1. Driving Quality Through Incentives in a Municipal Hospital System The Quality Colloquium, P4P Track August 20, 2007 Arnold Saperstein, MD President, MetroPlus Health Plan

2. 2 Session Outline MetroPlus Background Relationship with HHC Quality Incentive Programs Evolution, Fundamentals, and Results Generation 1: Annual QARR Awards Generation 2: Medical Provider Performance Pool (MPPP) Generation 3: Chronic Disease Pay-for-Performance (P4P) Success Factors Overall Take-Aways

3. 3 MetroPlus Background Licensed since 1985 in New York State as a Managed Care Organization Prepaid Health Services Plan (PHSP) Wholly owned subsidiary corporation of the New York City Health and Hospitals Corporation (HHC) Lines of business include Medicaid, Family Health Plus, Child Health Plus, MetroPlusGold, and HIV Special Needs Program To offer Medicare for Dual Eligibles & HIV/SNP in 2008

4. 4 MetroPlus Background Membership Membership at 265,000 as of July 1, 2007 Line of Business# Members Medicaid 202,000 Family Health Plus 41,000 Child Health Plus 19,000 MetroPlusGold 2,000 HIV Special Needs Plan 1,000 Primary Care Assignment HHC60% Community40%

5. 5 MetroPlus Background Network Built around HHC Ten years ago, MetroPlus began to add community providers and hospitals based on geographic and access needs. Our network, as of July 2007 Primary Care2,267 Specialty5,578 OB/GYN689 TOTAL 8,534

6. 6 Relationship with HHC HHC is the largest public hospital system in the United States. 11 tertiary care hospitals, 6 Diagnostic & Treatment Centers, over 70 offsite satellite clinics HHC is a quality focused organization with numerous initiatives active at every facility, including those for Chronic Disease Management, Patient Safety, and Cycle Time Redesign.

7. 7 Relationship with HHC (cont’d) Close collaboration with our parent company Forward-thinking environment Mutual population served Low-income, inner city communities, many racial minorities with higher health risk profiles Mutual achievements Rating of #1 Plan in NYC Overall Quality and Customer Satisfaction for two years in a row

8. 8 Quality Incentive Programs Evolution Since 1998, Annual QARR awards QARR = Quality Assurance Reporting Requirements, an annual collection of quality measures reported to the NYSDOH; based on NCQA HEDIS measures Since 2002, Medical Provider Performance Pool (MPPP) Quarterly profiles monitor and reward improvements in the process of care, recognizing above-average results for 14 claims-based indicators Since 2005, Chronic Disease Pay-for-Performance (P4P) Rewards improvements in outcomes for members with Asthma and Diabetes $31 million dollars have been paid to date for MPPP & P4P

9. 9 Generation 1 Annual QARR Awards 17 indicators were awarded during our 8 th Annual Awards ceremony in November 2006 MetroPlus awards: A $10,000 check for each indicator, recognizing the highest performing provider or facility A plaque to each HHC network, listing the indicators for which their facilities scored highest Program generates competition for the awards and goodwill between MetroPlus and our providers

10. 10 Why did we do this program? To improve the delivery of the preventive health measures included in QARR To improve the reporting of these measures based on administrative data Fundamentals All data based on claims, no medical record review Program includes all MetroPlus providers, both HHC & Non-HHC Providers are compared to the Plan mean and score points for performance statistically above the Plan mean Points are converted to dollars assigned to a performance pool Payments are made quarterly Generation 2 Medical Provider Performance Pool

11. 11 Based on Massachusetts’ Partnerships Primary Care Contract profiles, the quarterly profiles: Share results on key indicators prioritized for performance improvement Most indicators based on HEDIS or QARR Examples: Blood Lead Testing, Cervical & Breast Cancer Screening, Visits with assigned PCP, Emergency Room visits, Chlamydia Screening in Women, Well Child Visit Rates Enable MetroPlus and HHC providers to address Variation in practice Utilization patterns of members Capture of data in an administrative fashion Generation 2 MPPP (cont’d)

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16. 16 How results are shared Website Reports are sent out Checks are delivered by Provider Services Department staff An email is sent to all providers from the CEO to congratulate top performers Generation 2 MPPP (cont’d)

17. 17 Improved outcomes on all Profile indicators, excluding Mental Health Follow-up MetroPlus rated #1 in NYC for past two years on Quality & Member Satisfaction Adult and Child Access, two visit-based indicators, continue to increase, but appear to be leveling off Lab-based indicator rates (Blood Lead Testing, Cervical Cancer Screening, etc.) increased significantly in 2006 Generation 2 MPPP (cont’d)

18. 18 Notes (1) Methodology changes to asthma in 2006 explain the sharp increase in compliance in 2006.

19. 19 Notes (1) For Children’s Access to Primary Care, Q4 2003 data is unavailable.

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21. 21 Next Steps Profiles appear to be contributing to improved outcomes Parallel projects have likely contributed to increased rates Positive feedback from facilities Meaningful dialogue Requests for more information and improvement strategies Generation 2 MPPP (cont’d)

22. 22 Move from process to outcomes-based indicators, focusing on members with Asthma and Diabetes because of the high prevalence in our population and the shared objectives with HHC on chronic disease A joint HHC-MetroPlus workgroup developed the criteria, measures, benchmarks, and points for the program Members included MDs and Finance staff Generation 3 Chronic Disease P4P

23. 23 Key differences from MPPP Only HHC providers Each provider / facility is compared to its own past performance rather than to Plan average Measures are based on meeting or exceeding a benchmark, or improvement from the last data measured at the same facility Methodology guide and reports accessible on MetroPlus Website at any time to administrators and doctors Generation 3 Chronic Disease P4P (cont’d)

24. 24 Generation 3 Chronic Disease P4P (cont’d) Quarterly Process Step 1: MetroPlus identifies the population Step 2: MetroPlus claims and HHC clinical lab data are pulled for specified measures Step 3: For each measure, results are compared against established benchmarks and points are calculated Step 4: Facility-wide and provider/member-specific reports are published Semi-Annually Step 5: Rewards are distributed

25. 25 Generation 3 Chronic Disease P4P (cont’d) Asthma Utilization Rate per Thousand (Population) Percent Utilizing at Acute Level (Individual) Point CategoryPoint ThresholdPoint CategoryPoint Threshold ER Benchmark≤ 25 visits per 1000% Utilizing ER≤ 20% ER % Improvement≤ -10% Improvement in ER Utilization ≤ -10% IP Benchmark≤ 5 visits per 1000% Utilizing IP≤ 4% IP % Improvement≤ -10% Improvement in IP Utilization ≤ -10%

26. 26 Generation 3 Chronic Disease P4P (cont’d) Diabetes Clinical ValuePositive Point(s)Negative Point HbA1c = Glycated Hemoglobin Value is less than 7%; or greater than or equal to 7% but with reduction of at least one percentage point since last test (time between tests must be 2- 8 months) No test in last 8 months; or value increased by at least one percentage point and is greater than or equal to 7% LDL = Low-density Lipoprotein Blood Cholesterol Less than 100 mg/dlN/A Eye Exam Encounter within 12 monthsN/A Max Possible Points 3

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34. 34 Generation 3 Asthmatic Population

35. 35 Generation 3 Asthmatic Diagnosis Rate

36. 36 Generation 3 Results – Asthma Measures, Adults Total Facilities = 17, ER & Inpatient Measures Combined Average

37. 37 Generation 3 Results – Asthma Measures, Children Total Facilities = 17, ER & Inpatient Measures Combined Average

38. 38 Generation 3 Asthma Results As of the first two years: improving results in ER, Inpatient utilization More than half of the 17 facilities already meet the benchmarks A few provider sites have changed their practice patterns, showing improvement in results

39. 39 Generation 3 Diabetic Population

40. 40 Generation 3 Diabetic Diagnosis Rate

41. 41 Generation 3 Results – Diabetes Measures

42. 42 Generation 3 Results – Diabetes Measures (cont’d)

43. 43 Generation 3 Diabetes Results As of the first two years: an increasing number of members meeting the benchmark for LDL and HbA1c tests > ¾ of Diabetic members are receiving timely HbA1c tests > ½ of Diabetic members are reaching the LDL<100 mg/dl benchmark Less than half of Diabetic members are receiving yearly eye exams

44. 44 Generation 3 Challenges Data Member Identification (potential duplicates) Eye Exam Coding Communication of P4P program objectives and available reports & resources Financial incentive transparency: rewards are distributed at corporate level, not to individual physicians or teams

45. 45 Generation 3 Action Items Educate Providers and Hospital Administrators Continual education Share facility-specific results Work through data issues Collaborate with other initiatives and incentive programs Chronic Disease Patient Registry Chronic Care Collaboratives MetroPlus MPPP and Case Management programs Physician-level rewards pilot at HHC Networks slated to begin Fall 2007 Consider development of ROI and efficiency measures

46. 46 Success Factors MetroPlus is active in quality improvement initiatives with all of its providers Due to the higher level of communication, data availability, and inherent incentives to collaborate, we have been particularly successful through joint work with HHC, our provider owner Factors include: communication, data sharing, financial relationship, case management

47. 47 Success Factors Communication Joint MetroPlus/HHC Workgroups Quality Management, Finance, Managed Care, Medical Management, Reporting and Data Sharing Network Relations model with Plan clinical and customer service staff onsite Clinical outreach staff funded at every HHC facility We have email addresses for all administrators and providers at HHC, and for many of our community providers

48. 48 Success Factors Data Sharing The Report Delivery System on MetroPlus’ website houses all reports in a central location and is available to all providers and administrators We reap the benefits of our provider owner’s electronic medical records and have a partnership that permits access to clinical data stored in facility data warehouses

49. 49 Success Factors Financial Relationship Designed to incentivize better outcomes Recognizing that funds are limited, MetroPlus and HHC set up a financial risk arrangement focused on helping people manage their health, in order to decrease morbidity and the need for more intensive services

50. 50 Success Factors Case Management Available, proactive resources on hand: Case managers utilize P4P reports to identify and assess potential members for the Asthma and Diabetes programs HHC facilities collaborate with MetroPlus Case Management to maximize impact of interventions Implementation of a Predictive Modeling System (Fall 2007) will further aid in member identification and early enrollment into case management programs

51. 51 Overall Take-Aways Definitive success already seen for Generation 2 HEDIS- based indicators program, which has been in place for four years First two years show positive trends in Generation 3 Chronic Disease outcomes-based program, in addition to much provider and administrator interest

52. 52 Overall Take-Aways (cont’d) MetroPlus Health Plan and the New York City Health & Hospitals Corporation (HHC) are both quality-driven organizations. Being owned by a provider has allowed the Plan to establish greater communication, increased access to data and the providers for follow-up, the set-up of a financial relationship with appropriate incentives, and collaboration on complementary initiatives. All of these circumstances have allowed MetroPlus to develop effective programs and measure success in our quality improvement initiatives.