Arkansas Payment Improvement Initiative (APII) ADHD Certification and Reports Statewide Webinar

1. Arkansas Payment Improvement Initiative (APII) ADHD Certification and Reports Statewide Webinar May 20, 2013 0

2. Contents • Dawn Zekis, Medicaid Health Innovation Unit Director - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Communications Coordinator – Initiative Update • Patricia Gann, TITLE– Value Options - Provider Portal & certification • Paula Miller – HP APII Analyst - Reports

3. Overview Arkansas aims to create a sustainable patient-centered health system Focus of presentation Objective • Accountability for the Triple Aim • Improving the health of the population • Enhancing the patient experience of care • Reducing or controlling the cost of care Care delivery strategies • Population-based care delivery • Risk stratified, tailored care delivery • Enhanced access • Evidence-based, shared decision making • Team-based care coordination • Performance transparency • Episode-based care delivery • Common definition of the patient journey • Evidence-based, shared decision making • Team-based care coordination • Performance transparency Enablinginitiatives Payment improvement initiative Health care workforce development Consumer engagement and personal responsibility Health information technology adoption SOURCE: State Innovation Plan

4. Providers, patients, family members, and other stakeholders who helped shape the new model in public workgroups Public workgroup meetings connected to 6-8 sites across the state through videoconference Months of research,data analysis, expert interviews and infrastructure developmentto design and launch episode-based payments Updates with many Arkansas provider associations (e.g., AHA, AMS, Arkansas Waiver Association, Developmental Disabilities Provider Association) 1,000+ 29 26 Monthly Key Design Elements We have worked closely with providers and patients across Arkansas to shape an approach and set of initiatives to achieve this goal

5. Episodes Update For Medicaid, work has occurred on 15 Episodes, with 5 having gone live Live Pending legislative review In Development • Wave 1 Wave 1a Seeking clinical input Wave 1b • Wave 2 Wave 2a Wave 2b Wave 2c (not started) 1 Participation includes development and rollout of episode

6. Contents • Dawn Zekis, Medicaid Health Innovation Unit Director - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Patricia Gann, TITLE– Value Options - Provider Portal & certification • Paula Miller – HP APII Analyst - Reports

7. Upcoming Workgroup Meetings • May 22nd 4pm-6pm: Neonatal #2 Public Workgroup • May 28th 3:30pm-5:30pm: Long Term Services and Supports Public Workgroup

8. Contents • Dawn Zekis, Medicaid Health Innovation Unit Director - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Patricia Gann, TITLE– Value Options - Provider Portal & Certification • Paula Miller – HP APII Analyst - Reports

9. 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.

10. Provider Portal

11. Provider Portal

12. Provider Portal

13. 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

14. Provider Portal

15. 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

16. Provider PortalDMS-IV Guidelines

17. Provider PortalDMS-IV Guidelines

18. 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

19. Contents • Dawn Zekis, Medicaid Health Innovation Unit Director - Overview of the Healthcare Payment Improvement Initiative • Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update • Patricia Gann, TITLE– Value Options - Provider Portal & Certification • Paula Miller – HP APII Analyst - Reports

20. 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

21. ADHD algorithm summary (1/2) Medicaid ADHD episode v1.0

22. ADHD algorithm summary (1/2) Medicaid ADHD episode v1.0 1 Please note that DD comorbid exclusions (ICD-9 299.xx, 315.xx, 317.xx, 318.xx, 319.xx) will not be applied until July 2013 release

23. 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.

24. Medicaid Little Rock Clinic 123456789 April 2013 Arkansas Health Care Payment Improvement Initiative Provider Report Medicaid Report date: April 2013 Historical performance: January 1, 2012 – December 31, 2012 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. The figures in this report are preliminary and are subject to revision. For more information, please visit www.paymentinitiative.org

25. Division of Medical Services P.O. Box 1437, Slot S-415 · Little Rock, AR 72203-1437 501-683-4120 · Fax: 501-683-4124 Dear Medicaid provider, This is an update on the Arkansas Health Care Payment Improvement Initiative (APII) – a payment system developed with input from hundreds of health care providers, patients and family members. Our goal is to support and reward providers who consistently deliver high-quality, coordinated, and cost-effective care. As a reminder, a core component of this multi-payer initiative is episodes of care. An episode is the collection of care provided to treat a particular condition over a given length of time. Since July of 2012, Arkansas Medicaid has introduced new episodes, including Upper Respiratory Infection (URI), Perinatal (colloquially, called “pregnancy”), Attention Deficit/Hyperactivity Disorder (ADHD), and more. To see the most up to date list of episodes visit the APII website at www.paymentinitiative.org. For each episode, the provider that holds the main responsibility for ensuring that care is delivered at appropriate cost and quality will be designated as the Principal Accountable Provider (PAPs). For some episodes in the period covered in the attached report, you were identified as the PAP. After appropriate risk-adjustments and exclusions, your average quality and cost was compared with previously announced thresholds. This determines any potential sharing of savings or excess cost indicated in the report. Note that all information described throughout your report is based on claims already submitted and all providers should continue to submit and receive reimbursement for claims as they do today. This report contains episodes currently in the ‘preparatory phase’ and so the data and analyses for these reports are historical only (i.e. they are not data from the time period that you will be measured against). To see “performance” reports (i.e., containing episodes eligible for gain or risk sharing) for episodes launched earlier, log onto the provider portal at www.paymentinitiative.org to download a separate report. To aid you in your role as a PAP for future episodes, we have been working hard with providers and other payers to design a set of reports that give you detailed data about the quality and cost of your care as well as how this compares with previously announced thresholds and the range of performance of other providers. As each payer will send a report covering their patients, you may receive similar reports from Arkansas Blue Cross Blue Shield and / or QualChoice. We encourage you to log onto the provider portal to access your current and previous ‘preparatory period’ and ‘performance period’ reports. As a PAP for select episodes, you should begin using this portal to enter selected quality metrics for each patient with an episode of care starting. To see which episodes have quality metrics linked to gain sharing visit the APII website. We have been working diligently to solicit feedback from the provider community and will continue in our efforts to respond to all questions, comments and concerns raised in a timely and consistent manner. For answers to frequently asked questions regarding the initiative and episodes, please refer to the payment initiative website (www.paymentinitiative.org) You can also call us at 1-866-322-4696 or locally at 501-301-8311 with questions or email ARKPII@hp.com. Additionally, be sure to check the website regularly for updates on upcoming informational WebEx sessions, other resources, or to sign up for alerts. Sincerely, Andy Allison, PhD Medicaid Director 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. These figures are preliminary and are subject to revision. For more information, please visit www.paymentinitiative.org. 24

26. Medicaid Little Rock Clinic 123456789 April 2013 Table of contents Performance summary Attention Deficit/Hyperactivity Disorder (ADHD) – Level I Attention Deficit/Hyperactivity Disorder (ADHD) – Level II Cholecystectomy Colonoscopy Congestive Heart Failure Oppositional Defiant Disorder Perinatal Tonsillectomy Total Joint Replacement Upper Respiratory Infection – Non-specific URI Upper Respiratory Infection – Pharyngitis Upper Respiratory Infection – Sinusitis Glossary Appendix: Episode level detail

27. Medicaid Little Rock Clinic 123456789 April 2013 Attention Deficit / Hyperactivity Disorder (ADHD) – Level II Not eligible for gain sharing Upper Respiratory Infection – Sinusitis Will receive gain sharing Met Acceptable $0.00 N/A Commendable $349.50 Not eligible for gain sharing Not eligible for gain sharing Cholecystectomy Congestive Heart Failure Met Not met Acceptable Acceptable $0.00 $0.00 Not eligible for gain sharing Not eligible for gain sharing Perinatal Colonoscopy Met Met Acceptable Acceptable $0.00 $0.00 Not eligible for gain sharing Met Acceptable $0.00 Oppositional Defiant Disorder Not eligible for gain sharing Total Joint Replacement N/A Acceptable $0.00 Not eligible for gain sharing Tonsillectomy Met Acceptable $0.00 Upper Respiratory Infection – Non-specific URI Subject to risk sharing -$3,844.50 N/A Not acceptable Upper Respiratory Infection – Pharyngitis Not eligible for gain sharing Not met Acceptable $0.00 Performance summary 1 Quality of services and cost summary Quality of Service Average Episode Cost Share Amount Episode of Care Your Gain/Risk Share Not eligible for gain sharing Attention Deficit / Hyperactivity Disorder (ADHD) – Level I Met Acceptable $0.00 Across these Episodes of Care You are Subject to Risk Sharing: Stop-loss was applied -$3,000.00

28. Medicaid Little Rock Clinic 123456789 April 2013 $1,547 to $2,223 < $1,547 > $2,223 % Completed certification Avg. # of physician visits % Level I episodes ü ü Acceptable Not acceptable You Commendable Summary – ADHD: Level I closed episodes 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 You achieved selected quality metrics Your average cost is acceptable Linked to gain sharing Your total cost overview, $ Average cost overview, $ Episodes with medication There are no quality metrics linked to gain sharing generated from claims data. Selected quality data submitted on the Provider Portal will generate additional quality metrics for future reports. 512,000 2,000 466,000 1,750 100% 100% Standard for gain sharing You (non-adjusted) You (adjusted) You All providers 50% 50% 0% 0% Your episode cost distribution You Avg You Avg # episodes 100 100% 50 There is a graph behind the box Avg # of physician visits for JULY >$10157 <$700 $700- $1547 $1547- $1772 $1772- $1998 $1998- -$2223 $2223- $10157 50% 0% Distribution of provider average episode cost You Avg 7500 Cost, $ 20 5000 2500 10 Percentile 0 You Avg 5 Key utilization metrics All providers You Average number of psychosocial visits per episode Average number of visits per episode 4.1 62 3.9 38

29. Medicaid Little Rock Clinic 123456789 April 2013 Quality and utilization detail – ADHD: Level I closed You Metric linked to gain sharing Minimum standard for gain sharing 1 Quality metrics: Performance compared to provider distribution Percentile Percentile Metric You 25th 50th 75th 0 25 50 75 100 - % with completed certification 92% 50% 75% 85% % of episodes with medication 48% 40% 52% 67% % of episodes that are Level I 25% 20% 30% 40% Avg. physician visits per episode 4.1 2.3 3.9 4.3 - % non-guideline concordant 28% 10% 30% 50% - % non-guideline no rationale 15% 5% 15% 25% You achieved selected quality metrics û 2 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

30. Medicaid Little Rock Clinic 123456789 April 2013 Cost detail – ADHD: Level I closed episodes Total episode included = 233 You All provider average # and % of episodes with claims in care category Total vs. expected cost 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 ams@arkmed.org 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

35. Questions

36. 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