Practice Transformation Task Force

February 28, 2017

Meeting Agenda

6. CCIP Readiness Assessment Strategy

5. CPC+ Update

4. Primary Care Payment Reform Update and Discussion

3. Approval of the Minutes

2. Public comment

1. Introductions/Call to order

2

Item Allotted Time

5 min

10 min

5 min

80 min

10 min

5 min

8. Next Steps and Adjourn 5 min

3

Public Comments

2 minutes per

comment

4

Approval of the Minutes

Primary Care Payment Reform Update and Discussion

Why did we undertake the

Primary Care Payment

Reform Project?

Flexible and diverse care

team

Advanced Medical Home Program

New methods for engaging and

empowering consumers—

extending beyond the traditional

office visit

Plan and Manage Care

Track and Coordinate Care

Measure and Improve Performance

Enhance Access and Continuity

Team-Based Care

Population Health Management

Foundational primary care

capabilities that focus

on the whole person—

emphasis on health equity

and behavioral health

Flexible and diverse care

team

Community and Clinical Integration Program

New methods for engaging and

empowering consumers—

extending beyond the traditional

office visit

Comprehensive Medication Management

Oral health integration

E-consult

Comprehensive Care Management

Health Equity

Behavioral Health Integration

One of CCIP’s primary

aims is to more effectively

integrate non-clinical

community services and

traditional clinical care

into a set of

comprehensive, routine

primary care services.”

– CCIP Final Report.

What could we do to transform care?Patient Engagement and Support Care Team Diversity

Phone contact Nurse care manager

E-mail/text support Social Worker

Telemedicine visits Licensed BH clinician

Home visits Pharmacists

E-consult Nutritionist/dietician

Remote monitoringCare coordinator (community health

worker focus on community linkages)

Group visits (illness self-management,

prevention, lifestyle enhancement)Health coach (community health worker)

Tweet/chats/on-line support groups Patient navigator

Patient/family advisory council

Communication with child care/school

Transportation

Unlocking the Potential of Primary Care

How do we transform payment to finance these new

models of care?

We’re already doing payment reform—how does primary care payment reform fit into the picture?

Healthcare Payment Learning and Action Network (HCP LAN)

Alternative Payment Model Framework (At-a-Glance)

Alternative Payment Model (APM) Framework and Progress Tracking Work Group

Components of Primary Care Payment Models in Relation to

the Alternative Payment Model Framework

HCP LAN PCPM White Paper

How much of our health care

dollar is spent on primary care?

Total Cost of Care: What is the breakdown?

30%

20%

25%

20%

5%

Primary Care

Pharmacy

Specialist

Diagnostic

Hospital

Primary care: What is the

breakdown?

30%

20%

25%

20%

5%

45%

45%

10% OtherServices

Acute andChronicVisits (E&M)

PreventiveVisits

Project Scope

• Literature review

• Interviews with model national programs

• Stakeholder engagement• Providers

• Consumers

• Payers

• Compare and contrast payment model options

• Recommendations

What have we learned from

our review of the national

landscape?

Literature Search-What have we learned about primary care payment models?

• Cons: Drive the provision of low value care and services, inflexible…focuses attention on what’s reimbursable, not other value added activities

• Pros: When used with other payment models (e.g. bundle), supports provision of high value services (e.g. immunizations, wellness and preventive care)

FFS

• Pros: Support implementation of care management and care coordination services

• Cons: Without accountability, funds may not be used for what they are intended or result in ROI

Care Management Payments

• Pros: Generally bigger payments; support provider investment in infrastructure to support non-FFS activities

• Cons: Accountability as above; one-time grants often don’t result in sustainable change

Other Advance Payments

(e.g., grants, bundled, comprehensive payments)

• The model of care (desired by the payer) and the practice's business model (i.e., integrated delivery system-owned practice, IPA, independent practice) define the optimal model of payment…i.e., “one size does not fit all”

Model of Care/

Practice Business Model

Comparison of National ModelsCPC+ Evergreen Iora Kaiser

Payment Partial E&M

Bundle

Full primary care

bundle –

Enhanced

Full primary care

bundle - Enhanced

Part of Global

Budget/ Premium

R/S to PCP Independent Employed Employed Employed

Care Delivery Care coordinators,

home visits,

phone/e-

communication,

BH integration

BH, health

coaches, care

coordinators,

smoking cessation

telemedicine,

home visits, minor

procedures

Each PCP

supported by 4

coaches and

coordinator/BH

specialist

Diverse care team,

telehealth and

other non-visit

methods for

patient

engagement

PC as % of Cost ≈ 7.5% 10% 10% ?

Stakeholder Interviews: Early

Feedback From Connecticut’s

Provider Community

• Generally dissatisfied with current model of care delivery they’re able to

provide

• Focus is on day-to-day survival vs. transformation

• With few exceptions, they are not ready to discuss accepting risk; open to

potential new models that do not involve significant risk in the near term

• All are engaged primarily in pure FFS or FFS with upside Shared Savings

arrangement (commercial, Medicaid, and Medicare)

• Commercial payers may provide modest care management fee; Medicaid

may provide care management fees or enhanced office visit fees

• Current compensation is inadequate to fund innovation and transformation

What are some key messages we are hearing from

providers?

Unresolved Challenges to Transformation

• Attribution models

• Independent practice vs. provider organization based approach

• Shared Savings Program timelines of reconciliation - 18 months is too long & uncertain

• Implementation time frame for design of programs that help realize shared savings or mitigate risks

• Contracting process between payers and providers is improving, but has a long history and new contracting requirements (such as developing a risk adjusted budget) may take longer to find agreement. It is not just negotiating a fee schedule.

• Affordable Care Act unknowns

• Access to capital to support transformation investments

Early Impressions - Current CT Primary Care Environment

MD APRNLicensed

BehavioralClinician

PharmacistRN

Care Coord./Case Manager

Social Worker

Nutritionist/Dietician

CommunityHealth Worker

PatientNavigator

Medical Assistant

Large Integrated System ✓ ✓ ✓ ✓ ✓ ✓ ✓

IPA ✓ ✓ ✓ ✓ ✓

Solo Practitioner ✓ ✓ ✓

PredictiveModel

Risk Strat

High Risk

Rounds

Proactiveoutreach to at-risk

pop.

PatientEduca-

tion

Email/text

support

In-home CM

E-consultCommunication

w/Child Care/School

Patient/Family

Advisory Council

Online Support Groups

(i.e. tweet/chat)

Group Visits

Telehealth/Tele-monitoring

Large Integrated System

✓ ✓ ✓ ✓ ✓ ✓

IPA ✓ ✓ ✓ ✓

Solo Practitioner ✓ ✓

Care Team Composition

Non-Visit Based Care

Draft and Provisional

PredictiveModel

Risk Strat

High Risk

Rounds

Proactiveoutreach to at-risk

pop.

Patient

education

Email/text

support

In-home CM

E-consultCommunication

w/Child Care/School

Patient/Family

Advisory Council

Online Support Groups

(i.e., tweet/chat)

Group Visits

Telehealth, Tele-monitoring

Large Integrated System

✓ ✓ ✓ ✓ ✓ ✰ ✓ ✰ ✓

IPA ✰ ✓ ✓ ✓ ✓ ✰ ✰

Solo Practitioner ✰ ✓ ✓ ✰ ✰ ✰ ✰ ✰ ✰ ✰

Early Impressions: Wish-list for CT Primary Care Environment -What they wish they could do

✓ = Services being provided now✰ = Services they’d like to provide

Draft and Provisional

25

Learnings from CT Provider Stakeholders- Barriers to Primary Care Reform

Large Integrated System

Community-based (vs. employed) provider model

Solo Practitioner

Upfront $$ to invest

Interoperability

Support for transition in current environment

Administrative burdens (reporting & documentation requirements,

Lack of clear guidelines/payment methodology calculations

Extended timeframe for pay-out

IPA

Upfront $$ to invest

Down-side risk potential

Any requirement to decentralize

Reluctance to changing SCP referral patterns (to better control non-PCP costs)

Benefit design (e.g., cost-share for sick visits is a deterrent to care)

1. Size of networks (too broad)

2. % of premium for Primary Care too low (need >10%)

Draft and Provisional

Learnings from CT Provider Stakeholders- What they’re thinking about PCPM reform

“FFS is unsustainable; we must transform payment models and care”

“There is a real opportunity for employed primary care

providers to transition to a capitated model; community

practices are less likely to embrace it”

“We would support CPC+; all providers in the ACO would be expected to participate.”

“Primary care providers should be paid for services not currently being paid (e.g., email, group visits).”

”Adding BH has been transformative for the practices where its embedded”

Learnings from CT Provider Stakeholders- What they’re thinking about PCPM reform

“There are fundamental flaws with share savings program methodology”

“A hybrid bundle with full PCP capitation makes perfect sense; helps to move toward transformation”

“Incremental change is a must; we can’t just flip from FFS to full capitation”

“I would love to diversify my care team to include social worker,

navigators, etc. This would enable all team members to work at the top of their license. But this care

is not reimbursed, under FFS”

“ I would support a shared savings model where individual practitioners are recognized/penalized rather than in the aggregate”

Which primary care payment model do CT providers prefer?

Depends on your size, resources, capabilities…and tolerance for some risk

Key Learnings: Investing in Primary Care

• Difficult to transform primary care with FFS payment model

• Need more flexibility to change practice without losing visit based revenue

• Need more flexible funding up front; regular payments (e.g., PMPM), can’t simply wait for

shared savings

• Primary care is responsible for coordination, prevention and chronic disease

management, but account for a small portion of our total health care dollars

• % of premium paid to primary care may not be sufficient

Primary Care Payment Models

Primary Care Payment Reform Models

Fee for service

Partial E&M Bundle

Full E&M Bundle

Full Primary Care Bundle

Increasing Flexibility

Incre

as

ing

reven

ue

Enhanced Fee for service

Care Management Fee + Partial E*M Bundle

Care Management

Fee + Full E*M Bundle

Enhanced Primary Care

Bundle

Primary care: What is the

breakdown?

30%

20%

25%

20%

5%

45%

45%

10% OtherServices

Acute andChronicVisits (E&M)

PreventiveVisits

Option 1: Partial

E&M Bundle

45%

45%

10%

65% E&M

Bundle

(PMPM)

Care

Management

Fee (PMPM)+

45%

45%

10%OtherServices

Acute andChronicVisits (E&M)

PreventiveVisits

35% E&M

FFS

Option 2: Full E&M

Bundle

45%

45%

10%

100% E&M

Bundle

(PMPM)

Care

Management

Fee (PMPM)+

45%

45%

10%OtherServices

Acute andChronicVisits (E&M)

PreventiveVisits

Option 3: Full Primary

Care Bundle

45%

45%

10%

100% Full primary

care bundle*

*May allow for

limited exclusions

45%

45%

10%OtherServices

Acute andChronicVisits (E&M)

PreventiveVisits

• Possible age related payment model to account for abundance of well child visits in the early years

• Focus on health/developmental/socio-emotional promotion (e.g. healthy eating) and prevention

• Focus on early detection of concerns associated with life-long health, social and, productivity outcomes (ACES) and connection to services outside of primary care

• Less emphasis on chronic disease management

Considerations for Pediatrics

Option 1: Partial

E&M Bundle

Option 2: Full E&M Bundle

Option 3: Full Primary Care Bundle

• What benefits would these primary care payment models bring?

• Are some models better than others?

• Which are best for Connecticut’s providers and consumers?

How much should we be

paying for primary care?

5%?

7%?

10%?

How do we get there?

Q & A

CPC+ Update

“When primary care practices contract with

multiple payers and plans that employ different

sets of payment mechanisms and benefits,

misaligned incentives can distract practices and

stymie practice transformation.”

-HCP LAN PCPM White Paper

Is there any way for Medicare to participate in a state-

specific multi-payer primary care payment model?

• Medicare is a national program and they rarely participate in state-specific multi-

payer models

• However, they have launched a new multi-payer program that they are

implementing regionally: Comprehensive Primary Care Plus Initiative (CPC+)

• About 3,000 primary care practices representing 1.76 million Medicare

beneficiaries in 14 regions are participating. Medicare is aligning with 54 payers

across these regions.

• CMS reopened solicitations for payers this month. Part of the stakeholder

engagement process has been to discuss interest in this model.

CPC+ Primary Care Payment Model

CPC+

Fee for service

Partial E&M Bundle

Full E&M Bundle

Full Primary Care Bundle

Increasing Flexibility

Incre

asin

g r

even

ue

Enhanced Fee for service

Care Management Fee + Partial E*M Bundle

Care Management

Fee + Full E*M Bundle

Enhanced Primary Care

Bundle

CPC+

CPC+

CPC+

Next Steps

• Continued modification of payment models

• Ongoing stakeholder interviews: payers, providers, consumers

• Straw models

• Future meetings: PTTF, HISC

CCIP Readiness Assessment Strategy

Needs Assessment – Why?

An objective and comprehensive needs

assessment is key to successful

practice transformation

Experience:• Overestimate current

capabilities

• Underestimate what it will take to transform their practice

PCMH-A

32 Question

Assessment

Core and Elective

Standardized

Assessment

NeedsAssessment

Three Components

Part One: PCMH-A

• Validated tool measuring “medical homeness”

• Demonstrates if practices maintain and sustain PCMH principles

Part Two: 32 Question Assessment

• Capture PE specific information of infrastructure, care processes, and IT infrastructure

• Addresses the Learning Management System and child development

Part Three: The Core and Elective Standardized Assessment and Scoring Guide

Scoring ComponentPart Three: The Core and Elective Standardized Assessment and Scoring Guide

Modeled after validated Transforming Clinical Practice Initiative (TCPI) Assessment Tool

Develops Transformation Plan

Identifies transformational activities already occurring within a Participating Entity

Reduces redundancy

Ensures gap analysis information is actionable

Facilitates achievement of CCIP standards

Appendix

Traditional Payment Model

• Most prolific model on Primary Care Payments

• Varies greatly for pediatricians, family physicians, and internists

• Care management fees are common in CT landscape

• Potential innovations in care are difficult to fund with only care management fees

Partial E&M Bundle (65%)

• Blend of CMS and other payment models

• Preventive care and other services are paid FFS

• Chronic and acute care E&M services are paid at 35% from CMS

• A bundle payment is made equal to 65% of historic chronic and acute E&M services plus 10%

• May include PMPM care management payment based on clinical severity of the population

• Innovations in care (a range of expectations explicit with the program) funded by the enhanced care management upfront payments, efficiencies, larger panel size, and opportunities for shared savings variable to by payer

Full E&M Bundle (65%)

• Blend of CMS and other payment models

• Preventive care and other services are paid FFS

• Chronic and acute care E&M services are not reimbursable

• A bundle payment is made equal to 100% of historic chronic and acute E&M services plus 10%

• May include PMPM care management payment based on clinical severity of the population

• Innovations in care (a range of expectations explicit with the program) funded by the enhanced care management upfront payments, efficiencies, larger panel size, and opportunities for shared savings variable to by payer

Full Primary Care Bundle

• All E&M, most procedures, and other services included in bundle

• Limited items outside the bundle are paid FFS e.g. immunizations

• Innovations in care are funded by efficiencies, larger panel size, upfront payments and Shared Savings arrangements

Enhanced Primary Care Bundle

• All E&M, procedures, and most services included in bundle

• Limited items outside the bundle are paid FFS e.g. immunizations

• Robust and extensive innovations in care delivery are funded by the enhanced bundle(upfront payments)

• Shared Savings programs are critical to address the management of a total cost of care benchmark while meeting comprehensive quality measures