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Highmark Update A Bloschichak MD, MBA Sr Medical Director, Provider Strategy Highmark’s Pay-4-Value Programs Highmark’s P-4-V Strategy Highmark Goal: Move 75% of Highmark membership to “pay for value” programs over the next 3 to 5 years 4 Hospital QualityBlue Highmark’s PCMH/ACA Programs More than 69% of members in Western Pennsylvania now receive care within a Pay-forValue program More than 60% of members in Central Pennsylvania now receive care within a Pay-for-Value program Central Pennsylvania Quality Blue PCMH Western Pennsylvania Quality Blue ACA/PCMH • 287 practices representing 43 PCMH entities • 1,738 practitioners • 288,869 attributed members • 432 practices representing 62 PCMH and 77 ACA entities • 1,536 practitioners • 545,434 attributed members Delaware PCMH Pilot West Virginia Quality Blue PCMH • 92 practices representing 30 PCMH entities • 383 practitioners • 34,437 attributed members • 38 practices • 113 practitioners • 35,320 attributed members More than 840 practices More than 3,700 practitioners More than 906,000 members PERFORMANCE MEASUREMENT OVERVIEW Quality = 50% 28 metrics plus 1 informational Cost/Utilization = 50% Total PMPM trend metric DATA OVERVIEW: • Quality Measures • Care Management / Population Management • Cost / Utilization 7 PMPM Assessment Exceeding Trend Current Experience 7/1/2012 - 6/30/2013 Average Category Members Children 6,890 Adults 14,170 Medicare Advantage 1,039 Composite 22,098 Actual Experience $220.59 $521.35 $1,072.77 $453.51 Projected Base Period 1/1/2013 - 12/31/2013 Base Period PMPM $225.85 $532.92 $1,097.90 $463.74 Projected Benchmark Period 1/1/2014 - 12/31/2014 Threshold Market PMPM Full Savings PMPM PMPM $236.72 $234.55 $228.03 $556.78 $552.02 $537.71 $1,149.59 $1,139.26 $1,108.25 $484.86 $480.65 $467.98 8 COST & UTILIZATION Commercial Adult Avg Attrib Members Avg Member Risk Curr •Collapsed categories within Inpatient and Outpatient, and top 10 specialties within Professional •Broken into Commercial Adult, Commercial Pediatric, Medicare Advantage •Including Utilization/1000, months, year over year trend, and benchmarks Top 10 Billing Specialties and Primary Care Summarized Milliman Categories membership •Showing current 12 Member Months Mkt Member Risk Utilization / 1000 •Based on attributed PMPM 13,744 2.31 Totals represent all spend Trend Mkt 164,923 2.63 PMPM Trend Curr Trend Mkt Trend Facility Inpatient Medical Surgical Maternity Psych / Substance Abuse SNF / Rehab Subtotal 19.5 23.1 13.3 5.8 1.3 63.0 (10.0%) (5.1%) (4.6%) 26.6% (36.2%) (5.4%) 25.4 25.5 13.4 4.6 2.7 71.6 10.3% (1.5%) 4.1% 9.2% 19.8% 4.9% $26.81 60.65 5.84 4.13 1.65 $99.07 (10.3%) (1.0%) 3.4% 118.2% (44.2%) (2.5%) $25.54 58.43 7.10 2.82 2.72 $96.61 14.2% 7.2% 13.3% 9.0% 9.9% 9.6% Facility Outpatient Emergency Room Surgery - Hosp Outpatient Surgery - ASC Psych / Substance Abuse Radiology Pathology / Diagnostics Pharmacy Other Subtotal 144.6 67.4 111.3 111.6 430.4 1,073.7 88.6 1,810.2 3,837.7 (2.0%) 6.6% (1.5%) (13.9%) 1.5% 5.3% (27.0%) 10.5% 4.9% 183.3 92.3 109.0 78.8 492.5 1,004.8 161.5 2,121.0 4,243.2 7.8% 4.6% 4.6% (3.2%) 9.9% 5.4% 10.2% 25.1% 15.1% $19.89 40.32 22.68 1.18 25.37 12.25 4.37 33.87 $159.92 6.5% 11.8% 6.9% 0.7% 7.3% 4.1% (60.8%) 3.9% 2.3% $25.57 42.09 14.04 1.11 34.68 15.62 14.18 33.82 $181.11 13.5% 12.8% 8.3% 9.0% 14.9% (6.5%) 12.9% 20.3% 12.2% Professional - Show top 10 categories Primary Care Radiologist Ancillary Primary Care - Ped Anesthesiologist Orthopedics Physical Therapy Hospital Psychologist OBGYN Other Subtotal 4,355.8 1,348.8 874.5 65.8 331.9 550.0 2,159.7 613.0 458.3 630.1 6,043.0 17,430.8 9.8% 2.1% 1.8% (14.3%) (24.3%) 2.7% 5.2% 67777.3% 3.6% (2.8%) 3.0% 7.6% 4,895.6 1,522.6 2,564.5 109.8 350.3 671.5 2,055.5 195.0 403.5 638.1 6,981.1 20,387.5 6.8% 3.5% 10.2% (20.5%) (2.0%) 9.2% 7.8% 459.0% (10.7%) (0.0%) 5.3% 6.4% $24.21 9.94 7.71 0.39 7.51 6.61 6.61 6.20 3.96 6.62 46.48 $126.24 8.8% (4.5%) 8.7% (11.2%) (1.1%) 3.8% 15.0% 107436.3% 3.7% (2.1%) (0.3%) 7.8% $25.60 9.53 11.11 0.68 8.61 8.02 6.53 2.18 3.47 7.62 58.77 $142.11 8.2% (2.8%) 10.3% (13.4%) 8.8% 10.0% 10.3% 1066.8% (11.7%) (0.9%) 8.1% 8.0% Other Prescription Drugs Other Subtotal 16,568.9 884.4 17,453.4 (7.6%) 0.9% (7.2%) 16,346.2 1,000.1 17,346.3 (4.2%) 0.8% (3.9%) $88.63 11.29 $99.92 1.7% 5.7% 2.1% $95.54 11.69 $107.23 6.6% (1.7%) 5.6% Total Medical Total Product 21,331.6 38,784.9 7.0% 0.1% 24,702.3 42,048.7 7.8% 2.7% $385.23 $485.15 2.7% 2.6% $419.84 $527.08 10.1% 9.2% 9 Specialist Pay-4-Value Developed and implemented Specialist P-4-V programs in: • Oncology Oncology chemotherapy drug pathways OncMan oncology patient management P-4-V program. Focus is on preventing hospitalizations and ER visits for dehydration and pain in oncology patients actively receiving chemotherapy • Dialysis / ESRD In conjunction with DaVita • Orthopedics Orthopedics bundled payments utilizing “Potentially Avoidable Complications and Costs” (PACs) • Cardiology Quality and efficiency feedback utilizing episodes of care 10 ACO / Shared Savings Strategy is to build ACO / Shared Savings / Risk-Sharing partnerships with provider groups and systems that illustrate maturity in: • PCMH as foundation • Quality • Population Health – Culture and Tools • IT – EHR, Patient portal, use of registries • Care Management • Care cost and utilization reports and trends Currently have 6 ACO agreements in various stages of development in our markets 11 “The Future Ain’t What It Used To Be” Yogi 12 Highmark’s Advance Care Planning/End-of-Life (ACP/EOL) Initiatives The Palliative Care Dilemma - Nature of the Problem Historic Highmark programs have not been able to change the trajectory of care • Evident by a median hospice length of stay (LOS) of 14 days for Medicare Advantage Life Prolonging Therapy Hospice Benefit Death Life Prolonging Therapy Diagnosis of Serious Illness Palliative/Complex Care Coordination Bereavement 14 Highmark’s Advance Care Planning/End-of-Life (ACP/EOL) Initiatives Mission: Assist members to live better with serious, life limiting chronic illness by raising awareness of advance care planning and end-of-life issues. Primary Objective: Educate members and their families on informed decision making. This can be accomplished by guiding them through the process of clarifying and documenting their values, beliefs and goals for the care they wish to receive, or not receive, when faced with a life limiting illness. Secondary Objective: Encourage providers to initiate advance care planning discussions with their patients and to consider the value of palliative care both for patients receiving curative treatment and those who can no longer benefit from it. 15 Highmark’s Advance Care Planning/End-of-Life (ACP/EOL) Initiatives How is this accomplished? • Community outreach and collaboration to implement the use of POLST (Physician Order for Life-Sustaining Treatment) • Employee and Member Awareness Programs • Quality Blue Hospital Pay for Value Programs • Educational Tools for Providers • Advanced Illness Services Program 16 What Is Palliative Care? • The goal of palliative care is to relieve suffering and provide the best possible quality of life for people facing the pain, symptoms and stresses of serious illness • It is appropriate at any age and at any stage of an illness, and it can be provided along with treatments that are meant to cure 17 Palliative Care ≠ Hospice • Palliative care is not restricted to end-of-life care and is appropriate for any patient with a serious chronic illness, regardless of prognosis • Hospice is a form of palliative care specifically targeted to the dying, those with a prognosis of six months or less if the disease pursues its normal course 18 Palliative Care in Practice • Controls pain and symptoms • Uses the crisis of the hospitalization to facilitate communication and decisions about goals of care with patient and family: – Interdisciplinary approach – Needs-based service - any diagnosis, any prognosis, any stage, any setting – Provides practical support for family caregivers and helps patient remain safely at home • Coordinates care and transitions across a fragmented medical system 19 Chemotherapy + Early Palliative Care = A New Equation • Study in a Cancer Clinic of 151 patients with newly diagnosed metastatic non-small cell lung cancer • All patients received standard oncology care • Half of patients randomized to simultaneous outpatient palliative care by board certified MD and Advanced Practice Nurse following guidelines • Outcomes for patients receiving palliative care: - Better quality of life - Improved symptoms - Less depression - Less likely to receive aggressive end-of-life care - Extended life (11.6 vs 8.9 months) N ENGL J MED 2010 363:733-42 20 The Palliative Care Dilemma: Proposed Solution Integrate palliative care into curative care practices earlier in the disease trajectory • Access to consultation with palliative care team following diagnosis of life-limiting illness • Shifts care to home, providing the support to patients and families for whom the physician would “. . . not be surprised if they died within the next year” for Medicare Advantage members (identified with secondary CPT II codes: 1150F and 1152F) Build and support the needs of a Palliative Care Network • Include hospital-based palliative care programs, palliative care/hospice providers with a home health license Develop a coordinated process between Palliative Care Network and Highmark’s Health Management Services • Dedicated clinical team to manage members 21 Advanced Illness Services Program Implementation • AIS is a specialized program to support members in dealing with a life-limiting illness • Implemented in January 2011 • Uniquely qualified professionals provide emotional support, facilitate communication and complex decision-making related to goals of care, arrange referrals to community resources, coordinate care across care settings, and assist with control of pain and other symptoms • Program provides 100% coverage (no cost to the members) for a lifetime limit of 10 visits: palliative care physician consultation, CRNP, medical team conference, care plan oversight, registered nurse, or social worker 22 Advanced Illness Services Program A dedicated clinical team within Highmark: • Registered nurses and licensed social workers • Supports one-to-one relationships with members, families and providers • Ensures authorization for AIS services based on physician attestation (auto authorization © process through NaviNet ) • Leverages access to available benefits and programs • Remains a dedicated telephonic contact throughout the AIS program and potential hospice election period 23 Who Is Appropriate For A Referral? Ask yourself: • Does this patient have an advanced long term condition or a new diagnosis of a serious illness or both? • Would you be surprised if this patient died in the next 12 months? • Does this patient have decreased function, progressive weight loss, > 2 unplanned admissions in last 12 months, live in a Nursing Home or Assisted Living, or need more personal care at home? • Does this patient have advanced cancer or heart, lung, kidney, liver, or cognitive failure? Diane E. Meier, MD, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, Director, Center to Advance Palliative Care 24 Clinical Palliative Care Triggers General Triggers: • “Would you be surprised if this patient died in one year?” • 2 or more admissions to hospital in 6 months with functional decline • Psychosocial distress in a patient with a life-threatening illness • Uncontrolled symptoms in a patient with a life-threatening illness • Guideline met for hospice eligibility, but “not ready” Disease Specific Triggers: • Cancer: Stage III or Stage IV cancer • CHF: NYHC Stage III or Stage IV heart failure and signs of fluid overload • COPD: Oxygen dependent, low body mass/weight loss, poor functional status • Stroke: Unable to take oral nutrition, change in mental status, aspiration • Renal failure: Signs of uremia (itching, confusion), edema, in a patient not on dialysis • Liver Failure: Encephalopathy refractory to medications, coagulopathy, renal dysfunction 25 Members in the AIS Program • May receive home health care in addition to Advanced Illness Services • May reside in a long term care facility such as a Personal Care Home, Assisted Living, or Skilled Nursing Facility • May elect to enroll in hospice as hospice enrollment is voluntary 26 Highmark Advanced Illness Services Quick Reference Guide for Physician Practices How do I refer my Highmark Medicare Advantage Members? 1. Directly through NaviNet: see box below 2. Directly to an AIS contracted agency: www.highmarkbcbs.com > Find a Doctor, Hospital or Other Medical Provider > Search for Medical Supplies or Services > Enter a Plan, Enter an address or zip code>Select a Service Type = Advanced Illness Services 3. Directly to a Highmark Health Coach: 1-888-258-3428, Monday through Friday, 8:30 am – 4:30 pm NaviNet AIS Authorization Request Process 1. Select a Referred from Service Provider and enter the Proposed Date of Service 2. Enter Member ID with Date of Birth and/or Member First Name 3. Select Category: Advanced Illness Services 4. Select Service: Request 5. Enter a Referred to Facility: Enter ID or select one from the Search Option 6. Diagnosis Code V66.7 – Encounter for Palliative Care will automatically populate (no further diagnoses are required – however, you may enter up to three) 7. Additional Information – Click this box to indicate the member meets eligibility (medical necessity) for the AIS Program – a physician/non-physician practitioner with solid understanding of the patient’s current patterns of care (i.e. any physician/non-physician practitioner who knows the patient’s situation) 8. Complete the Referred From Provider Information 9. Provide any additional Comments, where applicable 10. Submit 27 AIS Headlines • Exceeded enrollment targets each year from 2011-2013 • 2013 patient satisfaction survey indicates 88.2% of participants would refer friends or family • Developed and refined the predictive model utilized to determine the probability of death within a year • Increased the number of contracted hospice providers 35% in 2013 (81 total vs. 60) in western and central PA, West Virginia, and NEPA • 2013 utilization analysis compared AIS enrolled members who died with non-enrolled members who died: - AIS members had hospice median length of stay (LOS) of 35 days compared to nonAIS members with 13 day LOS with greater use of hospice at time of death, 71% versus 52% - Reduced ER visits/chemotherapy in last 30/14 days of life respectively - Reduced hospital admissions in last 30, 90 and 180 days of life - Lower Hospital Allowed Charges 28 Program Successes • Members and families embraced the program – many positive testimonials • Well received by provider community • Favorable utilization trends • Dedicated clinical staff committed to high quality end-of-life care • Predictive Model Tool identified members with chronic/terminal conditions • Enhanced functionality for hospice providers to complete authorizations • Development of a comprehensive web-site for providers with information on the program • Gold Award winner of the 2013 Fine Award for Team Work Excellence in Health Care http://www.prhi.org/plugins/content/ezjwplayer/ezjwplayer/player.php?data=JmZpbGU9SGl naG1hcmtfdjUubXA0JndpZHRoPTk2MCZoZWlnaHQ9NTQwJnRodW1iPWZpbmVhd2FyZ HMuanBnJiZiYXNlPWh0dHA6Ly93d3cucHJoaS5vcmcv • Recognized nationally by CAPC and C-TAC 29 The Role of the PCP and Clinical Staff in Getting the Message Out • Meet with practice physicians, office manager and staff to educate on palliative care/end-of-life • Encourage the clinical staff to: "Have the conversation" by asking the surprise question: "Would you be surprised if this patient died in the next year?" If the answer is “No”, consider referral to the AIS Program • Identify and utilize the resources available to help your patients and families deal with chronic life limiting illness: - Palliative care consult/palliative care services - Advanced Illness Services - Hospice services – members enrolling directly into hospice do not require the services available through the AIS program - POLST/POST/MOLST 30 Advanced Illness Services Resources Index https://prc.highmark.com/rscprc/hbs/pub?document=/documents/ais-resources.html 31 Website Resources www.polst.org Center for Ethics in Health Care Oregon Health & Science University www.capc.org Center to Advance Palliative Care www.nhpco.org www.hardchoices.com www.eperc.mcw.edu National Hospice and Palliative Care Organization “Hard Choices for Loving People”: A resource for professionals, patients and their families regarding end-of-life decisions End-of-life and Palliative Care Education Resource Center 32 Advance Care Planning Website Resources www.prepareforyourcare.com www.acba.org www.wvendoflife.org/Resources--Links/Forms www.highmarkblueshield.com www.caringinfo.org www.agingwithdignity.org Prepare for Your Care website Allegheny County Bar Association/Allegheny County Medical Society Health Care Power of Attorney and Living Will Forms West Virginia Center for End-of-Life Care Highmark Provider Resource Center Download state specific Advance Directives Five Wishes www.eperc.mcw.edu End-of-Life and Palliative Care Education Resource Center www.coalitionccc.org Finding Your Way – Medical Decisions When They Count Most 33 References: Gawande , Atul, Letting Go,Hospice Medical Care for the Dying Patients: The New Yorker, Annals of Internal Medicine, August 2,2010. Hickman E. Susan PhD et al. The Consistency Between Treatment Provided to Nursing Facility Residents and Orders on the Physician Orders for Life-Sustaining Treatment. JAGS 2011. Temel,Jennifer MD et al. Early Palliative Care for Patients with Metastatic Non-Small –Cell Lung Cancer, New England Journal of Medicine 2010;363:733-42. Weissman, David E. MD and Meier ,Diane E. MD, Identifying Patients in Need of a Palliative Care Assessment in the Hospital Setting, A Consensus Report from the Center to Advance Palliative Care, Journal of Palliative Medicine, Volume 14,Number 1, 2011. American Society of Clinical Oncology 2011, www.asco.org/pco/palliativecare Campbell ML, Weissman DE, Nelson JE, Fast Facts and Concepts #253 May 2012, http://eperc.mcw.edu/fastfact/ff_253.htm 34 “It Gets Late early Here” Yogi 35