Transforming Primary Care Practice: The Southeast Pennsylvania Rollout

1. Pennsylvania’s Chronic Care CommissionTransforming Primary Care Practice:The Southeast Pennsylvania Rollout Status as of May 12, 2008

2. The State of Primary Care in the USA • Research shows patients with PCPs have lower costs, but… • Primary care practitioners declining in numbers – failure to attract new graduates • Low reimbursement compared to non-PCP peers • Low satisfaction • Current primary care practice is reactive, often responding to acute episodes, resulting from poor self-management by patients with chronic illness • Access is inadequate • Emphasis is on issuing referrals and not on coordinating care • Minimal focus on patient education and no support staff for patients • Slow to adopt evidence-based medicine • Generally lower level of sophistication (EMR, support staff, etc.) • Minimal communication between providers

3. Chronic Care Commission Origins • Pennsylvania Chronic Care Management, Reimbursement and Cost Reduction Commission created by Governor Rendell’s Executive Order, May 2007. • First requirement was to develop a strategic plan for implementing the Chronic Care Model to improve the quality of care while reducing avoidable illnesses and their attendant costs.

4. Chronic Care CommissionStrategic Direction • The Commission developed and delivered a strategic plan to the Governor and Legislature in February 2008 to: • Begin regional rollouts using learning collaboratives, practice coaches and provider and consumer incentive alignment beginning with Southeast PA in May 2008 • The model is an integration of Chronic Care Model and the Patient- Centered Medical Home concepts.

5. “The Chronic Care Model” • Team-based coordinated care, with a focus on patients with chronic illness • Origin: Ed Wagner, McColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound • Improved care coordination • Cost reductions from averted admissions • Improved quality of care • Several existing state and national collaboratives, e.g., • Vermont’s “Blueprint for Health” • WA state - based on the IHI Breakthrough Series Model • HRSA implementation through Federally Qualified Health Centers across the U.S., including 16 in PA

6. What is the Chronic Care Model? Health System Community Health Care Organization Resources and Policies ClinicalInformationSystems DeliverySystem Design Self-Management Support Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

7. “The Patient-Centered Medical Home” (PCMH) • Origin: American Academy of Pediatrics • Now embraced by American Academy of Family Physicians, American College of Physicians and American Osteopathic Association • Several pilots in place and emerging around the country (NY, CO) • Features • Open access scheduling • Use of a registry or EMR to manage a population • Use of a team: Physician, CRNPs, case managers, health educators • Improved communication (telephonic, e-mail) • Decision support

8. Pennsylvania’s Chronic Care Commission • Organization: • 45 Commission members • Provider, insurer, state government agency, organized labor, academic and consumer representatives • Four subcommittees include Commission members, plus additional representatives from stakeholder organizations • Practice Redesign • Consumer Engagement • Incentive Alignment • Performance Measurement • Fifth subcommittee in 6-08: Pooled Claims Database • Staffed and facilitated by the Governor’s Office of Health Care Reform

9. Pennsylvania’s Chronic Care Commission • February 2008 strategic plan created a framework to guide rollout activities in the Commonwealth’s six region • Each regional rollout must adhere to the framework, but has room to vary its approach • A Southeast PA Regional Rollout Steering Committee crafted the following specific model. Other regions of the state need not use this specific model.

10. Requirements: GOHCR • Funding faculty and expenses for a year-long learning collaborative for participating primary care practices • Coordinating the flow of data and funds to practices • Providing ongoing project management support • Funding cost of registry (first rollout excluded due to lack of appropriations) • Funding data collection, evaluation and reporting activities through a contracted 3rd party

11. Requirements: Primary Care Practices • Participate in seven days of learning collaborative meetings in year 1: initial focus on diabetes and pediatric asthma • Work with an assigned practice coach between learning collaborative sessions to transform practice • Use a patient registry to track patients with chronic illness • Achieve Level 1 NCQA PPC-PCMH Recognition within 12 months • Report data from the patient registry and other sources required for evaluation purposes • Reinvest funds into the practice site, including for case management in those instances where the practice does not already have that resource in place • Three-year commitment

12. Requirements: Primary Care Practices • Most importantly, implement fundamental redesign of the practice for all patients, including, for example: • Using the registry to send patient reminders • Conducting planned visits to address all aspects of the patients conditions • Providing team-based care, using non-physician personnel to support the patient (education, care coordination, etc.) • Providing self-management support, involving the patient in goal setting, action planning, problem-solving and follow-up • Providing enhanced access to the care team • Performing population-based data analysis

13. What is NCQA PPC-PCMH Recognition? **Must Pass Elements

14. Requirements: Payers • Three-year commitment • Financial support – design follows Commission framework, but specific to the Southeast rollout. Payments proportional to the revenues paid to each practice by each of the payers • Payment to IPIP (Improving Performance in Practice) for Practice Coaches (1 for every 15 practices) @$130K per coach per year • Three-part provider payment model: • Infrastructure development • Enhancement to existing FFS or capitation payments • Pay-for-performance

15. Requirements: Payers • Infrastructure development payments • Licensing fee for registry, support for data entry to registry, cost of NCQA survey tool, NCQA application fee, and lost revenue for time to attend 7 days of learning collaborative meetings in the first year • Enhanced payments to FFS/capitation • For initial three years, lump sum payments aligned with stepwise achievement of the three levels of NCQA PPC-PCMH recognition • Pay-for-performance • Maintenance of existing program – common measures across insurers by 2010

16. Requirements: Payers • Derivation of infrastructure development payments: • Infrastructure Costs to Practice During the First Year • 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 to attend learning collab (7 days/year) $11,655/clinician

17. Requirements: Payers • Derivation of enhancement of FFS/capitation: • Informed by analysis of limited available estimates of practice costs to implement CCM/PCMH ($4-$9PMPM range – excluding EMR) and of existing CCM/PCMH programs and pilots • Commission recognized that it is likely that costs would vary based on practice size and configuration. Some existing modeling assumes a solo PCP practice, while RI assumes a small group practice. • Southeast PA model provides up to approximately $4PMPM for NCQA PPC-PCMH recognition, less Medicare FFS share of practice • Per clinician amount decreases as practice size increases

18. Estimated Practice Costs [1] "The Medical Home: Disruptive Innovation for a New Primary Care Model", Deloitte Center for Health Solutions, 2008.

19. Estimated Practice Costs • Miscellaneous Notes: • Bridges to Excellence’s new medical home program estimates annual savings of $245 savings per patient from a medical home, and has capped award payments to providers at $100,000 per year. • United HealthCare estimates the additional reimbursement to a primary care practice for implementing a Patient-Centered Medical Home at 20% above baseline reimbursement. [1] Allan Goroll et. al. "Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care", Journal of General Internal Medicine. 22(3): 410–415, March 2007.

20. Examples of Other CCM/PCMH Programs

21. Examples of Other CCM/PCMH Programs [1] Elbert Huang et. al. “The Cost-Effectiveness of Improving Diabetes Care in U.S. Federally Qualified Community Health Centers”, Health Services Research, 2007. [2] Bruce E. Landon et. al. “Improving the Management of Chronic Disease at Community Health Centers”, New England Journal of Medicine, 356;9, March 1, 2007.

22. Payment Triggered by NCQA PPC–PCMH Recognition Annualized revenue per full-time-equivalent practitioner from all sources for implementing the features of the PCMH recognizes economies of scale and the incremental resources to achieve full transformation of the practice to include all features, discounted by the % of practice revenue derived by Medicare FFS and insurers with low market share.

23. Requirements: Payers • Commission is still working on recommendations for payer strategies to better engage consumers in self-management. • Currently considering piloting consumer incentives. Also looking at benefit design changes.

24. Participants • 34 practices • representing 165 clinician FTEs • serving 176,000 patients • internal medicine, family practice, pediatrics and NP-led practices • combination of independent practices and those affiliated with one of three academic systems • almost half have or are implementing an EMR • size of applicant practice sites: • 3 practices of 1 physician • 16 practices of 2-4 physicians • 10 practices of 5-8 physicians • 3 practices of 10-20 physicians

25. Ambler Pediatrics Buckingham Family Practice Children’s Health Center (VNA Community Services) CHOP Primary Care @ South Phila. Crozer-Keystone Center for Family Health Crozer Medical Associates Eagle Family Medicine Center Edward S. Cooper Practice Family Medicine, Geriatrics & Wellness Family Practice & Counseling Network Founders Medical Practice Greenhouse Internists Holland Medical Associates Jefferson Family Medicine Associates Kids First Chestnut Hill Kids First HighPoint Lower Bucks Pediatrics Mary Howard Health Center Medical Group at Marple Commons Mt. Airy Family Practice Ninth Street Internal Medicine Assoc. North Willow Grove Family Practice North Willow Grove Pediatrics Penn-Care Bala Cynwyd PennCare Internal Medicine at Mayfair Pennsbury Medical Practice PHMC Health Connection Project Salud Quality Community Health Care, Inc Rising Sun Health Center Sayre Health Center Temple Pediatric Care Penn Medicine at Radnor Participating Practices

26. Participants • 6 payers • Aetna, AmeriChoice (Medicaid), CIGNA Healthcare, Health Partners (Medicaid), Independence Blue Cross, Keystone Mercy Health Plan (Medicaid) • UnitedHealthcare may still join as the 7th insurer • Insurers including commercial (insured and self-insured), Medicaid and Medicare Advantage business, • no Medicare FFS

27. Supporting Coalition • The Primary Care Coalition • The PA Academy of Family Physicians, the PA Chapter of the AAP, and the PA Chapter of the ACP. Together they are the RWJF IPIP grantee in PA. • IPIP practice coaches will assist with: • transforming the practice • data collection and reporting • linking practices to community resources

28. Evaluation • The Commission has approved an evaluation design utilized matched pairs of practices as a control group. • 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

29. Evaluation • As part of the evaluation, the Commission will utilize standardized measure sets and performance goals for diabetes, asthma and hypertension adopted by IPIP. • These measures are based on national measures as defined by AQA/NQF and NCQA/HEDIS.

33. Performance Reporting System • The Commission require practices to submit monthly performance data on these measures through IPIP. • The measures apply to the entire practice population (e.g., population management). • Easy to report data from Colorado registry system.

34. 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

35. Next Steps • Finalizing contract with evaluation contractor, and then completing work on evaluation design. • Beginning planning for next regional rollout in South Central Pennsylvania in the fall of 2008.

36. Contacts for Additional Information • Phil Magistro, PA GOHCR • pmagistro@state.pa.us • Michael Bailit, consultant to PA GOHCR • mbailit@bailit-health.com