1. Results of 2016 PCMH Recognition Process
CTC-RI Practice reporting committee
January 24th 2017
Cory King - Office of the Health Insurance Commissioner

2. Office of the Health Insurance Commissioner
Agenda
Overview
Results of Year 1 Cost Management Strategy Data Reporting
Plans for Audit
Results of Year 1 Clinical Quality Data Reporting
Discussion & Questions
Office of the Health Insurance Commissioner

3. OHIC Theory of Action
Smarter Spending
Setting Rates for Commercial Insurers
Innovative Regulatory Approaches to Healthcare Reform
Better Care
Healthier Population
Affordability Standards
Compliance with State & Federal Statute & Regulation
Overview of OHIC’s tools for bringing about affordable health coverage
OHIC sets commercial health insurance rates each year through a process called Rate Review. In addition to ensuring rate increases are as low as possible and justified by actuarial data, OHIC oversees compliance with federal and state law. Coupled with the innovative regulatory approaches OHIC has taken to reform the healthcare delivery system, thanks to the Office’s forward thinking legislative charge, this rate setting process gives Rhode Island a one of a kind regulatory lever to bring about smarter spending – for individuals, businesses, and the system – better quality of care, and better health outcomes.
Care Transformation
Payment Reform
Cost Growth Containment

4. Office of the Health Insurance Commissioner
Overview
Survey results and pcmh recognition
Office of the Health Insurance Commissioner

5. Overview: Data Submissions
Submission results:
Cost strategy survey: 126 practices
Quality data submission: 125 practices
In comparison…
CTC-RI: 81 practices
RI primary care practice total (est.):
Office of the Health Insurance Commissioner

6. Attainment of 3-Part PCMH Definition
Transformation Experience n
Yes No
None reported 4
Less than one year (Year 1) practice joined CTC on January 1, 2016; joined TCPI in 2016; or practice is not participating in any transformation initiative 16 10 6
One to two years (Year 2): practice joined CTC on January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition during 2015 30
Three or more years (Year 3): practice joined CTC prior to January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition prior to January 1, 2015 76 73 3
Total
126
117 9
Office of the Health Insurance Commissioner

7. Results of Year 1 Cost Management Strategy Data Reporting
Office of the Health Insurance Commissioner

8. Attainment of 80% Cost Management Strategy Threshold
Transformation Experience n
Yes No
None reported 4
Less than one year (Year 1 ) practice joined CTC on January 1, 2016; joined TCPI in 2016; or practice is not participating in any transformation initiative 16 6 10
One to two years (Year 2): practice joined CTC on January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition during 2015 30 21 9
Three or more years (Year 3): practice joined CTC prior to January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition prior to January 1, 2015 76 74 2
Total
126
105
Note that only practices with three or more years of transformation experience were required to meet 80% threshold.
Office of the Health Insurance Commissioner

9. Cost Management Strategy Data – Digging Deeper
Office of the Health Insurance Commissioner

10. Cost Management Strategy Data – Digging Deeper
Office of the Health Insurance Commissioner

11. Most Common Elements Not Met – 3 or More Years of Experience (N=76)
Requirement 2: Related to care management/care coordination services.
The care management/care coordination resources contact every high-risk patient who has been discharged from hospital inpatient services after discharge to determine care management needs. (n=9) See question 7.
The care management/care coordination resources contact every known high-risk patient who has had an Emergency Department visit for a situation or condition that is related to or contributes to the patient's high-risk status. (n=8) See question 8.
Practices shall provide patient-engagement training to care managers/care coordinators, as necessary, to achieve these requirements. (n=5) See question 12.
Office of the Health Insurance Commissioner

12. Most Common Elements Not Met – 3 or More Years of Experience (N=76)
Requirement 3: The practice improves access to and coordination with behavioral health service. Note that practices needed to implement one of three by the end of year 1.
Most practices implemented: To promote better access to and coordination of behavioral health services, the practice has developed preferred referral arrangements with community behavioral health providers.
Practices did not tend to implement:
To promote better access to and coordination of behavioral health services, the practice has arranged for a behavioral health provider(s) to be co-located (or virtually located) at the practice for at least one day per week and assists patients in scheduling appointments with the on-site provider(s). (n=45) See question 2.
To promote better access to and coordination of behavioral health services, the practice is implementing or has implemented a co-located (or virtually located), integrated behavioral health services model. (n=39) See question 3.
Office of the Health Insurance Commissioner

13. Most Common Elements Not Met – 3 or More Years of Experience (N=76)
Requirement 4: The practice expands access to care both during an after office hours (defined as access beyond weekdays and between 9am and 5pm).
"The practice has created a secure web portal that enables patients to: send and receive secure messaging, request appointments, request referrals, request prescription refills, and review lab and imaging results.“ (n=12) See question 5.
The practice has an agreement with (or established) an urgent care clinic or other service provider which is open during evenings and weekends when the office is not open as an alternative to receiving Emergency Department care. (n=10) See question 3.
Office of the Health Insurance Commissioner

14. Most Common Elements Not Met – 1 to 2 Years of Experience (N=30)
Requirement 2: Related to care management/care coordination services.
The care management/care coordination resources participate in formal practice quality improvement initiatives to assess and improve effectiveness of care management service delivery. (n=14) See question 16.
The care management/care coordination resources arrange for, and coordinate all medical, developmental, behavioral health and social service referrals and tracks referrals and test results on a timely basis for high-risk patients. (n=10) See question 10.
The care management/care coordination resources complete a medication reconciliation after a high-risk patient has been discharged from inpatient services. (n=9) See question 9.
Office of the Health Insurance Commissioner

15. Most Common Elements Not Met – 1 to 2 Years of Experience (N=30)
Requirement 3: The practice improves access to and coordination with behavioral health service. Note that practices needed to implement one of three by the end of year 1.
Most practices implemented: To promote better access to and coordination of behavioral health services, the practice has developed preferred referral arrangements with community behavioral health providers.
Practices did not tend to implement:
To promote better access to and coordination of behavioral health services, the practice has arranged for a behavioral health provider(s) to be co-located (or virtually located) at the practice for at least one day per week and assists patients in scheduling appointments with the on-site provider(s). (n=18) See question 2.
To promote better access to and coordination of behavioral health services, the practice is implementing or has implemented a co-located (or virtually located), integrated behavioral health services model. (n=16) See question 3.
Office of the Health Insurance Commissioner

16. Most Common Elements Not Met – 1 to 2 Years of Experience (N=30)
Requirement 4: The practice expands access to care both during an after office hours (defined as access beyond weekdays and between 9am and 5pm).
"The practice has created a secure web portal that enables patients to: send and receive secure messaging, request appointments, request referrals, request prescription refills, and review lab and imaging results.“ (n=9) See question 5.
The practice utilizes formal quality improvement processes to assess and improve the effectiveness of its programs to expand access. (n=8) See question 4.
Office of the Health Insurance Commissioner

17. Most Common Elements Not Met – Less than 1 Year of Experience (N=16)
Requirement 1: The practice develops and maintains a high-risk patient registry.
The practice has developed and implemented a methodology for identifying patients at high risk for future avoidable use of high cost services (referred to as “high-risk patients). (n=6) See question 1.
Using information from a variety of sources, including payers and practice clinicians, the practice updates the list of high-risk patients at least quarterly. (n=6) See question 1.
To identify high-risk patients, the practice has developed a risk assessment methodology that includes at a minimum the consideration of the following factors: a). assessment of patients based on co-morbidities; b).inpatient utilization, and c).Emergency Department utilization. (n=7) See question 3.
Office of the Health Insurance Commissioner

18. Most Common Elements Not Met – Less than 1 Year of Experience (N=16)
Requirement 2: Related to care management/care coordination services.
The care manager/care coordinator completes within a specified period of time a patient assessment based on the patient's specific symptoms, complaints or situation. (n=10) See question 3.
Working with the patient and within two weeks of completing the patient assessment, the care manager/care coordinator completes a written care plan, that includes. (n=10) See question 4.
The care management/care coordination resources have in-person or telephonic contact with each high-risk patient at intervals consistent with the patient's level of risk. (n=10) See question 13.
Several other elements were not met by at least 7 practices.
Office of the Health Insurance Commissioner

19. Most Common Elements Not Met – Less than 1 Year of Experience (N=16)
Requirement 3: The practice improves access to and coordination with behavioral health service. Note that practices needed to implement one of three by the end of year 1.
Most practices implemented: To promote better access to and coordination of behavioral health services, the practice has developed preferred referral arrangements with community behavioral health providers. Only 8 practices implemented this.
Practices did not tend to implement:
To promote better access to and coordination of behavioral health services, the practice has arranged for a behavioral health provider(s) to be co-located (or virtually located) at the practice for at least one day per week and assists patients in scheduling appointments with the on-site provider(s). (n=10) See question 2.
To promote better access to and coordination of behavioral health services, the practice is implementing or has implemented a co-located (or virtually located), integrated behavioral health services model. (n=12) See question 3.
Office of the Health Insurance Commissioner

20. Most Common Elements Not Met – Less than 1 Year of Experience (N=16)
Requirement 4: The practice expands access to care both during an after office hours (defined as access beyond weekdays and between 9am and 5pm).
The practice has an agreement with (or established) an urgent care clinic or other service provider which is open during evenings and weekends when the office is not open as an alternative to receiving Emergency Department care. (n=5) See question 3.
The practice utilizes formal quality improvement processes to assess and improve the effectiveness of its programs to expand access. (n=3) See question 4.
Office of the Health Insurance Commissioner

21. Office of the Health Insurance Commissioner
Plans for Audit
CTC-RI, in consultation with OHIC, will be developing and carrying out an evaluation (or audit) to confirm the accuracy of the practice self-attestations.
The audit will be developed during the winter/spring, with plans to conduct the audit on one third of practices by the beginning of the fall.
Audit results will help inform future changes to the cost management strategies and the annual reporting process.
Office of the Health Insurance Commissioner

22. Results of Year 1 Clinical Quality Data Reporting
Office of the Health Insurance Commissioner

23. Clinical Quality Performance Measures
Adult practices required to submit the following 5 measures using clinical data specifications developed with CTC-RI:
Adult BMI, Screening for Clinical Depression and Follow-up Plan, HbA1c Control (<8), Controlling High Blood Pressure, Tobacco Cessation Intervention
Pediatric practices required to submit the following 4 measures using clinical data specifications developed with CTC-RI:
Weight Assessment and Counseling for Nutrition and Physical Activity (3 sub measures), Developmental Screening
All measures generally align with the SIM Aligned Measure Set, but are not identical.
Office of the Health Insurance Commissioner

24. Clinical Quality Performance Improvement Requirement Beginning in 2017
The following methodology was finalized by a work group of the Care Transformation Advisory Group in April 2016:
3 percentage point improvement over one or two years or
Performance at or above the national 66th percentile (average of HEDIS Medicaid (HMO) and commercial (PPO) values) or the state median (for non-HEDIS measures)
The work group also recommended:
Assessment of practical implications after a year of reporting
Sub-analysis of FQHC performance with baseline data
Office of the Health Insurance Commissioner

25. Clinical Quality Performance Measures: Baseline Data Analytical Plan
Compare baseline rates to non-Rhode Island benchmarks:
NCQA for HEDIS measures
Rates from other states for non-HEDIS measures
Compare CTC-RI and non-CTC-RI practices.
Conduct a focused analysis of FQHC rates as recommended by the work group in April.
Identify any potential data integrity concerns.
Office of the Health Insurance Commissioner

26. Non-RI Benchmarks: HEDIS
For the following HEDIS measures, we used an average of the National Commercial (PPO) and Medicaid (HMO) 66th percentile from NCQA’s 2016 Quality Compass product (CY2015 service period):
Adult BMI Assessment
Comprehensive Diabetes Care: HbA1c Control (<8.0)
Controlling High Blood Pressure
Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity (avg. of 3 components)
Office of the Health Insurance Commissioner

27. Non-RI Benchmarks: Non-HEDIS
For the non-HEDIS measures, we used the following:
Developmental Screening in the First Three Years of Life
Median rate of 9 states reporting using the Medicaid Child Core Set specifications (FFY 2014)
Screening for Clinical Depression and Follow-Up Plan
Oregon Medicaid Coordinated Care Organization (CCO) rate (CY 2015)
Tobacco Use: Screening and Cessation Intervention
Vermont commercial ACO rate (CY 2015)
Office of the Health Insurance Commissioner

28. Non-RI Benchmark Rates
Measure Category
Measure
Non-RI Benchmark Rate
Adult Measures
Adult BMI Assessment
81%
Comprehensive Diabetes Care: HbA1c Control (<8.0)
53%
Controlling High Blood Pressure
58%
Screening for Clinical Depression and Follow-Up Plan*
37%
Tobacco Use: Screening and Cessation Intervention*
89%
Pediatric Measures
Developmental Screening in the First Three Years of Life*
16%
Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity
62%
*Indicates a Non-HEDIS measure.
Office of the Health Insurance Commissioner

29. Performance of Practices Submitting Data to OHIC
Measure Category
Measure
Number of Practices Reporting (N)
Practices Performing at or above Non-RI Benchmark
Adult Measures
Adult BMI Assessment
105
97%
(n=102)
Comprehensive Diabetes Care: HbA1c Control (<8.0)
89%
(n=93)
Controlling High Blood Pressure
Screening for Clinical Depression and Follow-Up Plan
104
88%
(n=91)
Tobacco Use: Screening and Cessation Intervention
72%
(n=75)
Pediatric Measures
Developmental Screening in the First Three Years of Life 21
90%
(n=19)
Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity
81%
(n=17)
Office of the Health Insurance Commissioner

30. CTC-RI Practice Performance
Measure Category
Measure
CTC-RI Practices
Non-CTC-RI Practices N
Median Rate
Adult Measures
Adult BMI Assessment 68
99% 37
Comprehensive Diabetes Care: HbA1c Control (<8.0)
69%
66%
Controlling High Blood Pressure
84%
88%
Screening for Clinical Depression and Follow-Up Plan
80% 36
82%
Tobacco Use: Screening and Cessation Intervention
95%
94%
Pediatric Measures
Developmental Screening in the First Three Years of Life 8
58% 13
83%
Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity
92%
Office of the Health Insurance Commissioner

31. Office of the Health Insurance Commissioner
FQHC Performance
Measure Category
Measure
FQHC
Non-FQHC N
Median Rate
Adult Measures
Adult BMI Assessment 22
98% 83
99%
Comprehensive Diabetes Care: HbA1c Control (<8.0)
66%
71%
Controlling High Blood Pressure
77%
87%
Screening for Clinical Depression and Follow-Up Plan
83% 82
81%
Tobacco Use: Screening and Cessation Intervention
92%
96%
Note: Pediatric measures were excluded from this analysis because there were only two FHQCs that reported on the measures.
Office of the Health Insurance Commissioner

32. Data Integrity Concerns
Type of Concern
Detail
Aberrant Rates
1 practice submitted a rate that was greater than 100%.
9 practices submitted rates for a measure that were at or close to 0%.
27 practices submitted rates that were noticeably lower than the median rate for that measure.
Aberrant Denominators
3 practices submitted data for a measure where the denominator was less than 30.
17 practices reported a denominator for “Adult BMI Assessment” that was noticeably different than that of “Tobacco Use: Screening and Cessation Intervention.”
This is notable because the denominators for both of these measures should be similar.
Other
2 practices submitted rates for both Adult and Pediatric measures, whereas 1 practice did not submit rates for any measures.
Aberrant rates could be a result of a practice’s lack of familiarity with using an EHR to report on these measures, or with reporting on these measures entirely.
There is no correlation between aberrant rates and a practice’s inclusion in CTC-RI.
These rates will complicate OHIC’s ability to designate performance improvements in the next year.
Office of the Health Insurance Commissioner

33. Questions & Discussion
Office of the Health Insurance Commissioner