1. Implementation Update on OHIC Affordability Standards
Clinical practice champion quarterly learning session
December 9th 2016
Cory King - Office of the Health Insurance Commissioner

2. Office of the Health Insurance Commissioner
Agenda
Overview of OHIC Affordability Standards Initiatives + Opportunities for Collaboration in 2017
Results of Year 1 PCMH Reporting
Discussion & Questions
Office of the Health Insurance Commissioner

3. OHIC Theory of Action
Smarter Spending
Setting Rates for Commercial Insurers
Innovative Regulatory Approaches to Healthcare Reform
Better Care
Healthier Population
Affordability Standards
Compliance with State & Federal Statute & Regulation
Overview of OHIC’s tools for bringing about affordable health coverage
OHIC sets commercial health insurance rates each year through a process called Rate Review. In addition to ensuring rate increases are as low as possible and justified by actuarial data, OHIC oversees compliance with federal and state law. Coupled with the innovative regulatory approaches OHIC has taken to reform the healthcare delivery system, thanks to the Office’s forward thinking legislative charge, this rate setting process gives Rhode Island a one of a kind regulatory lever to bring about smarter spending – for individuals, businesses, and the system – better quality of care, and better health outcomes.
Care Transformation
Payment Reform
Cost Growth Containment

4. Affordability Standards Highlights to Date
Care transformation
Payment reform
Value-based PCMH definition that relies on NCQA recognition, clinical quality performance, and implementation of a standard set of cost management processes.
By 2019 health insurers must have 80% of contracted primary care clinicians practicing in PCMHs.
Practices that meet the 3-part PCMH definition qualify for a “sustainability” payment when included in insurer PCMH count.
Annual targets for the percentage of medical payments that must be paid under an Alternative Payment Model (APM) - 40% by and 50% by 2018
Concerted effort to have total cost of care contracts migrate to greater risk sharing.
Concerted effort to figure out the place of specialist providers in the world of population- based care.
Office of the Health Insurance Commissioner

5. Office of the Health Insurance Commissioner
2017 Care Transformation & APM Initiatives – Opportunities for Collaboration
Identification and Outreach Strategy to Non-PCMH Small Primary Care Practices
Primary Care Alternative Payment Model & Clinical Processes Under APMs
Evidenced-based Approaches for High Risk Patient Identification
Pilot Cost Management Strategy Data Audit
Specialist Engagement – Commonly Defined Episodes of Care
Office of the Health Insurance Commissioner

6. Small Practice Engagement
Identification and Outreach Strategy to Non-PCMH Small Primary Care Practices
Identify non-participating practices and to the extent possible, confirm their specific reason(s) for non-engagement. Among the identified practices, prioritize practices for transformation based on reason(s) for non- participation, and develop and implement a cooperative outreach strategy for engaging and supporting their practice transformation.
Consider redrafting PCMH standards for non-participating small practices and develop eligibility criteria for the revised standards and develop strategies with CTC-RI and RIQI for supporting practices through this transformation.

7. Office of the Health Insurance Commissioner
Primary Care APM
Primary Care Alternative Payment Model & Clinical Processes Under Alternative Payment
OHIC will convene a work group of insurers and interested primary care organizations in January 2017.
The work group will begin by defining the principles and objectives for the payment model.
The payment model design work will begin with service-based definitions of primary care and will include study of the CPC+ Track 2 Hybrid Model.
Work to be completed by June 30th, 2017.
Office of the Health Insurance Commissioner

8. Results of Year 1 PCMH Reporting
Cost management strategies & clinical quality performance
Office of the Health Insurance Commissioner

9. Office of the Health Insurance Commissioner
Review of Data on Cost Management Strategies and Clinical Quality Performance
Submission results:
Cost strategy survey: 126 practices
Quality data submission: 125 practices
In comparison…
CTC-RI: 81 practices
RI primary care practice total (est.):
Office of the Health Insurance Commissioner

10. Attainment of 3-Part PCMH Definition
Transformation Experience n
Yes No
None reported 4
Less than one year (Year 1) practice joined CTC on January 1, 2016; joined TCPI in 2016; or practice is not participating in any transformation initiative 16 10 6
One to two years (Year 2): practice joined CTC on January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition during 2015 30
Three or more years (Year 3): practice joined CTC prior to January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition prior to January 1, 2015 76 72
Total
126
116
Office of the Health Insurance Commissioner

11. Attainment of 80% Cost Management Strategy Threshold
Transformation Experience n
Yes No
None reported 4
Less than one year (Year 1 ) practice joined CTC on January 1, 2016; joined TCPI in 2016; or practice is not participating in any transformation initiative 16 6 10
One to two years (Year 2): practice joined CTC on January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition during 2015 30 21 9
Three or more years (Year 3): practice joined CTC prior to January 1, 2015 or independently achieved NCQA PCMH Level 3 recognition prior to January 1, 2015 76 73 3
Total
126
104 22
Note that only practices with three or more years of transformation experience were required to meet 80% threshold.
Office of the Health Insurance Commissioner

12. Cost Management Strategy Data – Digging Deeper
Office of the Health Insurance Commissioner

13. Cost Management Strategy Data – Digging Deeper
Office of the Health Insurance Commissioner

14. Clinical Quality Performance Measures
Adult practices required to submit the following 5 measures using clinical data specifications developed with CTC-RI:
Adult BMI, Screening for Clinical Depression and Follow-up Plan, HbA1c Control (<8), Controlling High Blood Pressure, Tobacco Cessation Intervention
Pediatric practices required to submit the following 4 measures using clinical data specifications developed with CTC-RI:
Weight Assessment and Counseling for Nutrition and Physical Activity (3 sub measures), Developmental Screening
All measures generally align with the SIM Aligned Measure Set, but are not identical.
Office of the Health Insurance Commissioner

15. Clinical Quality Performance Improvement Requirement Beginning in 2017
The following methodology was finalized by a work group of the Care Transformation Advisory Group in April 2016:
3 percentage point improvement over one or two years or
Performance at or above the national 66th percentile (average of HEDIS Medicaid (HMO) and commercial (PPO) values) or the state median (for non-HEDIS measures)
The work group also recommended:
Assessment of practical implications after a year of reporting
Sub-analysis of FQHC performance with baseline data
Office of the Health Insurance Commissioner

16. Clinical Quality Performance Measures: Baseline Data Analytical Plan
Compare baseline rates to non-Rhode Island benchmarks:
NCQA for HEDIS measures
Rates from other states for non-HEDIS measures
Compare CTC-RI and non-CTC-RI practices.
Conduct a focused analysis of FQHC rates as recommended by the work group in April.
Identify any potential data integrity concerns.
Office of the Health Insurance Commissioner

17. Non-RI Benchmarks: HEDIS
For the following HEDIS measures, we used an average of the National Commercial (PPO) and Medicaid (HMO) 66th percentile from NCQA’s 2016 Quality Compass product (CY2015 service period):
Adult BMI Assessment
Comprehensive Diabetes Care: HbA1c Control (<8.0)
Controlling High Blood Pressure
Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity (avg. of 3 components)
Office of the Health Insurance Commissioner

18. Non-RI Benchmarks: Non-HEDIS
For the non-HEDIS measures, we used the following:
Developmental Screening in the First Three Years of Life
Median rate of 9 states reporting using the Medicaid Child Core Set specifications (FFY 2014)
Screening for Clinical Depression and Follow-Up Plan
Oregon Medicaid Coordinated Care Organization (CCO) rate (CY 2015)
Tobacco Use: Screening and Cessation Intervention
Vermont commercial ACO rate (CY 2015)
Office of the Health Insurance Commissioner

19. Non-RI Benchmark Rates
Measure Category
Measure
Non-RI Benchmark Rate
Adult Measures
Adult BMI Assessment
81%
Comprehensive Diabetes Care: HbA1c Control (<8.0)
53%
Controlling High Blood Pressure
58%
Screening for Clinical Depression and Follow-Up Plan*
37%
Tobacco Use: Screening and Cessation Intervention*
89%
Pediatric Measures
Developmental Screening in the First Three Years of Life*
16%
Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity
62%
*Indicates a Non-HEDIS measure.
Office of the Health Insurance Commissioner

20. Performance of Practices Submitting Data to OHIC
Measure Category
Measure
Number of Practices Reporting (N)
Practices Performing at or above Non-RI Benchmark
Adult Measures
Adult BMI Assessment
105
97%
(n=102)
Comprehensive Diabetes Care: HbA1c Control (<8.0)
89%
(n=93)
Controlling High Blood Pressure
Screening for Clinical Depression and Follow-Up Plan
104
88%
(n=91)
Tobacco Use: Screening and Cessation Intervention
72%
(n=75)
Pediatric Measures
Developmental Screening in the First Three Years of Life 21
90%
(n=19)
Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity
81%
(n=17)
Office of the Health Insurance Commissioner

21. CTC-RI Practice Performance
Measure Category
Measure
CTC-RI Practices
Non-CTC-RI Practices N
Median Rate
Adult Measures
Adult BMI Assessment 68
99% 37
Comprehensive Diabetes Care: HbA1c Control (<8.0)
69%
66%
Controlling High Blood Pressure
84%
88%
Screening for Clinical Depression and Follow-Up Plan
80% 36
82%
Tobacco Use: Screening and Cessation Intervention
95%
94%
Pediatric Measures
Developmental Screening in the First Three Years of Life 8
58% 13
83%
Well Child Counseling: Weight Assessment and Counseling for Nutrition and Physical Activity
92%
Office of the Health Insurance Commissioner

22. Office of the Health Insurance Commissioner
FQHC Performance
Measure Category
Measure
FQHC
Non-FQHC N
Median Rate
Adult Measures
Adult BMI Assessment 22
98% 83
99%
Comprehensive Diabetes Care: HbA1c Control (<8.0)
66%
71%
Controlling High Blood Pressure
77%
87%
Screening for Clinical Depression and Follow-Up Plan
83% 82
81%
Tobacco Use: Screening and Cessation Intervention
92%
96%
Note: Pediatric measures were excluded from this analysis because there were only two FHQCs that reported on the measures.
Office of the Health Insurance Commissioner

23. Data Integrity Concerns
Type of Concern
Detail
Aberrant Rates
1 practice submitted a rate that was greater than 100%.
9 practices submitted rates for a measure that were at or close to 0%.
27 practices submitted rates that were noticeably lower than the median rate for that measure.
Aberrant Denominators
3 practices submitted data for a measure where the denominator was less than 30.
17 practices reported a denominator for “Adult BMI Assessment” that was noticeably different than that of “Tobacco Use: Screening and Cessation Intervention.”
This is notable because the denominators for both of these measures should be similar.
Other
2 practices submitted rates for both Adult and Pediatric measures, whereas 1 practice did not submit rates for any measures.
Aberrant rates could be a result of a practice’s lack of familiarity with using an EHR to report on these measures, or with reporting on these measures entirely.
There is no correlation between aberrant rates and a practice’s inclusion in CTC-RI.
These rates will complicate OHIC’s ability to designate performance improvements in the next year.
Office of the Health Insurance Commissioner

24. Questions & Discussion
Office of the Health Insurance Commissioner