The Payer Perspective

1
The Payer Perspective Richard Snyder, M.D.
2
Agenda

• The National Landscape
• Profiles of Single and Multi-Stakeholder Pilots
• North Dakota
• New Jersey
• Pennsylvania Chronic Care Management,
  Reimbursement Cost Reduction Commission

3
The National Landscape

• 24 Pilots / 10 Active
• Single and Multi-Stakeholder
• Public/Private
• Commercial, Medicare Advantage, Managed Medicaid
• 3 -100 Practices
• 13 6,471 Practitioners
• 850 1.7M Patients
• Diverse reimbursement strategies
• Variable degrees of clinical outcomes

4
BCBS of North Dakota Meritcare Health System

• Payer and Integrated Multi-specialty Medical
  Group
• Focus on diabetes started 2005
• Use of integrated RN CDM
• Emphasis on self-management, goals, education,
  follow-up
• Outcomes
• Improved satisfaction of patients and practices
• Improved results of comprehensive diabetes care
• Savings shared 5050 with practices
• 2005 - 531 per patient with diabetes
• 2006 - 1,213 per patient with diabetes
• Expanded to 4 practices, added HTN and CAD, added
  management fee and generic prescribing incentives

5
Horizon BCBS Partners in Care

• Payer and Physician Owned MSO
• Offered to New Jersey State Health Benefits
  Program
• Initially 1,300 patients
• Focus on diabetes started 2007
• Emphasis on care coordination and information
  sharing
• Complemented with Payer disease management
  program
• Outcomes between January and November 2007
• HgbA1c testing increased 43 to 91
• HgbA1c result between 7 and 9 increased from 15
  to 36
• PMPM medical spend dropped from 1,049 to 870
• Expanded to over 400 practices and 30,000
  patients

6
Chronic Care Management, Reimbursement Cost
Reduction Commission

• Part of Prescription for Pennsylvania
• Goal - Improve chronic care delivery in PA
• 1.7 billion in avoidable admissions
• Missed opportunities in process/outcomes measures
• 45 Provider, insurer, cabinet, organized labor,
  academic and consumer representatives
• Blend of Wagner Chronic Care Model and Patient
  Centered Medical Home Model
• Lead by Governors Office on Health Care Reform
• Learning sessions
• Practice coaches to support transformation
• NCQA PPC-PCMH recognition levels drive
  reimbursement

7
SE Pennsylvania Rollout

• 32 PCP (Ped, IM, FP, CRNP) Practices with 166
  PCPs
• 220,000 patients
• Multiple Payers (IBC, KMHP, Aetna, CIGNA, Health
  Partners, AmeriChoice)
• Primary Care Coalition (PAFP, ACP, AAP)
• Goals are to improve
• Access to care and communication with PCP
• Team based care coordination, health education
  and self-management skills
• Use of registry/EMR to report data
• Member and provider satisfaction
• Aggregation of payer and practice level data for
  reporting
• Improved quality, utilization and cost outcomes

8
Role of GOHCR

• Staffing
• Project management
• Funding
• Consultants
• Faculty and expenses for a year-long learning
  collaborative for participating primary care
  practices
• Cost of registry
• Data collection, evaluation and reporting
  activities through a 3rd party, including surveys
• Coordinating
• Flow of data between practices and payers
• Flow of funds from payers to practices and IPIP
  (Improving Performance in Practice) a PAFP 501c3
• Baseline and subsequent satisfaction surveys

9
Requirements of PCP Practices

• Three year commitment
• Attend Learning Collaborative meetings
• Work with assigned practice coach to transform
  practice
• Enhanced access to care
• Team based coordinated care
• Enhanced communication
• Self-management support
• Use a patient registry (or EMR) to track patients
  
• Report data from the patient registry and other
  sources required for evaluation purposes
• Achieve Level 1 NCQA PPC-PCMH Recognition in year
  1
• Reinvest funds into staff and technology at
  practice site

10
Requirements of Payers

• Three year commitment to fund and support
• Methodology payments proportionate to revenue
  from all sources as validated and coordinated
  through GOHCR
• Payment to IPIP for Practice Coaches
• Payment to PCP Practices are intended to offset
  costs
• Infrastructure development
• NCQA PPC-PCMH survey tool 80/practice
• Data entry to registry 800/practice
• Office assistant 8,000/practice
• NCQA application fee 360/clinician
• Registry license fee 275/clinician
• Time for practice team to attend learning
  collaborative are paid after attendance
• Seven days during 1st year 11,655/team
• Consist of quarterly 2 day learning meetings and
  final outcome meeting

11
Requirements of Payers

• Enhancement to current payer contractual payments
• Annual lump sum payments upon NCQA PPC-PCMH
  recognition yield up to 4PMPM
• Prorated for portion of year at each level of
  recognition
• Prorated based on PCP/CRNP FTEs in practice
• Discounted by of revenue from Medicare FFS and
  non-par payers
• Pay-for-performance standard process post first
  3 years based on clinical, utilization,
  satisfaction and financial outcomes

NCQA PCMH Recognition Level Practice 1 FTE Practice 2-4 FTEs Practice 5-9 FTEs Practice 10-20 FTEs
Level 1 40,000 36,000 32,000 28,000
Level 2 60,000 54,000 48,000 42,000
Level 3 95,000 85,500 76,000 66,500
12
Requirements of IPIP

• Provide Practice Coaches to assist
• With transforming the practice
• With data collection and reporting
• Linking practices to community resources
• With completing the NCQA PPC-PCMH recognition
  process
• Contribute to Consumer Engagement Strategy
• Community Registry of resources available to
  practices
• Building public-private partnerships to support
  self-management
• IPIP practice coach resource for training on
  self-management
• Reimburse self-management education services
• Contribute to community sponsored lay support
  services
• Contribute to standardized incentive program

Consumer Engagement
13
Evaluation

• The Commission has approved a methodology
• Data from payers, providers, and surveys to be
  aggregated by 3rd party
• Rollout intervention groups to be compared to
  control groups
• Metrics are based on nationally endorsed measures
  where possible (NCQA, AQA, etc.)
• The initiative will be evaluated using the
  following measurement domains
• Engaged providers
• Patient self-care knowledge and skills
• Patient function and health status
• Primary care practice satisfaction
• Appropriate and efficient utilization of services
  
• Clinical care quality
• Cost

14
Anticipated Gains

• Improved quality of care within 1 year
• Reduced admissions and cost in 3 years
• Improved access to care and member satisfaction
• Support for the vulnerable and essential primary
  care professional community
• A robust demonstration of the impact of a
  far-reaching, multi-payer strategy to transform
  care delivery
• Lessons learned to hopefully apply to a broader
  system-wide model application