Arkansas Payment Improvement Initiative (APII) Attention Deficit/Hyperactivity Disorder (ADHD) Statewide Webinar Novem

1. Arkansas Payment Improvement Initiative (APII) Attention Deficit/Hyperactivity Disorder (ADHD) Statewide Webinar November 14, 2012 0

2. Contents • Angela Littrell, Medicaid Health Innovation Unit Infrastructure Development and Implementation Manager - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Dr. William Golden, Medicaid Medical Director – ADHD Providers , Patients & Quality • Wanda Colclough and Paula Miller – HP Enterprises Technical Consultant and HP APII Analyst - Episode Descriptions & Reports • Patricia Gann – ValueOptions, Program Director - Portal & Certifications

3. Today, we face major health care challenges in Arkansas • The health status of Arkansans is poor, the state is ranked at or near the bottom of all states on national health indicators, such as heart disease and diabetes • The health care system is hard for patients to navigate, and it does not reward providers who work as a team to coordinate care for patients • Health carespending is growing unsustainably: • Insurance premiums doubled for employers and families in past 10 years (adding to uninsured population) • Large projected budget shortfalls for Medicaid

4. Our vision to improve care for Arkansas is a comprehensive, patient-centered delivery system… Focus today Objectives • Improve the health of the population • Enhance the patient experience of care • Enable patients to take an active role in their care For patients • Reward providers for high quality, efficient care • Reduce or control the cost of care For providers How care is delivered • Population-based care • Medical homes • Health homes • Episode-based care • Acute, procedures or defined conditions 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

5. 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

6. Medicaid and private insurers believe paying for results, not just individual services, is the best option to improve quality and control costs  • Transition to payment system that rewards value and patient health outcomes by aligning financial incentives • Reduce payment levels for all providers regardlessof their quality of care or efficiency in managing costs  • Pass growing costs on to consumers through higher premiums, deductibles and co-pays (private payers), or higher taxes (Medicaid)  • Intensify payer intervention in decisions though managed care or elimination of expensive services (e.g. through prior authorizations) based on restrictive guidelines  • Eliminate coverage of expensive services or eligibility 

7. We have worked closely with providers and patients across Arkansas to shape an approach and set of initiatives to achieve this goal • Providers, patients, family members, and other stakeholders who helped shape the new model in public workgroups 500+ • Public workgroup meetings connected to 6-8 sites across the state through videoconference 21 • Months of research,data analysis, expert interviews and infrastructure developmentto design and launch episode-based payments 16 • Updates with many Arkansas provider associations (e.g., AHA, AMS, Arkansas Waiver Association, Developmental Disabilities Provider Association) Monthly

8. The goal Accountability Incentives The episode-based model is designed to reward coordinated, team-based high quality care for specific conditions or procedures • Coordinated, team based carefor all services related to a specific condition, procedure, or disability (e.g., pregnancy episode includes all care prenatal through delivery) • A provider ‘quarterback’, or Principal Accountable Provider (PAP) is designated as accountable for all pre-specified services across the episode (PAP is provider in best position to influence quality and cost of care) • High-quality, cost efficient care is rewarded beyond current reimbursement, based on the PAP’s average cost and total quality of care across each episode

9. Contents • Angela Littrell, Medicaid Health Innovation Unit Infrastructure Development and Implementation Manager - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Dr. William Golden, Medicaid Medical Director – ADHD Providers , Patients & Quality • Wanda Colclough and Paula Miller – HP Enterprises Technical Consultant and HP APII Analyst - Episode Descriptions & Reports • Patricia Gann – ValueOptions, Program Director - Portal & Certifications

10. Wave 2 launch • In the first half of 2013, will launch four new medical episodes: Cholecystectomy (gallbladder removal), Tonsillectomy, Colonoscopy, and Oppositional Defiant Disorder • We are aiming to launch the next set of episodes in mid-2013. Some possibilities include: • Cardiac care • Orthopedic care: back pain, joint arthroscopy • Behavior health: Depression, Bipolar Disorder • Other specialty procedures: dialysis, hysterectomy • Stroke • NICU • Preschool children with developmental delays • We will launch Long Term Support Services (LTSS) and Developmental Disability (DD) episodes. The assessment period for DD will begin this month, and for LTSS will begin in the first quarter of 2013. • We also plan to launch Patient Centered Medical Homes and Health Homes for Behavioral Health.

11. Upcoming working groups Episode Public Working group Date & Time Oppositional Defiant Disorder Nov 20, 2012, 2:30-4:30 pm Cholecystectomy Nov 26, 2012, 4:00-6:00 pm Colonoscopy Nov 28, 2012, 5:00-7:00 pm Tonsillectomy Dec 4, 2012, 4:00-6:00 pm

12. Performance period updates Topic Stakeholder message Wave 1b preparatory period The performance period for Congestive Heart Failure and Total Joint Replacement (hip & knee replacement) will start on February 1, 2013. Providers will not be evaluated based on performance prior to that date. Providers will still receive their first full performance report reflecting settlement for risk and gain sharing payments in April 2014. • Current or Upcoming Performance Period • Episode URI Oct 1, 2012 to Sept 30, 2013 Perinatal Oct 1, 2012 to Sept 30, 2013 ADHD performance period The performance period for ADHD will end on December 31, 2013. Providers will still be evaluated based on performance starting on October 1, 2012, and the ADHD episode length remains unchanged at 12 months. Providers will receive their first full performance report reflecting settlement for risk and gain sharing payments in April 2014. ADHD Oct 1, 2012 to Dec 31, 2013 CHF Feb 1, 2013 to Dec 31, 2013 TJR Feb 1, 2013 to Dec 31, 2013 Performance periods Performance period dates for certain upcoming episodes and all active episodes can be found on the website.

13. Questions

14. Contents • Angela Littrell, Medicaid Health Innovation Unit Infrastructure Development and Implementation Manager - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Dr. William Golden, Medicaid Medical Director – ADHD Providers , Patients & Quality • Wanda Colclough and Paula Miller – HP Enterprises Technical Consultant and HP APII Analyst - Episode Descriptions & Reports • Patricia Gann – ValueOptions, Program Director - Portal & Certifications

15. Core provider for episode Episode ‘Quarterback’ Performance management The model rewards a Principal Accountable Provider (PAP) for leading and coordinating services and ensuring quality of care across providers What it means… PAP role • Physician, practice, hospital, or other provider in the best position to influence overall quality, cost of care for episode • PAP selection: • Payers review claims to see which providers patients chose for episode related care • Payers select PAP based main responsibility for the patient’s care • Leads and coordinates the team of care providers • Helps drive improvementacrosssystem (e.g., through care coordination, early intervention, patient education, etc.) • Rewarded forleading high-quality, cost-effective care • Receives performance reports and datato support decision-making NOTE: Episode and health home model for adult DD population in development. Model will utilize lead provider and health home to drive coordination

16. Ensuring high quality care for every Arkansan is at the heart of this initiative, and is a requirement to receive performance incentives Two types of quality metrics for providers Description 1 Quality metric(s) “to pass” are linked to payment • 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) 2 Quality metric(s) “to track” are not linked to payment • Key to understand overall quality of care and quality improvement opportunities • Shared with providers but not linked to payment

17. How episodes work for patients and providers (1/2) Patients and providers deliver care as today (performance period) 1 2 3 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

18. How episodes work for patients and providers (2/2) Payers calculate average cost per episode for each PAP1 Compare average costs topredetermined ‘’commendable’ and ‘acceptable’ levels2 • Based on results, providers will: • Share savings: if average costs below commendable levels and quality targets are met • Paypart of excesscost: if average costs are above acceptable level • See no change in pay: if average costs are between commendable and acceptable levels 6 4 5 Calculate incentive payments based on outcomes after close of 12 month performance period Review claims from the performance period to identify a ‘Principal Accountable Provider’ (PAP) for each episode 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

19. Shared savings No change PAPs that meet quality standards and have average costs below the commendable threshold will share in savings up to a limit Pay portion of excess costs - Shared costs High No change in payment to providers Acceptable Receive additional payment as share as savings + Commendable Gain sharing limit Low Individual providers, in order from highest to lowest average cost

20. Contents • Angela Littrell, Medicaid Health Innovation Unit Infrastructure Development and Implementation Manager - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Dr. William Golden, Medicaid Medical Director – ADHD Providers , Patients & Quality • Wanda Colclough and Paula Miller – HP Enterprises Technical Consultant and HP APII Analyst - Episode Descriptions & Reports • Patricia Gann – ValueOptions, Program Director - Portal & Certifications

21. Version 1.0 design elements specific to ADHD Episode definition/ scope of services • Any ADHD treatment (defined by primary diagnosis ICD-9 code), with exception of assessment CPT codes, is included in the episode • Start of episode • For new patients, episode begins on date of treatment initiation • For recurring patients, new episode starts on date of first treatment after previous episode ends (e.g. office visit or Rx filled) • The episode will have a duration of 12 months 1 Principal accountable provider(s) • PCP, psychiatrist or licensed clinical psychologist eligible to be the PAP • For Version 1.0, RSPMI provider organization will be official PAP when listed as billing provider, but reporting will be provided at performing provider level where available • If licensed clinical psychologist treats patient, a co-PAP is required and providers share gain / risk sharing 2 Patient severity levels and exclusions • Includes all ADHD patients aged 6 – 17 without behavioral health comorbid conditions1 • Two patient severity levels will be included • Patients with positive response to medication management, requiring only medication and parent / teacher administered support • Patients for whom response to medication management is inadequate and therefore psychosocial interventions are medically indicated • Severity will be determined by a provider certification 3 • 4 – 5 year olds will continue to be paid fee-for-service in version 1.0 because of limited evidence-based treatment guidelines and consensus • Level II episodes will not be available in July due to lack of data from the provider portal. Level II episodes started on October 2012

24. PAPs will be provided tools to help measure and improve patient care Example of provider reports • Reports provide performance information for PAP’s episode(s): • Overview of quality across a PAP’s episodes • Overview of cost effectiveness (how a PAP is doing relative to cost thresholds and relative to other providers) • Overview of utilization anddrivers of a PAP’s average episode cost NOTE: Episode and health home model for adult DD population in development. Tools and reports still to be defined.

25. PAP performance reports have summary results and detailed analysis of episode costs, quality and utilization Details on the reports • First time PAPs receive detailed analysis on costs and quality for their patients increasing performance transparency • Guide to Reading Your Reports available online and at this event • Valuable to both PAPs and non-PAPs to understand the reports • Reports issued quarterly starting July 2012 • July 2012 report is informational only • Gain/risk sharing results reflect claims data from Jan – Dec 2011 • Reports are available online via the provider portal NOTE: Episode and health home model for adult DD population in development. Tools and reports still to be defined.

26. Medicaid Acme Clinic July 2012 Arkansas Health Care Payment Improvement Initiative Provider Report Medicaid Report date: July 2012 Historical performance: January 1, 2011 – December 31, 2011 DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports is neither intended nor suitable for other uses, including the selection of a health care provider. For more information, please visit www.paymentinitiative.org

27. Medicaid Acme Clinic July 2012 Performance summary Upper Respiratory Infection – Pharyngitis Upper Respiratory Infection – Sinusitis Upper Respiratory Infection – Non-specific URI Perinatal Attention Deficit/Hyperactivity Disorder (ADHD) Total Joint Replacement Congestive Heart Failure Glossary Appendix: Episode level detail Table of contents

28. Acme Clinic Performance Summary

29. Medicaid Acme Clinic July 2012 $1,547 to $2,223 < $1,547 > $2,223 ü Acceptable Not acceptable You Commendable Summary – ADHD 1 Overview Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29 2 Cost of care compared to other providers Gain/Risk share $0 Commendable Acceptable Not acceptable You > $4000 All providers You will not receive gain or risk sharing • Selected quality metrics: N/A • Average episode cost: Acceptable 3 Quality summary 4 Cost summary No quality metrics linked to gain sharing at this time Your average cost is acceptable Linked to gain sharing Your total cost overview, $ Average cost overview, $ Episodes with medication 592,985 592,985 2,545 2,142 100% There are no quality metrics linked to gain sharing generated from historical claims data. Provider certifications submitted on the Provider Portal since October 1, 2012 will generate additional quality metrics for future reports. 50% You (non-adjusted) You (adjusted) You All providers 0% Your episode cost distribution You Avg 100 # episodes 50 <$1500 $1500 - $2000 $2000-$2500 $2500-$3000 $3000-$3500 $3500-$4000 >4000 Distributionof provider average episode cost 3000 Cost, $ 2500 1000 Percentile 5 Key utilization metrics All providers You Average number of psychosocial visits per episode Average number of visits per episode 4.1 62 38

30. Medicaid Acme Clinic July 2012 Quality and utilization detail – ADHD You Metric linked to gain sharing Minimum standard for gain sharing Quality metrics: Performance compared to provider distribution Percentile Percentile Metric You 25th 50th 75th 0 25 50 75 100 % of episodes with medication 88% 50% 90% 98% No quality metrics linked to gain sharing at this time Utilization metrics: Performance compared to provider distribution Percentile Percentile Metric You 25th 50th 75th 0 25 50 75 100 Average number of visits per episode 4.1 2.3 3.9 4.3 Average number of psychosocial visits per episode 62 15 38 74

31. Medicaid Acme Clinic July 2012 Cost detail – ADHD Total episode included = 233 You All providers # and % of episodes with claims in care category Total vs. expectedcost in care category, $ Average cost per episode when care category utilized, $ Care category 233 Outpatient professional 100% 550 128,150 100% 500 116,500 230 99% 2,415 555,450 Pharmacy 99% 2,400 552,000 221 Emergency department 95% 76 16,796 97% 76 16,796 184 79% 81 14,904 Outpatient lab 77% 81 14,904 Outpatient Radiology / procedures 21 75% 117 2,457 80% 95 1,995 16 78% 70 1,120 Inpatient professional 75% 75 1,200 12 5% 69 828 Inpatient facility 3% 62 744 1 Outpatient surgery <1% 97 97 <1% 84 84 7 3% 25 175 Other 4% 27 189

32. Contents • Angela Littrell, Medicaid Health Innovation Unit Infrastructure Development and Implementation Manager - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Dr. William Golden, Medicaid Medical Director – ADHD Providers , Patients & Quality • Wanda Colclough and Paula Miller – HP Enterprises Technical Consultant and HP APII Analyst - Episode Descriptions & Reports • Patricia Gann – ValueOptions, Program Director - Portal & Certifications

33. The provider portal is a multi-payer tool that allows providers to enter quality metrics for certain episodes and access their PAP reports Details on the provider portal • Accessible to all PAPs • Login with existing username/ password • New users follow enrollment process detailed online • Key components of the portal are to provide a way for providers to • Enter additional quality metrics for select episodes (Hip, Knee, CHF and ADHD with potential for other episodes in the future) • Access current and past performance reports for all payers where designated the PAP Login to portal from payment initiative website NOTE: Episode and health home model for adult DD population in development. Tools and reports still to be defined.

34. Provider Portal

35. Provider Portal

36. Provider Portal

37. Provider Portal To obtain access to the AHIN provider portal On the login screen of the AHIN portal the provider can click the link - Click here to enroll for APII access if not a current AHIN user or contact Customer Support (501) 378-2336 or email customersupport@ahin.net

38. Provider Portal

39. Provider Portal To obtain access to the AHIN provider portal On the login screen of the AHIN portal the provider can click the link - Click here to enroll for APII access if not a current AHIN user or contact Customer Support (501) 378-2336 or email customersupport@ahin.net

40. Provider PortalDMS-IV Guidelines

41. Provider PortalDMS-IV Guidelines

42. Certification would be required at the key points in care: entry into system, episode recurrence, and increase in severity • Completion details • Description • For which patients? • Requires providers to certify completion of several guideline-concordant components of assessment • Encourages thoughtful and high-quality assessment and diagnosis • Encourages appropriate diagnosis of comorbid conditions ‘Quality Assessment’ certification • All patients new to treatment and entering episode model • Completed after assessment, to initiate treatment • Completed by provider who will deliver care A ‘Continuing care’ certification • All recurring ADHD patients within episode model • Completed at episode recurrence (every 12 months) • Completed by provider who will continue care • Requires providers to certify adherence to basic quality of care measures and guideline concordant care • Encourages regular re-evaluation of patient and management at physician level B ‘Severity’ certification • All patients escalated to level 2 care, whether first-time or recurring • Completed at initial escalation and every level two episode recurrence • Completed by provider who will deliver level two care • Requires providers to certify severity for patients placed into level two care • Completed by physician providing level two care C

43. Questions

44. For more information talk with provider support representatives… Online • More information on the Payment Improvement Initiative can be found atwww.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 Phone/ email • Medicaid: 1-866-322-4696 (in-state) or 1-501-301-8311 (local and out-of state) orARKPII@hp.com • Blue Cross Blue Shield: Providers 1-800-827- 4814, direct to EBI 1-888-800-3283, APIICustomerSupport@arkbluecross.com • QualChoice: 1-501-228-7111, providerrelations@qualchoice.com