Transcript Payment Improvement Initiative

Arkansas Payment Improvement Initiative (APII)
William Golden MD MACP
Medical Director, Arkansas Medicaid
UAMS Professor of Medicine and Public Health
[email protected]
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Our vision to improve care for Arkansas is a comprehensive, patient-centered delivery
system…
Focus today
For patients
Objectives
For providers
How care is
delivered
▪
▪
▪
▪
Improve the health of the population
Enhance the patient experience of care
Enable patients to take an active role in their care
Encourage patient engagement/accountability
▪ Reward providers for high quality, efficient care
▪ Reduce or control the cost of care
Population-based care
▪ Medical homes
▪ Health homes
Episode-based care
▪ Acute, procedures or defined
conditions
▪ Results-based payment and reporting
▪ Health care workforce development
Four aspects of
broader program
▪ Health information technology (HIT) adoption
▪ Expanded access for health care services
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Medicaid and private insurers believe paying for patient results, rather
than just individual patient services, is the best option to control costs and
improve quality

▪ Transition to system that financially rewards value and

patient outcomes and encourages coordinated care
 Reduce payment levels for all providers regardless
of their quality of care or efficiency in managing costs
 Pass growing costs on to consumers through higher
premiums, deductibles and co-pays (private payers), or higher
taxes (Medicaid)
 Intensify payer intervention in clinical decisions
to manage use of expensive services (e.g. through prior
authorizations) based on prescriptive clinical guidelines
 Eliminate coverage of expensive services, or eligibility
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Payers recognize the value of working together to improve our system, with close involvement
from other stakeholders…
Coordinated multi-payer leadership…
▪ Creates consistent incentives and standardized reporting
rules and tools
▪ Enables change in practice patterns as program applies to
many patients
▪ Generates enough scale to justify investments in new
infrastructure and operational models
▪ Helps motivate patients to play a larger role in their health
and health care
1 Center for Medicare and Medicaid Services
STRATEGY
The populations that we serve require care falling into three domains
Patient populations
within scope (examples)
Prevention,
screening,
chronic care
Acute and
post-acute
care
Supportive
care
Care/payment models
• Healthy, at-risk
• Chronic, e.g.,
‒ CHF
‒ COPD
‒ Diabetes
Population-based:
medical homes responsible for care coordination,
rewarded for quality, utilization, and savings
against total cost of care
• Acute medical, e.g.,
‒ AMI
‒ CHF
‒ Pneumonia
• Acute procedural, e.g.,
‒ CABG
‒ Hip replacement
Episode-based:
retrospective risk sharing with one or more
providers, rewarded for quality and savings relative
to benchmark cost per episode
• Developmental disabilities
• Long-term care
• Severe and persistent mental illness
Combination of population- and episode-based
models:
health homes responsible
for care coordination; episode-based payment for
supportive care services
How episodes work for patients and providers (1/2)
1
Patients and
providers deliver
care as today
(performance
period)
Patients seek
care and select
providers as they
do today
2
3
Providers submit
claims as they do
today
Payers reimburse for
all services as they
do today
How episodes work for patients and providers (2/2)
4
5 Payers calculate average
cost per episode for each
PAP1
Calculate
incentive
payments based
on outcomes
after close of
12 month
performance
period
1 Outliers
Review claims from
the performance period to
identify a ‘Principal
Accountable Provider’
(PAP) for each episode
6 ▪ Based on results,
providers will:
▪
Share savings: if average
costs below commendable
levels and quality targets
are met
▪ Pay part of excess cost:
Compare average costs
to predetermined
‘’commendable’ and
‘acceptable’ levels2
if average costs are above
acceptable level
▪ See no change in pay: if
average costs are
between commendable
and acceptable levels
removed and adjusted for risk and hospital per diems
2 Appropriate cost and quality metrics based on latest and best clinical evidence, nationally recognized clinical guidelines and local considerations
PAPs that meet quality standards and have average costs below the
commendable threshold will share in savings up to a limit
Shared savings
High
Pay portion of excess
costs
Shared costs
No change
No change in payment to
providers
Acceptable
+
Receive additional payment as share as savings
Commendable
Gain
sharing limit
Low
Individual providers, in order from highest to lowest average
cost
Ensuring high quality care for every Arkansan is at the heart of this initiative, and is a
requirement to receive performance incentives
Two types of quality
metrics for providers
1
Quality metric(s) “to pass” are
linked to payment
Description
 Core measures indicating basic standard of care was
met
 Quality requirements set for these metrics, a provider
must meet required level to be eligible for incentive
payments
 In select instances, quality metrics must be entered in
portal (heart failure, ADHD)
2
Quality metric(s) “to track” are
not linked to payment
 Key to understand overall quality of care and quality
improvement opportunities
 Shared with providers but not linked to payment
Preliminary working draft; subject to change
EPISODE-BASED COMPONENT
Potential principal accountable providers across episodes
WORKING DRAFT
Principal accountable provider(s)
Hip/knee
replacements
Perinatal (non
NICU)
▪ Orthopedic surgeon
▪ Hospital
▪ Primary physician (e.g., OB/GYN, family practice
physician)
▪ (Hospital?)
▪ Provider for the in-person URI consultation(s)
Ambulatory URI
▪ Approaches under
consideration for
instances where
multiple providers
involved, e.g.,
– Prenatal care and
Acute/postacute CHF
delivery carried out
by different
providers
▪ Hospital
▪ (Outpatient provider will be incented by medical
home model to prevent readmissions)
– Patient sees
▪ Could be the PCP, mental health professional,
ADHD
Developmental
disabilities
and/or the RSPMI provider organization, depending
on the pathway of care
▪ Primary DD provider
1 Multiple approaches under consideration for instances when prenatal care and delivery carried out by different providers
multiple providers
for URI
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
PREVIEW: Wave 2a quality metrics (1/2)
Colonoscopy
Quality measures “to pass”
Quality measures “to track”
1. Cecal intubation rate reported by
provider on an aggregated quarterly
basis – must meet minimum threshold of
75%.1
1. Perforation rate
2. Post polypectomy/biopsy bleed rate
2. In at least 80% of valid episodes, the
withdrawal time must be greater than 6
minutes. 1
Tonsillectomy
1. Percent of episode with administration of
intra-operative steroids – must meet
minimum threshold of 85% 1
1. Post-operative primary bleed rate (i.e.,
post-procedure admissions or unplanned
return to OR due to bleeding within 24
hours of surgery)
2. Post-operative secondary bleed rate
3. Rate of antibiotic prescription postsurgery
Cholecystectomy
1. Percent of episodes with CT scan prior to
cholecystectomy – must be below
threshold of 44%
1. Rate of major complications that occur in
episode, either during procedure or in
post-procedure window: common bile
duct injury, abdominal blood vessel
injure, bowel injury
2. Number of laparoscopic
cholecystectomies converted to open
surgeries
1 Quality metric determined based on data entered into portal
3. Number of cholecystectomies initiated
via open surgery
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Wave 2B medical episodes overview
Brief description
Unique feature(s)
▪
Triggered by an angioplasty or
stent, procedural episode goes
from initial diagnostic angiogram
through 30 days post procedure
▪
Metric tracking the
appropriateness of each PCI
▪
Variable pre-procedure
window
▪
Triggered by a CABG procedure,
this procedural episode tracks
costs from the date of procedure
through 30 days after
▪
Aligned with Society of
Thoracic Surgery (STS)
quality metric database
▪
Triggered by ER/ Inpatient stay for
COPD, tracks length of stay and
care delivered for 30 days
following discharge
▪
▪
Aligns with CHF episode
Builds foundation/ template
for similar medical episodes
▪
Triggered by ER/ Inpatient stay for
asthma, tracks length of stay and
care delivered for 30 days
following discharge
▪
Large population covered,
primarily focused on young
▪
Has process in place to
confirm potential false
positive triggers
PCI
CABG
COPD
exacerbations
Asthma
exacerbations
SOURCE: Arkansas Department of Human Services (DHS), Division of Medical Services, Medicaid claims CY2011 (includes pharmacy)
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Draft thresholds for General URIs
Average cost / episode
Dollars ($)
Provider average costs for General URI episodes
Adjusted average episode cost per principal accountable provider1
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
Antibiotics prescription rate
above episode average2
Antibiotics prescription rate
below episode average2
Year 1 acceptable
67
Year 1 commendable
46
Gain sharing limit
Principal Accountable Providers
1 Each vertical bar represents the average cost and prescription rate for a group of 10 providers, sorted from highest to lowest average cost
2 Episode average antibiotic rate = 41.9%
SOURCE: Arkansas Medicaid claims paid, SFY10
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Provider Portal
POPULATION-BASED COMPONENT
Population-based models provide the “umbrella” for ensuring
that the full range of needs are met for a population
Elements of preliminary design
Medical homes
for most
populations
Health homes
for those receiving
supportive care
▪
Attribution of members to accountable
primary care provider, to avoid restrictions
on member access
▪
Care coordination for high-risk patients
with one or more chronic conditions
▪
Rewards for costs and quality of care
for direct, indirect decisions (e.g., referrals)
▪
▪
Similar approach as above; however,
Responsibility for health promotion and
care coordination vested with
providers of supportive care,
recognizing their greater influence in
daily routines
Each payor independently
defines incentives, to
include a combination of:
▪
▪
Care coordination fees
▪
For smaller providers,
bonus payments based
on quality and utilization
Shared savings against
total cost of care targets
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Arkansas PCMH strategy centers on three core elements:
Incentives
▪ Gain-sharing
▪ Payments tied to meeting quality metrics
▪ No downside risk
▪ Monthly payments to support care coordination and practice
Support for
providers
▪
▪
Clinical
leadership
transformation
Pre-qualified vendors that providers can contract with for
▪ Care coordination support
▪ Practice transformation support
Performance reports and information
▪ Physician “champions” role model change
▪ Practice leaders (clinical and office) support and enable
improvement
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2/3 Providers can then receive support to invest in improvements, as well
as incentives to improve quality and cost of care
2 Practice support
Invest in primary care to improve
quality and cost of care for all
beneficiaries through:
▪
▪
3 Shared savings
Reward high quality care and cost
efficiency by:
▪
Focusing on improving quality of
care
▪
Incentivizing practices to
effectively manage growth
in costs
Care coordination
Practice transformation
DHS/DMS will also provide performance reports and
patient panel information to enable improvement
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Activities tracked for practice support payments provide
a framework for transformation
Activity
Commit to
PCMH
Month 0-3
Start your
journey
Month 6
Evolve
your
processes
Month 12
Completion of activity
and timing of reporting
Continue
to innovate
Month
16-18
Month 24
1▪ Identify office lead(s) for both care coordination and
practice transformation1
2▪ Assess operations of practice and opportunities
to improve (internal to PCMH)
3▪ Develop strategy to implement care coordination and
practice transformation improvements
4▪ Identify top 10% of high-priority patients
(including BH clients)2
5▪ Identify and address medical neighborhood barriers to
coordinated care (including BH professionals and facilities)
6▪ Provide 24/7 access to care
7▪ Document approach to expanding access
to same-day appointments
8▪ Complete a short survey related to patients’ ability to
receive timely care, appointments, and information from
specialists (including BH specialists)
9▪ Document approach to contacting patients who have not
received preventive care
▪ Document investment in healthcare technology or tools
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that support practice transformation
▪ Join SHARE to get inpatient discharge information from
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hospitals
▪ Incorporate e-prescribing into practice workflows3
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▪ Integrate EHR into practice workflows
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1 - At enrollment; 2 - Three months after the start of each performance period; 3 - At 18 months
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Metrics tracked for practice support payments guide practices through
PRELIMINARY
improvements and measure performance
Target
 Metrics to be
evaluated as a
portfolio
 Practices will
need to meet
targets for the
majority of
metrics tracked
for practice
support
Metric
12 months
24 months
36 months
and beyond
▪ Percentage of high-priority
70%
90%
Increasing
67%
75%
Increasing
33%
Increasing
Increasing
<50%
Decreasing
Decreasing
patients that have a care plan in
medical record (incorporating
information from specialists,
including behavioral health)
▪ Percentage of high priority
patients that have been seen by
PCP at least twice in the past 12
months
▪ Percentage of patients who had
an acute inpatient hospital stay
who were seen by physician
within 10 days of discharge
▪ Percentage of emergency visits
that are non-emergent (NYU
algorithm)
24
3 Shared savings will reward eligible entities for performance on quality
and cost of care
Providers receive greater of two shared savings methods
if they have met performance on quality
▪
Practices must meet performance
benchmarks on quality
▪
Incentive payments are based on the
greater of two payment calculation
methods
▪
Model is upside-only, providers do not
risk-share
<
A
Provide efficient care
Practice costs in performance
period
State-wide cost
thresholds
OR
<
B
Manage growth of costs
Practice costs in performance
period
Practice-specific
benchmark cost
What shared savings could mean for your practice
Attributed beneficiaries: 6,000
Risk-adjusted per beneficiary benchmark cost: $2,000
Practice risk score: 1.0
2014 medium cost threshold: $2,032
Per beneficiary payment
Annual incentive payment
Risk-adjusted cost of care
$1,900
$ 66
$ 396,000
$1,800
$ 116
$ 696,000
25
Quality metrics tracked for shared savings incentive payments
promote provision of appropriate care
PRELIMINARY
Metric
Target (%)
▪ Percentage of pediatric patients
who receive age-appropriate
wellness visits
– 0-12 months
– 3, 4, 5, 6, years
– 12-20 years
▪ Percentage of diabetes patients
67
67
40
1. Assess quality metrics annually
75
who receive annual HbA1C testing
▪ Percentage of patients prescribed
appropriate asthma medications
▪ Percentage of CHF patients on beta
blockers
▪ Percentage of women > 50 years
who have had breast cancer
screening in past 24 months
Additional context
70
40
50
2. Each metric is evaluated only if n
is greater than or equal to 25
3. To be eligible for shared savings,
shared savings entities must
meet greater than or equal to 2/3
of quality metric targets
4. Quality metrics are likely to
evolve over time
▪ Percentage of patients on thyroid
drugs with a TSH test in past 18
months
80
▪ Percentage of patients prescribed
ADHD medications by PCP who
receive appropriate follow-up care
25
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▪ More information on the Payment Improvement Initiative
can be found at www.paymentinitiative.org
– Further detail on the initiative, PAP and portal
– Printable flyers for bulletin boards, staff offices, etc.
– Specific details on all episodes
– Contact information for each payer’s support staff
– All previous workgroup materials
Last Modified 11/13/2012 1:00 AM Central
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10/10/2012
3:32 PM India Standard Time
Time
Last Modified 11/13/2012 1:00 AM Central
PrintedStandard
10/10/2012
3:32 PM India Standard Time
Time
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Draft ADHD thresholds
Average cost / episode
Dollars ($)
ADHD provider cost distribution
Average episode cost per provider1
12,000
RSPMI
11,000
Physician or psychologist
10,000
9,000
8,000
Level II acceptable
$7,112
7,000
6,000
Level II commendable
$5,403
5,000
4,000
3,000
Level II gain sharing limit; Level I acceptable
2,000
Level I commendable
1,000
Level I gain sharing limit
$2,223
$1,547
$700
0
Principal Accountable Providers
1 Each vertical bar represents the average cost and prescription rate for a group of 3 providers, sorted from highest to lowest average cost
SOURCE: Episodes ending in SFY10, data includes Arkansas Medicaid claims paid SFY09 - SFY10