1. Pennsylvania Chronic Care Initiative Annual Summer Seminar School of Population Health George Valko M.D. Gustave and Valla Amsterdam Professor of Family and Community Medicine Vice-Chair for Clinical Programs Department of Family and Community Medicine

2. Pennsylvania Chronic Care Initiative I will discuss:  Origin of the PCCI  Plan  Rollout  Results  Future  A Sense of the Magnitude of the Initiative Why did Pennsylvania start this initiative? How we became involved Process of practice redesign and reporting Reports Reimbursements NCQA Recognition Process

3. Pennsylvania Chronic Care Initiative Governor Edward Rendell Creates the Office of Health Care Reform in 2003  Two Goals: oInsure All Pennsylvanians oChronic Care Reform

4. Pennsylvania Chronic Care Initiative Why Chronic Disease Care? oIncreasing Levels of Chronic Diseases

5. Pennsylvania Chronic Care Initiative Increasing Levels of Chronic Diseases

7. Pennsylvania Chronic Care Initiative Why Chronic Disease Care?  Increasing Levels of Chronic Diseases  Associated Costs Out of Control

8. Pennsylvania Chronic Care Initiative Associated Costs Out of Control

9. For 2007, it is projected that avoidable hospital admissions by chronic disease patients will top $4 billion in hospital charges – not counting emergency room visits

10. Pennsylvania Chronic Care Initiative Why Chronic Disease Care?  Increasing Levels of Chronic Diseases  Associated Costs Out of Control  Not Well Cared For at a Primary Care Level

11. Pennsylvania Chronic Care Initiative Not Well Cared For at a Primary Care Level

12. Current payment system fails to support or reward primary care practices for effective control of chronic diseases:

13. Pennsylvania Chronic Care Initiative Why Chronic Disease Care?  Increasing Levels of Chronic Diseases  Associated Costs Out of Control  Not Well Cared For at a Primary Care Level  Pennsylvania One of the Worst States

14. Pennsylvania Chronic Care Initiative Pennsylvania One of the Worst States Pennsylvania ranked 36 th – only 14 states were worse – based on avoidable hospital use and cost  Admission rates nearly three times higher than national average (15,000 avoidable hospitalizations per year)  Admission rates for asthma three times that of the best state (19,000 avoidable hospitalizations each year)  Admission rates for diabetes four times of the best-performing states (14,000 avoidable hospitalizations per year)

15. Pennsylvania Chronic Care Initiative Pennsylvania Chronic Care Management, Reimbursement and Cost Reduction Commission (Commission) Created by Executive Order in 2007 Pennsylvania is the first state to combine practice redesign with reimbursement redesign

16. Pennsylvania Chronic Care Initiative Why Reimbursement Redesign?  Patients with Primary Care Physicians (PCPs) have lower costs but PCPs are declining in numbers oLower reimbursements compared to non-PCP peers oLow satisfaction oFailing to attract new graduates

17. Pennsylvania Chronic Care Initiative The Commission developed a Strategic Plan to improve the quality of care and reduce avoidable illnesses and their attendant costs The Strategic Plan is based on a model which is an integration of the Wagner Chronic Care Model and the Patient Centered Medical Home

18. Pennsylvania Chronic Care Initiative Strategic Goals:  The widespread use of a new primary care reimbursement model  Broad dissemination of the CCM to primary care practices across Pennsylvania through regional chronic care learning collaboratives  Achievement of tangible and measurable improvement in the quality of care for chronically ill  Reduction in the cost of providing chronic care with the reduction of avoid hospitalizations and ED visits  Mechanisms to ensure that savings are realized by all entities paying for health care

19. Pennsylvania Chronic Care Initiative Incentives for the reimbursement redesign is based on the following:  Participation in the Learning Collaborative  Transform the practice by implementing the Chronic Care Model  Achieve NCQA Level (1,2,or 3) Recognition within 1 year

20. Pennsylvania Chronic Care Initiative Supporting Coalition  The Pennsylvania Primary Care Coalition oPA Academy of Family Physicians oPA Chapter of the American Academy of Pediatrics oPA Chapter of the American College of Physicians  The Robert Wood Johnson Foundation IPIP (Improving Performance in Practice) grantee in Pennsylvania

21. Pennsylvania Chronic Care Initiative Also on Board:  5 Payers oAetna oIBC oAmeriChoice oHealth Partners oKeystone Mercy o(NOT Medicare)  Pennsylvania is the convener; the insurance companies agreed to fund the initiative

22. Pennsylvania Chronic Care Initiative PCCI began rollouts in Southeast Pennsylvania (SEPA) in May 2008 Five Core Elements to be Implemented:  The establishment of primary care learning collaboratives and disease registries, as well as practice redesign and support  Insurer-provider incentives aligned with the Commission’s parameters  Insurer-consumer incentive realignment with Commission parameters  Community support resources  Measurement and evaluation

23. Pennsylvania Chronic Care Initiative SEPA Rollout Included:  33 Physician practices oFamily Medicine, Internal Medicine, Pediatrics, CRNP oRepresenting 165 clinician FTEs oServing 176,000 patients oCombination of independent practices and those affiliated with one of three academic systems oAlmost half have or implementing an EMR

24. Pennsylvania Chronic Care Initiative Evaluation of the program by the Commission will utilize standardized measure sets and performance goals for diabetes and asthma  These measures are based on national measures as defined by NCQA/HEDIS  Reviewed at the highest levels of the Government

25. Pennsylvania Chronic Care Initiative Mandatory Reporting Measures:  Count of all diabetics: o age 19-75 owho smoke owith latest HgbA1C > 9 (goal < 5%) owith latest BP 70%) owith latest LDL 70%) owith recent eye exam (goal > 80%) owith smoking cessation counseling (goal > 90%) owith medical attention to nephropathy (goal > 90%)

26. Pennsylvania Chronic Care Initiative Optional Reporting Measures:  Count of all diabetics: oage 55-75 with latest HgbA1C < 7 owith latest BP 140/90 (goal > 90%) oWith LDL 90%) owith >= 1 LDL owith annual foot exam (goal > 90%) owith flu vaccine oage 40-75 on aspirin owith self-management goal (goal > 90%) oage 55-75 on ACE/ARB owith pneumonia vaccine oon a statin oreferred for an eye exam oqueried about tobacco use owith >= 1 HgbA1C in past year

27. Pennsylvania Chronic Care Initiative In addition to the above measurements, each practice had to submit monthly, detailed progress reports and spread plans

28. Pennsylvania Chronic Care Initiative So Where Are We After Two Years?

29. Pennsylvania Chronic Care Initiative Current Status:  Seven Learning Collaboratives are in progress in all six regions of the state  Two more collaboratives are planned to begin this year  Existing collaboratives include 783 practitioners, 173 practices and 1.1 million patients  $30 million invested by insurers for practices to participate and attain benchmarks  Largest initiative of its kind in the nation  Preliminary results show that patients are healthier, doctors and other providers are energized, and costs are reduced  The Commonwealth Fund recently approved funding for RAND to conduct an evaluation of the initiative

30. Pennsylvania Chronic Care Initiative

40. The results look good – but is this reducing costs by keeping patients out of the ED and the hospital?  Preliminary reports – yes  Funding for 4 th year+?

41. Pennsylvania Chronic Care Initiative The Future is Now: new measures to be tracked:  ER visits  Hospitalizations  Cervical Screening  Colon Cancer Screening  Care Management Process o# of patients in CM highest risk registry o% of patients post hospital discharge receiving transition care within two days o% of patients in the CM registry with a care plan

42. Pennsylvania Chronic Care Initiative Lessons learned:  Well planned, well run program  This is hard work by all, but especially the clinicians  This takes lots of money  This takes lots of time  A two or three year long demonstration project is NOT enough time to show improvement