National Briefing Webinar Marci Nielsen, PhD, MPH February 11, 2016 - PowerPoint PPT Presentation

National Briefing Webinar Marci Nielsen, PhD, MPH February 11, 2016 1

AGENDA • PCPCC: – Who we are & what we do • 2015 Annual Evidence Report: – What we studied & what we learned • Paying for Value – Where delivery reform meets payment reform – What’s Next? • Q & A 2

Patient-Centered Primary Care (PCPCC) Unifying for a better health system - by better investing in patient- centered primary care PUBLIC: Patients, Families, PAYERS : Caregivers, Employees, Consumers Employers, Communities Health plans, Government, Policymakers PROVIDERS : Primary care team, medical neighborhood, ACOs, integrated care 3

Capitol Hill Briefing hosted by: The Primary Care Caucus Co-Chairs Honorable Joe Courtney (D-CT) Honorable David Rouzer (R-NC) 4

Section One: A CHANGING POLICY LANDSCAPE #PCMHEvidence 5

REVIEWERS AUTHORS Christine Bechtel, MA Marci Nielsen, PhD, MPH  Bechtel Health; National Partnership for Women Chief Executive Officer, PCPCC & Families Lisabeth Buelt, MPH • Asaf Bitton, MD, MPH Policy and Research Manager, Brigham and Women's Hospital & Harvard PCPCC Medical School Kavita Patel, MD, MS • Jean Malouin, MD, MPH Nonresident Senior Fellow, University of Michigan Economic Studies, The Brookings Institution Mary Minniti, BS, CPHQ Institute for Patient- and Family-Centered Care Len M. Nichols, PhD, MS, MA • Director, Center for Health Policy Bob Phillips, MD, MP Research and Ethics, George American Board of Family Medicine Mason University Sarah Hudson Scholle, DrPH, MPH National Committee for Quality Assurance Lisa Dulsky Watkins, MD Milbank Memorial Fund Multi-State Collaborative

PCMH MODEL/FRAMEWORK U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ). Patient-centered medical home 7 resource center, defining the PCMH. Retrieved from http://pcmh.ahrq.gov/page/defining-pcmh

PCMH EXPANDING RAPIDLY: BUT STILL AN EARLY INNOVATION 8

PAYING NOW… OR… PAYING LATER 9

PAYMENT REFORM AND MEDICARE Health & Human Services Congress • Shift 30% of Medicare FFS • Passage of Medicare Access payments to value through and CHIP Reauthorization APMs by 2016, 50% by Act (MACRA) 2018 • Merit-based Incentive • Created of Health Care Payment System (MIPS) Payment Learning & Action • Alternative Payment Network Models (APMs) • Investment in Multi-payer Efforts https://hcp-lan.org/ 10 http://doctorwhostories.wikia.com/wiki/The_Macra_Terror_(TS)

PAYMENT REFORM & PCMH • Fee-for service fails to compensate for PCMH scope of services – esp for small and independent practices • Numerous Alternative Payment Models (APMs) can support PCMH • Evidence does not point to single payment model that best supports PCMH 11

Section Two: NEW EVIDENCE FOR PCMH AND INNOVATIONS IN PRIMARY CARE #PCMHEvidence 12

METHODS INCLUSION CRITERIA • Predictor variable : – “Medical home” – “PCMH” – “Advanced primary care” • Outcome variable : – “Cost” or – “Utilization” • Date published: – Between Oct 2014 and Nov 2015 13

LIMITATIONS • Several reports published this year fall outside the scope of our inclusion criteria – We track these studies on our PCMH Map • Does not include studies focused on disease- specific, non-primary care medical homes • Generally include only the measures that reach statistical significance • Studies included vary significantly • DEFINING & MEASURING PCMH REMAINS A CHALLENGE 14

RESULTS: TRENDS (n 1 = Improvement in measure/n 2 = Measure assessed by study) #PCMHEvidence 15

DETAILS: Utilization “ED USE” (Peer reviewed studies n=17) MEASURES OF UTILIZATION • • S tudies below reported on “ED use” Emergency department (ED) use – All cause ED visits – 13 measures were ED use reductions, – Ambulatory care sensitive 1 measure was ED use increase condition (ASCS) ED visits – California Health Care Coverage – Non-urgent, avoidable, or Initiative preventable ED visits – CHIPRA Illinois study – ED utilization – Colorado Multi-payer PCMH pilot • Hospitalization – Medicare Fee-For-Service NCQA study – All cause hospitalizations – Pennsylvania Chronic Care Initiative – ACSC in-patient admissions – Rochester Medical Home study – In-patient days • – UCLA Health System study Urgent care visits • Readmission rate – Texas Children’s Health Plan • Specialist visits – Veterans Affairs PACT study (AJMC) – Ambulatory visits for specialists • Reported higher ED use for one measure, 16 and ACSC hospitalizations per patient

DETAILS: Cost “TOTAL COST” (Peer reviewed, n=17) MEASURES OF COST • S tudies below reported “Total cost of care” • Total cost of care – 10 measures were total cost of care – Net or overall costs savings, one measure was no net savings – Total PMPM spend – Geisinger Health System PCMH – Total PMPM for pediatric – Blue Cross Blue Shield of Michigan patients Physician Group Incentive Program ( Health – Total PMPM for adult patients Affairs ) • Total Rx spending – Blue Cross Blue Shield of Michigan • ED payments per beneficiary Physician Group Incentive Program • ( Medical Care Research & Review ) ED costs for patients with 2 or more comorbidities – Colorado Multi-payer PCMH pilot • PMPM spending on inpatient • No net savings over 2 year study • Inpatient expenditures (PMPY) – Pennsylvania Chronic Care Initiative • (American Journal of Managed Care) Outpatient expenditures (PMPY) – UCLA Health System study • Expenditures for dental, social, and community based supports – Vermont Blueprint for Health 17

DETAILS BY STUDY REFERENCE: Rosenthal, M.B., Alidina, S., Friedberg, M.W., Singer, S.J., Eastman, D., Li, Z., & Schneider, E.C. (2015). A difference-in-difference analysis of changes in quality, utilization and cost following the Colorado Multi-Payer Patient-Centered Medical Home Pilot. Journal of General Internal Medicine. DESCRIPTION: Authors conducted difference-in-difference analyses evaluating 15 small and medium- sized practices participating in a multi-payer PCMH pilot. The authors examined the post-intervention period two years and three years after the initiation of the pilot . 18

Section Three: DISCUSSION OF FINDINGS AND IMPLICATIONS #PCMHEvidence 19

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KEY FINDING • C ONTROLLING C OSTS BY PROVIDING THE R IGHT C ARE – POSITIVE CONSISTENT TRENDS: • By providing the right primary care “upstream,” we change how care is used “downstream” • Consistent reductions in high-cost (and many times avoidable) care, such as: emergency department (ED) use and hospitalization, etc • Cost savings evident – but assessment of total cost of care required (while assessing quality, health outcomes, patient engagement, & provider satisfaction) #PCMHEvidence 21

WHY DO SOME MEDICAL HOMES WORK WHILE OTHERS DON ’ T ?

KEY FINDING • A LIGNING P AYMENT AND P ERFORMANCE – BEST OUTCOMES FOR MULTI-PAYER EFFORTS: • Most impressive cost & utilization outcomes among multi-payer collaboratives with incentives/performance measures linked to quality, utilization, patient engagement, or cost savings … more mature PCMHs had better outcomes • No single best payment model emerged, but extended beyond fee-for-service 23

Trajectory to Value-based Purchasing: PCMH part of a larger framework Value-Based Purchasing : Value/ Reimbursement Outcome tied to Measurement performance on Reporting of Care value quality, Coordination : utilization and Coordination patient of care across engagement & Primary medical population Care neighborhood health Capacity : & community measures PCMH or supports for advanced patient, Alternative Payment primary care HIT families, & Models (APMs): Infrastructure : caregivers Supporting ACOs, PCMH, EHRs and & other value population health based arrangements management Source: THINC - Taconic Health Information Network and Community tools 24

25 APM FRAMEWORK WORK GROUP Population-B ased A ccountable A PMs • The LAN’s Alternative Payment Model Framework and Progress Tracking (APM FPT) Work Group was successful in C ategory 1 C ategory 2 C ategory 3 developing a Framework C ategory 4 Fee for Service – Fee for Service – APMs Built on Population-Based for categorizing APMs. No Link to Link to Fee-for-Service Payment Q uality & Value Q uality & Value Architecture • Within the APM A A A framework, population- Foundational Payments for APMs with C ondition-Specific Infrastructure & O perations U pside G ainsharing Population-BasedPayment based-payment models B B B fall into categories some Pay for R eporting APMs with U pside C omprehensive G ainsharing/D ownside R isk Population-Based of 3 and 4. Payment C R ewards for Performance D R ewards and Penalties for Performance