Statewide Tracking Report - Arkansas Center for Health Improvement

Transcription

Arkansas Health Care Payment
Improvement Initiative: 2nd Annual
Statewide Tracking Report
January 2016
Participating Payers:
Prepared by:
A nonpartisan, independent, health policy center that serves as a
catalyst to improve the health of Arkansans.
Acknowledgements
The staff at the Arkansas Center for Health Improvement (ACHI) appreciate the opportunity to work with
individuals leading the implementation of the Arkansas Health Care Payment Improvement Initiative.
The production of this report would not have been possible without the efforts of:
The Arkansas Department of Human Services, Division of Medical Services staff including Lee Clark, Sharon
Donovan, William Golden, MD, Kiral Gunter, Brandi Hinkle, Lech Matuszewski, Maggie Newton, Sheila Nix,
Anne Santifer, Dawn Stehle, Shelley Tounzen, David Walker, Michelle Young-Hobbs and other members of the
Arkansas Medicaid team.
General Dynamics Health Solutions staff including Jane Gokun, Marlo Harris, Nena Sanchez ,and E.J. Shoptaw.
Arkansas Blue Cross and Blue Shield Staff including Alicia Berkemeyer, Matt Flora, David Greenwood, Randal
Hundley, MD, Steve Spaulding, and Sarah Wang among others.
QualChoice staff including Mark Johnson, Lubna Maruf, MD, and Stephen Sorsby, MD.
ACHI staff including Michael Motley, Debra Pate, Leah Ramirez, and Joseph W. Thompson, MD, MPH.
This report was made possible in part by grant funding from Walmart.
Contact Information:
For general inquiries please contact:
Mike Motley, MPH
Interim Director, Health Care System Transformation
Arkansas Center for Health Improvement
1401 West Capitol Avenue, Suite 300 - Victory Building
Little Rock, AR 72201
[email protected]
501-526-2244
For Arkansas Blue Cross and Blue Shield Inquiries:
[email protected]
For Medicaid Inquiries:
Christine (Tina) Coutu
Business Operations Manager
DHS - Division of Medical Services
P. O. Box 1437, Slot S416
Little Rock, AR 72203
501-537-2195 Desk
501-350-7039 Mobile
[email protected]
Suggested citation: Arkansas Center for Health Improvement, Arkansas Health Care Payment Improvement Initiative, 2nd
Annual Statewide Tracking Report, Little Rock, AR: ACHI, January 2016
Arkansas Health Care Payment Improvement Initiative
Statewide Tracking Report, January 2016
Page 2
Table of Contents
Page
Executive Summary
4
Introduction
9
12
Patient-Centered Medical Homes
Arkansas PCMH Progress Overview
13
Commercial Payer PCMH Support
14
PCMH Practice Transformation Milestone Progress
14
PCMH Quality Metric Outcomes for Medicaid
15
Hospital and Emergency Department Utilization Impacts
16
PCMH Financial Outcomes for Medicaid
17
Provider Response to Shared Savings
18
19
Episodes of Care
Provider Spotlight: Episodes of Care
20
Overview of Episode Results
21
28
Conclusion
Appendix A Patient-Centered Medical Home Case Study:
Aligning Incentives and Rewarding Innovative Collaboration
(Regional Family Medicine, Mountain Home, Arkansas)
Appendix B Patient-Centered Medical Home Fact Sheet:
Shared Savings Update
Appendix C Episodes of Care Detailed Report
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Executive Summary
Statewide, multi-payer implementation of Arkansas’s Health Care Payment Improvement Initiative (AHCPII)
has positioned Arkansas as a national leader in value-based health care innovation. Since the first
components were launched in the summer of 2012, AHCPII has supported and incentivized delivery of highquality, efficient care for a large and increasing number of the state’s citizens. As a key part of the state’s
total health system transformation effort, the AHCPII has fortified broad goals that include improving quality,
expanding access, and avoiding unnecessary costs.
Arkansas was one of only six states awarded an initial State Innovation Model Testing grant by the Centers
for Medicare and Medicaid Services, receiving $42 million in federal funds to implement the AHCPII. AHCPII
now has a strong foothold across the state through deployment of two primary strategies: Patient-centered
medical homes (PCMH), designed to improve quality and contain costs by supporting the delivery of bettercoordinated, team-based care;a and a retrospective episodes of care model, designed to improve quality and
reduce variation in treatment of acute conditions and delivery of specialty procedures.
A third component, originally introduced in 2012 by Arkansas DHS was a Health Home model—a client-based
support strategy for individuals with needs exceeding the traditional medical home model. The health home
strategy proposed to optimize coordination of services for those individuals, including the frail elderly, the
severe and persistently mentally ill, and the developmentally disabled. These populations represent a large
proportion of the state’s overall Medicaid expenditure. As a Medicaid-only component of the AHCPII, the
model has been met with challenges from both the provider community and other stakeholders and has not
been implemented. The state is currently weighing alternative options to improve delivery of high-quality
and efficient care to these special needs populations and through their deliberations may choose to pursue
components of the Health Home model.
The AHCPII has the strength of multiple payer engagement with the participation of a majority of the state’s
health care payers including Arkansas Medicaid, Blue Cross and Blue Shield (AR BCBS), QualChoice (QC),
Centene, and United Healthcare, along with Walmart, the State and Public School Employee benefits
program, and other self-funded employers. Support for AHCPII includes a broader team of individuals at the
Arkansas Department of Human Services, Hewlett-Packard, General Dynamics Health Solutions, Arkansas
Foundation for Medical Care, Qualis Health, and the Advanced Health Information Network, among others.
As a result of continued progress and demonstrated success, additional payers have shown interest in joining
the AHCPII. Importantly, leaders at the Center for Medicare & Medicaid Innovation (CMMI) have
acknowledged the success of Arkansas’s model and approached the state regarding expanding the program
to include federal support for the approximately 71,000 Medicare beneficiaries in the state’s PCMH program.
As additional practices enroll, more of the state’s 400,000 Medicare Part A and B beneficiaries could be
served in a PCMH. CMMI has committed to assisting the state in exploring this opportunity—one that, if
successful, would make Arkansas only the second state in the nation (behind Maryland) to receive a Federal
Medicare waiver for a state-specific, value-based model.
AHCPII progress as well as quality and cost impacts are captured in this second annual AHCPII Statewide
Tracking Report. The Arkansas Center for Health Improvement (ACHI) has worked with individual payers and
providers to gather content for development of this report, designed to track progress and to help identify
challenges and lessons learned.
a
To view a comprehensive video about AHCPII, visit http://www.achi.net/pages/OurWork/Project.aspx?ID=81.
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Patient-Centered Medical Homes (PCMH)b
This multi-payer, team-based primary care strategy has received legislative support and been adopted
widely by providers across the state. Primary care clinics are given responsibility for total cost of care for
their panel of patients and receive upside gain-sharing if they meet quality metrics and bring total costs
under preset thresholds. Provider enrollment in the program is voluntary. The Medicaid PCMH results
depicted in this report are for beneficiaries that are managed by Arkansas Medicaid and do not include
results for those beneficiaries who are covered under a commercial qualified health plan (QHP). Results
from the QHP beneficiary PCMH experience are anticipated to be available for inclusion in the next
annual Statewide Tracking Report.
PCMH Highlights
•
Medicaid has more than 80 percent of its beneficiaries under this model.
•
In 2014, Medicaid realized $34.3 million in direct
cost-avoidance through trend reduction. Of the
$34.3 million in savings, $12.1 million went
toward care coordination payments to providers.
The remaining $22.2 million in net cost avoidance
was shared between the state and those
providers who met both quality and cost savings
requirements. Shared savings checks were issued
in October 2015, with several clinics receiving
over $100,000.
●
In 2014, enrolled practices
experienced a cost decrease of
1.2 percent, beating both the 2.6
percent benchmark trend increase
and the 0.6 percent cost growth of
non-participating practices.
Medicaid PCMH data provided by Arkansas DHS, pulled from PCMH Q4 reporting as of December 10, 2014. Enrollment figures include
practices that enrolled for 1/1/14, 7/1/14 and 1/1/15 start dates. Commercial carrier data provided by individual carriers.
b
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




In 2014, the vast majority of practices met
transformation milestones and either
improved or maintained prior-year levels for
78 percent of PCMH quality metrics. Quality
metrics include: increased pediatric wellness
visits, Hemoglobin A1c testing, breast cancer
screenings, improved Attention Deficit
Hyperactive Disorder (ADHD) management,
and thyroid medication management.
AR BCBS has recognized value and extended
attribution of patients to all of its covered lives;
AR BCBS has publicly stated intent to increase
payment to primary care through markedly
increased per-member per-month (PMPM) payments and hold/reduce fee-for-service (FFS) payments for
services rendered over time.
The federal Medicare program has approached the state to expand their participation to all Medicare
beneficiaries (participation is currently limited to the original 69 clinics in the Comprehensive Primary Care
Initiative). Arkansas would be only the second state for which Medicare has modified national payment
strategies to support local payment transformation.
Qualified health plans operating on the insurance exchange and dual-specialized needs managed care
plans are required to participate in the state PCMH program by either legislative or regulatory
requirements.
Performance target requirements for a proportion of hypertensive and diabetic individuals under clinical
control are proposed to explicitly link population health needs and clinical performance expectations.
Enrollment for Arkansas Medicaid (as of October 2015):



136 practices are participating out of 263 eligible (52%). For 2016, Medicaid will continue recruitment
of new practice participants as will both AR BCBS and Ambetter.
780 primary care providers are participating (69% of eligible Medicaid providers)
331,000 eligible Medicaid beneficiaries are covered under the state PCMH program (82%)
Enrollment for Commercial Carriers: (PCMH beneficiary attribution is still underway for the
commercial carriers. These are estimates for the number of attributed beneficiaries for each payer)




AR BCBS: 157,000 attributed beneficiaries
QC: 4,300 attributed beneficiariesc
Centene / Ambetter: 44,000 eligible beneficiaries (final attribution numbers pending)
United Healthcare: United is offering a QHP and will attribute members in 2016
Enrollment for Self-Insured Payers: Self-insured payers are also participating in the program, with
an anticipated increase in 2016 and beyond. Two of the largest self-insured participants are Walmart and
Arkansas State Employee and Public School Employee (ASEPSE) Plans, each with substantial numbers of
employees served under a PCMH:


c
Walmart: ~21,000 beneficiaries
Arkansas State Employees and Public School Employees: ~30,000 beneficiaries
Data provided by QualChoice in October 2015.
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Retrospective Episodes of Care
This model to improve quality and efficiency and eliminate variation has achieved both quality enhancement
and cost-saving goals. Since 2013 there have been 14 types of episodes launched with new episode
development focused primarily in the areas of surgical intervention and hospitalization management. While
employers, consumers, and the state strive to optimize the value of their health care expenditures,
Arkansas’s episodes of care model puts the clinical leader in charge and aligns incentives to achieve the
highest quality at the lowest cost.
In an ongoing coordinated effort that includes close involvement with providers and other stakeholders,
Arkansas Medicaid, AR BCBS, and QC all participate in the episodes model. Providers benefit from consistent
incentives and reporting tools across payers. Together these payers cover a majority of Arkansas citizens,
generating enough scale to promote change in practice patterns.
Medicaid has achieved quality improvements and cost avoidanced





Perinatal: C-section rate reduced from 39 percent to 34 percent, with an estimated 2-4 percent
direct savings to date.
URI: 17 percent reduction in antibiotic prescriptions; episode costs remained flat despite a 10
percent increase in drug prices.
ADHD: Average episode cost fell by 22 percent, with 400 providers contacted by Medicaid regarding
appropriate stimulant prescribing.
Total Joint Replacement: Number of episodes down from 141 to 101; 30-day all-cause readmission
rate reduced from 3.9 percent to 0 percent; estimated 5-10 percent direct savings to date.
The most recent gain and risk sharing calculations from finalized episodes resulted in 648 providers
receiving gain-share payments totaling $642,200 and 605 providers deemed eligible for risk sharing
totaling $710,034.
AR BCBS reported that this year they will pay out nearly $1.3 million in shared savings with
approximately $250K being recovered in the form of risk-sharing payments.
Data provided by Arkansas DHS/Medicaid. Information was presented by Arkansas Medicaid Director Dawn Stehle to the
Arkansas Legislative Health Care Task Force on July 16th, 2015.
d
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Following Arkansas’s lead, Medicare has now implemented its own version of mandatory episodes for
hip and knee replacement in 50 market areas nationally —inclusive of Hot Springs and Memphise.
Implementation of Episodes for Specialty, Surgical and Hospital Care



Additional episodes of care were launched by AR BCBS in January 2015, including Percutaneous
Coronary Intervention (PCI), Coronary Artery Bypass Grafting (CABG), Asthma, and Chronic
Obstructive Pulmonary Disease (COPD).
Medicaid and AR BCBS are considering potential development of additional episodes including
appendectomy, pediatric pneumonia, hysterectomy, and urinary tract infection (when an ER
visit is involved). AR BCBS is also reviewing tympanostomy (ear tube procedure) for possible
episode development.
Experience from episode analysis is aiding in the creation of chronic disease profiles, which
can be used by PCMHs in coordinating care for high risk patients as they pursue per member,
per year cost curve management.
System Infrastructure Development
The episode and PCMH models would not be possible without development of an advanced analytic
infrastructure allowing participating payers to process large amounts of data. This analytic capability has
been developed including a multi-payer portal on a common platform, enabling production of quarterly
reports to providers. These new tools detail utilization and quality indicators to support better decision
making and improved clinical outcomes. A large and increasing number of providers have accessed their
reports:

Approximately 500 million medical claims have been processed through the analytic engines for both
episodes and PCMH. For episodes, those claims resulted in over 3.78 million episodes.

As of October 2015, for episodes 31,781 reports were delivered to 2,252 distinct principal
accountable providers (PAP).f

Through September 2015, for PCMHs 1,918 reports have been provided to practices.
Today, the state’s Medicaid growth rate is relatively flat, the PCMH program has demonstrated quality
improvements and system savings, private payers have reported quality improvements and cost
avoidance in episodes of care, and providers and patients are benefitting from practice support and
improvements in quality of care. While results are encouraging, early challenges have helped identify
opportunities to improve the AHCPII. Continued engagement and input from providers, patients, state
leaders, and others is necessary to sustain progress of this initiative.
e
f
https://innovation.cms.gov/initiatives/cjr
Reporting totals provided by Arkansas DHS, October 2015
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Introduction
In 2011, Arkansas, like other states, faced an increasingly fragmented health care system and escalating
costs that threatened to exceed available revenue. With growing concern for the value of health care
expenditures in both public and private sectors, the State of Arkansas, through its Department of
Human Services (DHS), convened its Medicaid program and the two largest commercial carriers—
Arkansas Blue Cross and Blue Shield (AR BCBS) and QualChoice (QC)—to develop an initiative to
transform the Arkansas health care payment system to a value-based purchasing model. From this
convening, the collaborative effort known as the Arkansas Health Care Payment Improvement Initiative
(AHCPII) was established. Arkansas Medicaid (Medicaid), AR BCBS, and QC have worked in concert with
hundreds of physicians, hospital executives, patients, and advocates in designing, building, and
implementing Arkansas’s new payment and delivery system. More recently, Centene /Ambetter (CAM)
and United Healthcare, along with self-insured employers including Walmart and the State and Public
School Employee Benefits Program have joined and are participating in the initiative. The result is a bold
statewide innovation tailored to the needs of Arkansas patients and providers.
The AHCPII is designed to improve on the traditional fee-for-service (FFS) system by rewarding
physicians, hospitals, and other providers that deliver high-quality care in an optimally efficient manner.
Strategies to align financial incentives through structured provider payments across all payers result in
consistent, large-scale support that enables providers to transform their practices and achieve desired
outcomes. To view a comprehensive video about the AHCPII produced by the Arkansas Center for Health
Improvement (ACHI), please visit http://www.achi.net/pages/OurWork/Project.aspx?ID=81.
The AHCPII incorporates two complementary strategies. First is the commitment to support a robust
patient-centered medical home (PCMH) model. Through team-based preventive care and coordinated
chronic disease management along with increased information and responsibility for the total
experience of care, the PCMH is positioned to optimize appropriate patient utilization of services and
guide referrals to the highest-value specialty providers. With
Improvements in
design and implementation led by Medicaid, the expansion of
the PCMH model throughout the state has exceeded
Quality of Care
enrollment expectations. In 2015, additional payers, Including
 Reduction in use of
AR BCBS, QC, and Centene/Ambetter have begun or expanded
unnecessary antibiotics
their participation in Arkansas’s PCMH model, and United
 5.9% increase in Hemoglobin
Healthcare will engage in the PCMH model in 2016.
A1c screenings for diabetic
Complementing the PCMH model is the second major
treatment
component—Arkansas’s retrospective episodes of care model
 Increased follow-up care and
for acute conditions that require care coordination and a more
reduced readmissions for
intensive use of resources. In an episode of care, a principal
congestive heart failure
accountable provider (PAP) is identified to manage quality,
patients
minimize treatment variations, and control cost. Through
 14.6% increase in adolescent
identified opportunities to improve quality and reduce
wellness visits
complications for the entire episode, established performance
expectations enable the PAP to benefit from system
efficiencies. More details and additional graphical representations of results from the episodes of care
program can be found in Appendix C of this report.
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In addition to the episodes of care and PCMH models, a third component called health homes was
introduced by Arkansas DHS in 2012. Through independent assessment, tiered provider payments, and
accountability for quality targets, the health homes model was designed to provide additional support
for some of the most vulnerable populations in the state. These include individuals with developmental
disabilities, those who need long-term services and supports, and those with severe or persistent
behavioral health needs including mental health and substance abuse disorders. These populations
represent a major proportion of overall Medicaid expenditures in the state.
However, implementation of the health homes model was subsequently halted as a result of challenges
from the provider community and other stakeholders. The state is currently weighing alternative
options to provide higher-quality and efficient care for these high-needs and higher-cost populations
and through their deliberations may choose to pursue components of the developed health homes
model as a viable option.
This AHCPII Statewide Tracking Report is the second of three annual reports on the progress of the
state’s system transformation effort. Included as appendices are a PCMH practice-level case study
(Appendix A), a PCMH shared-savings update and fact sheet (Appendix B), and a detailed report on
quality and cost indicators for episodes spanning 2012-2014 (Appendix C). Information contained in this
report represents aggregate results provided by individual payers for descriptive purposes.
The state’s health care system has been impacted by the AHCPII in several ways. Enrollment in the
state’s PCMH model is widespread, having over half of all eligible primary care providers enrolled, with
the vast majority successfully completing practice transformation activities. Approximately 82 percent of
eligible beneficiaries are now receiving care under the state’s program, far exceeding the initial year-one
goal of 40 percent. In 2015, commercial carriers including AR BCBS, QC, and CAM have supported the
model with an increasing number of beneficiaries now attributed to PCMH clinics.
The episodes of care model has generated meaningful impacts on quality and efficiency, and many
providers have received enhanced payments for commendable performance or have been required to
pay back a portion of the cost overage for not achieving acceptable performance. For example, AR BCBS
results showed that quality of perinatal (pregnancy) care improved, and overall perinatal costs fell by 1.6
percent in 2014.
Efforts to increase support for the AHCPII continue. Expansion of the PCMH model through commercial
carriers operating as qualified health plans (QHPs) on the Health Insurance Marketplace was mandated
through legislation implemented in 2015. In addition, some commercial carriers are extending the PCMH
model to their fully insured, non-exchange
products. Self-insured interest continues to
Financial Impact and Cost
grow, with both public and private sector
Containment
expansions anticipated. New episodes have
 $34 million in savings from the PCMH
been launched and others are under
program in the first year
development, which continues to accelerate the
 -1.2% cost trend reduction in PCMH
proportion of surgical, specialty, or intensive
practices
care under value-based purchasing strategies.
 AR BCBS congestive heart failure costs were
reduced by 10.3% from 2013 to 2014
The largest challenge to full-scale
 Medicaid tonsillectomy episode costs were
implementation of the AHCPII remains the lack
reduced by 14.6%
of total participation by Medicare which
represents a significant portion of Arkansas’s
population and care usage in the state. The Centers for Medicaid and Medicare Services (CMS) has taken
notice of Arkansas’s nation-leading effort. Continued demonstration of successful progress will be used
Page 10
to solicit full federal participation. Continued success of the AHCPII relies on statewide participation,
ongoing innovation, and research. Initial findings from the PCMH and episodes of care models have
shown successes in the areas of improved practice patterns and more efficient treatment for patients.
Continued efforts to support practitioners with actionable information and to enable the more
appropriate use of the highest quality providers will enhance system transformation. Through the
avoidance of complications, re-hospitalizations, and unnecessary care, the goals of bending the cost
curve will be supported. Updated information on the AHCPII progress can be found at
www.paymentinitiative.org.
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Patient-Centered Medical Home (PCMH)
Now heading into the second year of implementation, Arkansas’s PCMH model is one of the largest of its
kind in the U.S. The state’s PCMH model is designed to support primary care providers with new tools
and resources in an effort to deliver high-quality primary care that is patient-centered and team-based,
with an emphasis on care coordination and
proactive preventive care. Goals of the PCMH
Provider Spotlight:
program are to help patients stay healthy,
Dr. Lonnie Robinson*
increase the quality of care they receive, and
“We formed a PCMH transformation team early
reduce costs. PCMH transformation has been
in the process and everyone wanted to be on the
underway in Arkansas since October 2012, with
team. Empowering our staff through the PCMH
69 practices initially selected to participate in
model has been very helpful. In the past our
the Comprehensive Primary Care (CPC)
model was very physician-centric … now we are
initiative—a multi-payer PCMH program
all taking care of the patients as a team.”
sponsored by the Center for Medicare and
1
Dr. Lonnie Robinson of Regional Family
Medicaid Innovation (CMMI). Building on
Medicine
successes and lessons learned from the CPC
initiative, wave-two expansion of the state’s
Practice Accomplishments Include:
Medicaid-led PCMH model began in January
 9% reduction in inpatient admissions
2014. While the first wave of the state’s
 24/7 live voice access to care and improved
program was predominately comprised of
patient communication
pediatric practices, subsequent enrollment

Improved staff engagement and job
periods and multi-payer participation have
satisfaction
expanded the range of participation. With more
providers delivering care under the PCMH
model, Arkansas has made substantial progress
towards the goal of having all of the state’s citizens receiving comprehensive primary care under the
PCMH model.
This year, for the first time, detailed information about system-wide cost and quality impacts of the
PCMH model are available. After only one year of implementation, the state’s model has demonstrated
improvements in a range of quality indicators, while saving the state approximately $34 million and
generating approximately $5 million in shared savings distributed to eligible providers. At the same time,
the Medicare-led CPC initiative has continued to support many of the state’s primary care providers in
delivering high-quality and efficient care. While this report focuses on the state’s own multi-payer PCMH
model, recent CPC program outcomes are available and have been detailed in separate reports.2
Participating PCMH practices receive up-front payments that enable them to more proactively meet
patient needs and practice transformation milestones, which include providing extended office hours
and 24/7 access to medical assistance. In addition to financial support for care coordination and practice
transformation in the form of per-member, per-month (PMPM) payments, PCMHs can receive upside
gain-sharing based on either performance improvements or high performance compared to statewide
averages. Quality metrics must be met under both options.
*A detailed PCMH case study of Dr. Lonnie Robinson and Regional Family Medicine is included as appendix A in this report.
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Arkansas PCMH Progress Overview
Enrollment

136 PCMHs are currently enrolledg in the state’s Medicaid-led, multi-payer PCMH program.
Approximately twelve of these practices are also enrolled in the CPC initiative.

Approximately 780 primary care providers are participating, representing 69 percent of all
eligible providers.

Approximately 331K Medicaid beneficiaries are covered, representing 82 percent of all eligible
Medicaid beneficiaries.

58 practicesh are currently enrolled in the Medicare-led CPC initiative.

Multi-payer participation in either the CPC initiative or the Arkansas PCMH program includes
Medicaid, Medicare, AR BCBS, QC, United Healthcare, Centene/Ambetter, Humana, Arkansas
State and Public School Employee Benefits Plan, Federal Employee Plan, Walmart, and Mercy
Accountable Care Organization (Medicare shared savings program accountable care
organization (ACO) in alignment with PCMH).
As of 2015, QHPs operating on the Health Insurance Marketplace are required to participate in
PCMH as mandated through the state’s Health Care Independence Act, known as the Private
Option.
Preliminary 2016 enrollment totals for Medicaid indicate sustained momentum, with
approximately 188 PCMHs enrolled, including 47 new PCMHs.


Practice Achievements
In 2014, the vast majority of practices met transformation milestones and either improved or
maintained prior-year levels for approximately three-fourths of PCMH quality metrics. Quality metrics
include: Increased pediatric wellness visits, Hemoglobin A1c testing for diabetics, breast cancer
screenings, improved ADHD treatment management, and thyroid medication management.
Cost Savings
The state realized $34.3 million in savings because of the PCMH program, of which $12.1 million went
towards care coordination payments to providers. The remaining $22.2 million in net cost avoidance
was shared between the state and 19 provider groups who met both quality and cost savings
requirements. Shared savings checks were issued in October 2015, with several clinics receiving over
$100,000.
In 2014, enrolled practices experienced a cost decrease of 1.2 percent, exceeding both the 2.6 percent
benchmark trend increase and the 0.6 percent cost growth of non-enrolled practices.
Data provided by Arkansas DHS, pulled from PCMH Q4 reporting as of October, 2015. Includes practices that enrolled for 1/1/14, 7/1/14,
and 1/1/15 start dates.
h Practices are enrolled individually in the CPC initiative and current enrollment numbers are tracked by the Centers for Medicaid and Medicare
Services: http://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/Arkansas.html.
g
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Proposed Performance Target
Performance target requirements for a proportion of hypertensive and diabetic individuals under clinical
control are proposed to explicitly link population health needs and clinical performance expectations.i
Commercial Payer PCMH Support
Beginning in 2015, AR BCBS, QC, and CAM offered financial support to practices enrolled in the state’s
PCMH program. United Healthcare will join in 2016. During the fall of 2015, AR BCBS and CAM held open
enrollment for practices to sign up for PCMH program support. In addition to offering support to those
PCMHs enrolled through Arkansas Medicaid, both AR BCBS and CAM have extended their support to
include those practices that are certified as PCMHs by the National Committee for Quality Assurance
(NCQA). For 2016, QC and United Healthcare will offer support to those PCMHs enrolled via Arkansas
Medicaid. Dual-specialized needs managed care plans are also required by regulation to participate in
the state PCMH program. PCMH beneficiary attribution is still underway for the commercial carriers, but
estimates for the number of attributed beneficiaries for each payer are:




Arkansas Blue Cross Blue Shield: 157,000 attributed beneficiaries
QualChoice: 4,300 attributed beneficiaries
Centene / Ambetter: 44,000 eligible beneficiaries (attribution totals pending)
United Healthcare: United is offering a qualified health plan (QHP) on the Health Insurance Exchange
and will attribute members in 2016
In an effort to improve overall population health management and support the PCMH model, AR BCBS
conducted a primary care provider attribution initiative for all beneficiaries in their fully-insured plans. In a
process that spanned most of 2015, AR BCBS identified which beneficiaries had not selected a primary care
provider. Those beneficiaries were subsequently assigned a primary care provider in their geographic
proximity. These newly-attributed beneficiaries were then notified by AR BCBS of their assigned primary care
provider. Beneficiaries are free to select a different primary care provider at any time. This process will allow
AR BCBS to accurately track progress of population health management and quality metric outcomes across
their enrolled PCMH practices.
PCMH Practice Transformation Milestone Progressj
Figure 1 displays required progress towards PCMH practice transformation.
i
For a full list of 2015 and 2016 PCMH performance targets and quality metrics, please visit
http://www.paymentinitiative.org/medicalHomes/Pages/Useful-Links.aspx or
j All Medicaid PCMH data, including enrollment totals, quality measure outcomes, activity metric outcomes, and financial results were provided
by Arkansas DHS in October 2015.
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Figure 1: Patient-Centered Medical Homes Milestones
As shown in Table 1, a vast majority of practices were validated as having completed these activities.
Table 1: Number of Practices Completing Transformation Milestones
Activity
2015
Activity A: Identify top 10% of high-priority beneficiaries (3 months)
133
Activity B: Assess operations of practice and opportunities to improve (6
months)
124
Activity C: Develop and record strategies to implement care coordination and
practice transformation (6 months)
124
Activity D: Identify medical neighborhood barriers to coordinated care at the
practice level (6 months)
124
Activity E: Make available 24/7 access to care (6 months)
123
Activity F: Track same-day appointment requests (6 months)
124
Activity G: Establish processes that result in contact with beneficiaries who
have not received preventive care (12 months)
107
Activity H: Complete a short survey related to beneficiaries’ ability to receive
timely care, appointments and information from specialists, including
Behavioral Health (BH) specialists (12 months)
107
Activity I: Invest in health care technology or tools that support practice
transformation (12 months)
107
Activity J: Join SHARE and be able to access inpatient discharge and transfer
information (12 months)
107
Activity K: Incorporate e-prescribing into practice workflows (18 months)
97
Activity L: Use Electronic Health Record (EHR) for care coordination (24
months)
*
*Deadline to complete 12/31/2015. Validation will be completed after 12/31/2015
Page 15
PCMH Quality Metric Outcomes for Medicaid
Figure 2 displays the percent change in PCMH quality metrics. The majority of quality metric outcomes
showed improvement over 2013 baseline levels.
Figure 2: PCMH Quality Metric Percent Change 2013-2014
Hospital and Emergency Department Utilization Impacts
Figure 3 displays hospital and emergency department utilization among PCMH beneficiaries in 2013 and
2014. Hospitalizations per 1,000 beneficiaries were reduced by 6 percent in 2014, while emergency
room visits were reduced by 1.7 percent over the same period.
Figure 3: PCMH Reductions in Hospitalizations and ED Visits
Page 16
PCMH Financial Outcomes for Medicaid
Figure 4 displays PCMH cost growth comparisons across 2013 and 2014 for PCMH practices and
practices not enrolled in the program. Participating practices experienced a 1.2 percent reduction in
trend growth, while their peers who were not enrolled in the program experienced a 0.6 percent cost
growth. Both groups achieved cost growth below the pre-set 2.6 percent benchmark trend, which is
based on historical Arkansas cost growth.
Figure 4: PCMH Cost Growth Comparisons
Figure 5 displays PCMH cost avoidance for 2014. Of the $34.3 million in savings, $12.1 million was
reinvested in system infrastructure via PMPM care coordination payments to providers, resulting in net
savings of $22.2 million. Once quality and activity target outcomes were assessed, qualifying practices
received a portion of $5.3 million in shared savings. In 2014, 19 provider groups throughout the state received
shared savings payments ranging from approximately $9,000 to $900,000. Figure 6 displays the location and
shared savings amounts of these providers groups. Appendix B of this report includes a detailed description of
PCMH shared savings recipients, outcomes, and methodology.
Figure 5: PCMH Cost Avoidance
Page 17
Figure 6: Locations of PCMHs Receiving Shared Savings Payments
Provider Response to Shared Savings
With many practices throughout the state receiving
the first round of shared-savings incentive payments,
providers have responded positively and
pragmatically. Anecdotal reports from the field
indicate that some providers have chosen to reinvest
these additional resources back into their practices. In
many instances, practices are now being enhanced by
new staff roles, infrastructure and tools. As the PCMH
program continues to support primary care delivery in
the state, providers may benefit by enhancing their
practice infrastructure including use of health
information technology, expansion of facilities, or
adding additional staff members.
“We set aside a large amount of our savings
payment to be shared among our staff – we
consider everyone a contributor and we have
used this incentive to get our staff motivated
over the past year. For 2016 we are looking at
ways to provide more frequent and timely
incentives to our staff, and with more payers
supporting the program we think the likelihood
of that will increase.”
Anecdotal reports also indicate that some sharedsavings recipients have chosen to reward their staff
members individually with a portion of the shared

Provider Spotlight:
PrimeCare Medical Clinic
Searcy, AR
Eric Booth, CEO
PrimeCare Medical Clinic
Prime Care Clinic received approximately
$235,000 for their 2014 PCMH performance
Page 18
savings. Under the PCMH model the entire staff, from the front desk to the lead doctor, is considered
part of the care team. This comprehensive, team-based approach is now being further reinforced as
incentive payments are shared among team members.
Episodes of Care
An episode of care is the collection of care provided to treat a particular condition for a given length of
time. The episode model assigns a PAP for each type of episode. The “patient journey” was developed
and reviewed by patients, providers, and payers to determine quality events that should happen and
potentially avoidable complications that should not happen. All providers submit claims and are paid at
the time service is provided. However, after each performance period, each provider’s average costs
are compared to pre-determined cost thresholds that have been established for each episode using
historical Arkansas data. Each payer sets their own cost thresholds independently. The thresholds
establish commendable, acceptable and unacceptable cost levels. PAPs are given quarterly reports that
outline their team’s performance across the entire episode, including quality metrics, utilization
variation, and aggregate costs. Upon completion of a retrospective performance period (usually one
year), each PAP may be eligible for gain-sharing if their team’s performance has achieved commendable
status. If the team’s performance is not acceptable and exceeds the acceptable threshold, the PAP may
be required to refund a portion of their payments.
To date, Medicaid has introduced fourteen different episodes of care. The following episodes have
completed at least one full performance period and have been reported by payers for this report: Upper
respiratory infections (URI), total hip and knee replacements, congestive heart failure (CHF), attention
deficit hyperactivity disorder (ADHD), perinatal, colonoscopy, tonsillectomy, cholecystectomy, and
coronary artery bypass grafting (CABG). For these episodes, payers agreed upon the following strategies
for aligning financial incentives to improve care:





Upper Respiratory Infections (URI): The episode trigger is the first diagnosis of a URI; the PAP is
the initial diagnosing clinician; the time period is 21 days; quality metrics include appropriate
testing prior to antibiotic use; costs include all associated diagnostic and therapeutic costs.
Perinatal: The episode trigger is delivery of a live infant; the PAP is the delivering provider; the
time period is the prenatal period and 60 days postpartum; quality metrics include prenatal
screenings and appropriate utilization of diagnostic tests; costs include all pregnancy related
costs.
Total Hip and Knee Replacements: The episode trigger is the total joint replacement; the PAP is
the orthopedic surgeon; the time period is 30 days preoperative to 90 days postoperative;
quality metrics include the use of deep-vein thrombosis prophylaxis and complication rates;
costs include all orthopedic related costs during the episode.
Congestive Heart Failure (CHF): The trigger is a hospitalization for CHF; the PAP is the admitting
hospital; the time period is the admission day plus 30 days; quality metrics include appropriate
cardiac medication management and follow up to avoid readmission; costs include all facility
services, inpatient professional services, emergency department visits, observation, and postacute care; any CHF-related outpatient labs and diagnostics, outpatient costs, and medications
are also included.
Attention Deficit Hyperactivity Disorder (ADHD): The trigger is diagnosis of ADHD; the PAP is
the provider (primary care or mental health provider) with the majority of visits; the time period
Page 19




is 12 months; complexity and quality assessments are through provider attestation; costs
include all ADHD-related charges.
Colonoscopy: The trigger is an outpatient colonoscopy procedure and primary or secondary
diagnosis indicating conditions that require a colonoscopy; the PAP is the primary provider
providing the colonoscopy; an episode begins with the initial consult with the performing
provider (within 30 days prior to procedure) and ends 30 days after the procedure; includes all
related costs 30 days prior to 30 days after the procedure except ER visits on the day of the
procedure; Quality metrics include cecal intubation rate and withdrawal time, perforation rate,
and post polypectomy/biopsy bleed rate.
Tonsillectomy: Episode is triggered by an outpatient tonsillectomy, adenoidectomy, or adenotonsillectomy procedure, and a primary or secondary diagnosis indicating conditions that
require tonsillectomy/adenoidectomy; the PAP is the provider performing the procedure;
episode begins with the initial consult with the performing provider (within 90 days prior to
procedure) and ends 30 days after the procedure; costs include all related services within the
episode duration. Quality metrics include the percent of episodes with administration of intraoperative steroids (must meet a minimum of 85% of episodes), post-operative primary bleed
rate, secondary bleed rate, and avoidance of post-operative antibiotics prescriptions.
Cholecystectomy: The episode is triggered by open or laparoscopic cholecystectomy procedure
and a primary or secondary diagnosis indicating related conditions; the PAP is the surgeon;
episode begins with the cholecystectomy procedure and ends 90 days post-procedure and
includes all related costs; Quality metrics include pre-operation CT scan rate (must be below
44%), rate of major complications, rate of procedures converted from laparoscopic to open
surgery, and number of procedures initiated via open surgery.
Coronary Artery Bypass Graft (CABG): The trigger is a CABG procedure; PAP is the physician
performing the CABG; episode duration is the timeframe from the date of surgery through 30
days post discharge from the facility stay during which the procedure occurred; costs include all
procedure services and all related services within 30 days of discharge; quality metrics require
PAPs to meet 2/3 of adverse outcome metrics inclusive of stroke, deep sternal wound, and renal
failure.
Provider Spotlight: Episodes of Care
The success and sustainability of the episodes model, and the AHCPII overall, would not be possible
without ongoing feedback and engagement from Arkansas’s provider community who have helped
shape the initiative throughout the course of its development. While provider-level feedback and
successes have been previously documented for the state’s PCMH programk, examples of provider-level
episode impacts have been documented more recently. The following examples are representative
providers’ experience in the episodes of care program:
Episode Provider Spotlight: Tonsillectomy
For Medicaid, the surgical pathology utilization rate has improved, down from 70.6 percent in 2013 to
50.1 percent in 2014, or a 29 percent relative decrease in utilization. Post-procedure antibiotic
k
A series of PCMH provider case studies are available at http://www.achi.net/pages/SuccessStories/
Page 20
prescribing rate has improved from 12.8 percent in 2013 to 3.3 percent in 2014, and average episode
costs fell by 14.6 percent from 2013 to 2014.
Tonsillectomy: Dr. H. Graves Hearnsberger
Affiliated Practice: Arkansas Otolaryngology Center
As a PAP for the tonsillectomy episode, Dr. Hearnsberger and his team have attested to
using quarterly episode reports to assess practice patterns and quality metrics, and have
been recipients of gain-share payments for providing high-quality and efficient care. “The
reports have been helpful to track steroid use and lack of use of post-operative antibiotics,”
said Hearnsberger. As a result of the episodes model, the team has changed their practice
patterns in an effort to provide more efficient care. ”We have stopped routinely sending
tonsillectomy and adenoidectomy tissue specimens for pathology analysis,” added
Hearnsberger. Regarding the episodes model overall, Dr. Hearnsberger concluded, “The
model makes physicians assess what they are doing and why―including the costs and
benefits of costly treatment options.”
Episode Provider Spotlight: Congestive Heart Failure (CHF)
For Medicaid CHF episodes, the rate of follow-up outpatient visits improved from 38.7 percent in 2013
to 47.6 percent in 2014. For AR BCBS CHF episodes, the 30-day all-cause readmission rate improved
from 14 percent in 2013 to 1% in 2014, and average episode costs were reduced by 10.3 percent over
the same period.
Congestive Heart Failure: Mercy Clinic Northwest Arkansas
As a PAP for CHF and other episodes, Mercy hospital and clinic has met quality metrics,
received gain-share payments and, to a lesser extent, has been subject to risk-share penalties.
Mercy Clinic serves the communities of Bella Vista, Bentonville, Centerton, Rogers, Lowell,
and Springdale, Arkansas. One provider at Mercy Clinic stated, “The AHCPII has motivated
and helped us assess our practices and to initiate an organizational project to standardize work
flow and use the care team to provide care where appropriate.” Providers also indicated that
continued advancements in provision of timely data and continued multi-payer reporting
alignment will make the initiative more successful. Mercy providers noted that, “We are
historically a low cost provider but are quick to say we have found improvement in our quality
metrics.” Providers also expressed willingness to supply ongoing feedback on their experience
and concluded that, “The episodes model is in general, an excellent way to raise awareness of
the change of payment model and the refocus to quality and cost of care.”
Page 21
Overview of Episode Results
Payers selected the episodes for implementation that met their covered population needs and
corporate interests; thus, not every episode was implemented by each payer. While design consistency
was achieved across all episodes by the payers, performance thresholding for gain and risk sharing was
established independently for each payer. Results from the first and second performance year, which
span approximately 2013 through 2014, are reported below for Medicaid, AR BCBS, and QC.
Perinatal Episode
The perinatal episode aims to ensure a healthy pregnancy and follow-up care for the mother and baby,
requiring months of care, possibly involving many different providers ranging from obstetricians, family
practice physicians, and nurse midwives, to hospitals, emergency departments, obstetric specialists, and
others. The perinatal episode includes all pregnancy-related care provided during the course of the
pregnancy. This includes all of the prenatal care, care related to labor and delivery, and postpartum
maternal care—roughly 40 weeks before delivery and 60 days postpartum. It encompasses the full range
of services provided during this time period.
Quality metrics for the perinatal episode are aimed at increasing pregnancy screenings as a form of
preventive care to reduce high-risk pregnancies. Perinatal care has three quality metrics that PAPs must
pass in order to participate in shared savings. Providers must provide the following quality metrics to
pregnant patients: HIV, Group B streptococcus (GBS), and Chlamydia screenings. Each screening must
meet the minimum threshold of 80 percent to pass. There are five additional quality metrics that PAPs
are tracked on in the perinatal episode for quality of care and care improvement opportunities. Four of
these metrics are the following screenings: ultrasound, gestational diabetes, asymptomatic bacteriuria,
and hepatitis B specific antigen. The fifth metric is Cesarean section (C-section) rate. Medicaid, AR BCBS,
and QC are participating in the perinatal episode. Key findings from this episode include the following:



Screening rates generally remained at prior year levels or continued to improve for QC, AR BCBS
and Medicaid. The Chlamydia screening rate showed the most improvement for both QC and
ARBCBS, while Medicaid showed the most improvement in asymptomatic bacteriuria screening.
Medicaid’s C-section rate improved from 38.6 percent in the baseline year to 34.7 in 2013 and
33.5 percent in 2014. The average length of inpatient stay for a C-section decreased slightly from
2.7 days in 2013 to 2.6 days in 2014.
AR BCBS average perinatal episode cost fell 1.6 percent from 2013 to 2014.
Total Joint Replacement (TJR): Hip and Knee Episode
Previously, multiple providers have been involved at each stage of total hip and knee replacements
without optimal care coordination. This led to duplication of efforts, increased costs, and the potential
for decreased quality of care. The hip and knee total joint replacement (TJR) episode includes all services
related to elective hip and knee replacement procedures, from the initial consultation to post surgery
follow-up care.3 Hip and knee replacements resulting from joint degeneration and osteoarthritis are
among the top five elective procedures performed. Each operation involves pre-surgery diagnostics and
testing, hospitalization, the procedure itself, and post-surgery rehabilitation.4 TJR includes all care
related to the procedure in the period 30 days prior to the surgery to 90 days after.3 This episode has
four quality metrics to track in place for quality of care and improvement opportunities: 30-day all-cause
readmission rate;l frequency of use of prophylaxis against postoperative Deep Venous Thrombosis
The 30-day all-cause readmission rate is for patient readmissions only related to the TJR procedure. Occurrences between 30-90 days postsurgery count toward the episode.
l
Page 22
(DVT)/Pulmonary Embolism (PE); frequency of postoperative DVT/PE; and 30-day wound infection rate.
Medicaid, AR BCBS, and QC are participating in the TJR episode. Key findings for the episode include:



For AR BCBS, the trend decreased for average length of stay for inpatient admissions for TJR,
from 2.7 days in the baseline year to 2.6 days and 2.3 days in 2013 and 2014 respectively.
For Medicaid, the 30-day wound infection rate improved to 1.7 percent for 2014, down from 2.0
percent in 2013. However, the post-operation complication rate worsened from 8.0 percent in
2013 to 14.1 percent in 2014.
AR BCBS was responsible for the majority of TJR episodes, with 862 episodes in 2014, compared
to 121 for QC and 121 for Medicaid.
Congestive Heart Failure (CHF) Episode
In Arkansas, 24 percent of hospitalized Medicare patients with congestive heart failure (CHF) will be readmitted within 30 days annually.5 Active management of CHF through adherence to proper diet, weight
management, and medication can reduce symptoms and improve quality of life for CHF patients. CHF
affects a significant number of Arkansans, and represents an opportunity to improve quality, patient
experience, and efficiency. CHF can be acute, sub-acute, or chronic. This episode focuses on acute CHF
exacerbations that result in hospitalization and post-acute follow-up care. The focus is on improved care
coordination and effectiveness between the hospital and post-discharge providers. Patient education
and post-discharge follow up are key factors to prevent readmission. Increased use of evidence-based
therapies could save the lives of up to 700 Arkansans each year.5
Quality metrics for the CHF episode include the prescribing rate of an angiotensin-converting enzyme
(ACE) inhibitor or angiotensin receptor blocker (ARB) therapy at hospital discharge to patients with left
ventricular systolic dysfunction (LVSD); frequency of outpatient follow up within seven and 14 days after
discharge; proportion of patients matching hyper dynamic, normal to severe dysfunction (for qualitative
assessments of the left ventricular ejection fraction [LVEF]); average quantitative ejection fraction value;
30-day all-cause readmission rate; 30-day heart failure readmission rate; and 30-day outpatient
observation care rate (a utilization metric).6 Medicaid and AR BCBS are participating in the CHF episode.
Key findings include:



For Medicaid, the rate of follow-up outpatient visits improved from 38.7 percent in 2013 to 47.6
percent in 2014.
For AR BCBS, the 30-day all-cause readmission rate improved greatly from 14 percent in 2013 to
1 percent in 2014.
For AR BCBS, CHF episode costs were reduced by 10.3 percent from 2013 to 2014.
Cholecystectomy Episode
Cholecystectomy is the surgical removal of the gall bladder, most commonly to alleviate gallstones. The
most common procedure used is called laparoscopic cholecystectomy. The cholecystectomy episode
includes all related services during cholecystectomy procedure and 90 days after procedure. This
includes inpatient and outpatient facility services, professional services, related medications,
complications and post procedure admissions. The cholecystectomy episode is triggered by services
provided by the responsible surgical team, and the PAP is the primary surgeon performing the
procedure. This episode includes patients between the ages of one year and 65 years.
In order to participate in Medicaid gain-sharing, providers are required to pass a quality metric related
to the percentage of episodes with CT scan 30 days prior to cholecystectomy. An acceptable threshold
Page 23
would be less than the state average of 44 percent of cases. Metrics intended for reporting only include
the rate of major complications occurring in the episode, either during the procedure or in the postprocedure window, such as common bile duct injury, abdominal blood vessel injury, bowel injury, the
number of laparoscopic cholecystectomies converted to open surgeries and the number of
cholecystectomies initiated via open surgery.


For Medicaid and AR BCBS, the CT scan rate increased from 2013 to 2014. Medicaid’s CT
scan rate increased from 16.6 percent in 2013 to 23.9 percent in 2014m, while AR BCBS CT
scan rate increased from 15 percent in 2013 to 19 percent in 2014.
For Medicaid there were 41 valid PAPs, 93 percent of whom met the quality metric for gainsharing. Among those PAPs, 20 also had costs within the commendable range and received
an average of $700 in gain-sharing payments for the 2014 performance period.
Colonoscopy Episode
Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel. It
is used for visual diagnosis or biopsy/lesion removal purposes. Colorectal cancer is the third most
commonly diagnosed cancer and the third leading cause of cancer death in both men and women in the
US, with an overall incidence rate per 100,000 of 57.2 for men and 42.5 for women7. The colonoscopy is
the only therapeutic technique used for removal of a potentially precancerous growth during the
screening procedure. The episode applies to patients between the ages of 18 and 64 and includes all
related services within seven days prior to the procedure, the day of the procedure and within 30 days
after the procedure. Two quality metrics cited by the American Society of Gastrointestinal Endoscopy
are included in this episode.
To participate in gain-sharing payments at least 80 percent of a provider’s valid colonoscopy episodes
must meet the following quality metrics: 1) documentation of endoscopy procedures reaching cecum,
and 2) an endoscope withdrawal time greater than six minutes. Reaching the cecum is critical to a
complete examination. Episode advisors have selected the following quality metrics to track for future
evaluation: 1) perforation rate and 2) post-polypectomy/biopsy bleed rate.


For Medicaid, the perforation rate and post polypectomy/biopsy bleed rate remained at 0
percent in 2014. Average episode costs fell from $893 in 2013 to $813 in 2014 for an
estimated overall cost avoidance of $122,528.
For AR BCBS, among the 138 PAPS across 2013 and 2014, nearly all either moved to or
remained in the commendable cost range in 2014. All 32 of the PAPS who had unacceptable
costs in 2013 improved, with 27 (90%) moving into the commendable cost range. Overall,
130 (94%) of all PAPS were in the commendable range in 2014, compared to 60 (43%) PAPs
that were in the commendable range in 2013.
Tonsillectomy Episode
Tonsillectomy is one of the most common surgical procedures in Arkansas in children under the age of
15.8 It is performed to alleviate such conditions as recurrent tonsillitis and sleep breathing disorder. A
For the Medicaid Cholecystectomy episode, additional CT scan codes were added to the episode algorithm for 2014 in order
to more accurately assess provider practice and service delivery.
m
Page 24
tonsillectomy episode is an outpatient tonsillectomy, adenoidectomy, or adeno-tonsillectomy procedure
on a patient between the ages of three and 21. It includes related procedure services during and within
90 days prior to and 30 days post-procedure. Examples of related services include initial consult,
inpatient and outpatient facility services, professional services, and related medications, or any postprocedure complications that result in additional care.
To participate in episode gain-sharing, providers are required to pass a quality metric to administer
intra-operative steroids in a minimum of 85 percent of their tonsillectomy episodes. The report-only
quality metrics are postoperative primary bleed rate, secondary bleed rate, and avoidance of postoperative antibiotic prescriptions. The American Academy of Otolaryngology recommends against the
use of antibiotics post-procedure.9



For Medicaid, surgical pathology utilization rate was greatly improved, down from 70.6 percent
in 2013 to 50.1 percent in 2014, or a 29 percent relative decrease in utilization.
The post-procedure antibiotic prescribing rate was decreased from 12.8 percent to 3.3 percent
in 2014. The post procedure secondary bleed rate improved from 2.5 percent to 1.6 percent
from 2013 to 2014.
For Medicaid, average episode cost fell from $1,024 in 2013 to $954 in 2014, for a 14.6 percent
cost decrease and an estimated overall cost avoidance of $226,427.
Upper Respiratory Infection (URI) Episode
Upper Respiratory Infection (URIs) is one of the most common illnesses suffered by Arkansans, leading
to more doctor visits than any other ailment each year.10 These infections are typically unaffected by
antibiotics, though antibiotics are routinely prescribed. Most URIs are viral infections that resolve
themselves without antibiotic use within 10 days. This episode encourages efficient treatment and
consultation with the physician, including follow-up appointments as well as urging physicians to better
manage prescribing antibiotics. The URI episode includes three different types of URI—non-specific URI,
sinusitis, and pharyngitis. Currently, Medicaid is the only payer participating in the URI episode.




All three of the URI (pharyngitis, sinusitis and non-specified URI) episode metrics for antibiotic
prescribing rates improved from the baseline to performance period.n,o
Non-specific URI: Among the valid episodes of non-specified URI, the prescribing rate decreased
from 44.6 percent of patients receiving antibiotic prescriptions in the baseline year to 37.3
percent in the performance year, with the trend continuing to decrease to 34.1 percent in 2014.
This decrease is an improvement toward the CDC recommendation that antibiotics should not
be used to treat non-specific URIs in adults, since antibiotics do not improve URI.11
Sinusitis URI: Of the valid episodes of sinusitis URI, the antibiotic prescribing rate decreased
from 90.1 percent in the baseline year to 88.9 percent in 2014.
Pharyngitis URI: Among the valid episodes of pharyngitis URI, the antibiotic prescribing rate
improved from 70.1 percent in 2013 to 69.2 percent in 2014.
Medicaid’s baseline period was 10/1/2011 through 9/30/2012, while the performance period (initial period for payment) was 10/1/2012
through 9/30/2013, and the second performance period was 10/1/2013 through 9/30/14.
o Having consistent start and end dates for baseline and performance effectively removes seasonality associated with URI rates.
n
Page 25
Attention Deficit Hyperactivity Disorder (ADHD) Episode
The American Psychiatric Association states in the Diagnostic and Statistical Manual of Mental Disorders
that 5 percent of children have ADHD.12 The primary care clinician should initiate an evaluation for
ADHD for any child four through 18 years of age who presents with academic or behavioral problems
and symptoms of inattention, hyperactivity, or impulsivity.13 In 2011, Arkansas ranked 2nd nationally in
parent-reported diagnoses of ADHD at 14.6 percent of children in the state.14 The episode includes all
ADHD-related care provided during the 12-month duration of the episode, excluding initial assessment.
This includes the full range of services provided (e.g., physician visits, psychosocial therapy) as well as all
medication used to treat ADHD. If a patient continues treatment after the end of the initial 12-month
episode, a new episode is triggered.
The ADHD episode consists of Level 1 and Level 2 patients. Level 1 patients who do not respond
adequately to medication and other primary treatments will begin a Level 2 episode once their provider
certifies the severity and rationale for Level 2 designation. ADHD is only being implemented by Medicaid
at this time.


For ADHD Level 1 episodes, the average number of behavioral therapy visits per episode improved
from 3.3 visits per episode in 2013 to 1.2 visits per episode in 2014. The number of episodes with
medication also improved from 97.1 percent in 2013 to 98.9 percent in 2014.
The average ADHD Level 1 cost fell from $1,808 in 2013 to $1,523 in 2014, for a decrease of 15.8
percent and an overall cost avoidance of $1,075,746.
Coronary Artery Bypass Grafting Episode
Coronary artery bypass graft (CABG) is the re-routing of blood vessels in the heart around blockages
using arteries or veins from other parts of the body. It is an open-chest surgery and is performed when
less invasive methods are not sufficient to restore blood flow through the blocked vessels. CABG
episodes begin on the first day of the procedure and end 30-days after discharge from the facility in
which the procedure occurred, or at the end of a readmission where the patient entered the hospital
within the 30 day post-discharge period. All inpatient, outpatient, professional, and pharmacy services
related to the CABG, delivered within the episode timeframe are included in the episode.


The proportion of CABG episodes with an adverse outcome, including stroke and/or deep
sternal wound within 30 days, was decreased from 3.1 percent in 2013 to 2.6 percent in 2014.
The average episode cost fell 11.3 percent from $10,820 in 2013 to $9,599 in 2014, for an
estimated savings of $47,632.
Page 26
Additional Episodes
Additional episodes deployed or under development are increasing the proportion of surgical, specialty,
or intensive care under value-based purchasing strategies. Additional episodes of care were launched by
AR BCBS in January 2015, including Percutaneous Coronary Intervention (PCI), Coronary Artery Bypass
Graft (CABG), Asthma, and Chronic Obstructive Pulmonary Disease (COPD). Medicaid and AR BCBS are
exploring development of additional episodes including appendectomy, pediatric pneumonia,
hysterectomy, and urinary tract infection (when an ER visit is involved). AR BCBS is also reviewing
tympanostomy (ear tube procedure) for possible episode development. Medicaid has agreed not to
develop any more episodes where a primary care provider will serve as the principal accountable
provider. This is because the state’s PCMH model is designed to support higher-quality and efficient care
for the bulk of care delivered by primary care providers. Experience from episode analysis is aiding in
the creation of chronic disease profiles which can be used by PCMHs in coordinating c are for high
risk patients as they pursue per member, per year cost curve management.
The consistent definition of the episode, identification of the PAP, and articulation of quality
expectations across payers will continue to reinforce and support the desired reduction in variability in
utilization, outcomes, and costs. Quarterly reports for each PAP will continue to inform and identify
areas of threat to quality and practice variation. Table 2 below illustrates the additional episodes
deployed or under development.
Table 2: Episodes Deployed, In Development, or Under Review for Potential Development
Episode
Payer Participation
Performance Period Start Date*
Upper Respiratory Infection (URI)
Medicaid
July 2012
Attention Deficit Hyperactivity
Disorder (ADHD)
Perinatal
Medicaid
July 2012
Medicaid, AR BCBS, QC
July 2012: Medicaid
January 2013: AR BCBS
January 2014: QC
Congestive Heart Failure (CHF)
Medicaid, AR BCBS
Total Joint Replacement (TJR)
Medicaid, AR BCBS,
QC**
October 2012: Medicaid
January 2014: QC
Cholecystectomy (Gall Bladder
Removal)
July 2013: Medicaid
January 2014: AR BCBS, QC
Colonoscopy
Medicaid, AR BCBS,
July 2013: Medicaid
Tonsillectomy
Medicaid, AR BCBS
July 2013: Medicaid
Oppositional Defiant Disorder
(ODD)
Coronary Artery Bypass Grafting
(CABG)
Medicaid
October 2013
Medicaid, AR BCBS
January 2014: Medicaid
Page 27
Asthma
Medicaid, AR BCBS
April 2014: Medicaid
Chronic Obstructive Pulmonary
Disease (COPD)
Medicaid, AR BCBS
Percutaneous Coronary
Intervention (PCI)
ADHD/ODD Comorbidity
Medicaid
July 2015: Medicaid
January 2016
Neonatal
Medicaid
TBD
Appendectomy
Medicaid, AR BCBS
TBD
Urinary Tract Infection
Medicaid, AR BCBS
TBD
Hysterectomy
Medicaid, AR BCBS
TBD
Pediatric Pneumonia
Medicaid, AR BCBS
TBD
Tympanostomy
AR BCBS
TBD
Conclusion
Now in its third year of implementation, the AHCPII has demonstrated statewide improvements in
quality and cost containment, while positioning Arkansas as a national leader in shifting a majority of
care to value-based models. Multi-payer participation has been more fully realized and in turn has
increased provider incentives and bolstered participation. The total transformation of Arkansas’s health
system will be strengthened if every payer in the state, including Medicare, operates under the AHCPII.
As more providers join the PCMH program, and more care is delivered under value-based strategies,
patients, providers, and payers all stand to benefit. Updated information on the AHCPII progress can be
found at www.paymentinitiative.org. Subsequent annual statewide tracking reports will capture future
system impacts, including more detailed information on PCMHs, episodes of care, and other applicable
value-based models.
“Patient Centered Medical Home.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. Last Updated April 2013.
Accessed on November 4, 2014 at
http://www.paymentinitiative.org/referenceMaterials/Documents/AHCPII%20PCMH%20Flyer%204-2013.pdf.
2 Taylor E, Dale S, Peikes D, et al. Evaluation of the Comprehensive Primary Care Initiative: first annual report. Princeton, NJ: Mathematica
Policy Research, 2015 (https://innovation.cms.gov/files/reports/cpci-evalrpt1.pdf ).
3 “Episode Summary: Total Hip and Knee Replacement.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012.
Accessed on November 15, 2015 at http://www.paymentinitiative.org/referenceMaterials/Documents/hipKneeEpisode.pdf.
4 Arkansas Blue Cross Blue Shield. “Provider Manual: Arkansas Health Care Payment Improvement Initiative Hip and Knee
Replacement Episode Reimbursement Program.” Little Rock, AR: Arkansas Blue Cross and Blue Shield. Accessed on
November 15, 2015 at http://www.arkansasbluecross.com/providers/manual/manual_default.asp?page=870&SectionID=3
5 “Episode Summary: Acute/Post-acute Congestive Heart Failure.” Arkansas Health Care Payment Improvement Initiative. [Online]
2012. Accessed on November 11, 2015 at
http://www.paymentinitiative.org/referenceMaterials/Documents/CHF%20Episode%20Descript_7-2014.pdf.
6 “Congestive Heart Failure Algorithm Summary.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited:
November 10, 2015]. http://www.paymentinitiative.org/referenceMaterials/Documents/CHF%20codes.pdf
1
Page 28
North American Association of Central Cancer Registries. Mortality: National Center for Health Statistics, Centers for Disease
Control and Prevention, as provided by the Surveillance, Epidemiology, and End Results Program, National Cancer Institute
8 Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report 2009; :1.
9 American Academy of Otorhinolaryngology Guidelines for 2011.
10 “Episode Summary: Ambulatory Upper Respiratory Infection (URI).” Arkansas Health Care Payment Improvement Initiative.
[Online] 2012. Accessed on December 15, 2014 at
http://www.paymentinitiative.org/referenceMaterials/Documents/upperRespiratoryEpisode.pdf
11 Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. “Use of Antibiotics for Adult Upper Respiratory Infections in
Outpatient Settings: A National Ambulatory Network Study.” Family Medicine. 2006 May; 38(5):349-54.
12 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth edition: DSM-5. Washington:
American Psychiatric Association, 2013.
13 American Academy of Pediatrics, Committee on Quality Improvement and Subcommittee on AttentionDeficit/Hyperactivity Disorder. Clinical practice guideline: diagnosis and evaluation of the child with attentiondeficit/hyperactivity disorder. Pediatrics. 2000;105(5):1158 –1170
14 Arkansas State Profile: Parent-Reported Diagnosis of ADHD by a Health Care Provider and Medication Treatment Among Children 4-17
Years: National Survey of Children’s Health Conducted by the CDC – 2003 to 2011. [Online] 2011. [Cited: November 19, 2015].
7
Page 29
APPENDIX A
Patient-Centered Medical Home Case Study:
Aligning Incentives and Rewarding Innovative
Collaboration (Regional Family Medicine,
Mountain Home, Arkansas)
Case Study
Patient-Centered Medical Homes:
Aligning Incentives and Rewarding
Innovative Collaboration
ACHI is a nonpartisan, independent, health policy center that serves as a catalyst to improve the health of Arkansans.
Regional Family Medicine
December 2014
The Arkansas Health System Improvement Initiative is designed to create a sustainable patient-centered
health system that embraces the triple aim of (1) improving the health of the population; (2) enhancing
the patient experience of care, including quality, access, and reliability; and (3) reducing, or at least
controlling, the cost of health care. While the initiative has broader goals of expanding coverage,
enhancing health information technology, and developing a quality health care workforce, a major focus
has been payment innovation and restructuring the system to incentivize quality outcomes. Patientcentered medical homes (PCMH) are a primary strategy of this innovation. Design and implementation
of the state’s PCMH efforts has been led by Arkansas Medicaid with support from Arkansas Blue Cross
and Blue Shield, Qualchoice of Arkansas, Humana, Centene/Ambetter, Medicare, Walmart, the State
Employees Plan, and others. This study is part of a series of case studies spotlighting practice
transformation to the PCMH model, emphasizing how individual practices have approached innovation
and implementation. For more information on the Arkansas Health System Improvement Initiative, and
access to additional case studies, visit www.achi.net or www.paymentinitiative.org.
“The PCMH program is exciting for primary care providers who’ve typically been underpaid for the value
they bring to the table – it’s an opportunity to demonstrate their worth” --Dr. Lonnie Robinson of Regional
Family Medicine in Mountain Home, AR
As a leader in the state’s patient centered medical home (PCMH) program,
Regional Family Medicine (RFM), nestled in Mountain Home, AR, in Baxter
County, serves a panel of approximately twenty-six thousand patients.
Including Dr. Robinson, RFM employs a staff of around fifty employees at
their Main and East Branch Clinics, both in Mountain Home. The staff
consists of eight doctors, three certified nurse practitioners (NP), several
licensed practical nurses (LPNs) around ten administrative personnel, four Xray technicians, two ultrasound technicians, and other staff.
RFM began participating in Arkansas’s PCMH model in January 2014, and
are now receiving per-member per-month financial support to enhance their
patient-centered approach. RFM is also participating in the Ft. Smith
Physician’s Alliance, an Accountable Care Organization (ACO) within the
Medicare Shared Savings Program (MSSP). Both programs incentivize
providers to manage the overall quality and total cost of patient care. With the multi-payer PCMH model
and other programs, RFM is now delivering a majority of care under a value-based purchasing model.
Robinson said, “When the Medicaid PCMH opportunity arose, I thought we needed to participate, but I
was concerned that it was a thin slice of our payer mix. Adding the private insurers to the model has
been the critical part. Now with the PCMH program and the ACO, we have eighty to ninety percent of
our care being delivered under some sort of value based model or alternative payment.”
A major factor in the success of Arkansas’s PCMH program to this point has been ongoing provider
input. Many providers, including Dr. Robinson, who previously served as President of the Arkansas
Patient-Centered Medical Homes
Through improved care coordination and communication, the goal of the Arkansas patient-centered medical home
(PCMH) program is to help patients stay healthy, increase the quality of care received, and reduce costs. A PCMH
accomplishes this by identifying and treating at-risk persons before they become sick. Success of the Arkansas
PCMH program relies on statewide multi-payer participation, ongoing innovation, and achievement of a specific set
of improvement milestones, such as 24/7 patient access to care via phone or e-mail, use of electronic health
records, and development of customized care plans for each patient.
1401 W Capitol Avenue, Suite 300 ● Little Rock, Arkansas 72201 ● (501) 526-2244 ● www.achi.net
BAXTER COUNTY PROFILE
Overall County Health Ranking: 20 (of 75)
Uninsured: 20% (AR: 20%)
Primary Care Physicians: 1,093:1 (AR: 1,586:1)
Diabetic Screening: 88% (AR: 82%)
Mammography Screening: 69% (AR: 58%)
Social & Economic Factor Ranking: 21 (of 75)
Poor or Fair Health: 18% (AR: 19%)
Mental Health Providers: 507:1 (AR: 696:1)
Low Birth Weight: 7.3% (AR: 9.0%)
Unemployed: 7.7% (AR: 7.3%)
*http://www.countyhealthrankings.org/app/#!/arkansas/2014/rankings/van-buren/county/outcomes/overall/snapshot
Academy of Family Physicians, have worked with public and private payers on a strategic advisory
group to shape the state’s Arkansas-centric program. A key design element of the model is that
providers have the opportunity to partner or “pool” with other participating practices. This feature
enables more providers, many of whom are in smaller practices, to be potentially eligible for shared
savings. The pooling feature also incentivizes PCMHs to share best practices and work together
towards meeting quality targets and managing costs. Robinson said, “We are pooling with Baxter
Regional Medical Center (BRMC) clinics and Lincoln-Paden Clinic. We have met with members of the
Lincoln-Paden team to offer some advice about selecting an EHR and getting started on the path to
PCMH transformation. I think that collaboration between provider groups is going to be important to our
mutual success. For them to succeed is for us to succeed.” Currently within the states PCMH program,
71 individual PCMHs have formed 25 voluntary pools, and 63
“We formed a transformation team early in the
PCMHs are in a statewide pool.
process – and everyone wanted to be on the
Like many PCMHs throughout the state, RFM has refined the
team. Empowering our staff through the PCMH
roles of their staff to achieve better-coordinated, team-based
model has been very helpful. In the past our
care. Each physician at RFM works closely with two nurses,
model was very physician-centric… now we are
one of whom serves as the care coordinator. “When we began
all taking care of the patients as a team”
thinking about what team member might best serve as care
--Lonnie Robinson, MD
coordinator, it became obvious to us that one of the nurses on
each care team was already filling that role to a large degree. Thus, we’re able to fill the role without
hiring another employee”, said Robinson. By facilitating optimal communication, including 24/7 livevoice access, RFM has influenced patients to seek care in an appropriate setting. Robinson said, “I tell
my patients to call me if they have an issue, and we’ll keep them out of the emergency room. I think
patients like it, knowing there is someone they can talk to gives them comfort - access is what matters
most to patients, being able to be seen in a timely manner.” In addition to the benefits to patients, the
staff at RFM has become more engaged in the team-oriented model and as a result is more satisfied
with their jobs. Robinson said, “Engaging with staff about how we talk to patients and giving them a
voice has been good. I’m a fan of the quadruple aim, provider satisfaction added, with the whole team
operating at the top of their license.”
“We’ve seen a 9% drop in inpatient
By aligning incentives and assigning responsibility for overall patient
admissions from RFM, and we’re
care to primary care providers (PCPs), The PCMH model has improved
expecting that number to drop more”
linkages and transitions of care between clinics and hospitals or other
--Ivan Holleman, CFO, Baxter
care settings. “We’ve seen a nine percent drop in inpatient admissions
Regional
from RFM”, said Ivan Holleman, VP and CFO of BRMC, one of the main
hospitals serving Mountain Home and the surrounding areas. BRMC has joined the state’s health
information exchange, The State Health Alliance for Records Exchange (SHARE), to receive alerts for
patient admissions, discharges, or transfers (ADTs) that will notify RFM and other groups and help
reduce unnecessary readmissions. “We’re working on sending real-time data back to primary care
providers. SHARE will put us in a better position to work with PCMHs as we transition patients, from
inpatient to outpatient settings,” said Holleman. For many providers working to manage care and
referrals efficiently, a challenge is gaining access to data, improved data transparency. “We have had
discussions with BRMC about the expected impact of PCMH on their bottom line. PCPs have an
inherent obligation to pursue the options for patients that provide the best quality and outcome at the
lowest cost, now that this information is available to them. We will all have to adjust to this new
environment, and we want to engage with our hospital and specialist providers to seek out ways we can
all thrive while caring for patients in this new reality” Robinson said.
This report was composed using information obtained during an in-person interview with Dr. Robinson of Regional Family
Medicine. The Arkansas Center for Health Improvement was granted written permission to use this information. Additional
information was gathered from the Arkansas Department of Human Services Division of Medical Services, the Arkansas Center
for Health Improvement, and County Health Rankings from the Population Health Institute at the University of Wisconsin.
Copyright © December 2014 by the Arkansas Center for Health Improvement. All rights reserved.
Case Study Patient-Centered Medical Homes: Aligning Incentives and Rewarding Collaboration
Page 2
APPENDIX B
Patient-Centered Medical Home Fact Sheet:
Patient-Centered Medical Homes:
Medicaid Shared Savings Update
● OCTOBER 2015
FACT SHEET
Arkansas has been a leader among states in full-scale healthcare system transformation. The state’s
transformation efforts have been successful in part because of multi-payer collaboration from both public and
private sectors and alignment of financial incentives across initiatives to achieve higher quality, more patientcentered, cost-effective care. The Arkansas Health Care Payment Improvement Initiative (AHCPII) is at the core of
these efforts and includes two primary strategic models for supporting these efforts: Patient-Centered Medical
Homes (PCMHs) and Episodes of Care. Both models are designed to incentivize providers and reward those who
meet quality and financial targets while providing better-coordinated, high-quality care. Support for Medicaid
components of the state strategy includes a team of individuals at the Arkansas Department of Human Services,
Hewlett-Packard, General Dynamics Health Solutions, the Arkansas Foundation for Medical Care, Qualis Health,
and the Advanced Health Information Network, among others. These efforts include providing quarterly progress
reports and leading, not only practice support initiatives across the state, but also monthly advisory calls with frontline physicians to shepherd the effort. For PCMH providers who achieve practice transformation and quality of care
targets, the program offers a shared-savings opportunity in which practices may receive up to half of the generated
savings. The 2014 outcomes from the PCMH program demonstrate a reduction in cost growth and improvements
in quality outcomes, resulting in significant shared savings for some providers. This fact sheet describes Arkansas
Medicaid’s shared-savings methodology and 2014 results.
SHARED SAVINGS METHODOLOGY
Arkansas Medicaid has established a PCMH shared-savings model
that rewards providers if they meet eligibility requirements and achieve
quality and financial targets. 1 To ensure that savings are the result of
real improvement and not random variation in utilization and cost,
enrolled practices must maintain a minimum patient volume of 5,000
attributed Medicaid beneficiaries. This threshold was selected as the
smallest actuarially approved number, with the goal of extending
eligibility to as many practices as possible. In 2014, practices could
meet the volume requirement independently or by joining with another
practice. Of the 123 practices or groups in the PCMH program in the
first year, 37 met the 5,000 Medicaid beneficiaries mark.1
Practice Requirements1
•
Must have at least 5,000
attributed Medicaid beneficiaries
as a shared-savings entity
•
Must achieve PCMH
transformation milestones and
process measures
•
Must meet at least two-thirds of
shared-savings quality metrics
• Must meet financial targets by
Quality and efficiency targets must be met in order to receive shared
either beating a historical
savings. Practices must meet a majority of practice support metric
statewide benchmark trend or
targets, achieve PCMH transformation milestones, and meet at least
improving on their own historical
two-thirds of the shared-savings quality metrics—all designed to
benchmark costs
increase preventive care and improve chronic disease management. In
2014, the vast majority of practices met transformation milestones, and
78 percent of quality measures improved or maintained prior-year levels. These quality measures include an
increase in pediatric wellness visits, hemoglobin A1c testing for diabetics, breast cancer screenings as well as
improved Attention Deficit Hyperactive Disorder management and thyroid medication management.1
2014 SHARED-SAVINGS OUTCOMES 2
In the first year of the program, there were 659 primary care physicians in 123 PCMH practices or groups enrolled
in the PCMH program covering 295,000 Medicaid beneficiaries. Among the 123 participating practices who
enrolled in January 2014, 37 practices or groups were potentially eligible for shared savings, having at least 5,000
Medicaid beneficiaries either as a stand-alone practice or by joining or pooling with one other participating practice.
Among the 37 eligible practices or groups, 19 received shared savings by both meeting quality and financial
targets. Shared savings amounts ranged from approximately $9,000 to $900,000, with an average shared-savings
payment of approximately $278,000.2
Overall, the PCMH program saved the state $34 million in Medicaid costs in 2014. Per-member per-month
payments to practices were factored into the overall program cost, resulting in a net-shared savings of $5.3 million
paid out to qualifying practices. After only one program year, the results are indicative of the program being cost
effective and sustainable beyond its first year of implementation.
ACHI is a nonpartisan, independent, health policy center that serves as a catalyst to improve the health of Arkansans.
1401 W Capitol Avenue, Suite 300 ● Little Rock, Arkansas 72201 ● (501) 526-2244 ● www.achi.net
Some participating practices met quality targets but not financial benchmarks, while others met financial targets but
failed to achieve quality targets. In both scenarios, shared savings were not awarded to those practices. Sharedsavings outcomes for the 2014 performance year—based on preliminary claims analysis and final reconciliation
based on fully adjudicated claims—will be completed in the first quarter of 2016. This final reconciliation may
slightly alter the final payment amounts for some practices.
2014 SHARED-SAVINGS AWARDEES2
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
University of Arkansas for Medical Sciences (UAMS) Regional
Programs (Area Health Education Centers in Ft. Smith, Fayetteville,
Springdale, Jonesboro and Texarkana) – $927,642.50
Mercy Clinic Northwest Arkansas (Bentonville) – $749,909.13
Drs. Collom and Carney Clinic (Texarkana) – $642,364.03
Monticello Medical Clinic PLC – $484,992.61
Hot Springs Pediatric Clinic – $448,847.62
Pillow Clinic PLC (Helena-West Helena) – $387,197.53
Mountain View Clinic LLC – $237,706.57
The Children’s Clinic of Jonesboro – $236,806.58
John Paul Wornock (Searcy) – $234,529.38
Central Arkansas Pediatric Clinic (Benton) – $229,927.88
Medical Associates of Northwest Arkansas (Fayetteville) –
$214,169.21
Pediatric Associates of West Memphis – $201,050.12
Arkansas Pediatric Clinic PLLC (Little Rock) – $66,267.51
Little Rock Pediatric Clinic – $65,581.17
Apache Drive Children’s Clinic (Jonesboro) – $57,498.31
Regional Family Medicine (Mountain Home) – $54,950.73
Conway Children’s Clinic – $32,572.28
Ozark Internal Medicine (Clinton) – $9,135.48
Mercy Health System of NWA (Rogers) – $8,567.56
Performance Expectations1
•
•
•
•
•
•
Take responsibility for total
care experience
Provide 24/7 live-voice access
to clinical advice
Demonstrate improved chronic
disease management
Identify and develop care
plans for top 10% of highpriority patients
Coordinate care of highpriority beneficiaries, including
post-hospital and transitional
care across facilities and
providers
Utilize health information
technology tools, including use
of Electronic Health Records
and incorporation of eprescribing into practice
workflows
INCREASING INCENTIVE OPPORTUNITIES
Because additional payers have joined in supporting the PCMH model, the incentives for participating in the
program are increasing. Beginning in 2015, Qualified Health Plans (QHPs) operating on the insurance exchange
and dual-specialized needs managed care plans are required to participate in the state PCMH program by either
legislative or regulatory requirements.3 These carriers include Arkansas Blue Cross and Blue Shield, Qualchoice,
Centene/Ambetter, United Healthcare, and other carriers. Commercial carriers are already supporting PCMH
practices with per-member per-month payments for care coordination and practice transformation and are required
to develop their own shared-savings methodology in 2016. These increased incentives will support and reinforce
changes in practice patterns and improvements in quality and efficiency of care delivery.
In addition to more payers supporting the program and offering shared savings in the future, all PCMH practices will
have an opportunity to achieve shared savings beginning in 2015. While practices had to meet the 5,000 Medicaid
beneficiary threshold—either as a stand-alone practice or with one other practice in 2014—the pooling options
increased in 2015. For the current 2015-performance year, the opportunity to be eligible for shared savings will be
extended to all PCMH practices—practices without at least 5,000 Medicaid beneficiaries as a stand-alone practice
may pool with one or more practices or be placed in a statewide default pool to meet eligibility requirements. While
there is no downside risk for PCMH providers, the opportunity cost of not participating in the program is becoming
greater as multi-payer per-member per-month payments and shared-savings potential increase. For this reason,
enrollment in the PCMH program is anticipated to increase beyond current levels and foster a rebalancing of the
state’s healthcare workforce toward primary care delivery and overall population health management.
REFERENCES
1
Arkansas Medicaid. “Patient-Centered Medical Homes: Provider Manual Section II.” Accessed on October 26, 2015;
https://www.medicaid.state.ar.us/download/provider/provdocs/manuals/pcmh/pcmh_ii.doc.
2
Amy Webb, Arkansas Department of Human Services Director of Communications, e-mail message to the Arkansas
Center for Health Improvement on October 23, 2015.
3
Rule 108, “Patient-Centered Medical Home Standards,” effective January 1, 2015.
Fact Sheet: Patient-Centered Medical Homes Medicaid
Page 2
Copyright © 2015. All rights reserved.
APPENDIX C
Episodes of Care Detailed Report
Appendix C:
Detailed Report on Episodes of Care
An integral component created and implemented as part of the AHCPII is an episode-based care delivery
model. The episode of care model is designed to improve quality and reduce or control the cost of care.
Episodes are focused on all the care provided to treat a particular condition for a given length of time.
For each episode of care, a principal accountable provider (PAP) is designated. The PAP is the provider with
responsibility for the majority of care in a given episode. In some cases, the PAP will be a physician or midlevel provider. In others, it will be a hospital or facility.
Payers provide quarterly data reports to providers outlining a peer level comparison of quality, cost,
and utilization patterns associated with specific episodes of care. These reports provide PAPs with
information they did not have access to prior to the implementation of episodes of care. PAPs are subject to
upside and downside cost-sharing based on achievement of established quality metrics and cost thresholds.
Actionable information contained in the reports allows for a better understanding of areas in which providers
are excelling and of areas in need of improvement in advance of performance cost-sharing. Payer
participation in episodes of care is voluntary. While quality metrics established for each episode are common
across all payers, cost thresholds are set separately by each participating payer based on historical Arkansas
cost data.
Payers have also aligned on common definitions for the patient journey, or course of service delivery
for each type of episode. Within each patient journey definition there are key drivers for quality and
utilization. For example, Figure 1 displays the patient journey for the perinatal (pregnancy) episode. More
information on episode development, design parameters and rationale, including patient journey and quality
metric definitions, can be found at: http://www.paymentinitiative.org/episodesOfCare/Pages/default.aspx
Figure 1: Perinatal Patient Journey
Initial
Assessment
Prenatal
Care
Prenatal
Care
Complications
Prenatal
Care
Prenatal
Care
Vaginal Delivery
Unplanned
C-section
C-section
A total of 14 episodes of care have been developed to date. Of those, the results of nine, for which at least
one performance year has been completed with results reported by at least one payer, are included in this
report.
Page 1
Perinatal Episode
The perinatal episode aims to ensure a healthy pregnancy and follow-up care for the mother and baby,
requiring months of care, possibly involving many different providers, ranging from obstetricians, family
practice physicians and nurse midwives, to hospitals, emergency departments, obstetric specialists, and
others.
Figure 2: Perinatal Episode Yearly Volume
Episode Definition: The perinatal episode includes all
2012
2013
2014
pregnancy-related care provided during the course of
Medicaid
5,845
5,946
12,596
the pregnancy. This includes all of the prenatal care,
care related to labor and delivery, and postpartum
AR BCBS
2,871
2,536
2,858
maternal care—roughly 40 weeks before delivery and 60
QC
NA
685
641
days postpartum. It encompasses the full range of
services provided during this time period (e.g., labs,
imaging, specialist consultations, and inpatient care). The initial episode design excludes neonatal care.
Designated PAP: The PAP for the perinatal episode is the physician or nurse midwife (provider or provider
group) who performs the delivery. This provider must also perform the majority of prenatal care for the
patient identified by claims with the appropriate global OB bundle procedure, prenatal care bundle
procedure, or office visit procedures.1
Participating Payers: Medicaid, AR BCBS, and QCa
Performance and Results: Quality metrics have been put in place to help with the overall
goal of increasing pregnancy screenings as a form of preventive care to reduce high-risk pregnancies.
Perinatal care has three quality metrics that PAPs must pass in order to participate in shared savings.
Providers must provide the following quality metrics to pregnant patients: HIV, Group B streptococcus (GBS),
and Chlamydia screenings. Each screening must meet the minimum threshold of 80 percent to pass.2 Five
additional tracked quality metrics in the perinatal episode include: Ultrasound, gestational diabetes,
asymptomatic bacteriuria, and hepatitis B specific antigen screenings and Cesarean (C-section) rate.
Payer Overall Quality Outcomes Summary (AR BCBS, Medicaid, and QC): Screening rates improved
or generally remained at prior levels across the board for all reporting payers.
Medicaid Quality Measure Summary: While Medicaid’s C-section rate decreased, the average length of
inpatient stay for a C-section increased, which may signify a shift to more appropriate C-section use. The Csection rate improved from 34.7 percent in 2013 to 33.5 percent in the 2014 performance year— lower than
the two participating commercial payers. The average length of stay for C-sections decreased very slightly
from 2.7 days in 2013 to 2.6 days in 2014.b
Unlike Medicaid and AR BCBS episodes of care participation among QCA providers is voluntary. Due to low volume in some QC episodes, yearto-year provider cost range comparisons were not available for this report.
b Medicaid’s baseline period was 3/1/2012 through 9/30/2012, while the performance period for 2013 was 3/1/2013 through 9/20/2013, and the
2014 performance year was 10/1/2013 through 9/30/2014.
a
Page 2
Figure 3: 2012-2014 Perinatal Episode Quality Metric Outcomes (Medicaid)
100.0%
80.0%
73.7%
67.5%
88.7%
84.3%
84.6%
83.1% 83.6%
85.3% 87.1%
82.9%
81.7%
81.5% 81.8%
76.9% 76.5%
60.0%
2012
2013
40.0%
2014
20.0%
0.0%
Asymptomatic
Bacteriuria
Screening
Chlamydia
Screening
HIV Screening
Hepatitis B
Screening
Group B Strep
Test
Provider Cost Range Movement: PAP Perinatal Performance (Medicaid): Figure 4 displays PAP
movement for Medicaid perinatal episodes across cost categories from 2013 through 2014. There were a
total of 109 PAPs who had 5,946 valid episodes of care in 2013, and 12,596 valid episodes in the 2014
performance period. The increase in episode volume in 2014 was the result of additional codes being added
to the Medicaid perinatal episode algorithm to more accurately capture valid perinatal episodes. Of the 20
PAPs who achieved costs within the commendable range in 2013, five moved to the acceptable range and 15
remained in the commendable range in the 2014 performance year. Of the 77 PAPs who experienced costs in
the acceptable range in their baseline year, five moved to the unacceptable category, 65 remained in the
acceptable category, and seven improved to the commendable category. Of the 12 PAPs who experienced
average perinatal episode costs in the unacceptable range in the baseline year, seven remained in the
unacceptable category, and five improved to the acceptable category in the performance year.
2013 PAP Baseline Range
Figure 4: 2014 Provider Cost Movement: Perinatal (Medicaid)
Commendable: 20 PAPs
5
Acceptable: 77 PAPs
5
Unacceptable: 12 PAPs
7
15
65
7
5
0
20
40
60
80
2014 PAP Movement Range Distribution
Unacceptable
Acceptable
Page 3
Commendable
100
AR BCBS Quality Metric Summary: All AR BCBS perinatal quality metrics (for screenings), either improved
or remained at or near prior year levels, with Chlamydia screening improving the most from 81.7 percent in
2013 to 91.5 percent in 2014.
The AR BCBS C-section rate increased slightly, from 38 percent in 2013 to 39 percent in the 2014
performance year.c The C-section length of stay remained flat at an average of 2.5 days across 2013 and
2014. Figure 5 displays perinatal screening outcomes for AR BCBS, among which chlamydia screening rates
have shown the most improvement from 2012 through 2014. AR BCBS has the highest perinatal screening
rates overall when compared to the other two participating payers.
Figure 5: 2012-2014 Perinatal Episode Quality Metric Outcomes (AR BCBS)
98.8%
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
99.4%
99.5%
96.3%
93.8% 94.0%
96.4%
81.7% 91.5%94.3% 96.3% 95.3% 96.2% 90.1%
64.7%
2012
2013
2014
Provider Cost Movement: PAP Perinatal Performance (AR BCBS): There were a total of 141 PAPs who
had 2,536 valid episodes of care in 2013 and 2,858 valid episodes in the 2014 performance period. Figure 6
displays PAP movement across cost categories from the baseline year to the performance year. Of the 64
PAPs who achieved costs within the commendable range, two moved to the acceptable range, and 62
remained in the commendable range in the performance year. Of the 47 PAPs who experienced costs in the
acceptable range in their baseline year, one moved to the unacceptable category, 20 remained in the
acceptable category, and 26 improved to the commendable category. Of the 30 PAPS who experienced
average perinatal episode costs in the unacceptable range in the 2013, six remained in the unacceptable
category, 21 improved to the acceptable category, and three improved to the commendable category in
2014.
Figure 6: 2014 Provider Cost Movement: Perinatal (AR BCBS)
2
62
Acceptable: 47 PAPs 1
20
6
0
26
21
10
3
20
30
40
50
60
70
Unacceptable
Acceptable
Commendable
AR BCBS baseline period was 1/1/2012 through 12/31/2012, while the first performance period was 1/1/2013 through 12/31/2013, and the
second performance period was 1/1/13 through 12/31/14.
c
Page 4
QC Quality Measure Summary: For QC, the majority of quality metrics either improved or stayed very
near prior-year levels. Chlamydia screening improved the most with a rate of 67 percent in 2014, up from 64
percent in 2013. The HIV screening rate fell slightly from 77 percent in 2013 to 73 percent in 2014.
The C-section rate was comparable to AR BCBS and remained flat at 36 percent across 2013 and 2014. Figure
7 displays the perinatal screening rates for QCA from 2013 through 2014.
Figure 7: 2013-2014 Perinatal Episode Quality Metric Outcomes (QualChoice)
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
72.1% 71.8%
76.5%
63.9% 66.6%
72.9%
74.7%
74.9%
87.7%
86.3%
2013
2014
QC Provider Cost Outcomes for Perinatald: Among QC PAPs, the proportion with average episode costs
in the commendable, acceptable or unacceptable range remained about the same from 2013 through 2014.
Among 185 PAPs in 2013, 55 had average costs in the commendable range, 109 had costs in the acceptable
range, and 21 had costs in the unacceptable range. Among 187 PAPs in 2014, 49 had commendable costs,
118 were in the acceptable range, and 20 PAPS had average costs that were in the unacceptable range.
Total Joint Replacement Episode
Previously, multiple providers were involved at each stage of total joint replacement (TJR) procedures
without optimal coordination.3 This
Figure 8: Total Joint Replacement Episode Yearly Volume
led to duplicative work, increased
costs and the potential for decreased
2012
2013
2014
quality of care. The hip and knee
Medicaid
141
100
121
episode includes all services related
AR BCBS
823
659
862
to elective hip and knee replacement
procedures, from the initial
QC
NA
111
122
consultation to post surgery followup care. Hip and knee replacements resulting from joint degeneration and osteoarthritis are among the top
five elective procedures performed.4 Each operation involves pre-surgery diagnostics and testing,
hospitalization, the procedure itself, and post-surgery rehabilitation.
Due to relatively low volume across performance years, QCA did not provide PAP cost movement in the same format as Medicaid
and AR BCBS. While Medicaid and AR BCBS data enable display of individual provider movement across years, QCA cost outcomes
were provided at the aggregate level within each cost category for each year. It is anticipated that additional PAP cost movement
information will be available in the next annual Statewide Tracking report.
d
Page 5
Episode Definition: The hip and knee TJR episode includes all services and care related to elective hip and
knee replacements from 30 days prior to the surgery through 90 days after surgery. This includes all-cause
readmissions within 30 days of hospital discharge, all facility services, inpatient professional services, and
rehabilitation services, as well as any hip/knee-related outpatient labs and diagnostics, outpatient costs, and
medications.
Designated PAP: The PAP for the hip and knee TJR episode is the orthopedic surgeon who performs the
surgical replacement procedure.
Participating Payers: Medicaid, AR BCBS, and QC
Performance and Results: Postoperative infection, blood clots, and pulmonary or other complications are
associated with hip and knee replacements, which can lead to readmissions and further complications.
Within the course of treatment for patients deemed eligible for hip and knee replacement surgeries, PAPs
have several opportunities to improve the quality and cost of care, including ordering appropriate
preoperative tests, using appropriate surgical techniques, utilizing appropriate precautions and medications
before and after surgery, and timely discharge from the hospital. These activities can help reduce infections
and other complications that may lead to readmissions. Improved outcomes are aimed at the overall goals of
improving quality and containing or improving costs.
Required quality metrics for participation in shared savings have not been selected. However, the following
four quality metrics are tracked for quality of care and improvement opportunities: 30-day all-cause
readmission rate;e frequency of use of prophylaxis against post-op Deep Venous Thrombosis
(DVT)/Pulmonary Embolism (PE); frequency of post-op DVT/PE; and 30-day wound infection rate.
The American Association of Orthopedic Surgeons recommends that pharmacologic and/or mechanical
prophylaxis should be used for the prevention of DVT/PE in patients undergoing elective hip or knee
arthroplasty who are not at elevated risk of DVT/PE or bleeding.5
Medicaid Quality Metric Summary: For the 2012 baseline year, post-operation DVT/PE prophylaxis
prescribing rate was not reported, but increased from 13 percent in 2013 to 17.4 percent in 2014. Postoperation DVT/PE rate was also not reported in the 2012 baseline year, but remained at 0 percent for 2013
and 2014 performance years.
Average length of stay for inpatient admissions trended upwards from 3.7 days in the 2012 baseline year to
an average of 4.3 days in both 2013 and 2014.
Figure 9: 2012-2014 TJR Quality Metric Outcomes (Medicaid)
14.1%
15.0%
10.0%
5.0%
8.0%
2012
6.4%
3.6%
0.0%
0.0%
1.4%
2.0%
2013
1.7%
2014
0.0%
30-day All Cause
Readmission Rate
30-day Wound
Infection Rate
Post-op
Complication Rate
The 30-day all-cause readmission rate is for patient readmissions only related to the TJR procedure. Occurrences between 30 and90 days post-surgery
count toward the episode.
e
Page 6
Provider Cost Outcomes: PAP Total Joint Replacement Performance (Medicaid): The average
episode cost increased slightly for Medicaid, from $9,194 in 2013 to $9,248 in 2014. There were a total of
three separate PAPs for the TJR episode with 100 valid episodes of care in 2013 and 121 valid episodes of
care in the 2014 performance year. One PAP’s baseline year costs fell within the commendable threshold,
and moved to acceptable during 2014. The remaining two PAPs stayed in the commendable cost threshold in
2013 and 2014.
AR BCBS Quality Measure Summary: The trend decreased for average length of stay for inpatient
admissions for TJR, from 2.7 days in the baseline year to 2.6 days and 2.3 days in 2013 and 2014 respectively.
Figure 10 displays additional quality metrics. The 30-day all-cause readmission rate remained flat at 1.0
percent, while the post-op complication rate increased very slightly from 2.0 percent to three percent in
2014. The prescribing rate of post-op DVT/PE prophylaxis decreased from 40 percent to 31 percent, which
may indicate more appropriate prescribing patterns.
Figure 10: 2012-2014 TJR Episode Quality Metric Outcomes (AR BCBS)
39.9%
40.0%
31.0%
2012
30.0%
20.0%
10.0%
2.6% 1.0%
2013
3.4% 2.0% 3.0%
0.2% 0.1% 0.9% 0.0%
0.0%
0.0%
1.0% 0.6%
2014
0.0%
30-day all
Cause
Readmission
Rate
Post-op
DVT/PE
Prophylaxis Rx
Rate
Post-op
DVT/PE Rate
30-day Wound
Infection Rate
Post-op
Complication
Rate
Provider Cost Outcomes: PAP TJR Performance (AR BCBS): There were a total of 28 PAPs who had 659
QC Quality Metric Summary for TJR:
Only two metrics were reported in the
2013 baseline year and in the 2014
performance year. The 30-day all-cause
readmission rate improved from 3.6
valid episodes of care in 2013 and 862 valid episodes in the 2014 performance period. Figure 11 displays PAP
movement across cost categories from the baseline year to the performance year. Of the 18 PAPs who
achieved costs within the commendable range, one moved to the acceptable range, and 17 remained in the
commendable range in the 2014
Figure 11: 2014 Provider Cost Movement:TJR (AR BCBS)
performance year. Of the seven PAPs who
experienced costs in the acceptable range
in 2013, all seven remained in the
Commendable: 18 PAPs 1
17
acceptable category. Of the three PAPS
who experienced average TJR episode
costs in the unacceptable range in 2013,
Acceptable: 7 PAPs
7
all remained in the unacceptable category
in 2014.
3
0
5
10
15
20
Unacceptable
Page 7
Acceptable
Commendable
percent in 2013 to 0 percent in 2014. The 30-day wound infection rate worsened from 0 percent in 2013 to
12.2 percent in 2014. It is possible that some of this increase can be attributed to incorrect diagnosis on the
part of a very few providers.
QC Provider Cost Outcomes for TJR:
Among QC PAPs, provider cost range outcomes from 2013 through 2014 for hip replacements and knee
replacements were reported separately as they are recognized as separate episodes by QC. For QC hip
replacements, the proportion of PAPs with average episode costs in the unacceptable range was slightly
higher in 2014. Among 14 PAPs in 2013, four had average costs in the commendable range, six had costs in
the acceptable range, and four had costs in the unacceptable range. Among 20 PAPs in 2014, five had
commendable costs, seven were in the acceptable range, and eight PAPs had average costs that were in the
unacceptable range.
For QC knee replacements the proportion of PAPs in the unacceptable cost range increased slightly in 2014.
Among 40 PAPs in 2013, 13 had average costs in the commendable range, 22 had costs in the acceptable
range, and five had costs in the unacceptable range. Among 39 PAPs in 2014, nine had commendable costs,
20 were in the acceptable range, and 10 PAPS had average costs that were in the unacceptable range.
Cholecystectomy Episode
Cholecystectomy is the surgical removal of the gall bladder, most generally to alleviate gallstones. The most
common procedure used is called laparoscopic cholecystectomy.
Episode Definition: The cholecystectomy episode is triggered by services provided by the responsible
surgical team. All related services during the cholecystectomy procedure and 90 days after the procedure,
including inpatient and outpatient facility services, professional services, related medications, related
complications and post-procedure
Figure 12: Cholecystectomy Episode Yearly Volume
admissions. This episode includes patients
2013
2014
between the ages of 1 year and 65 years.
PAP: The PAP is the primary surgeon
Medicaid
523
578
performing the Cholecystectomy.
AR BCBS
1,606
1,368
Participating Payers: Medicaid, AR BCBS,
QC
319
288
and QC.
Performance Results: In order to participate in Medicaid gain-sharing, providers are required to pass a
quality metric related to the percentage of episodes with CT scan 30 days prior to cholecystectomy. An
acceptable threshold would be less than the state average of 44 percent of cases. Metrics intended for
reporting only include the rate of major complications occurring in the episode, either during the procedure
or in the post-procedure window, such as common bile duct injury, abdominal blood vessel injury, bowel
injury, the number of laparoscopic cholecystectomies converted to open surgeries, and the number of
cholecystectomies initiated via open surgery.
Medicaid Quality Metric Summary: There are six quality metrics that were reported for the
Cholecystectomy episode. These were CT scan rate, Common bile duct injury rate, bowel perforation/ injury
rate, abdominal blood vessel injury rate, rate of episodes converted from laparoscopic to open surgery, and
rate of episodes initiated as open surgery.
Page 8
For Medicaid, all metrics remained at 0 percent from 2013 to 2014, with the exception of CT scan rate. The
CT scan rate increased from 16.6 percent in 2013 to 23.9 percent in 2014f.
Provider Cost Range Movement: PAP Cholecystectomy Performance (Medicaid): Figure 13 displays
PAP movement for Medicaid Cholecystectomy episodes across cost categories from 2013 through 2014.
There were a total of 29 PAPs who had 523 valid episodes of care in 2013 and 578 valid episodes in the 2014
performance period. Of the eight PAPs who achieved costs within the commendable range in 2013, four
moved to the acceptable range and four remained in the commendable range in the 2014 performance year.
Of the 17 PAPs who experienced costs in the acceptable range in their baseline year, two moved to the
unacceptable category,
Figure 13: 2014 Provider Cost Movement: Cholecystectomy (Medicaid)
eight remained in the
acceptable category,
and seven improved to
Commendable: 8 PAPs
4
4
the commendable
category. Of the four
Acceptable: 17 PAPs
2
8
7
PAPs who experienced
average costs in the
2
2
unacceptable range in
the baseline year, two
0
5
10
15
20
improved to the
acceptable category
Unacceptable
Acceptable
Commendable
and two improved to
the commendable category in 2014.
AR BCBS Quality Metric Summary: Figure 14 displays cholecystectomy quality outcomes for AR
BCBS. The CT scan rate increased from 15 percent in 2013 to 19 Percent in 2014. The rate of episodes
converted from laparoscopic to open surgery increased slightly from 0.8 percent in 2013 to 1.1 percent in
2014, while the rate of episodes initiated as open surgery slightly decreased from 3.5 percent in 2013 to 2.7
percent in 2014.
Figure 14: 2012-2014 Cholecystectomy Quality Metric Outcomes (AR BCBS)
19.0%
20.0%
15.0%
15.0%
20132
10.0%
5.0%
0.8%
1.1%
3.5%
2.7%
2014
0.0%
CT Scan Rate
Rate of Episodes
Converted from
Laparoscopic to
Open
Rate of Episodes
Initiated as Open
For the Cholecystectomy episode, additional CT scan codes were added to the episode algorithm for 2014 in order to more accurately
assess provider practice and service delivery.
f
Page 9
Provider Cost Range Movement: PAP Cholecystectomy Performance (AR BCBS): Figure 15 displays
PAP movement for AR BCBS Cholecystectomy episodes across cost categories from 2013 through 2014. There
were a total of 87 PAPs who had 1,606 valid episodes of care in 2013 and 1,368 valid episodes in the 2014
performance period. Of the 22 PAPs who experienced costs within the commendable range in 2013, four
moved to the acceptable range and 18 remained in the commendable range in the 2014 performance year.
Of the 55 PAPs who experienced costs in the acceptable range in their baseline year, seven moved to the
unacceptable
Figure 15: 2014 Provider Cost Movement: Cholecystectomy (AR BCBS)
category, 44
remained in the
4
18
acceptable category,
and four improved
Acceptable: 55 PAPs
7
44
4
to the
commendable
Unacceptable: 10 PAPs 3
7
category. Of the 10
PAPs who
0
10
20
30
40
50
60
experienced
average costs in the
Unacceptable
Acceptable
Commendable
unacceptable range
in the baseline year,
three remained in the unacceptable range, while seven improved to the acceptable category in 2014.
QC Quality Metric Summary: No quality metrics were reported for QC for the cholecystectomy
episode.
Provider Cost Outcomes: PAP Cholecystectomy Performance (QC): Among QC PAPs, the proportion of
PAPs with average episode costs in the commendable and acceptable ranges slightly decreased from 2013
through 2014, while the proportion of PAPs with average costs in the unacceptable range increased. Among
112 PAPs in 2013, 45 had average costs in the commendable range, 44 had costs in the acceptable range, and
23 had costs in the unacceptable range. Among 106 PAPs in 2014, 22 had commendable costs, 39 were in the
acceptable range, and 45 PAPS had average costs that were in the unacceptable range.
Congestive Heart Failure (CHF) Episode
In Arkansas, 24 percent of hospitalized Medicare patients with congestive heart failure (CHF) will be readmitted within 30 days annually.6 CHF affects a significant number of Arkansans and represents an
opportunity to improve quality, patient experience, and
Figure 16: CHF Episode Yearly Volume
efficiency. CHF can be acute, sub-acute or chronic. This
2012
2013
2014
episode focuses on acute CHF exacerbations that result in
hospitalization and post-acute follow-up care, with a focus
Medicaid
225
204
229
on improved care coordination and effectiveness among
AR BCBS
48
70
67
hospital care providers. Patient education and postdischarge follow-up are key ingredients to preventing readmission. Increased use of evidence-based
therapies could save the lives of up to 700 Arkansans each year.7
Episode Definition: The CHF episode focuses on acute and post-acute CHF care, defined as the CHF
hospitalization and the 30 days after discharge, including readmissions. All facility services, inpatient
professional services, emergency department visits, observation, and post-acute care, as well as any CHFrelated outpatient labs and diagnostics, outpatient costs, and medications are included.
Page 10
Designated PAP: Given the hospital’s critical role in discharge education and planning, the hospital for the
initial inpatient admission has been designated as the PAP for the CHF episode. When a CHF patient is
transferred from another facility, the facility that accepts the transfer patient and subsequently discharges
the patient will be considered the PAP.
Participating Payers: Medicaid and AR BCBS
Performance and Results: The CHF episode aims to improve coordination and effectiveness by extending
the hospital’s accountability beyond discharge. In doing so, the episode will reward lower readmission rates
and improved patient education, transitions, and quality of care. A substantial number of CHF deaths in this
country could potentially be prevented by optimal implementation of evidence-based therapies.8 In the CHF
episode, one of these therapies has been adopted as a quality metric that PAPs must pass in order to
participate in upside savings. The metric requires a minimum threshold of 85 percent of patients with left
ventricular systolic dysfunction (LVSD) be prescribed an ACE-inhibitor or angiotensin II receptor blocker (ARB)
therapy at hospital discharge.
Six other quality metrics are in place to track quality of care and improvement opportunities. The quality
metrics are: frequency of outpatient follow-ups within seven and 14 days after discharge; proportion of
patients matching hyper-dynamic, normal to severe dysfunction, (for qualitative assessments of the left
ventricular ejection fraction [LVEF]); average quantitative ejection fraction value; 30-day all-cause
readmission rate; 30-day heart failure readmission rate; and 14-day outpatient observation care rate (a
utilization metric). Outpatient observation may occur when a provider feels a patient needs to be monitored
in a hospital setting so that CHF patients may be in an appropriate setting to allow evaluation of the patient’s
condition and assessment for potential inpatient admission.
Medicaid Quality Metric Summary: The trend for average length of stay has continued to slightly
increase, with an average of 4.2 inpatient days in 2012, 4.5 days in 2013, and 4.8 days in 2014. Figure 17
displays CHF quality measure outcome from 2012 through 2014 for Medicaid. The 30-day all-cause
readmission rate improved from 17.2 percent in 2013 to 16.6 percent in 2014, as did the 30-day heart failure
readmission rate, which improved slightly from 6.9 percent to 6.6 percent from 2013 to 2014. The proportion
of episodes in which the patient had an outpatient visit within 14 days of hospital discharge also improved
Figure 17: 2012-2014 CHF Episode Quality Metric Outcomes (Medicaid)
60.0%
42.7%
38.7%
47.6%
2012
40.0%
16.0%
17.2% 16.6%
7.6%
20.0%
6.9%
6.6%
0.0%
% of Episodes with
Outpatient Visits
Within 14 Days
30-Day All-Cause
Readmission Rate
from 38.7 percent in 2013 to 47.6 percent in 2014.
Page 11
30-day Heart Failure
Readmission Rate
2013
2014
Three metrics were not reported by Medicaid in the 2012 baseline year: ACEI/ARB prescription rate for LVSD
patients, LVEF assessment, and 30-day outpatient observation care rate. Figure 19 displays outcomes for these
quality metrics from 2013 through 2014 for Medicaid CHF episodes. The ACEI/ARB prescription rate for LVSD
patients improved from 23.1 percent in 2013 to 27.4 percent in 2014. The LVEF assessment rate also improved over
the same period, from 35.8 percent to 39.7 percent. The 30-day outpatient observation rate increased from 8.3
percent in 2013 to 10.0 percent in 2014.
Figure 18: 2013-2014 CHF Episode Quality Metric Outcomes (Medicaid)
35.8%
39.7%
23.1% 27.4%
40.0%
30.0%
20.0%
10.0%
0.0%
8.3%
ACEI/ARB
Prescription Rate
for LVSD Patients
10.0%
2013
2014
LVEF Assessment 30-Day Outpatient
Observation Care
Rate
Provider Cost Range Movement: PAP CHF Performance (Medicaid): The average episode cost
increased from $4,708 in 2013 to $5,210 in 2014 for an estimated increase in overall episode costs of
$114,944. Figure 19 displays PAP movement for Medicaid CHF episodes across cost categories from 2013
through 2014. There were a total of 10 PAPs who had 204 valid episodes of care in 2013 and 229 valid
episodes in the 2014 performance period. Of the six PAPs who experienced costs within the commendable
range in 2013, three moved to the unacceptable range, and three moved to the acceptable range in the 2014
performance year. Of
Figure 19: 2014 Provider Cost Movement: CHF (Medicaid)
the three PAPs who
experienced costs in the
acceptable range in their
Commendable: 6 PAPs
3
3
baseline year, one
moved to the
Acceptable: 3 PAPs
1
2
unacceptable category,
while two remained in
1
the acceptable category.
The one PAP whose
0
2
4
6
8
average costs were in
the unacceptable range
Unnaceptable
Acceptable
Commendable
in 2013 improved to the
acceptable category in 2014.
AR BCBS Quality Metric Summaryg: Though lower overall than Medicaid’s average length of inpatient
stay, the AR BCBS trend for average length of stay has continued to slightly increase, with an average of 3.4
inpatient days in 2012, 3.6 days in 2013, and 4.1 days in 2014.
AR BCBS did not have portal entries in 2013 for the following measure: Patients with LVEF assessment results in hospital record.
Year-on-year comparisons of this measure are anticipated to be included in the next annual Statewide Tracking Report.
g
Page 12
Figure 20 displays CHF quality measure outcomes from 2013 through 2014 for AR BCBS. The 30-day all-cause
readmission rate improved greatly from 14 percent in 2013 to 1 percent in 2014. The 30-day heart failure
readmission rate worsened slightly from 1 percent to 3 percent from 2013 to 2014. The proportion of
episodes in which the patient had an outpatient visit within 14 days of hospital discharge improved from 57
percent in 2013 to 66 percent in 2014
Figure 20: 2013-2014 CHF Episode Quality Metric Outcomes (AR BCBS)
66.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
57.0%
2013
14.0%
15.0%
1.0%
% of Episodes with 30-Day All-Cause
Outpatient Visits Readmission Rate
Within 14 Days
1.0%
3.0%
4.0%
2014
30-Day Heart
30-Day Outpatient
Failure
Observation Care
Readmission Rate
Rate
Provider Cost Range Movement: PAP CHF Performance (AR BCBS): There was only one valid PAP, who
remained in the commendable cost zone in 2013 and 2014.
Colonoscopy Episode
Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel. It is
used for visual diagnosis or biopsy/lesion removal purposes. The colonoscopy is the only therapeutic
technique which can remove a potentially
precancerous growth during the screening
Figure 21: Colonoscopy Episode Yearly Volume
procedure.
2013
2014
Episode Definition: The colonoscopy episode
Medicaid
1,283
1,517
applies to patients between the ages of 18 and 64
and includes all related services within seven days AR BCBS
9,264
8,430
prior to the procedure, the day of the procedure
and within 30 days after the procedure.
Designated PAP: The provider performing the colonoscopy has been designated as the PAP.
Performance and Results: Two quality indicators cited by the American Society of Gastrointestinal
Endoscopy are included in this episode. To participate in gain-sharing payments, a provider’s valid
colonoscopy episodes must meet the following quality metrics: Documentation of endoscopy procedures
reaching cecum (at least 75%) and; an endoscope withdrawal time greater than six minutes (at least
80%). Reaching the cecum is critical to a complete examination.9 Episode advisors selected the following
quality metrics to track for future evaluation: Perforation rate and; post-polypectomy/biopsy bleed rate.
Medicaid Quality Metric Summary: Comparisons of two quality metric outcomes for the Medicaid
colonoscopy episode from 2013 through 2014 are not available at this time, including cecal intubation rate
and withdrawal passing rate (percent of episodes with at least six minute withdrawal time). These metrics
Page 13
were not reported for 2013 because available baseline data is based on historical data for a period in which
quality metrics for gain-sharing were not yet implemented. The perforation rate and post-polypectomy bleed
rate remained at 0 percent for all episodes across 2013 and 2014. The anesthesiologist rate increased from
2.26 percent to 46.47 percent from 2013 to 2014.h Additional quality measure comparisons for the Medicaid
colonoscopy episode are anticipated to be included in the next annual Statewide Tracking Report.
Provider Cost Range Movement: PAP Colonoscopy Performance (Medicaid): The average episode
cost fell from $893 in 2013 to $813 in 2014 for an estimated overall cost savings of $122,528. Figure 22
displays PAP movement for Medicaid colonoscopy episodes across cost categories from 2013 through 2014.
There were a total of 56 PAPs who had 1,283 valid episodes of care in 2013 and 1,517 valid episodes in the
2014 performance period. Of the 10 PAPs who experienced costs within the commendable range in 2013,
one moved to the unacceptable range, six moved to the acceptable range, and three PAPs remained in the
commendable range in the 2014 performance year. Of the 15 PAPs who experienced costs in the acceptable
range in 2013, three moved to the unacceptable range, six remained in the acceptable range, and six
improved to the commendable range in 2014. Of the 31 PAPs whose average costs were in the unacceptable
range in 2013, seven remained in the unacceptable range, 19 improved to the acceptable range, and five
improved to the commendable range in 2014.
Figure 22: 2014 Provider Cost Movement: Colonoscopy (Medicaid)
Acceptable: 15 PAPs
6
3
3
6
6
7
0
19
10
5
20
30
40
Unacceptable
Acceptable
Commendable
AR BCBS Quality Metric Summary:
Quality measure outcomes for the AR BCBS colonoscopy episode are limited because provider
portal entries were not collected for cecal intubation rate, withdrawal passing rate (percent of episodes
with at least 6 minute withdrawal time), or perforation rate. The post-polypectomy bleed rate was lowered
slightly from 0.03 percent in 2013 to 0.01 percent in 2014. Additional quality measure outcomes for the AR
BCBS colonoscopy episode are anticipated to be included in the next annual Statewide Tracking Report.
Provider Cost Range Movement: PAP Colonoscopy Performance (AR BCBS): Figure 23 displays PAP
movement for AR BCBS colonoscopy episodes across cost categories from 2013 through 2014. There were a
total of 138 PAPs who had 9,264 valid episodes of care in 2013 and 8,430 valid episodes in the 2014
performance period. Of the 60 PAPs who experienced costs within the commendable range in 2013, all but
one remained in the commendable range in the 2014 performance year. Of the 46 PAPs who experienced
costs in the acceptable range in their baseline year, two remained in the acceptable range, while 44
improved to the commendable range in 2014. Of the 32 PAPs whose average costs were in the unacceptable
The original logic for calculating anesthesia rates for Medicaid colonoscopy episodes was corrected for 2014. The 2014 rate is correct,
while the 2013 rate is artificially low due to the incorrect logic in place in 2013.
h
Page 14
range in 2013, all improved with five moving to the acceptable category and 27 moving to the commendable
category in 2014.
Figure 23: 2014 Provider Cost Movement: Colonoscopy (AR BCBS)
59
44
5
27
0
20
40
60
80
Unacceptable
Acceptable
Commendable
Tonsillectomy Episode
Tonsillectomy is one of the most common surgical procedures in the United States in children under the age
of 15.10 It is performed to alleviate such conditions as recurrent tonsillitis and sleep breathing disorder.
Episode Definition: A tonsillectomy episode is an outpatient tonsillectomy, adenoidectomy, or adenotonsillectomy procedure on a patient between the ages of three and 21. It includes related procedure
services during and within 90 days prior to and 30 days postFigure 24: Tonsillectomy Episode Volume
procedure. Examples of related services include initial
consult, inpatient and outpatient facility services,
2013
2014
professional services, and related medications. The episode
Medicaid
2,693
3,204
also includes complications that may occur after the
AR BCBS
670
409
procedure.
Designated PAP: The designated PAP is the provider performing the tonsillectomy/adenoidectomy.
Performance and Results: To participate in episode gain-sharing, providers must pass a quality
metric requiring that intra-operative steroids be administered in a minimum of 85 percent of
tonsillectomy
Figure 25: 2013-2014 Tonsillectomy Episode Quality Metric Outcomes (Medicaid)
episodes. The
report-only
quality metrics
70.6%
80.0%
are:
50.1%
60.0%
Postoperative
2013
12.8%
primary bleed
40.0%
rate; secondary
3.3%
0.3% 0.3%
2.5% 1.5%
20.0%
2014
bleed rate and;
0.0%
avoidance of
Post-Prcdr Abx
Post-Prcdr
Post-Prcdr
Surgical
postoperative
Rx Rate
Primary Bleed Secondary Bleed
Pathology
antibiotic
Rate
Rate
Utilization Rate
Page 15
prescriptions.
Medicaid Quality Metric Summary:i Figure 25 displays the tonsillectomy quality measure outcomes for
2013 through 2014 for Medicaid. Among Medicaid tonsillectomy episodes, the post-procedure antibiotic
prescribing rate decreased from 12.8 percent to 3.3 percent. The post-procedure secondary bleed rate
improved from 2.5 percent to 1.55 percent and the surgical pathology utilization rate was greatly improved,
down from 70.6 percent in 2013 to 50.1 percent in 2014, or a 29 percent relative decrease in utilization.
Provider Cost Range Movement: PAP Tonsillectomy Performance (Medicaid): The average episode
cost fell from $1,024.24 in 2013 to $953.57 in 2014 for an estimated overall savings of $226,427. Figure 26
displays PAP movement for Medicaid tonsillectomy episodes across cost categories from 2013 through 2014.
There were a total of 40 PAPs who had 2,693 valid episodes of care in 2013 and 3,204 valid episodes in the
2014 performance period. Of the 20 PAPs who experienced costs within the commendable range in 2013,
one moved to the unacceptable range, while 13 moved to the acceptable range and six remained in the
commendable range in the 2014 performance year. Of the 13 PAPs who experienced costs in the acceptable
range in their baseline year, five remained in the acceptable category while eight improved to the
commendable category. Of the seven PAPs whose average costs were in the unacceptable range in 2013,
only one remained in the unacceptable category, while four improved to the acceptable category and two
PAPS improved to the commendable category in 2014.
Figure 26: 2014 Provider Cost Movement: Tonsillectomy (Medicaid)
1
Acceptable: 13 PAPs
13
5
1
8
4
0
6
2
5
10
15
20
25
Unacceptable
Acceptable
Commendable
AR BCBS Quality Metric Summary: For the tonsillectomy episode for AR BCBS, some quality measure
comparisons are not available from 2013 through 2014. AR BCBS is not reporting surgical pathology
utilization and, for 2013, intra-operative steroid use and the post-secondary bleed rate metrics were not
collected via portal entry as they were in 2014. Postoperative bleed rate was available and was extremely
low, with two reported cases out of 670 episodes in 2013 and no reported cases among 409 episodes in
2014. Additional quality outcomes for the AR BCBS tonsillectomy episode are anticipated to be available in
the next annual Statewide Tracking report.
Provider Cost Range Movement: PAP Tonsillectomy Performance (AR BCBS): Figure 27 displays PAP
movement for AR BCBS tonsillectomy episodes across cost categories from 2013 through 2014. There were a
total of 31 PAPs who had 670 valid episodes of care in 2013 and 409 valid episodes in the 2014 performance
period. All of the 15 PAPs who experienced costs within the commendable range in 2013 remained
For the tonsillectomy episode, intra-operative steroid Rx rate was not reported for 2013 because baseline data is based on historical
data in which quality metrics for gain-sharing were not yet implemented. The intra-operative steroid Rx rate is anticipated to be
reported in the next annual Statewide Tracking Report.
i
Page 16
commendable in 2014Of the eight PAPs who experienced costs in the acceptable range in their baseline year,
two moved to the unacceptable category, while five remained in the acceptable category and one improved
to the commendable category. Of the eight PAPs whose average costs were in the unacceptable range in
2013, three remained in the unacceptable category, while five improved to the acceptable category in 2014.
Figure 27: 2014 Provider Cost Movement: Tonsillectomy (AR BCBS)
15
Acceptable: 8 PAPs
2
5
1
3
0
5
5
10
15
20
Unacceptable
Acceptable
Commendable
Upper Respiratory Infection Episode
An upper respiratory infection (URI), such as a cold, is one of the most common illnesses suffered by
Arkansans, leading to more doctor visits than any other ailment each year.11 Most URIs are viral infections
that resolve themselves within 10 days.12 These infections are typically unaffected by antibiotics; therefore,
antibiotics are rarely needed to treat these infections,
Figure 28: URI Episode Volume (Medicaid)
but are still regularly prescribed in Arkansas. This
episode encourages efficient treatment and
2012
2013
2014
consultation with the physician, including follow-up
Non-Specific
55,069 50,764 41,045
appointments, as well as urging physicians to better
manage prescribing antibiotics.
Pharyngitis
40,428 51,739 49,646
Episode Definition: Three types of episodes are
Sinusitis
22,696 22,643
covered—nonspecific URIs, acute pharyngitis, and acute
sinusitis. These share common characteristics, but are treated as separate episode types.
19,890
Designated PAP: The designated PAP for the URI episode is the first provider to see the patient in an inperson setting, even if other providers see the patient during the episode.
Participating Payers: Medicaid
Performance and Results: One of the primary goals of the URI episode is to improve quality of treatment
by reducing the rate of unnecessary antibiotic prescribing. Although patients often expect an antibiotic
prescription when they present with a URI, the majority of URIs are non-bacterial and therefore not
improved by antibiotics. The Institute of Medicine has identified antibiotic resistance as one of the key
threats to health in the United States, and has listed the decrease in inappropriate use of antibiotics as a
primary solution to this threat.13
Page 17
Medicaid Quality Metric Summary: Antibiotic prescribing rates improved from the baseline to
performance period for all three types of episodes within the URI episode.j,k



Non-specific URI: Among the valid episodes of non-specified URI, the prescribing rate decreased
from 44.6 percent of patients receiving antibiotic prescriptions in the baseline year to 37.3 percent in
the performance year, with the trend continuing to decrease to 34.1 percent in 2014. This decrease
is an improvement toward the CDC recommendation that antibiotics should not be used to treat
non-specific URIs in adults, since antibiotics do not improve URI.14
Sinusitis URI: Of the valid episodes of sinusitis URI, the antibiotic prescribing rate decreased from
90.1 percent in the baseline year to 88.9 percent in 2014.
Pharyngitis URI: Among the valid episodes of pharyngitis URI, the antibiotic prescribing rate
improved from 70.1 percent in 2013 to 69.2 percent in 2014.
Figure 29: 2012-2014 Non-specific URI Antibiotic Prescribing Rate
(Medicaid)
60.0%
44.6%
2012
37.3%
34.1%
40.0%
20.0%
2013
3.2%
2.4% 2.1%
2014
0.0%
At Least One
Antibiotic Filled
Multiple courses of
antibiotic filled
Figure 30: 2012-2014 Sinusitis URI Antibiotic Prescribing Rate
(Medicaid)
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
90.1%
89.6%
88.9%
2012
7.2% 6.8% 6.3%
At Least One Antibiotic
Filled
2013
2014
Multiple Courses of
Antibiotic Filled
Medicaid’s baseline period was 10/1/2011 through 9/30/2012, while the performance period (initial period for payment) was 10/1/2012 through
9/30/2013.
k Having consistent start and end dates for baseline and performance effectively removes seasonality associated with URI rates.
j
Page 18
Figure 31: 2013-2014 Pharyngitis URI Antibiotic Prescribing Rate
(Medicaid)
70.1%
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
69.2%
2013
4.6%
At Least One Antibiotic
Filled
4.3%
2014
Multiple Courses of
Antibiotic Filled
Provider Cost Range Movement: PAP URI Performance (Medicaid): The following section contains
information about provider movement across cost thresholds for the three different URI episode types: Non–
specific URI, pharyngitis, and sinusitis.
Non-Specific URI: Figure 32
illustrates PAP movement for
Figure 32: 2014 Provider Cost Movement: Non-Specific URI
Medicaid non-specific URI
episodes across cost categories
Commendable: 94 PAPs 3 37
54
from the baseline year to the
performance year. There were
Acceptable: 255 PAPs
31
198
26
a total of 442 PAPs who had
50,764 valid episodes of care in
45
44 4
2013 and 41,045 valid episodes
in the 2014 performance
0
50
100
150
200
250
300
period. Of the 94 PAPs who
2014
PAP
Movement
Range
Distribution
experienced costs within the
Unacceptable
Acceptable
Commendable
commendable range, three
moved to the unacceptable range, 37 moved to the acceptable range, and 54 remained in the commendable
range in 2014. Of the 255 PAPS who experienced costs in the acceptable range in their baseline year, , 198
remained in the acceptable category, and 26 improved to the commendable category. Of the 93 PAPs who
experienced average non-specific URI episode costs in the unacceptable range in the baseline year, 45
remained in the unacceptable category, 44 improved to the acceptable category, and four improved to the
commendable category in the performance year.
Sinusitis URI: Figure 33 displays PAP movement for Medicaid sinusitis URI episodes across cost categories
from the baseline year to the
Figure 33: 2014 Provider Cost Movement: Sinusitis URI
performance year. There were a
total of 328 PAPs who had 22,643
valid episodes of care in 2013 and
37
125
19,890 valid episodes of care in the
2014 performance period. Of the
53
42
164 PAPs who experienced costs
within the commendable range,
22
21 10
two moved to the unacceptable
range, 37 moved to the acceptable
0
50
100
150
range, and 125 remained in the
commendable range in the
Unacceptable
Acceptable
Commendable
Page 19
200
performance year. Of the 111 PAPS who experienced costs in the acceptable range in 2013, 16 moved to the
unacceptable category, 53 remained in the acceptable category, and 42 improved to the commendable
category. Of the 53 PAPS who experienced average sinusitis URI episode costs in the unacceptable range in
the baseline year, 22 remained in the unacceptable category, while 21 improved to the acceptable category
and 10 improved to the commendable category in the 2014 performance year.
Pharyngitis URI: Figure 34 displays PAP movement for Medicaid pharyngitis URI episodes across cost
categories from the baseline year to the performance year. There were a total of 498 PAPs who had 51,739
valid episodes of care in 2013 and 49,646 valid episodes of care in the 2014 performance period. Of the 43
PAPs who experienced costs within the commendable range, one moved to the unacceptable range, 21
moved to the acceptable range, and 21 remained in the commendable range in the performance year. Of the
345 PAPs who experienced costs in the acceptable range in their baseline year, 42 moved to the
Figure 34: 2014 Provider Cost Movement: Pharyngitis URI
Commendable: 43 PAPs 121 21
Acceptable:345 PAPs
42
276
65
27
45
0
100
200
300
400
Unacceptable
Acceptable
Commendable
unacceptable category, 276 remained in the acceptable category, and 27 improved to the commendable
category. Of the 110 PAPs who experienced average pharyngitis URI episode costs in the unacceptable range
in the baseline year, 65 remained in the unacceptable category, while 45 PAPs improved to the acceptable
category in the 2014 performance year.
Attention Deficit Hyperactivity Disorder (ADHD) Episode
The American Psychiatric Association states in the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) that 5 percent of children have ADHD15. In 2011, Arkansas ranked 2nd nationally in parent-reported
diagnoses of ADHD at 14.6 percent of children in the state.16 Because ADHD can occur in conjunction with
other behavioral health conditions and often includes
Figure 35: ADHD Episode Volume (Medicaid)
a number of different medical providers, the ADHD
episode encourages strong evidence-based care and
2013
2014
communication among providers.
Level 1
3,046
3,768
Episode Definition: The episode includes all ADHDLevel 2
2
108
related care provided during the 12-month duration
of the episode, excluding initial assessment. This
includes the full range of services provided (e.g., physician visits, psychosocial therapy) as well as all
medication used to treat ADHD. If a patient continues treatment after the end of the initial 12-month
episode, a new episode is triggered.
The ADHD episode consists of Level 1 and Level 2 patients. Level 1 patients who do not respond adequately
to medication and other primary treatments will begin a level 2 episode once their provider certifies the
severity and rational for Level 2 designation.
Page 20
Designated PAP: The Principal Accountable Provider (PAP) for the ADHD episode is the provider who
delivers the majority of care, determined by number of visits and cost of services delivered. When physicians
or Rehabilitative Services for Persons with Mental Illness (RSPMI) provider organizations deliver the majority
of care, they will be the sole PAP. When a licensed clinical psychologist not associated with an RSPMI delivers
the majority of care, he or she will require a co-PAP with the ability to write a prescription for medication.
Medicaid Quality Metric Summary:l Figure 36 displays Level 1 ADHD quality measure outcomes.
The percent of episodes with a completed certification decreased slightly from 46.4 percent in 2013 to 43.5
percent in 2014. The percent of episodes with medication improved from 97.1 percent in 2013 to 98.9
percent in 2014. The percent of non-guideline concordant care with no rationale slightly worsened from 3.4
percent in 2013 to 4.9 percent in the 2014 performance year.
Figure 36: 2013-2014 Level 1 ADHD Quality Metric Summary
97.1% 98.9%
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
46.4%
2013
43.5%
0.4%
% Completed % Episodes
Certification
with
Medication
0.5%
3.4% 4.9%
2014
% Non% NonGuideline
Guideline
Concordant Concordant
Care
Care with No
Rationale
Figure 37 displays ADHD Level 1 episode quality and utilization outcomes. The average number of
physician visits per episode was reduced from 3.5 in 2013 to 3.3 in 2014. The average number of
behavioral therapy visits per episode improved from 3.3 in 2013 to 1.2 in 2014.
Figure 37: 2013-2014 Level 1 ADHD Utilization Summary
3.5
4.0
3.0
2.0
1.0
0.0
3.3
3.3
2013
1.2
0.9
0.9
2014
Average Number Average Number Average Number
of Physician
of Behavioral
of Medication
Visits per
Visits per
Fills per Episode
Episode
Episode
Provider cost movement and quality measure year-on-year comparisons are only available for ADHD Level 1 episodes at this time.
ADHD Level 2 episode provider cost movement and quality measure outcome comparisons from 2013-2014 are not available due to
low volume and no PAPs having at least five valid ADHD Level 2 episodes in 2013. ADHD Level 2 episode outcomes for 2014-2015
are anticipated to be reported in the next annual Statewide Tracking Report.
l
Page 21
Provider Cost Range Movement: PAP ADHD Performance (Medicaid) m:
For ADHD Level 1, the
average episode cost fell
Figure 38: 2014 Provider Cost Movement: ADHD Level 1 (Medicaid)
from $1,808 in 2013 to
$1,523 in 2014 for a
53
10
projected overall savings of
$1,075,746. Figure 38
48
6
displays PAP movement for
Medicaid ADHD Level 1
Unacceptable: 7 PAPs 5 2
episodes across cost
categories from the baseline
0
20
40
60
80
year to the performance
year. There were a total of
Unacceptable
Acceptable
Commendable
125 PAPs who had 3,046 valid
episodes of care in 2013 and 3,768 valid episodes of care in the 2014 performance period. Of the 63 PAPs
who experienced costs within the commendable range in 2013, 53 moved to the acceptable range, and 10
remained in the commendable range in the 2014 performance year. Of the 55 PAPs who experienced costs in
the acceptable range in their baseline year, one moved to the unacceptable category, 48 remained in the
acceptable category, and six improved to the commendable category. Of the seven PAPs who experienced
average episode costs in the unacceptable range in 2013, five remained in the unacceptable category, while
two PAPs improved to the acceptable category in the 2014.
Coronary Artery Bypass Graft (CABG) Episode
Coronary artery bypass graft (CABG) is the re-routing of blood vessels around blockages using arteries or
veins from other parts of the body. It is an open-chest surgery and
Figure 39: CABG Episode Volume
is performed when less invasive methods are not sufficient to
restore blood flow through the blocked vessels.
2013
2014
Episode Definition: CABG episodes begin on the first day of the
Medicaid
32
39
procedure and end 30-days after discharge from the facility in
which the procedure occurred, or at the end of a readmission where the patient entered the hospital within
the 30 day post-discharge period. All inpatient, outpatient, professional, and pharmacy services that are
related to the CABG and are delivered within the episode timeframe are included in the episode.
Designated PAP: The physician entity that performs the CABG is the designated.
Provider cost movement is only available for ADHD Level 1 episodes. ADHD Level 2 episode provider cost movement is not
available because there were no PAPs with at least five valid ADHD Level 2 episodes in 2013.
m
Page 22
Performance and Results: The CABG episode includes three quality metrics that PAPs must pass in
order to qualify for gain-share payments. These include percent of patients with stroke in 30 days
post-procedure, percent of patients with deep sternal wound infection in 30 days post-procedure,
and percent of patients with postoperative renal failure in 30 days post-procedure. For two of these
three metrics PAPs must meet a maximum threshold of 0 percent.
Additional quality metrics include percent of episodes during which at least one adverse outcome
occurs (with adverse outcome defined as patients with either stroke, deep sternal wound infection,
or postoperative renal failure in 30 days post-procedure), percent of patients on a ventilator for
longer than 24 hours after surgery, average length of preoperative inpatient stay, percent of
patients admitted on day of surgery, and percent of patients for whom an internal mammary artery
is used.
Medicaid Quality Metric Summary: The proportion of CABG episodes with an adverse outcome was
decreased from 3.1 percent in 2013 to 2.6 percent in 2014. Additional quality measure outcomes for CABG
are displayed in figure 43.
Figure 40: 2013-2014 CABG Quality Metric Summary
78.1% 79.5%
100.0%
50.0%
31.3% 33.3%
3.1%
0.0%
0.0%
2.6%
3.1%
2013
2.6%
0.0%
% of
Episodes
with Stroke
in 30 Days
% of
Episodes
with Deep
Sternal
Wound in 30
days
% of
"Adverse
Outcome"
Episodes
% of Patients % for Whom
Admitted on an Internal
Day of
Mammary
Surgery
Artery was
Used
2014
Figure 41 displays average preoperative inpatient length of stay for CABG episodes, which was reduced from
2 days in 2013 to 1.6 days on average in 2014.
Figure 41: 2013-2014 CABG Inpatient Utilization
(Medicaid)
2
1.6
2
2013
2014
1
0
Average length of pre-operative inpatient stay (days)
Page 23
Provider Cost Range Movement: PAP CABG Performance (Medicaid): The average episode cost fell
from $10,820 in 2013 to $9,599 in 2014 for an estimated overall savings of $47,632. There were two PAPs for
the CABG episode from 2013 through 2014 and both moved from the acceptable cost category to the
commendable category from 2013 to 2014.
Provider Manual: Arkansas Health Care Payment Improvement Initiative (AHCPII). “Perinatal Episode Reimbursement
Program – Perinatal Algorithm Summary.” Arkansas Blue Cross and Blue Shield. [Online] 2012. [Cited: November 17,
2015.]http://www.arkansasbluecross.com/doclib/forms/manual/Algorithm_Perinatal_V1.3.pdf.
2 Perinatal Care Algorithm Summary. AR Health Care Payment Improvement Initiative. [Online] 2012. [Cited: November 17, 2015.].
http://www.paymentinitiative.org/referenceMaterials/Documents/2012_1011%20Perinatal%20codes.pdf.
3 Provider Manual: Arkansas Health Care Payment Improvement Initiative (AHCPII). “Hip and Knee Reimbursement Program.”
Arkansas Blue Cross and Blue Shield. [Online] 2012. [Cited: November 19, 2015.]
http://www.arkansasbluecross.com/providers/manual/manual_default.asp?page=870&SectionID=3.
4 Provider Manual: Arkansas Health Care Payment Improvement Initiative (AHCPII). “Hip and Knee Reimbursement Program.”
Arkansas Blue Cross and Blue Shield. [Online] 2012. [Cited: November 19, 2015.]
http://www.arkansasbluecross.com/providers/manual/manual_default.asp?page=870&SectionID=3.
5 National Guideline Clearinghouse (NGC). Guideline synthesis: Venous thromboembolism (VTE) following total hip and knee
arthroplasty: risk assessment and prevention. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for
Healthcare Research and Quality (AHRQ); 2009 Dec (revised 2014 Mar). [Cited: November 12, 2015]. Available:
http://www.guideline.gov/syntheses/synthesis.aspx?id=47770
6 “Episode of Care: Congestive Heart Failure (CHF).” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited:
November 20, 2015.] http://www.paymentinitiative.org/episodesOfCare/Pages/Congestive-Heart-Failure.aspx.
7 “Congestive Heart Failure Algorithm Summary.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited:
November 19, 2015.] http://www.paymentinitiative.org/referenceMaterials/Documents/CHF%20codes.pdf.
8 Fonarow GC, Yancy CW, Hernandez AF, Peterson ED, Spertus JA, Heidenreich PA. “Potential Impact of Optimal Implementation
of Evidence-Based Heart Failure Therapies on Mortality.” American Heart Journal. June 2011; 161(6):1024-30.e3.
http://www.ahjonline.com/article/S0002-8703(11)00206-7/pdf.
9 Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US
Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143:844–857.
10 Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report 2009; :1.
11 “Episodes of Care: Upper Respiratory Infection Arkansas Payment Improvement Initiative. [Online] 2012. [Cited: November 21, 2015.]
http://www.paymentinitiative.org/episodesOfCare/Pages/Upper-Respiratory-Infection-(URI).aspx.
12 “Episode Summary: Upper Respiratory Infection (URI).” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited:
November 21, 2015]. http://www.paymentinitiative.org/referenceMaterials/Documents/upperRespiratoryEpisode.pdf.
13 “Get Smart: Know When Antibiotics Work.” Centers for Disease Control and Prevention (CDC). [Online] 2013. [Cited: December
15, 2015]. http://www.cdc.gov/getsmart/campaign-materials/about-campaign.html.
14 Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. “Use of Antibiotics for Adult Upper Respiratory Infections in
Outpatient Settings: A National Ambulatory Network Study.” Family Medicine. 2006 May; 38(5):349-54.
15 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth edition: DSM-5. Washington:
American Psychiatric Association, 2013.
16 Arkansas State Profile: Parent-Reported Diagnosis of ADHD by a Health Care Provider and Medication Treatment Among Children 4-17 Years:
National Survey of Children’s Health Conducted by the CDC – 2003 to 2011. [Online] 2011. [Cited: November 19, 2015].
1
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Statewide Tracking Report - Arkansas Center for Health Improvement

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