Randeep Kahlon, MD, MSDTimothy Constantine, President, BCBSDDelaware Health Care CommissionMarch 1, 2012

RationaleRationale

The “Triple Aim”

Lower CostsImprove Quality Better Health Outcomes

Fundamentals for PCMH TransformationFundamentals for PCMH Transformation

Outcomes Reporting

Leadership & Team-Based Care

Practice Viability & Efficiency

Care Mgmt, Coordination & Communication

Patient Engagement &

Access

Medical Homes &Medical Neighborhoods

3

PCMH Gets ResultsPCMH Gets ResultsIntegrated Delivery System:Group Health Cooperative of Puget Sound•$10 PMPM reduction in total costs

Private Payer Sponsored:Blue Cross Blue Shield of North Dakota•Hospital admissions decreased by 6% and emergency department visits decreased by 24% in the PCMH group from 2003 to 2005, while increasing by 45% and 3%, respectively, in the control group.

PCMH Gets Results PCMH Gets Results continuedcontinued

Medicaid-sponsored:Community Care of North Carolina•Cumulative savings of $974.5 million over 6 years (2003-2008) •40% decrease in hospitalizations for asthma•16% lower emergency department visit rate

These results, and more, are available in the report “The Outcomes of Implementing Patient-Centered Medical Home Interventions” Prepared by Kevin Grumbach, MD, Thomas Bodenheimer, MD MPH, and Paul Grundy MD, MPH August 2009. http://www.pcpcc.net/files/pcmh_evidence_outcomes_2009.pdf

A Forum for Statewide PCMH EffortsA Forum for Statewide PCMH Efforts

Patients First in the First State was created as a partnership between Blue Cross Blue Shield of Delaware (BCBSD) and Medical Society of Delaware (MSD).

Objectives:

•Design and launch an operational statewide PCMH program.

•Provide a policy and program design framework for analysis and adoption of standardized criteria.

•Provide an information-sharing infrastructure for multiple stakeholders for best practices.

Multi-Stakeholder Leadership Team

-MSD -BCBSD-QID -Physician Specialty Societies -Hospitals* -State of DE* -DSCC/DPPI* -Others TBD*

Operational Workgroup

Representatives of partner organizations

who plan technical design and processes

Physician Advisory Workgroup

Physician leaders from Primary Care Specialty

Societies and MSD.

BCBSD Incentivized

Quality-Focused, Programs

Other Health Planswhose PCMH

conformsto Patients First

Criteria

Other Plans/InitiativesWhose PCMH does/does not conform but who seek

dialogue

TBD Practice Support

P4P“PCMH Light”

PCMH

Education & Disease Management (HealthWays)

MSD Practice Support

(15 practices)

*A multi-stakeholder structure has been assembled but has not been fully activated due to the rigors of the early design period. Full team concept is anticipated with launch of the program May 2012.

Patients First in the First StatePatients First in the First State

MULTI-STAKEHOLDERMULTI-STAKEHOLDERLEADERSHIP TEAM- INVITEESLEADERSHIP TEAM- INVITEES

Conveners• Blue Cross Blue Shield of Delaware & Medical Society of Delaware

Physician Specialty Societies• Delaware Chapter of the American Academy of Pediatrics• Delaware State Osteopathic Medical Society• Delaware Chapter of the American College of Physicians

IPAs• MedNet of Delaware

MULTI-STAKEHOLDERMULTI-STAKEHOLDERLEADERSHIP TEAM- INVITEES, LEADERSHIP TEAM- INVITEES, continuedcontinued

Hospitals• A.I. duPont Hospital for Children• Bayhealth Medical Center• Beebe Medical Center• Christiana Care Health System• Nanticoke Memorial Hospital• St. Francis Hospital• VA Health Care System

Employers/Purchasers• AstraZeneca • Delaware State Chamber of Commerce

MULTI-STAKEHOLDERMULTI-STAKEHOLDERLEADERSHIP TEAM- INVITEES, LEADERSHIP TEAM- INVITEES, continuedcontinued

Payers• Blue Cross Blue Shield of Delaware• Aetna • Delaware Health and Social Services, Division of Medicaid & Medical

Assistance

Others• Delaware Health and Social Services, Division of Public Health• Delaware Health Care Commission• Delaware Health Sciences Alliance• QID• Others TBD

PrinciplesPrinciples

• Adheres to the Joint Principles of the PCMH as approved by the American Academy of Family Physicians, American Academy of Pediatricians, American College of Physicians and American Osteopathic Association

• Utilizes the National Committee for Quality Assurance’s (NCQA) Physician Practice Connections® PCMH Recognition Process as a framework

• Serves patients from all age groups and medical conditions

• Targets Primary Care Providers (PCPs) as participants, including family medicine, internal medicine and pediatrics

• Stimulates multi-payer environment

® Registered trademark of the National Committee for Quality Assurance

Program StructureProgram Structure

Three-phases (3 years)

Targeted to:• BCBSD contracted physicians• Primary Care Physicians (FP, IM, and PEDS)

• Members of MSD and MedNet• Practices with a minimum number of BCBSD members

13

An Alignment of EffortAn Alignment of Effort

Payment StructurePayment StructureYear 1: Educational/Transformation

o Enhanced Fee for Service Rates

Year 2: Care Coordination/Clinical Metricso Additional per-member-per-month (PMPM)

reimbursement for care coordination (ideally adjusted for intensity of care needed – e.g., burden of illness or case- mix)

Year 3: Outcomes and Performance Incentives

Program ComponentsProgram Components

Program Components-1 Program Components-1

Administrative Requirements•Indicators of whether a participating physician’s technological infrastructure/capacity will facilitate the exchange of information required for successful performance as a PCMH (e.g., EMR/DHIN participation)

Program Components - 2Program Components - 2Clinical Quality Metrics•Based on HEDIS•Focus on Preventive Care including pediatric immunization, cancer screenings and well visits•Regular visits for patients with chronic conditions •Scorecards will provide performance measures to participants•Targets established for phases of the program for continued participation and bonus eligibility

Program Components - 3Program Components - 3

Value & Utilization Benchmarks in place to:•Improve health care utilization patterns specific to laboratory, radiology, and ambulatory surgery services•Prevent unnecessary emergency department utilization

Program Components - 4Program Components - 4

NCQA AccreditationParticipants must earn a minimum of Level 1 NCQA PCMH Recognition by the end of the 3 years

MSD Practice Support ProgramMSD Practice Support ProgramPractice TransformationEnhanced in-office support and “Learning Collaborative” education for up to 15 participating sites. A “Practice Coach” will provide support with:

– Use of data to guide the delivery of clinical care, – Training on the NCQA PCMH requirements, – Practice re-engineering.

MSD is partnering withA nationally recognized company in Colorado to plan and administer the practice support program.

Clinical Care Coordination

Leveraging ExpertiseLeveraging Expertise

The Wall Street Journal, The Denver Post, and The Northern Colorado Business Report all recently spotlighted patient-centered care, compensation to primary care physicians and HealthTeamWorks.

In the Colorado PCMH initiative with Anthem BCBS, PCMH practices being coached by HealthTeamsWorks;•Reduced hospital admissions by 18% •Reduced ED use by 15% •Reduced total cost of care by 14.5% (compared to non-PCMH practices•Experienced Return on Investment ranging from 250 to 450%

VisionVisionMulti-Payer PCMH Environment Remains Optimal

• Not practical to treat patients within the same practice differently

based upon their insurance carriers

• A PCMH program including attribution, metrics, practices support,

and payment structure has been created

• An infrastructure for sharing lessons learned/best practices for the

State and other payers has been created

VisionVisionOpportunity for Multiple Stakeholders to Participate

With formal launch of program in May 2012, additional

opportunities for participation will include:

•Committees

•Information Sharing Conference Calls

•Educational Sessions & Expert Speakers (w/ CME)

•“Consortium” meetings

Randeep Kahlon, MD, MSDTimothy Constantine, President, BCBSDDelaware Health Care CommissionMarch 1, 2012

Thank you for your support and participation.