1. Physician Group Practice Transition Demonstration
Frederick J Bloom, Jr. MD MMM
Assistant Chief Quality Officer
Geisinger Health System
9/20/2011

2. Centers for Medicare and Medicaid Services Physician Group Practice Demonstration Project
First value based purchasing demonstration applied to providers
Goals – Improve efficiency (decrease costs) while improving quality (measured on 32 quality metrics) for assigned vs. comparison group of Medicare beneficiaries in the same geographic location getting care from non-site providers.
Improve coordination of Part A & Part B expenditures
Align reimbursement with quality
Reward for improving health outcomes

3. Successful? |

4. Centers for Medicare and Medicaid Services Physician Group Practice Demonstration Project
10 Physician Groups
All are groups of > 200 physicians
Long term commitment –
Application 2003
Baseline data 2004
Originally 3 years starting 4/1/05
Extended to 5 years (5th year completed 3/31/2010)
Added risk adjustment cap in the 5th year
Currently the next phase - PGP Transition Demonstration Project

5. PGP Demonstration Participants
Dartmouth-Hitchcock Clinic– Hanover, NH
Deaconess Billings Clinic- Billings, MT
Forsyth Medical Group– Winston-Salem, NC
Geisinger Clinic– Danville, PA
Integrated Resources for Middlesex Area– Middletown, CT
Marshfield Clinic– Marshfield, WI
Park Nicollet Health Services– St. Louis Park, MN
St. John’s Health System– Springfield, MO
The Everett Clinic– Everett, WA
University of Michigan Faculty Group Practice– Ann Arbor, MI

6. Shared Savings Methodology
If assigned beneficiary total Medicare expenditure risk adjusted growth rate is > 2% below local market growth rate
Then Groups Share up to 80% above the 2% threshold
Shared Savings Capped at 5% of expenditures
Risk Adjustment Capped at 10% above comparison group in year 5

7. PGP Demonstration Quality Measures
Diabetes Mellitus
Congestive Heart Failure
Coronary Artery Disease
Hypertension
& Cancer Screening
HbA1c Management
LVEF Assessment
Antiplatelet Therapy
Blood Pressure Screening
HbA1c Control
LVEF Testing
Drug Therapy for Lowering LDL Cholesterol
Blood Pressure Control
Blood Pressure Management
Weight Measurement
Beta-Blocker Therapy – Prior MI
Blood Pressure Plan of Care
Lipid Measurement
Blood Pressure
Breast Cancer Screening
LDL Cholesterol Level
Patient Education
Lipid Profile
Colorectal Cancer Screening
Urine Protein Testing
Beta-Blocker Therapy
Eye Exam
Ace Inhibitor Therapy
Foot Exam
Warfarin Therapy
Influenza Vaccination
Pneumonia Vaccination
Note: Claims based measures in italics

8. PGP Demonstration Results - Quality|

9. PGP Demonstration Results – Overall Financial
Source: RTI International |

10. PGP Demonstration Results – PGP Shared Savings
Source: RTI International |

11. PGP Demonstration Results – PGP PQRI Earnings
Source: RTI International |

12. What does it take to be successful?
More than 75% of Medicare spending occurs in patients with 4 or more chronic diseases. (CB0)
25% of Medicare beneficiaries consume 85% of the Medicare expenditures. (CBO)
10% of the US population consumes 65% of all health care spending. (CMWF Health Affairs 2007)

13. How did Marshfield Clinic intervene for the PGP project?
Multiple simultaneous interventions – there is no silver bullet!
Best practice models developed for core conditions
Computer based CME opportunities
Care management programs
Population based feedback to providers
Health Information Technology
Physician/Clinical Nurse Specialist regional teams
ALL interventions for the CMS PGP demo are applied to ALL Marshfield Clinic patients.

14. PGP Demonstration Design Flaws
Shared savings started at 2% threshold
Local Comparison Group
Beneficiary Assignment Based on all outpatient E&M services (primary care and specialty)
Risk Adjustment
Poor Access to Data
Also all low cost areas (but does not explain the variation in results) |

15. Beneficiary Assignment Local Comparison Group
Based on plurality of outpatient E&M services
All Specialties
3 groups
PGP assignment if PGP group provided the plurality of services
Null group if PGP touched but did not have the plurality of services
Comparison group if not assigned to the PGP in the prior year and no claims with the PGP in the demonstration year |

16. Geisinger Physician FTE Growth
43 % Physician Growth |

17. Issues with beneficiary assignment model E&M
Included all specialty outpatient E&M services Patients managed by a non-PGP primary care physician could move into the attribution population based on high cost specialty episode Patients managed by a PGP primary care physician could move out of the attribution population based on an out of system specialty episode |

18. PGP Transition Demonstration
Shared Savings Split – 1st dollar, 50/50 split
“Corridor” of significance – 95% confidence interval – varies with population size
5% Savings Cap
Attribution – 2 retrospective options
Comparison Group - National
Risk Adjustment - Prospective, capped at 0.4% per year.
New Quality Criteria
Leading Quality Option – earns 60/40 split

19. CMS negotiations
Included representatives from all 10 PGP’s Weekly meetings with CMS over 8 month period 2 workgroups: Design Quality Criteria Large amount of data shared by CMS Many options discussed and modeled |

20. Corridor of Significance
A threshold to be sure that the results are not normal variation – statistical “noise”
95% one sided confidence interval
The larger the population, the smaller the improvement needed to be statistically significant
Produces a 2% threshold above 20,000 patients
Rises to a 4-5 % threshold below 10,000 patients
SIZE of the population is very important |

21. |

22. Prospective vs Retrospective Assignment
Prospective Allows population to be identified, tracked and managed However “stayer rate” averaged 74 % for the PGP participants Choosing this option would reduce the size of the assigned beneficiary Retrospective Larger assigned beneficiary pool Primary care assignment improved the percentage of E&M services provided by the PGP |

23. Attribution – Picked 2 options from 7
Method 1: PGP (Current) demonstration method. All specialty E&M services Method 2: Primary Care – Broad (with cardiology, endocrinology, nephrology) Method 3: Primary Care – Narrow Method 4: Hybrid of M2 and M1 if no Primary Care Method 5: Hybrid of M3 and M1 if no Primary Care Method 6: M1 plus additional E&M codes for nursing facility services and domiciliary, rest home, or custodial care services and home services Method 7: M5 with additional E&M codes above |

24. Attribution Modeling - Retrospective|

25. Risk Adjustment – PGP demonstration
Different than the “prospective” scoring used in Medicare Advantage
Based on retrospective (concurrent year) HCC scoring
Gave more relative weight to acute conditions that occurred in the performance year
Risk scores rose for all groups during the demonstration
A cap on risk score of 10% above the comparison group was added in year 5 |

26. Prospective Risk Scoring
Uses prior year diagnosis to calculate beneficiary risk scores Includes age, sex and cost matched population controls Gives greater relative weighting to chronic conditions Normalized to adjust for year to year coding pattern changes as in Medicare Advantage |

27. PGP Transition – Final Design Overview
Performance Period: 2 years (1/1/ /3/12)
Beneficiary Assignment: Pick Model 1 or 7
Comparison Population: National
Baseline is weighted risk adjusted expenditures in past 3 years
Trended forward based on national average growth rate (absolute per capita dollar increase – risk adjusted)
Risk Adjustment : Prospective
Capped at +/- 0.4% in year 1 and 0.8% in year 2 relative to base year
Minimum Savings Requirement: 95% one sided
Shared Savings: 50% split from 1st dollar savings
Quality Gated
25% withhold |

28. PGP Transition Quality Measures Pay for Performance Year 1 &2
Diabetes Mellitus
Heart Failure
Coronary Artery Disease
Hypertension
Prevention/ Cancer Screening
HgbA1c > 9%
LV Function Assessment
Antiplatelet Therapy
BP < 140/90
Screening Mammography
Blood Pressure < 140/90
LV EF testing - Hospitalized
Drug Therapy for LDL > 130
Plan of Care
Colorectal Screening
LDL < 100
Weight Measurement
Beta Blocker if prior MI
Influenza Vaccination > Age 50
Urine Protein Testing
Heart Failure Education
LDL Level < 100
Pneumocococcal Vaccination > Age 65
Dilated Eye Examination
Beta Blocker Therapy
ACE or ARB w/DM
Foot Examination
ACE or ARB Therapy
Warfarin Therapy w/AF

29. Care of the Frail Elderly
PGP Transition Quality Measures Pay for Reporting Year 1 Pay for Performance Year 2
COPD
Care of the Frail Elderly
Meaningful Use
Tobacco Use Assessment/Cessation Intervention
Screening for future fall risk
Adult Weight Screening and Follow-up
Spirometry Evaluation
Osteoporosis Management in Women Who Had a Fracture
Hypertension - BP measurement
Bronchodilator Therapy
Monitoring INR for Patients on Warfarin
Tobacco Assessment/Cessation Intervention

30. PGP Transition Quality Measures Pay for Reporting Year 1 &2
Transitions of Care/ Care Coordination
Post Discharge Medication Reconciliation
30 Day Post Discharge Provider Visit
All Cause Readmissions
Ambulatory Care Sensitive Condition Admissions - DM Short Term Complications
Ambulatory Care Sensitive Condition Admissions - COPD
Ambulatory Care Sensitive Condition Admissions - Congestive Heart Failure
Ambulatory Care Sensitive Condition Admissions - Bacterial Pneumonia
Ambulatory Care Sensitive Condition Admissions - Uncontrolled Diabetes

31. PGP Transition Quality Measures
Savings are quality gated
80% in Year 1
90% in year 2
Quality Targets are based on best performing group in the prior year
Payment on a scale from a minimum to maximum target score for each measure |

32. PGP Transition Quality Benchmarks|

33. Quality Leader Option
Moves from a 50/50 to a 60/40 split 5% additional savings for reporting on a patient experience measure. Will be specified in MSSP final regulation – likely to be CAHPS-CG 5% additional savings for reporting metrics in an all- or-none fashion for DM, HF, CAD, HTN, and COPD. Data Sharing PGP’s agree to public reporting of quality and financial results. |

34. PQRI
PGP’s will earn their PQRI incentive payments based on the demonstration quality measures. PGP’s will earn 100% of the PQRI dollars if their overall quality score is > 90%. If quality score is < 90%, the PQRI dollars will be scaled with the maximum equal to 90%. |

35. Transition Options
The PGP’s will have the option to transition to MSSP or another initiative in the innovation center when available. |

36. Lessons learned
The PGP demonstration showed that it is possible to reduce costs and improve quality – even in prior low cost areas of the country. Quality scores were uniformly improved by all members of the demonstration but did not translate into shared shavings. The shared savings were not uniformly distributed to the PGP participants due to numerous design flaws. CMS was receptive to resolving many of these design flaws in the new Transition Demonstration |

37. Questions?