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1 1 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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Arkansas Payment Improvement Initiative (APII)
William Golden MD MACP
Medical Director, Arkansas Medicaid
UAMS Professor of Medicine and Public Health
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Our vision to improve care for Arkansas is a comprehensive, patient-centered delivery system…
Episode-based care▪ Acute, procedures or defined
conditionsHow care is delivered
Population-based care▪ Medical homes ▪ Health homes
Objectives
▪ 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
Four aspects of broader program
▪ Results-based payment and reporting
▪ Health care workforce development
▪ Health information technology (HIT) adoption
▪ Expanded access for health care services
For patients
For providers
Focus today
▪ Reward providers for high quality, efficient care
▪ Reduce or control the cost of care
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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
Eliminate coverage of expensive services, or eligibility
Pass growing costs on to consumers through higher premiums, deductibles and co-pays (private payers), or higher taxes (Medicaid)
▪ Transition to system that financially rewards value and
patient outcomes and encourages coordinated care
Intensify payer intervention in clinical decisions to manage use of expensive services (e.g. through prior authorizations) based on prescriptive clinical guidelines
Reduce payment levels for all providers regardlessof their quality of care or efficiency in managing costs
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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
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The populations that we serve require care falling into three domains
Acute andpost-acute
care
Prevention,screening,
chronic care
Supportivecare
Patient populationswithin scope (examples)
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
STRATEGY
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How episodes work for patients and providers (1/2)
Patients seek care and select providers as they do today
Providers submit claims as they do today
Payers reimburse for all services as they do today
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Patients and providers deliver care as today (performance period)
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▪ Based on results, providers will:
▪ Share savings: if average costs below commendable levels and quality targets are met
▪ Pay part of excess cost: if average costs are above acceptable level
▪ See no change in pay: if average costs are between commendable and acceptable levels
How episodes work for patients and providers (2/2)
1 Outliers 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
Review claims from the performance period to identify a ‘Principal Accountable Provider’ (PAP) for each episode
Payers calculate average cost per episode for each PAP1
Compare average costs to predetermined ‘’commendable’ and ‘acceptable’ levels2
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Calculate incentive payments based on outcomesafter close of12 month performance period
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PAPs that meet quality standards and have average costs below the commendable threshold will share in savings up to a limit
Shared savings
Shared costs
No change
Low
High
Individual providers, in order from highest to lowest average cost
Acceptable
Commendable
Gain sharing limit
Pay portion of excess costs-
+
No change in payment to providers
Receive additional payment as share as savings
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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)
Ensuring high quality care for every Arkansan is at the heart of this initiative, and is a requirement to receive performance incentives
Key to understand overall quality of care and quality improvement opportunities
Shared with providers but not linked to payment
Description
Quality metric(s) “to track” are not linked to payment
Quality metric(s) “to pass” are linked to payment
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Two types of quality metrics for providers
Preliminary working draft; subject to change
Potential principal accountable providers across episodes
▪ Orthopedic surgeon
▪ HospitalHip/knee replacements
▪ Primary physician (e.g., OB/GYN, family practice physician)
▪ (Hospital?)
Perinatal (non NICU)
Principal accountable provider(s)
1 Multiple approaches under consideration for instances when prenatal care and delivery carried out by different providers
▪ Provider for the in-person URI consultation(s)
Ambulatory URI
▪ Hospital
▪ (Outpatient provider will be incented by medical home model to prevent readmissions)
Acute/post-acute CHF
▪ Could be the PCP, mental health professional, and/or the RSPMI provider organization, depending on the pathway of care
ADHD
▪ Primary DD providerDevelopmental disabilities
▪ Approaches under consideration for instances where multiple providers involved, e.g.,
– Prenatal care and delivery carried out by different providers
– Patient sees multiple providers for URI
WORKING DRAFT
EPISODE-BASED COMPONENT
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
PREVIEW: Wave 2a quality metrics (1/2)
1. Cecal intubation rate reported by provider on an aggregated quarterly basis – must meet minimum threshold of 75%.1
2. In at least 80% of valid episodes, the withdrawal time must be greater than 6 minutes. 1
1. Perforation rate
2. Post polypectomy/biopsy bleed rateColonoscopy
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 post-surgery
Tonsillectomy
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
3. Number of cholecystectomies initiated via open surgery
Cholecystectomy
Quality measures “to pass” Quality measures “to track”
1 Quality metric determined based on data entered into portal
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Wave 2B medical episodes overview
COPD exacerbations
Asthma exacerbations
CABG
Brief description
▪ Triggered by a CABG procedure, this procedural episode tracks costs from the date of procedure through 30 days after
▪ Triggered by ER/ Inpatient stay for COPD, tracks length of stay and care delivered for 30 days following discharge
▪ Triggered by ER/ Inpatient stay for asthma, tracks length of stay and care delivered for 30 days following discharge
PCI▪ Triggered by an angioplasty or
stent, procedural episode goes from initial diagnostic angiogram through 30 days post procedure
▪ Aligned with Society of Thoracic Surgery (STS) quality metric database
▪ Aligns with CHF episode ▪ Builds foundation/ template
for similar medical episodes
▪ Large population covered, primarily focused on young
▪ Has process in place to confirm potential false positive triggers
▪ Metric tracking the appropriateness of each PCI
▪ Variable pre-procedure window
Unique feature(s)
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
Provider average costs for General URI episodes Adjusted average episode cost per principal accountable provider1
0102030405060708090
100110120130140150
Ave
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/ e
pis
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olla
rs (
$)
Principal Accountable Providers
15
46
67
Antibiotics prescription ratebelow episode average2
Antibiotics prescription rateabove episode average2
1 Each vertical bar represents the average cost and prescription rate for a group of 10 providers, sorted from highest to lowest average cost2 Episode average antibiotic rate = 41.9%SOURCE: Arkansas Medicaid claims paid, SFY10
Year 1 acceptable
Year 1 commendable
Gain sharing limit
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Provider Portal
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Population-based models provide the “umbrella” for ensuring that the full range of needs are met for a population
Medical homesfor 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
▪ Shared savings against total cost of care targets
▪ For smaller providers, bonus payments based on quality and utilization
Elements of preliminary design
POPULATION-BASED COMPONENT
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Clinicalleadership
▪ Physician “champions” role model change
▪ Practice leaders (clinical and office) support and enable improvement
Support for providers
▪ Monthly payments to support care coordination and practice transformation
▪ Pre-qualified vendors that providers can contract with for
▪ Care coordination support
▪ Practice transformation support
▪ Performance reports and information
Arkansas PCMH strategy centers on three core elements:
Incentives
▪ Gain-sharing
▪ Payments tied to meeting quality metrics
▪ No downside risk
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Providers can then receive support to invest in improvements, as well as incentives to improve quality and cost of care
Practice support Shared savings
DHS/DMS will also provide performance reports and patient panel information to enable improvement
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Invest in primary care to improve quality and cost of care for all beneficiaries through:
▪ Care coordination
▪ Practice transformation
Reward high quality care and cost efficiency by:
▪ Focusing on improving quality of care
▪ Incentivizing practices to effectively manage growth in costs
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Completion of activity and timing of reporting
Commit to PCMHMonth 0-3
Start your journeyMonth 6
Evolve your proce-ssesMonth 12Activity
Month 16-18 Month 24
▪ Identify office lead(s) for both care coordination and practice transformation1
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▪ Assess operations of practice and opportunities to improve (internal to PCMH)
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▪ Develop strategy to implement care coordination and practice transformation improvements
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▪ Identify top 10% of high-priority patients (including BH clients)2
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▪ Identify and address medical neighborhood barriers to coordinated care (including BH professionals and facilities)
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▪ Provide 24/7 access to care6
▪ Document approach to expanding access to same-day appointments
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▪ Document approach to contacting patients who have not received preventive care
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▪ Document investment in healthcare technology or tools that support practice transformation
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▪ Join SHARE to get inpatient discharge information from hospitals
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▪ Incorporate e-prescribing into practice workflows312
▪ Integrate EHR into practice workflows13
Continue to innovate
Activities tracked for practice support payments provide a framework for transformation
▪ Complete a short survey related to patients’ ability to receive timely care, appointments, and information from specialists (including BH specialists)
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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 to be evaluated as a portfolio
Practices will need to meet targets for the majority of metrics tracked for practice support
Metrics tracked for practice support payments guide practices through improvements and measure performance
Target
Metric36 monthsand beyond12 months 24 months
▪ Percentage of high-priority patients that have a care plan in medical record (incorporating information from specialists, including behavioral health)
Increasing70% 90%
▪ Percentage of high priority patients that have been seen by PCP at least twice in the past 12 months
Increasing67% 75%
Increasing▪ Percentage of patients who had an acute inpatient hospital stay who were seen by physician within 10 days of discharge
33% Increasing
▪ Percentage of emergency visits that are non-emergent (NYU algorithm)
<50% Decreasing Decreasing
PRELIMINARY
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What shared savings could mean for your practiceWhat shared savings could mean for your practice
Attributed beneficiaries: 6,000 Risk-adjusted per beneficiary benchmark cost: $2,000Practice risk score: 1.0 2014 medium cost threshold: $2,032
$1,800 $ 116 $ 696,000
Per beneficiary payment Annual incentive payment Risk-adjusted cost of care
$ 66 $ 396,000$1,900
▪ 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
Shared savings will reward eligible entities for performance on quality and cost of care
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Manage growth of costs
Providers receive greater of two shared savings methods if they have met performance on quality
<
Provide efficient careState-wide cost
thresholdsPractice costs in performance
period
<
OROR
A
B
Practice-specific benchmark cost
Practice costs in performance period
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Quality metrics tracked for shared savings incentive payments promote provision of appropriate care
PRELIMINARY
1. Assess quality metrics annually
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
Additional context
Target (%)
▪ Percentage of diabetes patients who receive annual HbA1C testing
75
▪ Percentage of patients prescribed appropriate asthma medications
70
▪ Percentage of CHF patients on beta blockers
40
▪ Percentage of women > 50 years who have had breast cancer screening in past 24 months
50
▪ Percentage of patients on thyroid drugs with a TSH test in past 18 months
80
▪ Percentage of pediatric patients who receive age-appropriate wellness visits– 0-12 months– 3, 4, 5, 6, years– 12-20 years
676740
▪ Percentage of patients prescribed ADHD medications by PCP who receive appropriate follow-up care
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Metric
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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
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Draft ADHD thresholds
ADHD provider cost distributionAverage episode cost per provider1
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
11,000
12,000
Ave
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t /
ep
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Dol
lars
($)
Principal Accountable Providers
$700
$1,547
$2,223
$5,403
$7,112
1 Each vertical bar represents the average cost and prescription rate for a group of 3 providers, sorted from highest to lowest average cost
RSPMI
Physician or psychologist
SOURCE: Episodes ending in SFY10, data includes Arkansas Medicaid claims paid SFY09 - SFY10
Level II commendable
Level II acceptable
Level II gain sharing limit; Level I acceptable
Level I commendable
Level I gain sharing limit
