FACCT Memo by undul844

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Memorandum
Date: July 14, 2005 To: RE: PEBB Board Update on primary care contract criteria, 2007 From: David Lansky

FACCT and the Technical Advisory Committee have been asked to advise PEBB on a set of criteria it can use to contract for health care services for the state’s 110,000 employees and dependents. For the purposes of analysis, we have organized these services into nine categories:        
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Wellness Screening Primary care Specialty care Hospital care Mental health Prescription drugs Chronic care Information services

These are not discrete categories, of course – primary care providers would offer many of these services, for example. Our initial exercise has concentrated on identifying the criteria that PEBB should use in each category, recognizing that the ultimate suppliers of these services may engage in contracts that cover multiple services. This memo provides some background information and lists some of the criteria for PCP performance now in use around the country.

1200 NW Naito Parkway, Suite 470 Portland, OR 97209 (503) 223-2228, Fax: (503) 223-4336 E-Mail: dlansky@facct.org

Board criteria On May 18, the PEBB Board offered its guidance regarding the most important criteria – broadly stated – in each category. With regard to primary care, the Board indicated its interest in providing services that are:        Accessible (in terms of location, cost, culture) Effective at coordinating care across settings and providers and offer a “medical home” Efficient and comprehensive Accountable for performance (outcomes) Consistent with scientific evidence Proactive and lead to reduced demands for episodic care Integrated with electronic health records and clinical decision support

Current primary care arrangements  Kaiser o No. of members: about 15% of PEBB membership (5,800 of 44,000 subscribers) o Geographic availability: Portland metro (about 2,800 subscribers) and Salem (about 2,800) only Regence Blue Cross o No. of members: 85% of membership o Plan design: PPO (discounted FFS) o Highly dispersed members throughout state (see map)

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Current primary care performance on Board criteria The Board is not satisfied that its primary care criteria are being met with the current arrangements. From the Board perspective, it is not possible to distinguish between having evidence that the goals are being met vs. whether they are being met because the supply of relevant information is simply not adequate. For example, the Board is interested in knowing if the best possible health outcomes are being achieved, yet it presently has virtually no information on the current health status or intermediate outcomes (lipid levels, asthma symptoms, etc.) of its members. In order to move towards the 2007 Vision, PEBB will need to encourage movement on several parallel levels: 1. Encourage adoption of an adequate information infrastructure that will permit monitoring of goals (system or “structural” changes) 2. Encourage performance of specific care processes consistent with evidence

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3. Encourage measurement and tracking of individual patient outcomes (or population-wide outcomes). These are interdependent and cannot be achieved overnight in the current provider environment. The primary care strategy needs to be mapped to the realities of the Oregon delivery system infrastructure and encourage innovative and incremental steps towards these criteria. Possible structures (see p. 19-20 of Vision document) PEBB currently arranges primary care through the two health plan contracts with Kaiser and Regence. These arrangements could be continued in future years, they could be modified to include new contractual criteria, or arrangements with other delivery systems could be implemented. At this early time in our work we will not discuss the appropriate business model for securing primary care services, but we are cognizant that any of the following models may be used in the future:  Health plan committing to meeting specified PCP performance requirements in aggregate  Health plan committing to PCP performance reporting/transparency  Health plan carving out preferred provider network that meet criteria  Health plan or system willing to create qualifying practices in target locations  IPA committing to PCP performance  Direct contracting with distinguished practices or networks Models to consider In addition, PEBB may ultimately wish to apply the primary care contracting criteria in a variety of ways, including:     Individual physician performance criteria (e.g., U.K. GP contract) for selection into panel or pay-for-performance Members choose PCPs based on recognition of performance levels and/or use of financial incentives to encourage choice of higher-performing MDs Contracting with delivery systems that commit to criteria (e.g., Greenfield, PEBB operated clinic, IPA contracting) Bundled payment for populations, outcomes (e.g., fee for solution)

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Criteria Provider-facing criteria  Evidence-based practice – need to specify? o Conditions: e.g., asthma, diabetes, back pain o Domains: e.g., screening, US CPSTF o Services: e.g., prescribing Health risk assessments and monitoring of progress on behaviors? Define and achieve health outcome goals (e.g., Bridges to Excellence) Patient satisfaction: access, communication, experience of care Transparency, willingness to report data (e.g., chronic care outcomes) Use of clinical information systems (e.g., electronic health record, eprescribing, patient e-mail) Chronic care model (e.g., Casalino care management processes) Training and education; care team composition Other …?

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Member-facing criteria  Incentives to members (can be linked to clinician incentives) o Pay for HRA to be done o Pay to accomplish behavior goals (e.g., smoking, weight) o Pay to select preferred MD o Pay to achieve chronic care goals

Issues Regardless of the contractual criteria we might recommend, a number of difficult implementation issues exist. These should be reviewed in the context of the recommended criteria and might lead to changes in how we view the practicality of the criteria:         Application to rural areas Incentives vs. standards (requirements) Incentives for quality performance vs. incentives for system/process adoption Incentive design: Withhold vs. bonus Perceived value of practice profiling, risk adjusted outcomes? Identifying partners (purchasers, payers) willing to use same model, create common incentives Which of these strategies can be done without partners, with small penetration of PEBB members into most PCP practices? Possible member hostility at being directed to certain practices

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Principles for Primary Care Contracting At its July 2 meeting, the Technical Advisory raised several critical points:  Criteria and incentive structures that emphasize choice or recognition of “highquality” providers are not likely to be effective in much of Oregon where few providers are available – and for most members who currently have strong relationships with their providers. The primary care incentives and criteria should support greater “systemness” in practice and delivery system design across all settings. Individual physician profiling will not be of high value until data is available that addresses the elements of PEBB’s Vision, so initial contract criteria should encourage adoption of the necessary infrastructure. Member choice or competition among primary care providers as a driver of change will be two to four years away, pending the availability of relevant data. The attributes of the “medical home” are important to adults as well as children, and should be supported in the criteria list. The criteria should encourage primary care providers to solicit and respect patient values and preferences, recognizing that patient values are not always aligned with the standards of evidence-based practice. The criteria should begin with an expectation of evidence-based care, but accommodate patient preferences. This dimension should be reflected in: o Greater use of shared decision-making tools o Measurement of and reward for achieving good health outcomes as defined by the patient, including functioning, quality of life, self-care ability.   Measurement and reporting of a small set of high-value care processes can be reasonably achieved across most primary care settings. Use of interoperable clinical information technology is essential to many of the changes PEBB seeks, including evidence-based practice, better patient-provider communication, and quality reporting, and should be encouraged across all settings. The proposed criteria are appropriate to use in contracting but the challenge will be in devising a program that encourages their adoption across a variety of settings, cultures, and geography.

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Proposed Approach (preliminary) This approach recognizes that primary care is now delivered through many mechanisms, ranging from large integrated group practice (e.g., Kaiser) to small group practice (e.g., Greenfield) and solo practice in much of rural Oregon. We also understand that each practice is at a different starting point and will make its own progress towards the key attributes PEBB seeks to encourage – such as use of EMR, the chronic care model, and evidence-based care. PEBB can recognize practices that are taking steps towards improved care, reward them financially, and provide them with a few tools to support their improvement. Conceptually, this approach classifies each of the primary criteria into one of three categories:    Core competency – expected of all primary care providers serving PEBB members Patient-centeredness System-ness

We understand that small practices, for example, will find it harder to achieve “systemness” than large group practices with substantial infrastructure and diverse professional staff. But we would expect them to perform well on patient-centeredness while they continue to explore partnerships and care designs that help them achieve the attributes of “systemness.” PEBB can also establish transparency to the members and the public. Transparency to the member should not only include reporting of quality measures and structural characteristics of primary care practices, but also engaging members in the use of assessment and educational tools, particularly those that involve close coordination between patient and primary care provider. This approach also borrows from the General Medical Contract in the U.K. both the notion of creating a fluid scoring system to capture improvement and the idea of providing financial rewards for “aspiration” as well as achievement, i.e., for moving from a baseline score to an improved score year by year, rather than checking off static requirements. These criteria and this scoring approach can be used in several ways: 1. For rating and selecting providers (or networks) for contracting 2. For providing member incentives for selecting higher-performing practices within a large network 3. For providing differential payment incentives to providers within a large network 4. As an educational strategy, to establish provider understanding of PEBB’s goals and emerging requirements.

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In the short term, PEBB could use this approach to design an RFI to be issued to plans, IPAs, or individual practices that want to rate themselves on these criteria – essentially simulating their current score. If used as a payment system, PEBB could invite contracted provider networks (or individual practices) to rate themselves at the beginning of the contract (beginning of Year 1) and to propose a target score for Year 2, then make both “aspiration” and “achievement” payments during each of the first three years. This draft model assumes that PEBB has made several key resources available, such as HealthDialogue and the WebMD Health Quotients. PEBB would also need to specify the various process measures and patient satisfaction survey instruments. The weights illustrated below could be adjusted over time. Initially, the weights might put greater emphasis on achieving the core but gradually be changed to favor outcomes reporting and outcomes improvements. Sample Weighted Criteria Set for Primary Care Selection and Rewards
Phase of Primary Care development Electronic medical record Provides patient access to EMR/PHR Offers secure email with patients E-prescribing Reports selected process measures for entire panel (e.g., screenings, immunizations, diabetes process measures) Reports enhanced measures for target populations (e.g., Bridges to Excellence outcomes – BP control, lipid control, HbA1c control) Achieves BTE target values for PEBB members with diabetes, heart disease Can demonstrate positive change in BTE standards per patient, 1 year Can document completed HRA with patient Can document health risk behavior plan with patient Core Pt centered Pt centered Core Core System Structure, Incentive Units Process, points Outcome s s s s p o 100 per MD 50 per MD 50 Per MD 50 per MD 100 Per MD 100 Per MD

System System

o o

10 Per patient 20 Per patient

Core Pt centered

p p p p p

10 Per patient 10 Per patient 10 per patient 10 per patient 10 per patient

Refers patients to HealthDialogue portal where appropriate System Refers patients to WebMD HRA where appropriate System Refers patients to patient coaching tool (CYC, Subimo, System Nexcura) for selected conditions Conducts patient satisfaction survey to entire panel & reports results Has completed ACIC chronic care improvement selfassessment tool (from Ed Wagner’s group) Pt centered

o

100 Per MD

System

s

100 per MD

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Process for further refinement This process is beginning with the specification of PEBB’s desired outcomes. The second stage is to test whether the Oregon marketplace is willing to make changes that increase the chance of achieving those outcomes. Following the Board’s review of this proposed approach, we will conduct both informal and public reviews in order to gauge the level of interest by provider organizations, carriers, and other possible partners. Based on these reality-checks, we will make pragmatic adjustments. Our process for reviewing this approach will be as follows: - Technical Advisory Committee reviewed and approved on July 16 - Preliminary (conceptual) discussion with the PEBB Board on July 20 - Discussion with a few industry "key informants" July 26-30 - Discussion at open meeting of health system stakeholders, August 2 - Discussion with focus group of PEBB members (employees), early August - Final review by Technical Advisory Committee, August 13 - Revised proposal to PEBB Board August 17

Background Notes on Relevant Models Bridges to Excellence (www.bridgestoexcellence.org)  Incentives to both physicians and patients based on achieved results  Operating in Cincinnati, Boston, Schenectady  MDs must submit data revealing performance  MD rewards up to $160/patient peryear  Patient rewards are vouchers for health care supplies  Initial focus on diabetes, heart disease, systems adoption  Diabetes:  HbA1c tested and in control  LDL tested and in control  BP tested and in control  Eye, foot, urine exams  Heart:  LDL tested and in control  BP tested and in control  Aspirin  Smoking cessation

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UK General Medical Contract  Applies to all UK NHS general practitioners.  Payment based on four standards:  Clinical – includes ten conditions  Organizational – includes records and information, communications, education and training, medication management, practice management  Additional (e.g., screening)  Patient experience  Three payment types:  Preparation payments: to collect baseline data, allow each practice to determine where it is starting from; first 3 years  Aspiration payments: practice defines its goals, payment helps practice implement necessary infrastructure; years 2-3  Achievement payments: based on degree of goal achievement PBGH/IHA incentive program    Part of IHA pay for performance (which also includes HEDIS measures and satisfaction scores at group level) Focus on IT adoption and use; 20% of total Pay for performance Two measures:  Population based management (e.g., producing reminder lists, HEDIS data)  Point-of-care clinical decision support (e.g., accessing lab results, e-prescriing, chronic care reminders)

NBCH RFP (evalu-8) (summary not yet available) Chronic care systems (Casalino et al, External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA 2003; 289(4):434.)  Assumes that adoption of care management processes are necessary to chronic care outcomes:  Case management  Physician feedback  Disease registry  Clinical practice guidelines  Self-management skills instruction  Adoption of care management processes is helped by:  Public recognition for high performance  Financial rewards for high performance  Better contracts with health plans  Being required to report satisfaction, HEDIS data, etc.

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Focused solution model (diPiero & Sanders)   Global payment for delivering all services required to treat a condition Providers set own price and compete, in reference pricing environment

Medical home model (Annals of Family Medicine 2004, 2(Supp1): 533; AAP principles: Pediatrics 2002; 110(1): 184.) Provider profiling; predictive modeling PEBB has some interest in conducting risk-adjusted outcomes analysis to identify superior performing providers in the state. Third party vendors could also be used to help evaluate pricing or provide continuing provider or member feedback. Such services are in use by the Group Purchasing Alliance of Massachusetts (state employees), for example.  Active Health Management  Resolution Health

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From Strategic Planning 2003 Report to the PEBB Board, Aon Consulting, p. 19:

―PROVIDER BASED DESIGN
Provider based design approaches were examined with financial arrangements, organizational relationships and incentive options in mind. Continuums from traditional approaches to innovative approaches were considered and discussed. One specific delivery system design approach was presented in detail for discussion. Strengths and weaknesses of this specific approach were identified. The specific approach would identify organized delivery systems (medical groups, IPAs, carriers, but no individual doctors) willing to administer a plan favoring the most cost effective and good quality sites. Quality and cost effectiveness would be defined based on evidence. Stability and innovative culture would be insisted upon. Provider sites would be independently identified through risk adjustment and robust analytic systems — starting with the most cost effective and requiring a quality threshold. Strategic partnership arrangements would be created with these organizations and sites over time, and dedicated sites would be an option. Contract arrangements could be structured to reward innovation and success with additional stability, commitment, and infrastructure investment. Strengths of such an approach include the creation of new community collaboration with a culture defined by the collaboration. Participants would be selected based on the presence of a cost effective culture but inclusive by welcoming organized groups of providers who were willing to pursue the same model. Value would be improved. PEBB would become a market leader. Weaknesses of such an approach include the risks of trying to put aside old cultures. PEBB would need to anticipate that such a delivery system would include only a minority of providers in any region (meaning other options would need to be pursued in order to provide sufficient access and choice during initial implementation of the approach). In addition, innovation in provider groups can be risky — many provider groups have been unstable in the last ten years. Market leaders are also easily identified and targeted by interest groups. A variety of other strategies related to a provider based approach were also discussed including: Consolidation of carriers i.e., encourage competition at the provider level (based on health outcomes as well as cost). Encourage unique carrier delivery systems promoting competition among providers rather than all carriers (except Kaiser) contracting with the same providers; Leverage size with providers as well as plans (through direct and indirect contracting methods). Use both positive and negative incentives; Contracting with ―Centers of Excellence‖ for select clinical services particularly in clinical areas in which evidence supports improved outcomes with higher volumes—heart surgery, vascular surgery, transplant; Development of tiered networks (e.g., PatientChoice, AccessBlue); and Selective/exclusive contracting (e.g., pilot in specific geographic locale(s) emphasizing innovative approaches, improved infrastructure). Focus group comments on provider based design approaches emphasized the importance of creating an environment of trust and support. The current carrier/provider culture is a challenging one. Trust is low. Relationships have returned to traditional ones similar to those of the 1970s and 1980s. The difference is that no party believes the current system is sustainable or provides value. An approach as outlined would be attractive to providers and potentially several carriers, but would require acknowledgement of culture change for all (change from ―they are to blame‖ to ―we are to blame‖), clear cut articulations of clinical outcome goals, incentives supporting these goals, alignment of members and long term commitment. ―

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