Small Companies (Owner) –Healthcare: a necessary evil (or not!) –Broker-driven Medium Companies (HR) –Make me look good –Consultant Driven Large Companies (Health Benefits Pro) –Devoting staff to strategically manage the system

5. The Money Side: A Typical Financial Chart

6. CFO’s Concern Over Rising Healthcare Costs

7. Principal Motivator For Response to Rising Health Care Costs 2004 IBI Employer Survey – 620 Respondents

8. The Four Pillars of Value-Based Purchasing Performance Measurement Transparency and Public Reporting Payment Reform Informed Consumer Choice

9. eValue8: A Health Plan Assessment that Articulates Employer Expectations Do Plans Coordinate Care?

10. eValue8 Collaborators Centers for Disease Control (CDC) Centers for Medicare and Medicaid Services (CMS) Substance Abuse and Mental Health Services Administration (SAMHSA) Agency for Healthcare Research and Quality (AHRQ) National Committee on Quality Assurance (NCQA) Joint Commission for the Accreditation of Health Care Organizations (JCAHO) URAC eHealthInitiative (eHI) The Leapfrog Group Pennsylvania State University George Washington University

11. 2008 Evaluation Areas Profile: Collaboration/Accreditation/Disparities Consumer Engagement Provider Measurement Pharmaceutical Management Prevention & Health Promotion Chronic Disease Management –Cardiovascular Disease Management –Diabetes Management Behavioral Health

12. Provider Measurement Contracting Physician Referral Support Practitioner Performance Measurement –What is measured –What is reported back & benchmarked –Do the reports reach physicians representing a large % of members Practitioner Differentiation/Incentives –Types of measures used –Types of incentives (bonus, fees, plan design) Facility Performance Measurement Facility Differentiation/Incentives Centers of Excellence and High Performance Network

13. Expectation: Provider Measurement “This module assesses how the Plan measures, differentiates and rewards provider performance. Purchasers are also interested in how a plan recognizes and rewards superior provider performance (e.g., financial, benefit design that may include differential cost sharing or access to steer members to higher performing providers or public recognition).”

14. Consumer Engagement Provider Performance Transparency –Practitioners and/or Groups –Hospitals Shared Decision Making Support Claims and Financial Information Pharmaceutical Management CAHPS Ratings

15. Consumer Engagement Efforts to engage members more actively in managing their own care focus on two central areas: proactive personalized information sent to the member and comprehensive interactive decision support when a member is making treatment decisions. Maximum credit is awarded for sophisticated and ongoing efforts to proactively send members information based on knowledge gained via an HRA, PHR, medical management program, or claims data. Interactive decision support is most effective the more personalized it becomes and when it is made available directly on the Plan's website.

16. Prevention & Health Promotion Worksite Health Promotion Risk Factor –Education for children/parents –HRA content, use and reporting –Screening and risk calculators Screening: Immunizations, Cancer, Other Tobacco Use Obesity

17. Chronic Disease Management: Coordinated Care? Program Scope and Coordination Member Identification Member Support –Stratification –Interventions, especially outreach Practitioner Support –Member-specific reminders –Comparative reports Performance Measurement –HEDIS –Non-HEDIS

18. Chronic Disease Management: Coordinated Care? “It is expected that disease management programs facilitate coordination of care beyond the specific individual disease state. Each program should include coordination of care across comorbid conditions, depression, alcohol and tobacco screening for members, and inclusion of pharmacy expertise.”

19. Expectations : Interventions

20. Expectations: Triggers

21. Expectations : Support

22. Expectations: Verify

23. Chronic Disease 2009

25. Medical Home Employers Support Health Plan Pilots of the Patient- Centered Medical Home MBGH conducted a survey in September, 2009 to better understand employer views on the "patient- centered medical home (PCMH)," a model of care that relies on physicians partnering with patients and guiding them through the health care maze. Care coordination is the core of this model to obtain optimal integrated care for each individual. The PCMH would offer continuous communication and quality information systems to deliver more efficient and improved care.

26. Medical Home The survey received 35 responses and the findings revealed that employers support health plan pilots of the patient-centered medical home. 70% of employers support health plans giving a higher payment to a medical group that is structured or accredited as a Medical Home 67% of employers would encourage their companies to participate in a PCMH pilot sponsored by a health plan 17% of employers would participate as a plan sponsor if a patient-centered medical home pilot were available in Illinois; 48% would participate as patients

27. Patient-Centered Medical Home (Plan Level) Practice Requirements Payment and Practice Support Consumer Support: directory Evaluation

28. Practice Capabilities At the time of an office visit, member- specific gaps in care are identified for members needing preventive and chronic care services enabling them to be addressed at the visit. For members who do not schedule a visit, but have gaps in care, there is an outbound mechanism to remind them (e.g., IVR, mail, care manager calls, e-mail, etc.)

29. Practice Capabilities e-Prescribing Office computer and/or PDA is present with ePrescribing software Member plan design-specific formulary resides on the computer/PDA Identifies generically equivalent drugs Directly or through integration with global software supports evaluation of clinical alternatives Accesses the member’s pharmacy history and automatically checks for duplication, conflicts, etc Is integrated with the EHR and automatically cross-references medical history, lab results, etc. Calculates member out-of-pocket costs for alternative choices of prescriptions Transmits paperless prescription directly to pharmacies or electronic “hub” Receives and integrates into the EHR

30. Practice Capabilities How is care management handled by the designated practices? Nurse or other clinical personnel are dedicated to care management Non-clinical resources are the primary personnel dedicated to care management Personnel resources are employee by each practice individually Personnel resources are shared among practices. The Plan provides personnel resources that can be shared by the practices. Use of personnel (shared or not) dedicated to care management is a requirement of PCMH designation.

31. Consumer Incentives (Plan) Agreement with employer on waived or decreased premium share for use of the medical home Waived or decreased co-payments/deductibles for use of the medical home - Office visits Waived or decreased co-payments/deductibles for use of the medical home - Pharmaceuticals for chronic condition Waived or decreased co-payments/deductibles for use of the medical home - Tests recommended for chronic conditions, etc. Waived or decreased co-payments/deductibles for reaching biometric goals (e.g., BMI level or change, HbA1c improvement or levels, etc.) Waived or decreased co-payments/deductibles for enrollment or affiliation with a medical home in non-HMO products Waived or decreased co-payments/deductibles for use of selected chronic care medications Incentives to adhere to evidence-based self-management guidelines Incentives to adhere to recommended care coordination encounters

32. Consumer Support (Practice) Evidenced-based shared decision tools (e.g. Health Dialog, Healthwise Decision Points) Specialist Performance Reports Hospital Performance Reports Electronic Personal Health Record Reminders about Gaps in Preventive Care Reminders about gaps in Rx fills Reminders about non-Rx gaps in management of chronic conditions Web-based consultations E-mail with physician office

33. Evaluation Evidence-based processes of preventive care Evidence-based processes of chronic care Evidence-based outcomes of chronic care (including experience of care measures) Utilization of services Cost Primary care practice organization and care delivery Primary care clinician experience

34. NCQA Medical Home Clinically Important Conditions The most patients The most visits The greatest costs The best likelihood of being amenable to care management.

35. NCQA Medical Home PPC 1: Access and Communication PPC 2: Patient Tracking and Registry Functions PPC 3: Care Management PPC 4: Patient Self-Management Support PPC 5: Electronic Prescribing PPC 6: Test Tracking PPC 7: Referral Tracking PPC 8: Performance Reporting and Improvement PPC 9: Advanced Electronic Communications

36. What do Employers Want? Evidence-based, cost-effective care. Questions?