1. WVMGMA 2014 FALL CONFERENCE Transformation and Transition to Pay For Value September 19, 2014

2. - Transformation -
It is generally recognized that the current “system” for the delivery of healthcare in the United States is broken. “Fee for service” has led the US to spiraling costs and average quality. Medical inflationary rates are nearly double the rest of the economy. For Highmark WV, “Transformation” is the transition in the way care is delivered to our members. Highmark has developed several programs that promote this transition from Fee for Service to Pay for Value.
The Patient Centered Medical Home will shift away from our current volume driven health care reimbursement to a new care delivery and reimbursement model that considers value for the patient.
The model will focus on providing high quality care and a reimbursement model that supports reduction in health care costs:
High quality, reduced health care cost equals value.
This new care delivery model is a program aimed at supporting the creation of a sustainable healthcare delivery system.
Patients will continue to require greater transparency of both the cost and quality of their health care
The health care financing and delivery systems must integrate to succeed in a healthcare world that focuses on value and assures optimal patient outcomes and the experience of care.
The Quality Blue Patient Centered Medical Home begins the transformation and provides a focus on population management and leveraging information and technology that has not been done historically.

3. - Highmark Goal -
The Highmark Goal is that at least 75% of the Highmark membership will be cared for in at least one Pay for Value program by the end of 2015.
The Patient Centered Medical Home will shift away from our current volume driven health care reimbursement to a new care delivery and reimbursement model that considers value for the patient.
The model will focus on providing high quality care and a reimbursement model that supports reduction in health care costs:
High quality, reduced health care cost equals value.
This new care delivery model is a program aimed at supporting the creation of a sustainable healthcare delivery system.
Patients will continue to require greater transparency of both the cost and quality of their health care
The health care financing and delivery systems must integrate to succeed in a healthcare world that focuses on value and assures optimal patient outcomes and the experience of care.
The Quality Blue Patient Centered Medical Home begins the transformation and provides a focus on population management and leveraging information and technology that has not been done historically.

4. Highmark Pay for Value Programs
Quality Blue Physician P4V (Level 1)
Quality Blue Patient Centered Medical Home (PCMH)
Quality Blue ACA
Highmark MA Incentive Program (STARS)
Quality Blue Hospital
Future Programs
ACO Gain Share
Specialist Pay for Value
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

5. Quality Blue Physician P4V (Level 1)
Quality Blue Level 1 is Pay for Value program, similar to existing PCMH Programs
Quality Blue Level 1 will Launch in WV in October 2014
Practices are now receiving information on participation
All practices are eligible to participate, if the have at least 100 attributed patients and are Navinet users
There is no special contracting required, if a group is successful, they will receive incentive
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

6. Overview of the Quality Blue Physician P4V (Level 1) Program
The are three components to the Quality Blue Level 1 Program
Quality
The practices are measured on the same 24 measures that are included in the Quality Blue PCMH Program
A successful quality score in Level 1 is 25% lower than PCMH
There are two efficiency measures to gauge successful reduction of costs
Generic Prescribing
ED Utilization Efficiency
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

7. Overview of the Quality Blue Physician P4V (Level 1) Program
Quality Component
Participants will be measured on their performance on claims-based clinical quality metrics
In order to qualify for the fee increase in the Program, Participants will be required to meet a minimum quality threshold
Participants are scored for successfully achieving the better of: (1) the 50th percentile of the national HEDIS® Commercial PPO metric benchmark; or (2) the 50th percentile of the Highmark network benchmark; or (3) the 2015 projected 4 Star cut-point as determined by CMS
Participants can receive up to 50 points from quality
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

8. Quality Measures Breast Cancer Screening Colorectal Cancer Screening
Prevention
Breast Cancer Screening
Colorectal Cancer Screening
Cervical Cancer Screening
Chronic Condition Care
Comprehensive Diabetes Care
Pediatric Diabetes Care: HbA1c Testing
Follow-Up Care for Children on ADHD Medication:
CAD: Lipid Profile or LDL-C Testing
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
Diabetes, CHF, COPD: Office Visits 2 or more per year
Use of Appropriate Medications for People With Asthma
Cholesterol Mgmt. for Patients with Cardiovascular Conditions: LDL-C Screening
Pediatric and Adult Well Care
Appropriate treatment for children with URI
Appropriate Testing for Children with Pharyngitis
Adolescent Well-Care Visits
Well-Child Visits in the First 15 Months of Life: Six or more visits
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
Adults' Access to Preventive/Ambulatory Health Services
Childhood Immunization Status: MMR Vaccination
Childhood Immunization Status: Varicella (VZV) Vaccination
Geriatric Care
Glaucoma Screening in Older Adults
Urinary Incontinence Assessment for Older Women
Urinary Incontinence Plan of Care for Older Women
Fall Risk Assessment for Older Adults
Fall Plan of Care for Older Adults

9. Overview of the Quality Blue Physician P4V (Level 1) Program
Generic Prescribing
Rates of generic drug prescriptions will be compared to network specialty averages for Family Practice, Internal Medicine and Pediatrics
The Program awards between five and twenty-five points for ordering more generic prescriptions than the specialty average. Ordering the same amount of generic drugs as the specialty average earns zero points; ordering 1% more generic drugs than the specialty average earns 5 points, and so on, to a maximum of 25 points
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

10. Overview of the Quality Blue Physician P4V (Level 1) Program
ED Utilization Efficiency
This metric will calculate the rate of Emergency Department visits per 1,000
The ED Utilization rate is compared to the WV market averages and scored
Practices Earn up to 25 points for being below the 50th %tile in ED Utilization
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

11. Overview of the Quality Blue Physician P4V (Level 1) Program
Each measurement facet will carry a different weight (50 points for Quality; 25 points for Generic Prescribing; 25 points for ED Utilization) for a total of 100 possible points. A Participant must earn a minimum of 10 points in one of the two Operational Efficiency Measures -- Generic Dispensing or ED Utilization -- in addition to a minimum of 15 Quality points
Successful participation provides a $3 Fee Incentive Paid on E and M services through claims payment (as in PCMH)
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

12. Quality Blue Patient Centered Medical Home (PCMH)
As practices evolve in their transformation, Highmark WV can extend the opportunity to participate in the Quality Blue Patient Centered Medical Home. Practices participating PCMH receive a greater incentive, consultant assistance, access to more detail reporting. Practices who successfully participate in PCMH will initially receive a $10 fee incentive for each E and M code billed. There is also a $2 incentive for Meaningful Use Attestation and $5 for PCMH Accreditation. Additionally advanced success in scoring creates the opportunity to receive a total of $27 in incentives added to E and M codes. The PCMH participants meet monthly with the Highmark Clinical Consultant team to assist with the transformation process. The PCMH participants also receive access to the Provider Intelligence reporting tool to assist with population management activities.
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

13. Overview of the Quality Blue PCMH Program
Quality Scoring:
The PCMH Participants are evaluated on the same 24 quality measures previously mentioned (for Level 1).
A minimum quality score of 20 is required for continuing in the program. There are 50 quality points possible.
Participants are evaluated for cost and utilization control. A Medical PMPM is developed for each practice. For success in the program, a practice will need to manage the cost of care for their patients to a level less than the average annual increase of their peers (trend). There are 50 cost and utilization points possible.
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

14. Quality Blue ACA
The Quality Blue ACA is an off-shoot of the Quality Blue PCMH
The ACA includes a “Network” of providers and facilities
Practices are measured on the same 24 PCMH Measures with the same requirements for success in the program
Practices are measured on Cost and utilization control as in the PCMH. However, there are 20 points possible for Cost and Utilization as opposed to 50 in the PCMH
The practices are measured on their ability to refer within the ACA “Network”. There are 30 points possible for this component of the ACA
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

15. Highmark MA Incentive Program (STARS)
This program is structured to assess and improve the process of care for Highmark Medicare Advantage patients provided by their primary care practices using specific CMS Stars measures as the clinical quality component. The program will have two defined components:
1. Care Gap Closure
2. Star Performance Results
Care Gap Closure Assessment Incentive Component
• Participating practices will receive Care Gap Patient listing reports that identify attributed members and eligible per measure gaps in care as attributed at time of report run date. These lists will update based upon claims received by Highmark throughout the course of the measurement year.
• Care gaps are defined as Medicare Advantage patients that are identified by Highmark claims as patients that have not yet received the expected care as indicated by the national HEDIS® measurements or CMS Star measurements.
Each gap in care closed on identified static measures between January 1, 2014 and September 30, 2014 will be noted to be eligible for care gap incentive payment.
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

16. Highmark MA Incentive Program (STARS)
Program Performance Level Incentive Component
Highmark will calculate a practice level star rating using administrative claims data reflecting a date of service of January 1, 2014 through December 31, All claims for consideration must be submitted to Highmark by January 31, 2015.
At the conclusion of the measurement period, performance will be assessed and the practice will receive a lump –sum performance level incentive payment based upon practice level overall star rating. Incentives will be made for performance levels ≥3.5 stars overall.
Results and Scoring
Care Gap Component
Each of the static measures with care gaps closed by date of service September 31, is eligible to receive a $10 incentive per gap.
Star Performance Measurement-
A minimum of a 3.50 overall weighted star rating must be obtained to receive the performance level incentive payment.
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

17. Highmark MA Incentive Program (STARS)
Overall
Payment Per
Star Score
Attributed MA Member 5
$150
$125
$90
$75
$50
$20
$10
< 3.50 $0
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

18. Highmark MA Incentive Program (STARS) Quality Measures
C01: Breast Cancer screening C02: Colorectal Cancer screening C03: Cholesterol Management for patients with Cardiovascular Conditions: LDL-C Screening C04: Comprehensive Diabetes Care: LDL-C Screening C10: Adult BMI Assessment C14: Osteoporosis Management in Women who had a fracture
C15: Comprehensive Diabetes Care: Eye Exam (retinal) performed
C16: Comprehensive Diabetes Care: Medical Attention for Nephropathy
C17: Comprehensive Diabetes Care: HbA1c Control (≤9%)
C18: Comprehensive Diabetes Care :LDL-C Control (<100mg/dL)
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

19. Highmark MA Incentive Program (STARS) Quality Measures (continued)
C20: Disease Modifying Anti- Rheumatic Drug Therapy for Rheumatoid Arthritis
C23: All cause readmissions: Medicare Advantage
D11: Use of High Risk Medications
D12: Diabetes: Appropriate Treatment of Hypertension
D13: Medication Adherence for Diabetes Medications
D15: Medication Adherence for Cholesterol (Statins)
C51: Annual Wellness Visit and Initial Preventive Physical Exam Rate
DMC16: Pharmacotherapy Management of COPD Exacerbation: Systemic Corticosteroids within 14 days
DMC17: Pharmacotherapy Management of COPD Exacerbation: Bronchodilator within 30 days
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

20. Quality Blue Hospital
Hospitals are evaluated and scored based on a series of quality measures:
Readmissions
30- day acute 3- day acute 7- day return to ED
Healthcare Associated Adverse events (HAAE)
CAUTI CDI LabID CLABSI SSI- IP SSI – OP VTE
Advance Care Planning and/or Palliative Care for Complex Patients
Perinatal
Efficiency Measure (Medicare Spending Per Beneficiary –MSPB)
In addition, hospitals are evaluated on the success of their employed physicians on a set of Medicare Advantage quality measures. The employed physicians are required to maintain a minimum Star Measurement on a subset of the Senior Quality Measures.
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

21. Future Programs ACO Gain Share Specialist Pay for Value
As PCMH / ACA mature in West Virginia, we will begin talking to entities about gain share opportunities. These will be regional groups of providers who will use the reporting tools and information and share in the gains from efficiency.
Specialist Pay for Value
Currently piloting or evaluating Specialist Pay for Value programs including Oncology and Orthopedics. These opportunities will be advancing in the coming months.
Overview of the Patient Centered Medical Home model.
The Quality Blue PCMH model is designed to drive high quality care by monitoring of quality, cost and utilization metrics to drive the optimal patient experience
The initial focus of the model is to have physicians move toward a patient centered model of care
Primary Care Physicians participating the PCMH program will no longer be eligible to participate in the Quality Blue Physician incentive program. Instead, Highmark will strongly encourage all eligible PCPs to participate in the Quality Blue PCMH model over time.
PCPs electing not to participate in the PCMH model will still be able to participate in the Quality Blue Physician program.
The model will continue to evolve over time to incorporate best practices, technology enhancements, and leverage lessons learned

22. Benefits of Transformation
Source: Patient-Centered Primary Care Collaborative, “Benefits of Implementing the Primary Care Medical Home: A Review of Cost & Quality Results, 2012”

23. What About West Virginia?

24. Highmark helps you succeed
What you have to do to succeed
Your obligations may vary in precise details according to your contract, but all participants will be required to commit to:
Support a physician champion
Support a clinical champion
Educate your entire team
Encourage your team to practice to “top of license”
Highmark helps you succeed
Highmark’s Medical Directors, Clinical Transformation Consultants (CTC) and Provider Relations Representatives work every day with your peers who are undergoing the same transformations
Among many resources we can make available through channels such as in-person meetings, online webinars and print publications, we will share:
Best Practices in transformation
Expertise in attesting to Meaningful Use
Expertise in achieving certification as a PCMH

25. Questions? Jason Landers Director, Provider Strategic Initiatives–