1. PCPCC Center for Multi-payer Demonstrations
The Rhode Island Chronic Care Sustainability Initiative: A Multi-payer Demonstration of the Patient-Centered Medical Home
Presented to:
PCPCC Center for Multi-payer Demonstrations
March 2, 2010
Deidre S. Gifford, MD, MPH
Health Progress
Project Director

2. Overview Key Program Elements: Results to date Future plans
Oversight and Governance
Participants
Contract/pilot program
Practice Responsibilities
Plan Responsibilities
Collaborative Responsibilities
Results to date
Future plans

3. CSI Oversight and Governance:
Developed, implemented, monitored and governed by a statewide, multi-stakeholder collaborative
Convened by Health Insurance Commissioner
Collaborative includes payers, purchasers, providers, state, technical experts
Convening infrastructure initially grant-funded, now funded by plans

4. Key Elements of Program: Oversight and Governance
Conveners invited original participants (2006)
Leaders from primary care community and largest employers invited to participate in collaborative
Common Contract elements negotiated in public by collaborative
Decisions by consensus with rare votes
Transparency to build trust

5. CSI Steering Committee (OHIC, Collaborative Members)
CSI Management
(Health Progress)
CSI Steering Committee
(OHIC, Collaborative Members)
CSI Medical Home Pilot Sites
Data, Reporting and Evaluation Committee
Governance and Sustainability Committee
Communications and Stakeholder Engagement Committee
Practice Training and Support Committee
South County Hospital Patient- Centered Medical Community
Program Evaluation (CMWF and Harvard School of Public Health)

6. Key Elements of Program: Participating Payers
All commercial payers in Rhode Island
UHC New England
BCBS Rhode Island
Tufts Health Plan
Medicaid FFS* and Managed Care
Neighborhood Health Plan of Rhode Island
All commercial product lines, including Medicare Advantage and ASO
In total: 67% of insured in RI
*some contract variations

7. Key Program Elements: Practices and Patients
Phase 1:
Oct – Sept. 2010
Phase 2:
April 2010 – March 2012
Total
Number of Practices 5 8 13
Number of Patients covered by PMPM
24,279
21,791
46,070
Total patients in pilot practices (includes estimated FFS Medicare)
30,348
27,238
57,586
Number of Providers 28 35 63

8. Key program elements: What constitutes an all-payer initiative?
Common Practice Sites
All payers will select the same core group of practice sites in which to administer their pilot. Requires common set of practice qualifications.
Common Services
All payers will agree to ask the pilot sites to implement the same set of new clinical services, drawn from the PCMH Principles.
Common Conditions
Pilot sites will not be asked by payers to focus improvement efforts on different chronic conditions
Common Measures
All payers will agree to assess practices using the same measures, drawn from national measurement sets.
Consistent Payment
Method and intent of incentive payments
will be consistent across all payers

9. Key program elements: Contracts
Practice responsibilities:
Achieve Level 1 NCQA recognition by 9 months into pilot
Level 2 NCQA by 18 months
Report clinical quality measures from EMR/registry in 3 conditions beginning Q2 of pilot
Participate in training collaborative
Hire and utilize nurse care manager

10. Key program elements: Contracts
Plan responsibilities:
Attribution of patients to practices
Pay $3 PMPM for all members
Provide salary and benefits for NCMs
Provide data and feedback on utilization
Support project infrastructure

11. Key program elements: Contracts
Attribution:
24 month look back
Patient attributed to last PCP seen in 24 month period
Patient must be active plan member at time of attribution
Calculated quarterly: no payment adjustments unless >10% change

12. Key program elements: Clinical Conditions
Based on RI – specific prevalence, cost and utilization
Employer input
Adults with:
Diabetes
Coronary artery disease
Depression

13. Key program elements: Practice reporting
Practices report quarterly:
CAD: Beta blocker post MI
CAD: Smoking cessation counseling
Diabetes: Hgb A1c control
Diabetes: BP control
Depression: Annual screen for all adults

14. Key program elements: Health plan reporting (Q1 2010)
Inpatient (excluding mental health and substance abuse and maternity and delivery)
Inpatient admissions per 1000
Inpatient days per 1000
Average inpatient length of stay
Inpatient per person cost trend (compared to same quarter of previous year)
Inpatient mental health and substance abuse
Outpatient ER and Urgent Care
ER visits per 1000
# of members with multiple ER visits (within 90 days)
ER per person cost trend (compared to same quarter of previous year)
Pharmacy
% generic of total utilization
Outpatient specialty and primary care
Primary care visits per 1000
Specialty care visits per 1000
Radiology procedures per 1000
Behavioral health per 1000

15. Key Program Elements: Collaborative Responsibilities
Oversight:
Convene regular oversight meetings
Identify and engage stakeholders
Ensure communication between stakeholders
Pilot program development and implementation:
Facilitate negotiations, propose compromises
Review contracts to ensure comparability across plans and practices
Allocate nurse care managers
Ensure adequate program evaluation
Collect and distribute performance data
Liaison with outside evaluator
Engage and ensure technical assistance for pilot sites
Cheerlead, cajole, influence, etc. to move project forward
Plan for long term sustainability

16. Evaluation Meredith Rosenthal et al., Harvard SPH
Funded by Commonwealth Fund
Will look for evidence that:
Organizations providing care adopt components of the patient-centered medical home model
Intervention has an impact on patients, including changes in care processes, outcomes and experiences of care
Intervention is associated with changes in the cost of care
Qualitative information on experience of PCMH adoption

17. Results! All 5 initial sites achieved NCQA recognition on time
All sites successfully reporting quality measures
NCMs hired, integrated and functioning with practices
1st year collaborative training completed

18. Results: Qualitative changes at Practice Sites
Enhanced care coordination
Enhanced patient engagement leading to better quality
Use of Advanced HIT functionality to manage populations
More pro-active care teams
Happier providers

19. What you will hear about this morning is the result of a lot of hard work
Superb access to care
Patient engagement in care
Clinical IS that support high-quality care, practice-based learning and quality improvement
Care coordination
Integrated, comprehensive care and smooth information transfer across a fixed or virtual team of providers
On-going, routine patient feedback to a practice
Publicly available information on practices
Lessons learned b 19

20. Results: Beta blocker in CAD

21. Results: Depression Screening and Tobacco Cessation

22. Results
Stakeholders enthusiastic about qualitative improvements and quality data, but looking for cost data
Expansion to double in size beginning Q2 2010

23. Future
Legislation being introduced to institutionalize collaborative and multi-payer involvement
Decisions on how to formalize convening and management infrastructure
More formal connections with hospitals and community resources
Medicare?

24. Future Focus TA on reducing ED use and hospital re-admissions
Re-negotiate first round contracts beginning Q2 2010

25. CSI Rhode Island Project Director
Contact:
Deidre S. Gifford, MD, MPH
CSI Rhode Island Project Director
Health Progress