Partnership HealthPlan of California

Partnership HealthPlan of CaliforniaPrograms to Improve CareRobert Moore, MD MPHChief Medical Officer

Aligned ValuesQualityAccessValue

Provider satisfactionMember satisfactionServing the communityComparing to Values of FQHCs

2Improving CareQuality Programs

Care Coordination Programs

Partnership HealthPlan of CaliforniaQuality ProgramsQuality Improvement Incentive Program (Pay for Performance)Quality Assurance ProgramsPeer ReviewData Analysis and FeedbackQI ProjectsConvening of peer networks/collaborative learning efforts/educational eventsCultural and Linguistic Quality4Quality Improvement Incentive ProgramPrinciplesTypesCategoriesFunds: Compared to other plans.Related to PPSRelated to PCMH Measures.An ExampleQIP PrinciplesCollaboration with ProvidersSimplicity in the number of measuresActionableFeasible data collectionSizeable IncentivesComprehensive measurement setAlign measures that are meaningfulPay for Exceptional Performance and ImprovementStable measuresDistribute 100% of Fixed PMPM FundsCollaboration with Providers: The QIP is designed in partnership with PHCs primary care provider community.Simplicity in the Number of Measures: A set of core measures is developed to encourage focused improvements and greater performance levels.Actionable: Measures can be impacted by provider sites. Feasible data collection: Data can be collected administratively with minimal to no burden on providers and PHC.Sizeable Incentives: Incentives will be significant to encourage providers to focus energy on improvement and to justify investment in system changes. Comprehensive measurement set: Balanced set of measures to evaluate patient care including measures of clinical quality, patient experience, appropriate use of resources, and operational quality and access.Align measures that are meaningful: Align measures with those collected for Meaningful Use, UDS, Patient-Centered Medical Home Certification, HEDIS, RPMS and IHAs Pay for Performance program. Pay for Exceptional Performance and Improvement: Rewards will be based on meeting high performance thresholds or demonstrating significant improvement. Stable measures: Use existing measures for sequential years and when major changes or new measures are proposed, pay for reporting rather than outcomes. Distribute 100% of Fixed PMPM Funds: Since the global pool available for quality benchmarks is set, lower scores for one provider will not lead to money saved for Partnership, but rather more money for higher scoring providers or providers with greater improvements. 6QIP typesFixed Pool PMPMSet amount of dollarsAll dollars given outOne providers low performance means more money to higher performers

Unit of Service MeasuresPayment for completion of ProjectPayment for discrete actionsQIP CategoriesClinical Measures: 35%Appropriate Use of Resources: 35%Access: 20%Patient Experience: 10%

Size of the QIPLargest of any HealthPlan in California5 other County Organized Health Systems10 Local Initiatives5 Private HealthPlansAlignment with PCMH51% of points of fixed pool PMPM are for measures that impact PCMH status

8 out of 9 unit of service measures are related to PCHHHow is PPS affected?How does Capitation affect PPS?

How does fee for service affect PPS?

How does Quality Improvement Incentive Program affect PPS?

How do risk pool payments affect PPS?QIP example: Medium Sized FQHC: Visit IncomeHealth Center Budget: $500,000 per month ($6 million/yr)Unfavorable Payer mix: 25% Partnership MediCalAbout 4000 Capitated Patients: 70% Adults, 30% ChildrenCapitation Check: About $50,000 per monthVisits per month: 1000 by Capitated Patients400 by Special Members (Non-capitated): Paying $30 per visitPPS Rate: $150 per visitTotal Monthly Income from PPS Visits: $210,000Balance of PPS Rate Paid by State: $210K-$50K-12K / 1400 Visits= $105 per visit

QIP example:Medium Sized FQHC: Other incomeNot subject to PPS limit:

QIP: Fixed Pool: $4 PMPM allocated100% of points awardedAverage score of all providers 80%Effective payout $4.80 PMPMEqual to $230,400 per year, or $19,200 per monthOther QIP Income: $66,000 per year or $5500 per monthSpecial Member Risk Pool: $48,000 per year or $4000 per month

QIP ExampleMedium Sized FQHC: Grand totalVisit Income from Cap: $50,000 per month Other Income from PHC: $28,700 per monthPPS wraparound from state: $160,000 per month

Total $238,700 per month$170.50 per visit48% of budget

QIP ExampleMedium Sized Health CenterInvesting QIP money:Staff incentive or reward programHire chronic disease case managers Womens health DiabetesAllocate staff time to QIP activities:In-reachOrganizing formsProvider and Staff Education on Topics affecting QIPReviewing list of patients that went to Emergency Room each DayCase managing patients in hospital/discharged from hospitalData AnalysisQIP coordinating committeeCare Coordination ActivitiesTransportation BenefitGrowing Together Program (Perinatal)Care Transitions

Case ManagementComplex Case Management (telephonic)Intensive Case Management (in-person)Home Visiting Nurse Practitioner Program16Drivers of high hospital costsTop 1-5% of patients by total cost drive most hospital costs

Inappropriate care in severely ill individualsExcess specialty carePatients with poorly controlled substance abuse, mental health problems with serious chronic medical illness

Major theme: need better care and more coordinationTop 1% of patients: 20% of health care expendituresTop 5% of patients: 55% of health care expenditures17

Severity-specific Care CoordinationHomebound, frail, labile health, very high costs Clinician home visits, reliable on callFrequent hospitalizations, medical and behavioral issues0.1%3%Intensive case management7%Complex Case ManagementCase Management20%70%Primary CareChronically Ill, 3 modifiable conditionsNeed specific, short-term supportWell, or stable chronic illness18Case I: 50 yo woman from VallejoHealth Plan Contracted outside FNP agencyHome Visit BasedHome Bound patient

Patient with COPD: acute exacerbationPCP: Clinic that doesnt do Home Visits, has poor phone access, poor appointment accessReadmission rate decrease

19Barriers to Care Coordination for patients at homeClinic culture that is provider-centric instead of patient centric

Unable to come up with system to pay for home care

Links with ER doctors and hospitalistsUsing primary care to radically reduce health care spending and improve quality requires a lot of cooperation from two physician groups: ER doctors and hospitalists."You need to be able to rely on ER physicians to alert you when they're seeing your patient and and not admit unnecessarily," Milstein said, "and on hospitalists to help you understand what it was about the prior care that failed and caused the patient's admission to the hospital." (Project Director/Milstein)20Case Study II: 40 yo woman with diabetes Plan based telephonic case managementNurse-navigator teamsRemote care, patient at home

3 or more chronic medical conditions with 2 or more modifiable risk factors, willingness to participate/change, OK with telephonic case management.

Partnership HealthPlan currently has a telephonic complex case management program with nurses and health navigators, based on Care Oregon Model. For patients amenable to telephonic case managers, this system works well and has been demonstrated to decrease hospital re-admissions and a positive return on investment. Psychosocial support plays a key role. A major gap in this program is that patients who have unstable housing situation or telephone coverage or trust issues cannot be managed telephonically.

21Atul Gawandes Hot Spotters articleCare Oregons case managers embedded in PCP office/clinicMonarch Health: non-integrated high-risk touch teamHealthCare Partners: Embedded Complex Case ManagementWellpoint: pay for care plan submissionIntensive Case Management Evidence BaseAs outlined by Atul Gawande's January 2011 article "Hot Spotters", a small number of patients are responsible for considerable health care expenditures, and intensive case management using unconventional means can result in marked improvement of quality of care, quality of life and marked decreases in costs of care.

Care Oregon tried funding health centers to use RNs funded as case manager for highest cost patients, but discontinued the program, not able to demonstrate ROI, partly related to RNs not focusing only on Health Plans high cost patients. Their current model is to use non-clinical case managers with strong background in community collaboration/community organization to do this case management. They are paid for by the health plan but embedded in the community health centers.

Monarch health: High risk touch team program: Began with high risk clinic for transition out of hospital back to primary care (transition of care program). LCSW, Geriatric NP, Geriatrician: low utilization of clinic, because wanted to see PCP. Other models have hospitalists from hospital. Even with inreach in hospital, not much better. Not integrated with hosp or PCP (because run by health Plan), project stopped.HealthCare Partners: High Risk programs, complex case management Top 5% of utilizers change from year to year, but responsible for 55% of cost. Looking forward: decreased admit rate in year coming up among those with most conditions, due to Death, disability, disenrollment (including hospice). High risk patients referred by inpatient case managers. Focus on motivational interviewing: when to call the doctor, education when should call. Site based care management: tried in sites with good admit rates and poor admit rates. Added RN CM, non-clinical patient coach to the site focused on the panel, in outpatient setting. New program, no data yet.

22Contracted Services Model: $100,000 of funding to the health center/clinic which will hire, train and oversee case manager. Embedded Case Manager Model: Partnership HealthPlan Hires a Case manager who will be embedded in the health center/clinic$5,000 of funding to health center/clinic to cover collateral expenses. Integrated Care Team Case Management:$100,000 of funding to support training many case managers, each based in a primary care teamAll Models:focusing on 50 high-cost and complex patients who are primary care patients at the health center/clinic

Intensive Case ManagementIntensive Case Management PrinciplesFunded through Payer, by savingsReduce Readmissions and Inappropriate AdmissionsTarget highest cost patientsWork with PCPIn person case managementAccountability: Care Plan submissionRole of Integrators in triple aimMicro integrator

Macro integrator

Macrointegrator: COHS, with stakeholder governance

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Questions?

Partnership HealthPlan Leadership TeamTopics for Afternoon:Pharmacy transition96% of $ back to communityPhysician advisory committee: TeleconferenceGovernance/BoardRural Hospital 27