The Payer Perspective Richard Snyder, M.D.

1. The Payer Perspective Richard Snyder, M.D.

2. Agenda • The National Landscape • Profiles of Single and Multi-Stakeholder Pilots • North Dakota • New Jersey • Pennsylvania Chronic Care Management, Reimbursement & Cost Reduction Commission

3. The National Landscape • 24 Pilots / 10 Active • Single and Multi-Stakeholder • Public/Private • Commercial, Medicare Advantage, Managed Medicaid • 3 -100 Practices • 13 – 6,471 Practitioners • 850 – 1.7M Patients • Diverse reimbursement strategies • Variable degrees of clinical outcomes

4. BCBS of North Dakota &Meritcare Health System • Payer and Integrated Multi-specialty Medical Group • Focus on diabetes – started 2005 • Use of integrated RN – CDM • Emphasis on self-management, goals, education, follow-up • Outcomes • Improved satisfaction of patients and practices • Improved results of comprehensive diabetes care • Savings shared 50:50 with practices • 2005 - $531 per patient with diabetes • 2006 - $1,213 per patient with diabetes • Expanded to 4 practices, added HTN and CAD, added management fee and generic prescribing incentives

5. Horizon BCBS &Partners in Care • Payer and Physician Owned MSO • Offered to New Jersey State Health Benefits Program • Initially 1,300 patients • Focus on diabetes – started 2007 • Emphasis on care coordination and information sharing • Complemented with Payer disease management program • Outcomes between January and November 2007 • HgbA1c testing increased 43% to 91% • HgbA1c result between 7 and 9 increased from 15% to 36% • PMPM medical spend dropped from $1,049 to $870 • Expanded to over 400 practices and 30,000 patients

6. Chronic Care Management, Reimbursement & Cost Reduction Commission • Part of Prescription for Pennsylvania • Goal - Improve chronic care delivery in PA • $1.7 billion in avoidable admissions • Missed opportunities in process/outcomes measures • 45 Provider, insurer, cabinet, organized labor, academic and consumer representatives • Blend of Wagner Chronic Care Model and Patient Centered Medical Home Model • Lead by Governor’s Office on Health Care Reform • Learning sessions • Practice coaches to support transformation • NCQA PPC-PCMH recognition levels drive reimbursement

7. SE Pennsylvania Rollout • 32 PCP (Ped, IM, FP, CRNP) Practices with 166 PCPs • 220,000 patients • Multiple Payers (IBC, KMHP, Aetna, CIGNA, Health Partners, AmeriChoice) • Primary Care Coalition (PAFP, ACP, AAP) • Goals are to improve: • Access to care and communication with PCP • Team based care coordination, health education and self-management skills • Use of registry/EMR to report data • Member and provider satisfaction • Aggregation of payer and practice level data for reporting • Improved quality, utilization and cost outcomes

8. Role of GOHCR • Staffing • Project management • Funding • Consultants • Faculty and expenses for a year-long learning collaborative for participating primary care practices • Cost of registry • Data collection, evaluation and reporting activities through a 3rd party, including surveys • Coordinating • Flow of data between practices and payers • Flow of funds from payers to practices; and IPIP (Improving Performance in Practice) a PAFP 501c3 • Baseline and subsequent satisfaction surveys

9. Requirements of PCP Practices • Three year commitment • Attend “Learning Collaborative” meetings • Work with assigned practice coach to transform practice • Enhanced access to care • Team based coordinated care • Enhanced communication • Self-management support • Use a patient registry (or EMR) to track patients • Report data from the patient registry and other sources required for evaluation purposes • Achieve Level 1 NCQA PPC-PCMH Recognition in year 1 • Reinvest funds into staff and technology at practice site

10. Requirements of Payers • Three year commitment to fund and support • Methodology – payments proportionate to revenue from all sources as validated and coordinated through GOHCR • Payment to IPIP for Practice Coaches • Payment to PCP Practices are intended to offset costs • Infrastructure development • 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 for practice team to attend learning collaborative are paid after attendance • Seven days during 1st year $11,655/team • Consist of quarterly 2 day learning meetings and final outcome meeting

11. Requirements of Payers • Enhancement to current payer contractual payments • Annual lump sum payments upon NCQA PPC-PCMH recognition yield up to $4PMPM • Prorated for portion of year at each level of recognition • Prorated based on PCP/CRNP FTEs in practice • Discounted by % of revenue from Medicare FFS and non-par payers • Pay-for-performance – standard process post first 3 years based on clinical, utilization, satisfaction and financial outcomes

12. Requirements of IPIP • Provide Practice Coaches to assist • With transforming the practice • With data collection and reporting • Linking practices to community resources • With completing the NCQA PPC-PCMH recognition process • Contribute to Consumer Engagement Strategy • Community Registry of resources available to practices • Building public-private partnerships to support self-management • IPIP practice coach resource for training on self-management • Reimburse self-management education services • Contribute to community sponsored lay support services • Contribute to standardized incentive program Consumer Engagement

13. Evaluation • The Commission has approved a methodology • Data from payers, providers, and surveys to be aggregated by 3rd party • Rollout “intervention” groups to be compared to control groups • Metrics are based on nationally endorsed measures where possible (NCQA, AQA, etc.) • 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

14. 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