Arkansas Payment Improvement Initiative (APII) April Statewide Webinar April 17, 2013

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Arkansas Payment Improvement Initiative (APII)

AprilStatewide Webinar

April 17, 2013

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Contents

▪ Dr. Bill Golden, DMS Medical Director - Overview of the Healthcare Payment Improvement Initiative

▪ Anita Castleberry and Dr. Justin Hunt, Medical Assistance Manager, BH and ValueOptions Medical Director - Oppositional Defiant Disorder

▪ Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update

▪ Sheena Olson, Assistant Director, Medicaid Programs and Provider Management – Patient Centered Medical Home Update

Paula Miller, HP Enterprises Analyst - PAP Report Update

Arkansas aims to create a sustainable patient-centered health system

SOURCE: State Innovation Plan

Enablinginitiatives

Health information technology adoption

Payment improvement initiative

Health care workforce development

Consumer engagement and personal responsibility

Care delivery strategies

Episode-based care delivery▪ Common definition of the

patient journey▪ Evidence-based, shared

decision making▪ Team-based care coordination▪ Performance transparency

Population-based care delivery▪ Risk stratified, tailored care delivery▪ Enhanced access▪ Evidence-based, shared decision

making▪ Team-based care coordination▪ Performance transparency

Objective Accountability for the Triple Aim▪ Improving the health of the population▪ Enhancing the patient experience of care▪ Reducing or controlling the cost of care

Focus of presentation

Overview

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Payers recognize the value of working together to improve our system, with close involvement from other stakeholders…

Coordinated multi-payer leadership…

▪ Creates consistent incentives and standardized reporting rules and tools

▪ Enables change in practice patterns as program applies to many patients

▪ Generates enough scale to justify investments in new infrastructure and operational models

▪ Helps motivate patients to play a larger role in their health and health care

1 Center for Medicare and Medicaid Services

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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE

We have worked closely with providers and patients across Arkansas to shape an approach and set of initiatives to achieve this goal

▪ Providers, patients, family members, and other stakeholders who helped shape the new model in public workgroups

▪ Public workgroup meetings connected to 6-8 sites across the state through videoconference

▪ Months of research, data analysis, expert interviews and infrastructure development to design and launch episode-based payments

▪ Updates with many Arkansas provider associations (e.g., AHA, AMS, Arkansas Waiver Association, Developmental Disabilities Provider Association)

1,000+

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Monthly

Key Design Elements

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Wave (description)Approach

Popu

latio

n-ba

sed

mod

els

Epis

ode-

base

d m

odel

s Population & episode-based delivery systems roll-out: next 3-4 years

Timing

1 CPC practice participation as of March, 20132 Virtual aggregation of patient panels to meet scale of 5,000 persons

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Episodes: Retros-pective risk-based

3Q 2012 –- 4Q 2012

4Q 2012 –- 4Q 2013

4Q 2013 –- 2Q 2016

▪ Multi-payer launch of first 5 episodes (ADHD, URI, CHF, Joint replacement, Perinatal)

▪ Transition to scale while maintaining momentum: 1-2 sub-waves of 5-10 episodes

▪ Accelerate scale up: quarterly launch of 5-10 episodes

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3

1

Health Homes

1H 2013 –- 1H 2014

2H 2013 –- 2H 2014

▪ All adult DD providers (children follow 6-12 months)

Voluntary enrollment for eligible BH providers2

1

2Q 2012 –- 3Q 2012

3Q 2013 –- 3Q 2014

3Q 2014 –- 3Q 2015

▪ 69 CPC enrolled practices, ~230 providers, 100k+ Arkansans1

▪ Target voluntary enrollment up to 30% of practices (including “virtual practices,” 2), focusing initially on Pediatrics

▪ Target enrollment of remaining primary care practices

PCMH2

3

1

Episodes: Assess-ment based

2H 2013 –- 2H 2014 All adult DD and LTSS services (DD kids phase-in 6-12 months behind adult)

A

Source: State Innovation Model Application

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Contents






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For Medicaid, work has occurred on 15 Episodes, with 5 having gone live

Episode Legislative Review

Reporting Period Start Date

Multipayer Participation1

1 Upper Respiratory Infection Spring 2012 July 2012

2 Attention Deficit Hyperactivity Disorder (ADHD) Spring 2012 July 2012

3 Perinatal Spring 2012 July 2012

4 Congestive Heart Failure November 2012 December 2012

5 Total Joint Replacement (Hip & Knee) November 2012 December 2012

6 Colonoscopy May 2013 Q2 CY 2013

7 Cholecystectomy (Gallbladder Removal) May 2013 Q2 CY 2013

8 Tonsillectomy May 2013 Q2 CY 2013

9 Oppositional Defiance Disorder (ODD) May 2013 Q2 CY 2013

10 Coronary Artery Bypass Grafting (CABG) July 2013 Q3 CY 2013

11 Percutaneous Coronary Intervention (PCI)

12 Asthma July 2013 Q3 CY 2013

13 Chronic Obstructive Pulmonary Disease (COPD)

14 ADHD/ODD Comorbidity July 2013 Q3 CY 2013

15 Neonatal Q3 CY 2013 H2 CY 2013

… Undecided Q1 2014 …




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Wav

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Live Pending legislative review

In Development Seeking clinical input

1 Participation includes development and rollout of episode

Episodes Update

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Contents




Paula Miller, HP Enterprises Analyst– PAP Report Update


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PCMH town hall schedule

AddressDate LocationApril 164 – 6 pm

Little Rock UAMS at I. Dodd Wilson Education Building -- Rooms 126 & 2264301 W. MarkhamLittle Rock, AR 72205

April 184 – 6 pm

Mountain Home Arkansas State University-Mountain Home – McMullin Hall1600 South College StreetMountain Home, AR 72653

April 224 – 6 pm

Fort Smith Golden Living Building – Rogers Taylor Conference Room1000 Fianna WayFort Smith, AR 72919

April 254 – 6 pm

El Dorado South Arkansas Community College – Library Auditorium300 S. West AvenueEl Dorado, AR 71730

May 74 – 6 pm

Hot Springs National Park Community College – Auditorium101 College DriveHot Springs, AR 71913

May 94 – 6 pm

Bentonville Northwest Arkansas Community College – Wal-Mart Auditorium1 College DriveBentonville, AR 72712

May 154 – 6 pm

Paragould Arkansas Methodist Medical Center – Auditorium900 West Kings HighwayParagould, AR 72451

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Contents






Guideline-concordant treatment pathway for clients diagnosed with ODD

SOURCE: Expert Interviews, Journal of Clinical Child and Adolescent Psychiatry and Clinical Guidelines for treatment of ODD, American Academy of Child and Adolescent Psychiatry

Assessment & Diagnosis

▪ Thorough assessment is performed

▪ Licensed clinician confirms diagnosis and is responsible for care

▪ Parent/caregiver notification

Treatment

▪ Initial treatment plan1: 2 visits per week2 for 12 weeks (based on evidence based programs) – ~40% improve3

– Re-assess those that do not improve

▪ Second treatment plan1: 2 visits per week2 for 12 weeks (based on evidence based programs)– ~30% improve3

– Re-assess those that do not improve

▪ Medication may be a useful adjunct (primarily with comorbidities)– For comorbid ADHD/ODD,

treatment should address ADHD symptoms first

Outcomes

▪ Effectiveness of treatment

▪ Reasons necessitating second treatment plan

▪ Continuing care

1 Evidence Based Psychosocial Treatments for Children and Adolescents with Disruptive Behavior; 2 Visits may include client or parent/caregiver therapy; 3 Expert Interviews

PRELIMINARY

Distribution of number of non-comorbid ODD clients treated by individual providers

Number of clients treated by individual providers (clients aged 6 – 17, no comorbid conditions) 1

# clients

101+ 51-100 21-50 11-20 6-10 1-5

240

Clients treated

40

010

50

2030

Prov

ider

cou

nt

1 Episode defined as one 90 day program SOURCE: Arkansas Department of Human Services (DHS), Division of Medical Services SFY2010-SFY2011 Claims data (includes pharmacy)

Episodes ending in SFY 2010 – SFY 2011 (i.e., two years of data), Medicaid only

54% 9% 12% 13% 7% 5%

PRELIMINARY

% of Providers

1.2 1.6 2.0 2.3 2.6 2.5Average episodesper client1

0.8% 2.4% 6.1% 18.1% 26.5% 46.0%% of Episodes

Assessment1

$1 M

Total

$19 M

Medication

$2 M

Non-medication interventions3

$13 M

Office visits

$2 M

Testing2

$1 M

Concordant with evidence-based programs, the most frequent services provided are non-medical interventions

Cost breakdown by service type for ODD episodes (clients aged 6 – 17, no comorbid conditions)Total cost, ($ millions)

% total cost 5% 6% 11% 9%

PRELIMINARY

% episodes with occurrence

69% 17% 78% 39%

68%

92%

1 Represents assessments billed to Medicaid. 58% of spend is from 90885 9 ZZZ, Psychiatric evaluation of hospital records; 42% of spend from 90801 9 ZZZ Psychiatric diagnostic interview exam

2 90% of spend from uncoded claims (no CPT code); 5% of spend from 90801 9 AR1, Psychological testing; 4% of spend from 96101 9 ZZZ, Psychological testing (includes psychodiagnostic tests of emotion); 1% other

3 Non-medication interventions includes all psychotherapy, counseling, community support, and therapeutic activitiesSOURCE: Arkansas Department of Human Services (DHS), Division of Medical Services; Arkansas Department of Human Services (DHS),

Division of Medical Services SFY2011 Claims data (includes pharmacy)

Episodes ending in SFY 2011 (i.e., one year data), Medicaid only (N = 10,477)

Other1

$0.1M

Behavioral health provider organization

$18.5M

Physician (PCP or Psychiatrist)

$0.4M

Total

$19M

Behavioral Health Providers provide the vast majority of ODD care in Arkansas

Cost breakdown by provider for ODD episodes (clients aged 6 – 17, no comorbid conditions)Total cost, ($ millions)

% total episodes 1.8% 98% 0.5%

190 10,225 62Episode count

1 Other includes FQHC providers, non-behavioral health provider school-based providers, and non-standard providers of care

SOURCE: Arkansas Department of Human Services (DHS), Division of Medical Services SFY2011 Claims data (includes pharmacy)

Average cost / episode $1,311 $1,782 $731

PRELIMINARYEpisodes ending in SFY 2011 (i.e., one year data), Medicaid only (N = 10,477)

A third of clients (32%) are receiving care above and beyond what is recommended in guidelines and evidence-based treatments

Episode cost distribution for episodes (clients aged 6 – 17, no comorbid conditions)Average cost / episode ($)

0

500

1,000

1,500

2,000

Epis

ode

coun

t

Average cost / episodeDollars

More

14,00013,00012,00011,00010,0009,0008,0007,0006,0005,0004,0003,0002,0001,0000

1 Evidence Based programs suggest 1-2 treatments per week for 12-14 weeks = ~30 treatments; Medicaid data shows median cost/treatment = $72; 30 treatments x $72/treatment = $2160 per episode.

SOURCE: Evidence Based Psychosocial Treatments for Children and Adolescents with Disruptive Behavior; Journal of Clinical Child and Adolescent Psychology and Clinical Guidelines for treatment of ODD, American Academy of Child and Adolescent Psychiatry; Arkansas Department of Human Services (DHS), Division of Medical Services; Arkansas Department of Human Services (DHS), Division of Medical Services SFY2010-SFY2011 Claims data (includes pharmacy)

Episodes ending in SFY 2010 – SFY 2011 (i.e., two years of data), Medicaid only

Estimated cost of effective evidence based programs1

These clients represent 63% of spend

PRELIMINARY

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Contents






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Arkansas Health Care Payment Improvement InitiativeProvider Report

MedicaidReport date: April 2013

Historical performance: April 1, 2012 – March 31, 2013

Medicaid Little Rock Clinic 123456789 April 2013

DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports is neither intended nor suitable for other uses, including the selection of a health care provider. For more information, please visit www.paymentinitiative.org

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Division of Medical ServicesP.O. Box 1437, Slot S-415 · Little Rock, AR 72203-1437

501-683-4120 · Fax: 501-683-4124

Dear Medicaid provider,

This is an update on the Arkansas Health Care Payment Improvement Initiative – a payment system developed with input from hundreds of health care providers, patients and family members. Our goal is to support and reward providers who consistently deliver high-quality, coordinated, and cost-effective care.

As a reminder, a core component of this multi-payer initiative is episodes of care. An episode is the collection of care provided to treat a particular condition over a given length of time. Since July, Arkansas Medicaid introduced five episodes: Upper Respiratory Infection (URI), Perinatal, Attention Deficit/Hyperactivity Disorder (ADHD), Total Joint Replacement (TJR), and Congestive Heart Failure (CHF), with many more episodes to be added over time.

For each episode, the provider that holds the main responsibility for ensuring that care is delivered at appropriate cost and quality will be designated as the Principal Accountable Provider (PAPs). For some episodes in the period covered in the attached report (Jul 2011 to Jun 2012), you were identified as the PAP. After appropriate risk-adjustments and exclusions, your average quality and cost was compared with previously announced thresholds. This determines any potential sharing of savings or excess cost indicated in the report. Note that all information described throughout your report is based on retrospective claims and all providers should continue to submit and receive reimbursement for claims as they do today.

The TJR and CHF episodes are currently in the preparatory phase and this current report is historical only, covering episodes completed between Jul 2011 and Jun 2012. The ‘performance period’ for these episodes will start February 1, 2013, and reports reflecting episodes eligible for risk and gain sharing will follow beginning in July 2013, due to time needed for appropriate claims to be received.

To aid you in your role as a PAP for future episodes, we have been working hard with providers and other payers to design a set of reports that give you detailed data about the quality and cost of your care as well as how this compares with the range of performance of other providers. As each payer will send a report covering their patients, you may receive similar reports from Arkansas Blue Cross Blue Shield or QualChoice.

We encourage you to log onto the provider portal at www.paymentinitiative.org to access your current and previous ‘preparatory period’ reports. As a PAP for either the CHF or TJR episodes, you should begin using this portal to enter selected quality metrics for each patient with an episode of care starting after February 1, 2013.

We have been working diligently to solicit feedback from the provider community and will continue in our efforts to respond to all questions, comments and concerns raised in a timely and consistent manner. For answers to frequently asked questions regarding the initiative and episodes, please refer to the payment initiative website (www.paymentinitiaitve.org). You can also call us at 1-866-322-4696 or locally at 501-301-8311 with questions or email [email protected]. Additionally, be sure to check the website regularly for updates on upcoming informational WebEx sessions, other resources, or to sign up for alerts.

Sincerely,

Andy Allison, PhD

Medicaid Director

DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports is neither intended nor suitable for other uses, including the selection of a health care provider. For more information, please visit www.paymentinitiative.org

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Table of contentsPerformance summary

Upper Respiratory Infection – Pharyngitis

Upper Respiratory Infection – Sinusitis

Upper Respiratory Infection – Non-specific URI

Perinatal

Attention Deficit/Hyperactivity Disorder (ADHD) – Level I

Total Joint Replacement

Congestive Heart Failure

Glossary

Appendix: Episode level detail

Colonoscopy

Oppositional Defiant Disorder

Cholecystectomy

Attention Deficit/Hyperactivity Disorder (ADHD) – Level II


Tonsillectomy

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Performance summary

Episode of CareQuality of Service

Share Amount

Average Episode Cost Your Gain/Risk Share

Upper Respiratory Infection – Pharyngitis

Not met $0.00Acceptable Not eligible for gain sharing

Upper Respiratory Infection – Sinusitis N/A Commendable Will receive gain sharing $349.50

Perinatal Met $0.00Acceptable Not eligible for gain sharing

Attention Deficit / Hyperactivity Disorder (ADHD) – Level II

Met $0.00Acceptable Not eligible for gain sharing

Quality of services and cost summary1

Across these Episodes of Care You are Subject to Risk Sharing: -$3,000.00Stop-loss was applied

Total Joint Replacement N/A $0.00Acceptable Not eligible for gain sharing

Congestive Heart Failure Not met $0.00Acceptable Not eligible for gain sharing

Upper Respiratory Infection – Non-specific URI

N/A Not acceptable Subject to risk sharing -$3,844.50

Colonoscopy Met $0.00Acceptable Not eligible for gain sharing

Cholecystectomy Met $0.00Acceptable Not eligible for gain sharing

Tonsillectomy Met $0.00Acceptable Not eligible for gain sharing

Attention Deficit / Hyperactivity Disorder (ADHD) – Level I

Met $0.00Acceptable Not eligible for gain sharing


Oppositional Defiant Disorder Met $0.00Acceptable Not eligible for gain sharing

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Quality summary Cost summary

Key utilization metrics

Overview

Cost of care compared to other providers

3

1

2

4

5

Summary – ADHD: Level I closed episodes

$1547-$1772

$700-$1547

<$700 $1772-$1998

$1998--$2223

$2223-$10157

50100

You (non- adjusted)

You (adjusted)

512,000 466,000 1,750

All providersYou

2,000Your total cost overview, $

Distribution of provider average episode cost

Your episode cost distribution

Average cost overview, $

Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29

Your average cost is acceptable

Selected quality metrics: Met Average episode cost: Acceptable

# ep

isod

esC

ost,

$

You

Commendable Not acceptableAcceptable

> $4000

3862

Average number of visits per episodeAverage number of psychosocial visits per episode All providers

You

You are not eligible for gain sharing

$0

Percentile

Gain/Risk share

All providers

Not acceptableAcceptableCommendableYou

< $1,547 > $2,223$1,547 to $2,223

5000

2500

7500

Linked to gain sharing

Avg0%

50%

100%

You

% episodes with medication

4.1 3.9

>$10157

100%

50%

0%You Avg

% Level I episodes

Avg. physician visits/episode

AvgYou0%

50%

100%Completed certification

Standard

for gain sharing

You achieved selected quality metrics

20

10

0AvgYou


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Quality and utilization detail – ADHD: Level I closed

Metric 25th 50thYou 75th 5025PercentilePercentile

0 100

Average number of visits per episode 4.1

Average number of psychosocial visits per episode

15 3862 74

2.3 3.9 4.3

75

Metric linked to gain sharingYou Minimum standard for gain sharing

Utilization metrics: Performance compared to provider distribution2

5025Percentile

Metric You 25th 50th 75thPercentile

0 100

92% 50%75% 85%% with completed certification

75

Quality metrics: Performance compared to provider distribution 1

48% 40%52% 67%% of episodes with medication

25% 20%30% 40%% of episodes that are Level I4.1 2.3 3.9 4.3Avg. physician visits per episode

28% 10%30% 50%% non-guideline concordant15% 5%15% 25%% non-guideline no rationale


--

-


24

189175

8497

744828

1,2001,120

1,9952,457

14,90414,904

16,79616,796

552,000555,450

116,500128,150

Cost detail – ADHD: Level I closed

Care category

All providersYou

4%3%

<1%<1%

3%5%

75%78%

80%75%

77%79%

97%95%

99%99%

100%100%

2725

8497

6269

7570

95117

8181

7676

2,4002,415

500550

Total episode included = 233

Inpatient – PAP

Outpatient – PAP

Ancillary professional

Outpatient facility

Pharmacy

Emergency department

Other

233

230

221

184

21

16

12

1

7

# and % of episodes with claims in care category

Total vs. expected cost in care category, $

Average cost per episode when care category utilized, $

Inpatient readmission or transferPrimary inpatient admission


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Cost summary


Overview


1

2

4

5

Summary – ADHD: Level II closed episodes

10050

$7112-$12601

$6543-$7112

$5973-$6543

$5403-$5973

$2223-$5403

<$2223

You (adjusted)

466,000

You (non- adjusted)

512,000

All providers

1,750

You

2,000Your total cost overview, $



Average cost overview, $


Your average cost is acceptable

Selected quality metrics: Met Average episode cost: Acceptable

# ep

isod

esC

ost,

$

You


> $4000

3862

Average number of visits per episodeAverage number of psychosocial visits per episode All providers

You

You are not eligible for gain sharing

$0

Percentile

Gain/Risk share

All providers


< $5,403 > $7,112$5,403 to $7,112

7500

5000

2500

3.94.1

>$12601

Quality summary3

Linked to gain sharing% episodes with medication

% Level II episodes

Avg. physician visits/episode

AvgYou0%

50%

100%Completed certification

Standard

for gain sharing


Avg0%

50%

100%

You

100%

50%

0%You Avg

20

10

0AvgYou


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Quality summary Cost summary


Overview


3

1

2

4

5

Summary – Perinatal

$3735-$3906

$3906-$5399

>$5399

50100

$3565–$3735

$3394–$3565

$2000-$3394

<$2000

850,000

You (non- adjusted)

You (adjusted)

815,500 3500 3400

You All providers



30%17%

C-section rate Avg. number of ED visits per episode


You achieved selected quality metrics Your average cost is acceptable

All providersYou

Gain/Risk share

You are not eligible for gain sharing Selected quality metrics: Met Average episode cost: Acceptable

# ep

isod

esC

ost,

$

You All providers


> $4000$0

Percentile

12000

8000

4000


< $3,394 > $3,906$3,394 to $3,906

100%

50%

0%AvgYou

50%

0%AvgYou

100%

50%

AvgYou0%

100%

AvgYou0%

100%

50%

You0%

Avg

50%

100%

You Avg

50%

0%

100%

HIV screening

Group B Strep screening

Chlamydia screening

Gestational DM screening

Bacteriuria screening

Hepatitis B screening

Standard

for gain sharing

Standard

for gain sharing

Standard

for gain sharing

Linked to gain sharing Your total cost overview, $ Average cost overview, $

2.11.3


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Quality and utilization detail – Perinatal

5025Percentile

Metric You 25th

97% 50%HIV screening rate

Group B strep screening rate 87% 60%

Chlamydia screening rate 90% 63%


Metric 25th 50th

C-section rate 23% 30%

% episodes with an ultrasound 71% 75%

50th

66%

83%

84%

75th

99%

93%

87%

You

17%

78%

75th

40%

81%

5025Percentile

Gestational diabetes screening rate 56% 42% 50% 65%

Asymptomatic bacteriuria screening rate 90% 43% 62% 73%

Hepatitis B screening rate 58% 41% 55% 69%

Percentile

Percentile

Avg number of ED visits per episode 1.7 2.11.3 5.1

--

--

--

0

0

100

100

75

75

Metric linked to gain sharingYou Minimum standard for gain sharingQuality metrics: Performance compared to provider distribution

Utilization metrics: Performance compared to provider distribution

1

2


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Questions

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For more information talk with provider support representatives…

▪ More information on the Payment Improvement Initiative can be found at www.paymentinitiative.org

– Further detail on the initiative, PAP and portal

– Printable flyers for bulletin boards, staff offices, etc.

– Specific details on all episodes

– Contact information for each payer’s support staff

– All previous workgroup materials

Online

Phone/ email ▪ Medicaid: 1-866-322-4696 (in-state) or 1-501-301-8311 (local and out-of state) or [email protected]

▪ Blue Cross Blue Shield: Providers 1-800-827- 4814, direct to EBI 1-888-800-3283, [email protected]

▪ QualChoice: 1-501-228-7111, [email protected]

Arkansas Payment Improvement Initiative (APII) April Statewide Webinar April 17, 2013

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