Partnership HealthPlan of California

1. Partnership HealthPlan of California Programs to Improve Care Robert Moore, MD MPH Chief Medical Officer

2. Aligned Values • Quality • Access • Value • Provider satisfaction • Member satisfaction • Serving the community

3. Improving Care • Quality Programs • Care Coordination Programs Partnership HealthPlan of California

4. Quality Programs • Quality Improvement Incentive Program (Pay for Performance) • Quality Assurance Programs • Peer Review • Data Analysis and Feedback • QI Projects • Convening of peer networks/collaborative learning efforts/educational events • Cultural and Linguistic Quality

5. Quality Improvement Incentive Program • Principles • Types • Categories • Funds: Compared to other plans. • Related to PPS • Related to PCMH Measures. • An Example

6. QIP Principles • Collaboration with Providers • Simplicity in the number of measures • Actionable • Feasible data collection • Sizeable Incentives • Comprehensive measurement set • Align measures that are meaningful • Pay for Exceptional Performance and Improvement • Stable measures • Distribute 100% of Fixed PMPM Funds

7. QIP types • Fixed Pool PMPM • Set amount of dollars • All dollars given out • One provider’s low performance means more money to higher performers • Unit of Service Measures • Payment for completion of Project • Payment for discrete actions

8. QIP Categories • Clinical Measures: 35% • Appropriate Use of Resources: 35% • Access: 20% • Patient Experience: 10%

9. Size of the QIP • Largest of any HealthPlan in California • 5 other County Organized Health Systems • 10 Local Initiatives • 5 Private HealthPlans

10. Alignment with PCMH • 51% of points of fixed pool PMPM are for measures that impact PCMH status • 8 out of 9 unit of service measures are related to PCHH

11. How 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?

12. QIP example: Medium Sized FQHC: Visit Income • Health Center Budget: $500,000 per month ($6 million/yr) • “Unfavorable” Payer mix: 25% Partnership MediCal • About 4000 Capitated Patients: 70% Adults, 30% Children • Capitation Check: About $50,000 per month • Visits per month: • 1000 by Capitated Patients • 400 by “Special Members” (Non-capitated): Paying $30 per visit • PPS Rate: $150 per visit • Total Monthly Income from PPS Visits: $210,000 • Balance of PPS Rate Paid by State: • $210K-$50K-12K / 1400 Visits= $105 per visit

13. QIP example:Medium Sized FQHC: Other income • Not subject to PPS limit: • QIP: Fixed Pool: $4 PMPM allocated • 100% of points awarded • Average score of all providers 80% • Effective payout $4.80 PMPM • Equal to $230,400 per year, or $19,200 per month • Other QIP Income: • $66,000 per year or $5500 per month • Special Member Risk Pool: • $48,000 per year or $4000 per month

14. QIP ExampleMedium Sized FQHC: Grand total • Visit Income from Cap: $50,000 per month • Other Income from PHC: $28,700 per month • PPS wraparound from state: $160,000 per month • Total $238,700 per month • $170.50 per visit • 48% of budget

15. QIP ExampleMedium Sized Health Center • Investing QIP money: • Staff incentive or reward program • Hire chronic disease case managers • Women’s health • Diabetes • Allocate staff time to QIP activities: • In-reach • Organizing forms • Provider and Staff Education on Topics affecting QIP • Reviewing list of patients that went to Emergency Room each Day • Case managing patients in hospital/discharged from hospital • Data Analysis • QIP coordinating committee

16. Care Coordination Activities • Transportation Benefit • Growing Together Program (Perinatal) • Care Transitions • Case Management • Complex Case Management (telephonic) • Intensive Case Management (in-person) • Home Visiting Nurse Practitioner Program

17. Drivers of high hospital costs • Top 1-5% of patients by total cost drive most hospital costs • Inappropriate care in severely ill individuals • Excess specialty care • Patients with poorly controlled substance abuse, mental health problems with serious chronic medical illness • Major theme: need better care and more coordination

18. Severity-specific Care Coordination Clinician home visits, reliable on call Homebound, frail, labile health, very high costs 0.1% Frequent hospitalizations, medical and behavioral issues Intensive case management 3% Chronically Ill, 3 modifiable conditions Complex Case Management 7% Need specific, short-term support Case Management 20% Well, or stable chronic illness Primary Care 70%

19. Case I: 50 yo woman from Vallejo • Health Plan Contracted outside FNP agency • Home Visit Based • Home Bound patient

20. Barriers to Care Coordination for patients at home • Clinic 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 hospitalists

21. Case Study II: 40 yo woman with diabetes • Plan based telephonic case management • Nurse-navigator teams • Remote care, patient at home

22. Intensive Case Management – Evidence Base • Atul Gawande’s “Hot Spotters” article • Care Oregon’s case managers embedded in PCP office/clinic • Monarch Health: non-integrated “high-risk touch team” • HealthCare Partners: Embedded Complex Case Management • Wellpoint: pay for care plan submission

23. Intensive Case Management • Contracted 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 team • All Models: • focusing on 50 high-cost and complex patients who are primary care patients at the health center/clinic

24. Intensive Case Management Principles • Funded through Payer, by savings • Reduce Readmissions and Inappropriate Admissions • Target highest cost patients • Work with PCP • In person case management • Accountability: Care Plan submission

25. Role of Integrators in triple aim • Micro integrator • Macro integrator

27. Questions? Partnership HealthPlan Leadership Team