PARTNERSHIP HEALTHPLAN OF CALIFORNIAPrograms to Improve Care

Robert Moore, MD MPHChief Medical Officer

Aligned Values• Quality• Access• Value

• Provider satisfaction• Member satisfaction• Serving the community

Improving Care

• Quality Programs

• Care Coordination Programs

Partnership HealthPlan of California

Quality Programs• Quality Improvement Incentive Program (Pay for

Performance)• Quality Assurance Programs• Peer Review• Data Analysis and Feedback• QI Projects• Convening of peer networks/collaborative learning

efforts/educational events• Cultural and Linguistic Quality

Quality Improvement Incentive Program

• Principles• Types• Categories• Funds: Compared to other plans.• Related to PPS• Related to PCMH Measures.• An Example

QIP Principles1. Collaboration with Providers

2. Simplicity in the number of measures

3. Actionable

4. Feasible data collection

5. Sizeable Incentives

6. Comprehensive measurement set

7. Align measures that are meaningful

8. Pay for Exceptional Performance and Improvement

9. Stable measures

10. Distribute 100% of Fixed PMPM Funds

QIP types• Fixed Pool PMPM

• Set amount of dollars• All dollars given out• One provider’s low performance means more money to higher

performers

• Unit of Service Measures• Payment for completion of Project• Payment for discrete actions

QIP Categories

• Clinical Measures: 35%• Appropriate Use of Resources: 35%• Access: 20%• Patient Experience: 10%

Size of the QIP• Largest of any HealthPlan in California

• 5 other County Organized Health Systems• 10 Local Initiatives• 5 Private HealthPlans

Alignment with PCMH

• 51% of points of fixed pool PMPM are for measures that impact PCMH status

• 8 out of 9 unit of service measures are related to PCHH

How is PPS affected?

• How does Capitation affect PPS?

• How does fee for service affect PPS?

• How does Quality Improvement Incentive Program affect PPS?

• How do risk pool payments affect PPS?

QIP example: Medium Sized FQHC: Visit Income• Health Center Budget: $500,000 per month ($6 million/yr)• “Unfavorable” Payer mix: 25% Partnership MediCal• About 4000 Capitated Patients: 70% Adults, 30% Children• Capitation Check: About $50,000 per month• Visits per month:

• 1000 by Capitated Patients• 400 by “Special Members” (Non-capitated): Paying $30 per visit

• PPS Rate: $150 per visit• Total Monthly Income from PPS Visits: $210,000• Balance of PPS Rate Paid by State:

• $210K-$50K-12K / 1400 Visits= $105 per visit

QIP example:Medium Sized FQHC: Other income• Not subject to PPS limit:

• QIP: Fixed Pool: $4 PMPM allocated• 100% of points awarded• Average score of all providers 80%• Effective payout $4.80 PMPM• Equal to $230,400 per year, or $19,200 per month

• Other QIP Income: • $66,000 per year or $5500 per month

• Special Member Risk Pool: • $48,000 per year or $4000 per month

QIP ExampleMedium Sized FQHC: Grand total• Visit Income from Cap: $50,000 per month • Other Income from PHC: $28,700 per month• PPS wraparound from state: $160,000 per month

• Total $238,700 per month• $170.50 per visit• 48% of budget

QIP ExampleMedium Sized Health Center• Investing QIP money:

• Staff incentive or reward program• Hire chronic disease case managers

• Women’s health • Diabetes

• Allocate staff time to QIP activities:• In-reach• Organizing forms• Provider and Staff Education on Topics affecting QIP• Reviewing list of patients that went to Emergency Room each Day• Case managing patients in hospital/discharged from hospital• Data Analysis

• QIP coordinating committee

Care Coordination Activities• Transportation Benefit• Growing Together Program (Perinatal)• Care Transitions

• Case Management• Complex Case Management (telephonic)• Intensive Case Management (in-person)• Home Visiting Nurse Practitioner Program

Drivers of high hospital costs• Top 1-5% of patients by total cost drive most hospital

costs

• Inappropriate care in severely ill individuals• Excess specialty care• Patients with poorly controlled substance abuse, mental

health problems with serious chronic medical illness

• Major theme: need better care and more coordination

Severity-specific Care Coordination

Homebound, frail, labile health, very high costs

Clinician home visits, reliable on call

Frequent hospitalizations, medical and behavioral issues

0.1%

3%Intensive case management

7%Complex Case Management

Case Management

20%

70%

Primary Care

Chronically Ill, 3 modifiable conditions

Need specific, short-term support

Well, or stable chronic illness

Case I: 50 yo woman from Vallejo• Health Plan Contracted outside FNP agency• Home Visit Based• Home Bound patient

Barriers to Care Coordination for patients at home

• Clinic culture that is provider-centric instead of patient centric

• Unable to come up with system to pay for home care

• Links with ER doctors and hospitalists

Case Study II: 40 yo woman with diabetes

• Plan based telephonic case management• Nurse-navigator teams• Remote care, patient at home

• Atul Gawande’s “Hot Spotters” article• Care Oregon’s case managers embedded in PCP

office/clinic• Monarch Health: non-integrated “high-risk touch

team”• HealthCare Partners: Embedded Complex Case

Management• Wellpoint: pay for care plan submission

Intensive Case Management – Evidence Base

• Contracted Services Model: • $100,000 of funding to the health center/clinic which will hire, train

and oversee case manager.

• Embedded Case Manager Model: • Partnership HealthPlan Hires a Case manager who will be

embedded in the health center/clinic• $5,000 of funding to health center/clinic to cover collateral

expenses.

• Integrated Care Team Case Management:• $100,000 of funding to support training many case managers, each

based in a primary care team

• All Models:• focusing on 50 high-cost and complex patients who are primary

care patients at the health center/clinic

Intensive Case Management

Intensive Case Management Principles

• Funded through Payer, by savings• Reduce Readmissions and Inappropriate Admissions

• Target highest cost patients• Work with PCP• In person case management• Accountability: Care Plan submission

Role of Integrators in triple aim• Micro integrator

• Macro integrator

Questions?

Partnership HealthPlan Leadership Team