1. CTC Total COST of CARE UPDATE
CTC versus Comparison Practices
by Cohort and Payer Type
6/24/2016

2. Cost Measures for Today
CTC Cohorts 1 & 2 versus comparison
Stratifications by payer type
Commercial
Medicare FFS
Medicare Advantage
Rhody Health Partners
Breakouts by service type
Inpatient
Outpatient
Professional Services
Pharmacy

3. CTC Multi-payer, Multi-year Dataset
RI covered lives (residents and nonresidents)
Data from three plans (NHP, United Healthcare, BC&BS-RI)
Data from RI EOHHS (Medicaid)
Date from CMS (Medicare FFS beneficiaries)
Utilization: through June 2015
Expenditures: 2011 through June 2015
Adults only (claims for kids received but not used)
Non-residents excluded (by RTI) if they receive primary care services out of state
Unlike the APCD, identifiers are specific to each payer (crossovers appear as multiple individuals)
Some claims are excluded
Pharmacy and substance abuse claims for Medicare FFS data
Wrap-around claims for Medicaid

4. Profile of Data (Adults), 7/2014 ‒ 6/2015 (in thousands)
Total1
All CTC practices
Other Medical Homes
Comparison practices
Attributed outside RI
Unattributed
Persons2
827
226
107
216 23
255
Member years3
622
179 88
173 18
164
1 Includes data from UHC, NHP, BCBS-RI, Medicare FFS, Medicaid FFS.
2 Each member is counted the percent of time they were in each group with their total time adding to one person.
3 Each member is counted in only one group per month based on attribution for that month.

5. CTC Cohort 1: 15 practice sites
Blackstone Valley Community Health Care, Inc.
Coastal Medical, Inc. - Greenville
Coastal Medical, Inc. - Hillside
Coastal Medical, Inc. - Narragansett
Coastal Medical, Inc. - Wakefield
Family Health and Sports Medicine
Kristine Cuniff
Memorial Hospital Family Care Center
South County Hospital Family Medicine
South County Internal Medicine
Stuart Demirs
Thundermist CHC - Wakefield
Thundermist CHC - Woonsocket
University Family Medicine
University Medicine - Governor Street Primary Care

6. CTC Cohort 2: 21 practice sites
Anchor Medical Associates - Lincoln
Anchor Medical Associates - Providence
Anchor Medical Associates - Warwick
Aquidneck Medical Associates - Newport
Aquidneck Medical Associates - Portsmouth
Associates in Primary Care Medicine
East Bay Community Action Program - East Providence
East Bay Community Action Program - Newport
Medical Associates of RI - Bristol
Medical Associates of RI - East Providence
Ocean State Medical, LLC
Tri Town Community Action Program
University Internal Medicine
University Medicine North Main Street
University Medicine - Barrington
University Medicine - East Ave
University Medicine - Plain Street
University Medicine - Warwick Family Medicine
WellOne Primary Medicine - Foster
WellOne Primary Medicine - North Kingstown
WellOne Primary Medicine - Pascoag

7. CTC Cohort 3: 12 practice sites
Affinity Physicians Family Medicine – Pawtucket
Comprehensive Community Action Program - Family Health Services of Coventry
Comprehensive Community Action Program - Family Health Services of Cranston
Comprehensive Community Action Program - Wilcox Health Center
Internal Medicine Center
Internal Medicine Partners
Nardone Medical Associates
Richard M Del Sesto
South County Walk-in & Primary Care
Thundermist CHC - West Warwick
Women's Primary Care, Women's Medicine Collaborative
WoodRiver Health Services

8. Statewide: Raw Total Quarterly $PMPM with Rolling Year Trend Line

9. TCOC Service Categories
Inpatient: overnight stay in the hospital, either non-acute or acute submitted on a CMS 1450 claim form.
Outpatient: all non-inpatient claims submitted on CMS 1450 forms (without a room and board revenue code).
Professional: claims submitted on a CMS 1500 form and place of service is either non-facility or facility.
Pharmacy: pharmacy claims.
Source:

10. Methodologies Measure is dollars per member per month ($PMPM)
Using all costs instead of a subset (utilizations measures have exclusions)
Variations of each cost metric are calculated
Raw costs (based on allowed amounts, capped at $100K, inflation adjusted to 2015 dollars)
Risk-adjusted costs
Risk adjustment
RTI method containing health status (HCC score), age, and gender
Health status measure used for health insurance exchanges

11. Assumptions Comparison group is thought to represent secular trends.
A standard risk-adjustment methodology across all payer types is sufficient and allows for meaningful comparisons.
Attribution method is sufficiently accurate.
Price adjustment within payer type would not change the estimates materially.
Medical homes might increase some services (e.g., office visits) in an effort to decrease unnecessary hospital services.
During this period ( ) medical homes were sufficiently developed to affect costs; but CTC is only part of an effort to transform care and reduce costs.

12. Limitations Attributing people to practice sites is imperfect.
Some attribution bias in 2011 for commercial payers
Consistent with plan payments
Assigned PCPs might not be actual PCPs
Results are sensitive to sample sizes.
Changes in monthly amounts are relatively small.
Secular trends affect the metrics.
Risk-adjustment is the same for all payer types; it could be customized for each payer type.

13. RHP: 7/2014 ‒ 6/2015 Demographics CTC Cohort 1 Cohort 2 Comparison
Members
2,807
2,143
6,183
Member months*
26,301
18,890
57,570
% Male 40 45 44
Mean age 46
Mean HCC score (member quarters)
4.2
4.4
4.5
*Member months with Rx coverage were imputed to be the same as medical member months if the member had no Rx coverage.

14. RHP Cohort 1: Raw Total Quarterly $PMPM with Rolling Year Trend Line

15. RHP Cohort 1: Adjusted Total Quarterly $PMPM with Rolling Year Trend Line

16. RHP Cohort 1: 7/2014-6/2015 Raw and Adjusted $PMPM
CTC Cohort 1
(N=2,807 members)
Comparison
(N=6,183 members)
Differences
Raw
Risk Adj.
Inpatient
145
187
188
(42)
(43)
Outpatient
211
215
223
232
(12)
(16)
Prof. Serv.
162
159
165
(3)
Pharmacy
239
238
302
325
(63)
(87)
Total
757
758
878
908
(121)
(150)
Add calculations

17. RHP Cohort 2: Raw Total Quarterly $PMPM with Rolling Year Trend Line

18. RHP Cohort 2: Adjusted Quarterly $PMPM with Rolling Year Trend Line

19. RHP Cohort 2: 7/2014-6/2015 Raw and Adjusted $PMPM
CTC Cohort 2
(N=2,143 members)
Comparison
(N=6,183 members)
Differences
Raw
Risk Adj.
Inpatient
196
195
187
188 9 7
Outpatient
205
199
223
232
(18)
(33)
Prof. Serv.
185
180
165
162 20 18
Pharmacy
287
294
302
325
(15)
(31)
Total
873
869
878
908
(5)
(39)
Add calculations

20. Summary: Rhody Health Partners
Cohort 1 demographics and average risk score are slightly different from the comparison group.
Total cost are lower in recent quarters for PCMHs.
Cohort 1 has about a $150 lower raw and risk-adjusted total costs. This is largely driven by pharmacy costs.
Cohort 2 has slightly lower costs (about $40).
Small sample sizes for this group.
Attribution is based on PCP visited or (in case of no visits) assigned PCP.

21. Commercial: 7/2014 ‒ 6/2015 Demographics
CTC
Cohort 1
Cohort 2
Comparison
Members
34,821
45,098
121,580
Member months*
342,124
445,062
1,138,899
% Male 43 49
Mean age 46 47 45
Mean HCC score (member quarters)
1.9
2.1
2.0
*Member months with Rx coverage were imputed to be the same as medical member months if the member had no Rx coverage.

22. Commercial Cohort 1: Raw Total Quarterly $PMPM with Rolling Year Trend Line

23. Commercial Cohort 1: Adjusted Total Quarterly $PMPM with Rolling Year Trend Line

24. Commercial Cohort 1: 7/2014-6/2015 Raw and Adjusted $PMPM
CTC Cohort 1
(N=34,821 members)
Comparison
(N=121,580 members)
Differences
Raw
Risk Adj.
Inpatient 76 57 79 78
(3)
(21)
Outpatient
128
130
131
(2)
Prof. Serv.
159
157
154
152 5
Pharmacy
121
125
126
(5)
Total
484
467
488
489
(4)
(22)
Add calculations

25. Commercial Cohort 2: Raw Total Quarterly $PMPM with Rolling Year Trend Line

26. Commercial Cohort 2: Adjusted Quarterly $PMPM with Rolling Year Trend Line

27. Commercial Cohort 2: 7/2014-6/2015 Raw and Adjusted $PMPM
CTC Cohort 2
(N=45,098 members)
Comparison
(N=121,580 members)
Differences
Raw
Risk Adj.
Inpatient 77 78 79
(2)
(1)
Outpatient
137
136
130
131 7 6
Prof. Serv.
165
163
154
152 11
Pharmacy
126
128 2
Total
504
508
488
489 16 18
Add calculations

28. Summary: Commercial
Cohort 1 demographics and average risk score are similar to the comparison group.
Slightly lower total costs (about $20) for Cohort 1 in the most recent year.
Slightly higher total costs (about $20) for Cohort 2 in the most recent year.
We do not know the extent to which the comparison practices act like medical homes.

29. Medicare Advantage: 7/2014 ‒ 6/2015 Demographics
CTC
Cohort 1
Cohort 2
Comparison
Members
6,812
10,187
28,699
Member months*
63,594
97,316
268,483
% Male 41 40 44
Mean age 72 73
Mean HCC score (member quarters)
4.0
4.1
4.4
*Member months with Rx coverage were imputed to be the same as medical member months if the member had no Rx coverage.

30. Medicare Advantage Cohort 1: Raw Total Quarterly $PMPM with Rolling Year Trend Line

31. Medicare Advantage Cohort 1: Adjusted Total Quarterly $PMPM with Rolling Year Trend Line

32. Medicare Advantage Cohort 1: 7/2014-6/2015 Raw and Adjusted $PMPM
CTC Cohort 1
(N=6,812 members)
Comparison
(N=28,699 members)
Differences
Raw
Risk Adj.
Inpatient
143
144
155
(12)
(11)
Outpatient
123
118
(5)
Prof. Serv.
197
195
193
190 4 5
Pharmacy
181
199
165
169 16 30
Total
645
656
637
636 8 20
Add calculations

33. Medicare Advantage Cohort 2: Raw Total Quarterly $PMPM with Rolling Year Trend Line

34. Medicare Advantage Cohort 2: Adjusted Total Quarterly $PMPM with Rolling Year Trend Line

35. Medicare Advantage Cohort 2: 7/2014 ‒ 6/2015 Raw and Adjusted $PMPM
CTC Cohort 2
(N=10,187 members)
Comparison
(N=28,699 members)
Differences
Raw
Risk Adj.
Inpatient
156
157
155 1 2
Outpatient
117
115
123
(6)
(8)
Prof. Serv.
193
190
Pharmacy
165
159
169
(10)
Total
632
620
637
636
(5)
(16)
Add calculations

36. Summary: Medicare Advantage
Cohort 2 demographics and average risk score are slightly different from the comparison group.
Slightly higher total costs (about $20) for Cohort 1 in the most recent year.
Slightly lower total costs (about $20) for Cohort 2 in the most recent year.
Small differences in the individual cost components.

37. Medicare FFS: 2014 Demographics
CTC
Cohort 1
Cohort 2
Comparison
Members
7,006
9,434
24,281
Member months*
39,548
53,743
136,931
% Male 42 44 46
Mean age 71 72
Mean HCC score (member quarters)
4.5
4.7
5.0
*Member months with Rx coverage were imputed to be the same as medical member months if the member had no Rx coverage.

38. Medicare FFS Cohort 1: Raw Total Quarterly $PMPM with Rolling Year Trend Line

39. Medicare FFS Cohort 1: Adjusted Total Quarterly $PMPM with Rolling Year Trend Line

40. Medicare FFS Cohort 1: 2014 Raw and Adjusted $PMPM
CTC Cohort 1
(N=7,514 members)
Comparison
(N=27,391 members)
Differences
Raw
Risk Adj.
Inpatient
177
173
205
207
(28)
(34)
Outpatient
165
167
163
164 2 3
Prof. Serv.
285
286
289
292
(4)
(6)
Pharmacy -
Total
627
625
657
663
(30)
(38)
Add calculations

41. Medicare FFS Cohort 2: Raw Total Quarterly $PMPM with Rolling Year Trend Line

42. Medicare FFS Cohort 2: Adjusted Total Quarterly $PMPM with Rolling Year Trend Line

43. Medicare FFS Cohort 2: 2014 Raw and Adjusted $PMPM
CTC Cohort 2
(N=10,168 members)
Comparison
(N=27,391 members)
Differences
Raw
Risk Adj.
Inpatient
193
190
205
207
(12)
(17)
Outpatient
153
152
163
164
(10)
Prof. Serv.
272
270
289
292
Pharmacy -
Total
618
612
657
663
(39)
(51)
Add calculations

44. Summary: Medicare FFS
Demographics and average risk score are slightly different from the comparison group.
Favorable trend for Cohort 1 with costs higher initially and lower in the most recent year. Inpatient costs lower
Cohort 2 had lower costs throughout the period; less so in the most recent year. All cost components slightly lower.

45. Summary of Cost Differences (7/2014 – 6/2015; 2014 for Medicare FFS)
Member Months
$PMPM Cost differences
Annual Cost Differences
Cohort 1
Cohort 2
RHP
26,301
18,890
$ (150)
$ (39)
$ (3,945,150)
$ (736,710)
Commercial
342,124
445,062
$ (22) $
$ (7,526,728)
$ 8,011,116
Medicare Adv.
63,594
97,316 $
$ (16)
$ ,271,880
$ (1,557,056)
Medicare FFS
39,548
53,743
$ (38)
$ (51)
$ (1,502,824)
$ (2,740,893)
$ (11,702,822)
$ 2,976,457