1. NH Multi-Stakeholder Medical Home Pilot February, 2009

2. NH Multi-Stakeholder Pilot Origins  Dialogue began within the Reimbursement Work Group, which was tasked with addressing reformation of the reimbursement system to:  Improve the quality of care;  Mitigate the increasing trend in cost of care;  Align reimbursement to obtain the kind of care we wanted;  Act in consideration of workforce challenges that are exacerbated by the current system.

3. Reimbursement Composition  Reimbursement work group is comprised of leadership from:  NH Medical Society and AMA Delegation  Commercial Carriers (Anthem Wellpoint, CIGNA and Harvard Pilgrim)  State Insurance Department and NH Medicaid  CMS  Center for Medical Home Improvement  Behavioral Health Association  Hospital Association  Primary Care and Independent Multi-Specialty Practices  NH QIO

4. NH Multi-Stakeholder Pilot Origins  In order to achieve its goals, the Reimbursement Work Group felt that it must first define the “right” care  Clinical and carrier leadership put forth the concept of Medical Homes as the right way to deliver care  Rich history of implementation and success with pediatric medical homes by the Center for Medical Home Improvement  Timely publications from the Commonwealth Fund on medical homes (Beal, et al, June 2007) and reimbursement (Miller, September 2007)  Alignment with work effort by the Quality Team in definitions

5. Medical Home Project Team  The NH Multi-Stakeholder Medical Home Project was initiated in January of 2008 as a joint effort of all NH Payers and representatives of the clinical communities.  The pilot will commence on 01/01/2009, payment will begin 06/01/2009 and will run until 5/30/2011.  It is our desire and intent to offer uniformity in patient attribution, reimbursement, technical support and outcomes measurement to deliver the greatest effectiveness possible in program design.

6. Why Medical Homes? It is about the transformation of primary care:  Putting the patient not just at the fore, but at the center  Enforces, and requires, a team approach to care delivery, both within and across practices and sites of care  Is just as much about care, coordination and services when the patient isn’t there as when they are National movements, employer interest and payer support in the pilots now provide the reimbursement vehicle to pay for the essential services that should and do occur outside of an office visit

7. Patient-Centered Medical Home Joint Principles  Personal Physician  Physician directed medical practice  Whole person orientation  Care is coordinated and/or integrated  Quality and safety are hallmarks  Enhanced access

8. Joint Principles Reimbursement should  Reflect the value of non-face time  Pay for care coordination  Support adoption and use of HIT for QI  Support enhanced communication such as secure email and telephone consultation  Allow for separate fee-for-service visit payment  Recognize case mix differences in patient population  Allow for physicians to share in savings from reduced hospitalizations  Allow for additional payments for achieving measureable quality improvements

9. Pilot Decisions 1.Selection Criteria  Geographic Diversity  Demonstrated Medical Home Readiness  Able to reach a minimum of NCQA Level-1  Organizational Commitment

10. NCQA PPC- PCMH

12. Pilot Decisions 2.Pilot Size 1.11 practices with approximately 39k total members 2.Family Practice, Internal Medicine and General Practitioners 3.Infrastructure & Practice Support Model  Initial vetting and training  Collaboration

13. Pilot Decisions 4.Attribution Method (United & Colorado Model)  Derived  Retrospective view of Medical E&M and Rx for 18 months  Algorithm will select most recent date and will break ties with visit volume and spend  Semi-Annual reporting

14. Pilot Decisions 5.Reimbursement  Per member per month care management fee  Fee for service  Pay for performance through existing carrier programs 6.Evaluation  Proposal for evaluation design is in the process of review

15. Practices Selected Practice NameCity/TownPractice Type Ammonoosuc Community Health ServicesLittletonHealth Center Cheshire Medical Center Dartmouth Hitchcock KeeneKeeneInd Multi-Specialty Practice Concord Hospital Family Health Center ConcordHospital Owned/ Residency COOS County Family Health ServicesBerlinHealth Center Derry Medical CenterDerryIndependent MD Practice Elliot Family Medicine at Bedford CommonsBedfordHospital Owned Practice Lamprey Health CareNewmarketHealth Center Life Long CareNew LondonIndependent ARNP Practice Manchester Community Health CenterManchesterHealth Center Mid-State Health CenterPlymouthHealth Center Westside HealthcareFranklinHospital Owned Practice

16. Evaluation Cost & Utilization Avoidable in-patient stays ED utilization Office visits (specialty, primary care) Pharmacy Outpatient procedures and diagnostics Total cost Should include risk adjustment

17. Evaluation Quality  Claims and chart based Modeled after CMS Group Practice Demo Diabetes Coronary Heart Disease Congestive Heart Failure Prevention  Infrastructure  Patient and family satisfaction  Practice culture, teamwork and satisfaction