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Webinar Learning SessionJuly 22, 2015
www.hcgc.org
Welcome! We will get started at 1:05pmToday’s Learning Topic: Primary Care Transformation is happening NOW!
Thank you for joining us to explore progress and lessons learned from the CMS-Comprehensive Primary Care (CPC) initiative underway in Southwest Ohio.
CPC is the foundation for spreading patient-centered medical homes aligned with public-private payment innovation as outlined in Ohio’s State Innovation Model (SIM) grant.
Featured Speakers: The Health Collaborative, Cincinnati, OhioCMS-CPC Regional Learning Faculty Richard Shonk, MD PhD
Chief Medical Officer Barbara B Tobias, MD
Medical Director
August 21st In-Person Learning SessionPopulation Health Management: Why it matters,
How it's done, What's next?Featured Speaker: Pamela Peele, PhD, Chief Analytics Officer,
University of Pittsburgh Medical Center (UPMC) Health Plan
Regional Panel David Applegate, MD, Chief, Primary Care
Transformation, OhioHealth Physician Group Arick Forrest, MD, Medical Director,
Ambulatory Services, The Ohio State University Wexner Medical Center
Tricia Schmidt, Client Advocate, Willis of Ohio
Ben Shaker, Vice President and COO, Mount Carmel Health Partners
King Stumpp, President and CEO, Netcare Access
Bruce Wall, MD, Senior Medical Director, Aetna
Lead Supporter
Major Supporters
Individual & CorporateDonations
100% of our Board of Directors
& Staff
Additional Supporters
Our Public-Private Funding Partners
Clarity Consultancy Services, our social enterprise subsidiary
Webinar Learning SessionJuly 22, 2015
www.hcgc.org
Please share your questions throughout the session by using the webinar chat feature, or by
texting them to (614)906-2440
COMPREHENSIVE PRIMARY CARE
REGIONAL UPDATE
4
Richard Shonk, MD PhD Barbara B Tobias, MD
Chief Medical Officer Medical Director
The Health Collaborative,
Cincinnati, Ohio
CMS-CPC Regional Learning Faculty
AN OVERVIEW
Proof of Concept
6 Source: CMS.gov
What is the Comprehensive Primary Care Initiative
• CPC is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care.
• Medicare is working with commercial and state health insurance plans to offer per member per month (PMPM) payments to primary care doctors to better coordinate care for their patients.
• Primary care practices selected to participate in this initiative are provided payments, tools and other resources to better coordinate primary care for their patients.
CPC National Regions
Greater Cincinnati
1 of only 7chosen sites nationally
65 miles from
Williamstown, KY to Piqua, OH
75 practices and
260 providers
Multi- payer:
8 health plans +
Medicare
220,000 estimated
commercial,
Medicaid and
Medicare enrollees
CPC – Our region
Components of CPC
10
PCMH
Transforming
primary care
through
milestone
process
measures and
clinical quality
outcomes
metrics
PaymentReform
Payment
Reform to align
payment to
outcomes –
Comprehensive
Primary Care
initiative
Data Collection
Building a
robust
database
CPC Change Diagram
The Health Collaborative Roles
• Learning and Diffusion
• Regional Convener
• Data Aggregation
12
CPC Provider Stakeholders
Generations Family
Medicine
Springfield Health Care
Center
Springfield Center for
Family Medicine
Maineville Family
Physicians
Lawrence P. Wang MD LLC
Family Practice Associates
CPC Payer Stakeholders
15
Shared Savings
(2015-2016)
Care management fee for commercially
insured
Care management
fee for Medicare
beneficiaries
CPC Payment Model
Total Care Management Payments to CPC Practices through 12/31/13
16
What payments did payers provide?
17
1. Annual Budget
2. Care Management of High-Risk patients
3. Patient Access and Continuity
4. Assess and improve patient experience of care
5. Use data to guide improvement
6. Care coordination across the medical neighborhood
7. Improve patient shared decision-making
8. Participate in market based learning collaborative
9. Health Information Technology
Annual Practice Milestones
PROGRESS TO DATE
CPC Milestone Highlights
Care Management and Care Coordination• 84,000 patients receiving personalized care
management
• Post-Discharge and Emergency Department
Visit follow-up
24/7 Access • All practices offering enhanced access via
Patient portals, after hours call lines,
structured phone visits, text messaging,
eVisits
Quality Improvement
• Using data to guide improvements in care
• Improving quality while reducing cost and
inappropriate utilization
Patient Experience
• Patient Family Advisory Councils
• Office Survey
CPC Milestone Highlights
Shared Decision Making• 8,700 shared decisions on Advance Care
Planning
• 42,000 shared decisions on Smoking
Cessation
What data did payers provide?
22
CPC National Y1 ResultsControl Group Comparison
(October 2012-September 2013)
Bulk of savings generated by patients
in the highest-risk quartile
Expenditures reduced enough to
offset CMS Care Management fee
Decreased hospital admissions by 2%
Decreased emergency department visits by
3%
Additional time and data needed to
assess the impact on care quality
First 12 month findings caveats:
24
An Initiative of the Center for Medicare & Medicaid InnovationProject Timeline: 2013-2016
250 Providers 9 Health Plans220,000 Beneficiaries
Regional Data Transparency + Engaged Physicians = National Leaders in Primary Care Transformation
42,000Discussed Smoking Cessation TreatmentOptions
8,700 Discussed Advance Care Plan Options
Ev
ide
nc
e-B
ase
d C
are
Overall
Hospital
Admissions
Primary Care
Treatable
Admissions
Readmissions
Overall
Expenditures
-8%
-10%
-3%
-3.4%
Data-Driven Improvement
Patient Experience
24/7 Access to Medical Record
Shared Decision Making
Clinical Quality Improvement
Care Management
Medicare Outcomes to Date
Po
pu
lati
on
He
alt
h
Ke
y F
un
cti
on
s 84,000Patients Received Care Management
Medicare Unadjusted Expenditure Trends
Medicare Unadjusted Expenditure Trends
Medicare Admission Trends
Medicare ACSC Admission Trends
What’s going on at the practice level?
$0
$200
$400
$600
$800
$1,000
$1,200
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75
4-Quarter Risk Adjusted Average Medicare Expenditures per Patient per Month-Practice related to Regional Expenditures
Practice Average-4-QuarterRisk Adjusted AverageMedicare Expenditures perPatient per Month
Regional Average 4-QuarterRisk Adjusted AverageMedicare Expenditures perPatient per Month
Webinar Learning SessionJuly 22, 2015
www.hcgc.org
Please share your questions throughout the session by using the webinar chat feature, or by
texting them to (614)906-2440
LESSONS LEARNED
A N
eu
tral S
pa
ce
Promote the consumer voice from the patient perspective
Discern what access looks like when it is convenient
Determine how information can be transmitted and made understandable
Provide practices with needed cost, quality and patient feedback views that
permit them to manage the Triple Aim patient-by-patient and population-by-
population
Keep a constant eye on the administrative burden and unintended
consequences to clinical workflow
Identify best practices, subject matter experts, learning networks
Maintain alignment among payers regarding measurement, attribution and
risk adjustment
Avoid programs that undermine the pay for value incentive
Maintain focus on clinical and cost outcomes
Provide forum for aggregating data, analyzing trends and reporting results
A forum to advocate for necessary Policy, Accountability, and Standardization
Liaison with government as payer/employer to maintain alignment
A forum for the community to address the health care system as a whole and
not system-by-system
Integrate Population Health initiatives into Comprehensive Primary Care
approach
Managing The Work of Relationships
12345
Patient Centered
Consumer Advocacy
Clinical
Practices
Health Plans
and Employers
Federal and State
Government
Community Needs
5 E
sse
nti
alE
lem
en
ts Investment up front – Infrastructure to
convert a practice is costly
Payment Models – gradual movement from FFS to value-based
Critical Mass – over 50% of practice population covered by participating payers
Multi-payer approach
Transparent payment and practice compensation models are critical for physician engagement and payer comfort
Consistent; standard measures
Contiguous; tracked over time
Comprehensive; a majority of practice's patient panel is included
Credible; timely, accurate, and usable; e.g. identifying high risk patients/patterns
Cost/Quality Balance; measuring to manage value
Aligned: Similar Payment/financial model Attribution Risk adjustment Guidelines and goals
Standardized: Same Metrics Reports Communication Format and Links
Employers, Health Plans, and Government need to eliminate conflicting incentives for clinicians
Create ownership mentality; empowerment vs employment
Integrate into workflow; if what we do distracts providers from patient care then we have failed
Incentives and rewards have to be palpable
Willingness to change from physician autonomy to team-based care
Delegation – team members practicing at highest extent of licensure
Identification of high risk patients for outreach and management.
Stakeholder recognition that primary care practice must be the quarterback for all care management for all entities that touch their attributed patients.
A Call to Action:
Recognition by educational and trainingprograms that the availability of individuals
competent in this role are at a premium today and will only grow as this approach to health
care is expanded.
1Comprehensive Primary Care Drivers
Sustainable
Prospective Care
Management
Payments
2Clinical and Claims
Data Aggregation:
The "Five C's"
3Avoiding
Administrative
Overload for
Practices
4Physician/Provider/
Practice Culture
5Care Coordination
and Care
Management
5 Im
po
rta
nt
Ele
me
nts
Patients need to connect easily to their Medical Home and their medical
record via office, phone, email, virtual visits etc…
Practices need to know when patients access other points of the health
system.
Practices need cost, quality and patient feedback views that permit them to
manage the Triple Aim patient-by-patient and population-by-population.
Information needs to be less than three clicks away in the EHR.
Behavioral Health Integration:
co-management of common co-morbid
mental health conditions; integration of
behavioral components in self-
management of chronic disease.
Specialist Care: warm hand offs;
quality and cost information about
hospitals and other providers
Reliable Programs and Outreach
Efforts for the management of the
patient’s medical and social needs
Awareness of Population Health
efforts within the community and how
they can be integrated for their
patients
Real time communication within the Medical Neighborhood
Real time communication by and with the patient
Transform health information exchange into health information knowledge
Payment upfront for value requires that a practice demonstrate credibly to
payers that they can account for how value is generated and increased.
Required process measures and their milestones need to be clear and
aligned across payers.
Comprehensive Primary Care Drivers
12345
Timely Access
Actionable
Tools
A Supportive
Medical
Neighborhood
Electronic Health
Record Capability
Supported by
Health Information
Exchange (HIE)
Structured Programs
for Budgeting and
Process
Improvement
OH/KY CPC Data Aggregation
Project
• Providers and Payers agreed contract
with the Health Collaborative and jointly
fund the effort
• CMS now able to participate with its data
• The Health Collaborative Powered by
HealthBridge, subcontracts with OnPoint
Health Data
• All Health Plans submit claims data to
develop aggregated reports
Patient-centered medical homes Episode-based payments
Goal 80-90 percent of Ohio’s population in some value-based payment model (combination of episodes- and population-based payment) within five years
Year 1 ▪ In 2014 focus on Comprehensive Primary Care Initiative (CPCi)
▪ Payers agree to participate in design for elements where standardization and/or alignment is critical
▪ Multi-payer group begins enrollment
strategy for one additional market
Year 3
Year 5
▪ State leads design of five episodes:
asthma (acute exacerbation), perinatal,
COPD exacerbation, PCI, and joint
replacement
▪ Payers agree to participate in design
process, launch reporting on at least
3 of 5 episodes in 2014 and tie to
payment within year
▪ Model rolled out to all major markets
▪ 50% of patients are enrolled
▪ 20 episodes defined and launched across payers
▪ Scale achieved state-wide
▪ 80% of patients are enrolled
▪ 50+ episodes defined and launched across payers
State’s Role▪ Shift rapidly to PCMH and episode model in Medicaid fee-for-service▪ Require Medicaid MCO partners to participate and implement▪ Incorporate into contracts of MCOs for state employee benefit program
5-Year Goal for Payment Innovation
Appendix
38
Process and Milestones
Milestone #1: Budget
Record actual CPC funding and expenditures from previous
program year and complete annotated annual budget with
anticipated revenue and spending for upcoming program year.
Milestone #2: Provide care management for high-risk
patients
Empanel active patients to a provider/care team, stratify
patients by risk status, and implement one or more of the
following advanced primary care strategies: Behavioral Health
Integration, Medication Management, and Self-Management
Support for 3 high risk conditions.
Milestone #3: 24/7 Access to medical record and
continuity
Expand access to medical record outside of office hours,
implement an asynchronous form of communication, and
measure visit continuity of patients with their empaneled
provider.
Milestone #4: Assess and improve patient experience of
care
Assess patient experience by conducting monthly practice-
based surveys or convening a patient and family advisory council
at least quarterly.
• Process
Measures/Milestones
Milestone #5: Data-Driven Quality Improvement
Use EHR Clinical Quality Metric (CQM) data to perform continuous
quality improvement on 3 such measures and use health plan data to
identify and reduce a high cost area.
Milestone #6: Coordination Across the Medical Neighborhood
Implement two of the following: Track % of patients receiving a follow-
up call within 1 week of an ED visit, Contact at least 75% of patients
discharged from target hospital(s) within 2 business days or 72hrs.
Milestone #7: Shared Decision Making
Use at least 3 decision aids to support shared decision making for
preference-sensitive conditions and track the amount of eligible patients
receiving those decision aids.
Milestone #8: Participation in the Learning Collaborative
Fully engage and cooperate with Regional Learning Faculty, participate
in webinars and attend all CPC Learning Sessions in their region.
Milestone #9: Health Information Technology
All eligible professionals must work toward attestation of Meaningful
Use stages 1 and 2 in the timelines set by the EHR incentive program.
Patients in CPC
40
Aligned Measures List
Domain NQF
Number
Measure Title Measure
Steward
Rationale for Inclusion
Patient/Caregiver
Experience
0005 CG-CAHPS: Getting Timely Care,Appointments, and Information; How Well Your Doctors Communicate; Patients'Rating of Doctor; Access to Specialists; Health Promotion and Education; Shared Decision Making
AHRQ CMS CPC Measure
Patient/CaregiverExperience
0006 CAHPS: Health Status/Functional Status AHRQ CMS CPC Measure
Domain NQF
Number
Measure Title Measure
Steward
Rationale for Inclusion
CareCoordination
1768 All-Cause Unplanned Readmission NCQA CMS CPC Measure
CareCoordination N/A
Ambulatory Sensitive Conditions Admissions: Overall Composite (AHRQ Prevention Quality Indicator PQI #90)
AHRQ CMS CPC Measure
CareCoordination
0275 Ambulatory Sensitive ConditionsAdmissions: Chronic Obstructive Pulmonary Disease (AHRQ Prevention Quality Indicator PQI #5 )
AHRQ CMS CPC Measure
CareCoordination
0277 Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure(AHRQ Prevention Quality Indicator PQI#8 )
AHRQ CMS CPC Measure
Clinical Process/Effectiveness
0058, 0052,N/A
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis, Imaging for Low Back Pain, and/or Imaging for Non-complicated Headache
HEDIS Choosing Wisely
Survey-based Quality Measures
Claims-based Quality Measures
Aligned Measures List
EHR-based Quality Measures
Domain NQF Number Measure Title
Clinical Process/Effectiveness
0018 Controlling High Blood Pressure
Population/Public Health
0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Clinical Process/Effectiveness
N/A Breast Cancer Screening
Clinical Process/Effectiveness
0034 Colorectal Cancer Screening
Population/Public Health
0041 Preventive Care and Screening: Influenza Immunization
Clinical Process/Effectiveness
0043 Pneumonia Vaccination Status for Older Adults
Clinical Process/Effectiveness
0059 Diabetes: Hemoglobin A1c Poor Control
Clinical Process/Effectiveness
0064 Diabetes: Low Density Lipoprotein (LDL) Management
Clinical Process/Effectiveness
0075 Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
Clinical Process/Effectiveness
0083 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Patient Safety 0101 Falls: Screening for Future Fall Risk
Population/Public Health
0418 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Patient Safety 0419 Documentation of Current Medications in the Medical Record
*Practices Report 9 of 13
Domain NQF
Number
Measure Title Measure
Steward
Rationale for Inclusion
Care
Coordination
1768
All-Cause Unplanned Readmission NCQA NCQA PCR Measure
Care
Coordination N/A Ambulatory Sensitive Conditions
Admissions: Overall Composite (AHRQ
Prevention Quality Indicator PQI #90)
AHRQ CMS CPC Measure
Care
Coordination
0275
Ambulatory Sensitive Conditions
Admissions: Chronic Obstructive
Pulmonary Disease (AHRQ Prevention
Quality Indicator PQI #5 )
AHRQ CMS CPC Measure
Care
Coordination
0277
Ambulatory Sensitive Conditions
Admissions: Congestive Heart Failure
(AHRQ Prevention Quality Indicator
PQI #8 )
AHRQ CMS CPC Measure
Clinical
Process/
Effectiveness
LBP Use of Imaging Studies for Low
Back Pain
HEDIS HEDIS
Claims-based Quality Measures
OH/KY Data Aggregation Measures
OH/KY Data Aggregation Measures
Cost and Utilization Measures
Source Measure Title
IHA P4P Manual claims
Total Cost PMPY
claims Total Prescription PMPY
IHA P4P Manualclaims
Inpatient PMPY
IHA P4P Manualclaims
Emergency Department PMPY
IHA P4P Manualclaims
Hospital discharges/1000
IHA P4P Manualclaims
Hospital days/1000
IHA P4P Manual claims
ED Visits/1000
claimsPCP visits/1000 and PCP Cost PMPY
claimsSpecialist visits/1000 and Specialty Costs PMPY
Webinar Learning SessionJuly 22, 2015
www.hcgc.org
Please share your questions throughout the session by using the webinar chat feature, or by
texting them to (614)906-2440
Webinar Learning SessionJuly 22, 2015
www.hcgc.org
Thanks to Dr. Shonk and Dr. Tobias for sharing learning
from SW Ohio!
Please respond to a brief online survey!
Please join us on August 21st.Register at www.hcgc.org
August 21st In-Person Learning SessionPopulation Health Management: Why it matters,
How it's done, What's next?Featured Speaker: Pamela Peele, PhD, Chief Analytics Officer,
University of Pittsburgh Medical Center (UPMC) Health Plan
Regional Panel David Applegate, MD, Chief, Primary Care
Transformation, OhioHealth Physician Group Arick Forrest, MD, Medical Director,
Ambulatory Services, The Ohio State University Wexner Medical Center
Tricia Schmidt, Client Advocate, Willis of Ohio
Ben Shaker, Vice President and COO, Mount Carmel Health Partners
King Stumpp, President and CEO, Netcare Access
Bruce Wall, MD, Senior Medical Director, Aetna