Evaluation Issues: NH Multi-Payer Medical Home Pilot

1. Evaluation Issues:NH Multi-Payer Medical Home Pilot October 28, 2008

2. Major Evaluation Questions • If payers and providers make the investment in patient-centered medical homes, can it create value (as defined by cost savings or higher quality of care)? • Will there be sufficient value created to cover costs of investment? • What are the metrics that are best correlated to value creation?

3. Possible Secondary Evaluation Questions • Is there a dose-response (better outcomes with higher levels of Medical Home) • Are there specific elements of PCMH that are better correlated with outcomes • How did practices transform

4. Methods Overview • Qualitative and descriptive. Best suited for process improvement, and sharing lessons learned regarding infrastructure issues, support teams etc… • Quantitative. Quasi-experimental design involving simple pre-post comparisons, contemporaneous controls and interrupted time series. Metrics include: cost, quality (structural efficiency measures and process), patient experience, and provider satisfaction.

5. What Cost Outcomes? Prior consensus: • Standard utilization metrics • Avoidable in-patient stays • ED utilization • Office visits (specialty, primary care) • Pharmacy • Outpatient procedures and diagnostics • Total cost • Risk adjustment • CHIS data and software available

6. Which Quality Outcomes Measures? Recommend: • CMS Group Practice Demo Metrics • Clinical outcomes consistent with other pilots

7. Claims Based Hgb-A1c tests LDL test Microalbumin testing or Dx/Tx for nephropathy Retinal exam by MD/OD: 1year/high risk, 2 years/low risk Chart/Hybrid Based HgbA1c ≤ 9.0% BP< 140/90 LDL<130 Complete foot exam documented Influenza vaccine Pneumoccocal vaccine Quality Measures: Diabetes% of patients in performance year with

8. Claims Based Lipid profile Chart/Hybrid Based LDL<130 Antiplatelet Rx Lipid Rx Hx MI, on ß-blockers BP @ last visit DM &/or LVSD on ACEI Quality Measures: CAD% of patients in performance year with

9. Claims Based LV-EF in same year if hospitalized for HF Chart/Hybrid Based Qualitative/quantitative LVF Assessment Visits Weight documented Visits BP documented HF Education documented in last 6 months LVSD on ß-blocker LVSD on ACEI HF/AF on Warfarin Influenza vaccine Pneumococcal vaccine Quality Measures: HF% of patients in performance year with

10. Claims Based ♀ 50-69 y.o. w/ mammogram in current or prior year Chart/Hybrid Based “Screened” for colon Cancer BP documented Last BP<140/90 If BP is >140/>90  documented plan of care Quality Measures: Preventive Care% of patients in performance year with

11. Which P4P Measures? Recommend PQRI Measures : (up to 4% Medicare payment) • Electronic prescribing • Chronic care management • Diabetes: HgbA1c Control, LDL Control, BP Control, Dilated Eye Exam, Urine Microalbumin • CHF: ACEI/ARB, betablocker • Asthma: pharmacologic therapy • CAD: antiplatelet therapy, betablocker post MI, ASA post MI • Care coordination: Medication reconciliation • Prevention • Flu vaccine • Pneumovax

12. Outcomes: Infrastructure • Assessing Level of Medical Home • Pre-post design • Validation of practice transformation • Determination of what makes a difference • Correlation issues • Instruments: • NCQA (a priori, therefore predictor not an outcome) • Medical Home Index • TransforMed • Starfield survey • Primary Care Assessment Survey (PCAS)

13. Which Infrastructure Tools? Recommend: • Medical Home Index • Starfield survey • Primary Care Assessment Survey (PCAS) • TransforMed

14. Other Domains Recommend: • Patient perspective: • PCAS (based on CG-CAHPS) • Practice culture, teamwork, staff satisfaction: • Assessing the culture of Medial Group Practice (Krelewski) • Practice staff Questionnaire (PSQ) (Stange, Crabtree, et al) • Microsystems Assessment Tool (Nutting) • Leadership capacity (MHIQ subsection) • Community Linkages section of Assessing Chronic Illness survey (Wagner)

15. Unresolved Analytic Issues • Sample size and power calculations • How many comparisons can we make? • Unit of analysis • Practices vs Practitioners • Individual patients vs Patient panels • Will P4P confound outcomes measurement and does it matter

16. Next Steps Recommend: • Select principal investigator • David Laflamme, UNH ? • Andy Coburn, Muskie ? • PCMH evaluation consultation • Meredith Rosenthal, HSPH • PI writes evaluation plan before start of pilot • Evaluation plan agreed upon by practices • PI and workgroup seeks evaluation funding • Consider collaboration with Maine (RWJF)