CALIFORNIA ASSOCIATION OF HEALTH PLANS

1
Colorado Multi-Payer, Multi-State PCMH Pilot
Program

• CALIFORNIA ASSOCIATION OF HEALTH PLANS
• 21 OCTOBER 2009
• ELIZABETH KRAFT, MD, MHS, FAAFP
• ASSOCIATE MEDICAL DIRECTOR,
• ANTHEM BLUE CROSS AND BLUE SHIELD IN
  COLORADO/NEVADA
• Elizabeth.Kraft_at_Anthem.com

2
Objectives

• The PCMH Colorado pilot program
• Background
• Key stakeholders
• Goals
• How it happened
• Timeline
• CCGC role
• Project details
• Attribution
• Payment incentive approach
• Practice transformation
• Culture change
• Measures
• Challenges

3
The Patient Centered Medical Home

• An approach to providing high quality, safe,
  continuous, coordinated, comprehensive care, with
  a partnership between patients and their personal
  healthcare team.

4
Key Stakeholders

• Health Plans
• Aetna
• Anthem Blue Cross and Blue Shield in
  Colorado/Nevada
• CIGNA
• Colorado Access
• Colorado Medicaid (HCPF)
• Cover Colorado
• Humana
• United Healthcare
• Employer/Employer Groups
• Colorado Business Group on Health
• IBM
• McKesson
• Patient Centered Primary Care Collaborative
  (PCPCC)
• State of Colorado
• Centura Hospital
• Physician Societies

5
Key Stakeholders

• Others
• Colorado Department of Public Health
  Environment (CDPHE)
• University of Colorado Health Sciences Center
• Associated IPAs
• Integrated Physician Network
• Northern Colorado IPA
• Physician Health Partners
• Primary Physician Partners
• South Metro Physicians
• MedSouth
• Pilot Partner Region
• Health Improvement Collaborative of Greater
  Cincinnati
• Pilot Evaluator
• Harvard School of Public Health (Meredith
  Rosenthal)
• Funders

6
Key Stakeholders

• The practices 16 FP and IM practices
• NCQA PPC-PCMH
  recognized

7
Goals

• To pilot test the Patient-Centered Medical Home
  model in qualified primary care practices to
  determine if this model provides higher quality
  and more efficient care for our members and leads
  to higher satisfaction for both patients and
  primary care physicians
• Improve Quality and Coordination of Care
• Reduce Healthcare Costs (trends)
• Improve engagement and experience for patients
  and the
• healthcare team

8
Goal
Goal
9
Timeline

• 2 year pilot (after 15 mo planning)
• First face to face meeting January 2008
• Steering Committee
• Physician Advisory Committee
• Recruitment of practices by Oct 2008
• Kick Off Dec 2008
• NCQA applications submitted by April 2009
• Payment Start Date May 2009
• 1st Learning Collaborative - June 2009
• Pilot end date April 2011 unless extended

10
Colorado Clinical Guidelines Collaborative (CCGC)

• Convening organization
• Technical assistance for practice transformation
• MAKING A HOUSE A HOME!
• Marjie Harbrecht, MDmharbrecht_at_coloradoguidelines
  .org
• www.coloradoguidelines.org

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Project Details

• Attribution methodology
• 2 year look back
• Any interaction (claims, pharm, lab)
• Pmpm
• Tiers based upon NCQA recognition level
• 2 - 8
• No severity adjustment
• Inclusive of pediatric patients
• No Medicare

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Project Details

• Step 1
• Total Practice Patients 2400
• Average Medicare/Medicaid 40
• Average Commercial 60
• Average Commercial Patients 1440
• HP share of Patients 40
• HP share of Patients- specific
• Step 2

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Project Details
Project Details

• Step 3

14
Payment Approach
15
Practice Transformation Culture Change
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Chronic Care Model

• Patient-Centered Planned Chronic Care Model
• Access and Scheduling
• Increase points of Access
• Team Based Care
• Develop Care Plan
• Care Plan Management/Care Coordination/Test and
  Referral Tracking
• Implement Care Plan
• Patient Centered Care Self management support
• Engage and support patient
• Registry and Population Management - Technology
• Measure progress - Outreach to those not coming
  in
• Monthly metric reports
• Organization of Practice
• Leadership Team-building Human Resources
  Finances
• Tools (CCGC Technical Assistance)
• Rapid cycle changes
• Daily team huddles
• Learning collaboratives
• In-office coach

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Clinical Measures

• Phase I

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Clinical Measures
19
Resource Use Measures

• Utilization
• ER
• Hospitalizations
• Pharmacy
• Generics

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Outcomes (IPIP)
Practice Profile Internal Medicine
Approximately 7000 patients 4 MDs
2 Mid-level providers
No experience with Quality
Improvement Payer Mix Medicare 60
Uninsured
2 Medicaid 2 Commercial
36
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Challenges

• Building Medical Homes in current complex
  environment
• Tremendous fragmentation
• Involving neighborhood (specialists, hospitals,
  etc)
• Misaligned incentives
• Many practices in survival mode
• Practice Transformation is hard work!!!
• Determining appropriate Care Management Fee to
  ensure it is sufficient
• Setting realistic expectations for impacts on
  quality, cost, satisfaction in short time period
• PMPM- timely, all-inclusive, ?severity adjusted
• ASO- small, price-sensitive employer engagement
• P4P
• Balancing
• Internal QI with External measurement

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Medical Home to a Medical Neighborhood

• ACO model for Colorado Medicaid

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Thank you Anthem Blue Cross and
Blue Shield is the trade name of In Colorado and
Nevada Rocky Mountain Hospital and Medical
Service, Inc., an  independent licensee of the
Blue Cross and Blue Shield Association. ANTHEM
is a registered trademark of Anthem Insurance
Companies, Inc. The Blue Cross and Blue Shield
names and symbols are registered marks of the
Blue Cross and Blue Shield Association.