Statewide Tracking Report - Arkansas Center for Health Improvement

Statewide Tracking
Report
January 2015
Participating Payers:
ACHI is a nonpartisan, independent, health policy center that serves as a catalyst to improve the health of Arkansans. 1401 West Capitol Avenue Suite 300, Victory Building Little Rock, Arkansas 72201 www.achi.net Copyright © January 2015 by the Arkansas Center for Health Improvement. All rights reserved.
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Arkansas Health Care Payment Improvement
Initiative: Statewide Tracking Report
Executive Summary
Arkansas’s total health system transformation effort has broad goals that include improving quality, expanding access, and avoiding unnecessary costs. The Arkansas Health Care Payment Improvement Initiative (AHCPII) is a key component of this effort and is based on an innovative restructuring of the system to incentivize quality outcomes. This multi‐payer endeavor is being accomplished collaboratively by the largest public and private carriers in the state. The two main components of AHCPII are: 

Patient‐centered medical homes (PCMH), designed to improve quality and contain costs by supporting
the delivery of better‐coordinated, team‐based carea
An episodes of care model, designed to improve quality and reduce variation in common procedures
and the treatment of acute conditions
Arkansas has become a national leader in payment transformation activities and is on a path to deliver 70 percent of the state’s health care under value‐based purchasing models. As one of only six states awarded an initial round‐one State Innovation Model Testing grant by the Centers for Medicare and Medicaid Services, Arkansas has pursued all of the proposed elements of the AHCPII, including PCMH and episodes of care. While the AHCPII has the strength of multiple payer participation, because of the nature of health care services provided to specific populations, some elements of AHCPII involve only Arkansas Medicaid. This includes development of health homes for those with complex or extensive needs. AHCPII implementation progress as well as quality and cost impacts based on currently available data are captured in the inaugural AHCPII Statewide Tracking Report. This is the first of three annual reports designed not only to track progress but also to help identify areas in need of adjustment. As the initiative progresses, we expect that more robust cost and quality information from the payers will be available for future reports. Patient‐Centered Medical Homes (PCMH)b Building on the success of the Comprehensive Primary Care (CPC) initiative, and with design and implementation being led by Medicaid, the state’s PCMH program has exceeded initial enrollment expectations. Team‐based preventive care, chronic disease management, increased information, and responsibility for the total experience of patient care culminate to position the PCMH to optimize utilization of services by patients and guide referrals to the highest‐value specialty providers. Patient‐Centered Medical Home Highlights 
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Approximately 780 primary care providers enrolled
309K Medicaid beneficiaries served representing 80% of eligible Medicaid beneficiaries
The vast majority of PCMHs successfully completed 3‐month and 6‐month
transformation milestones
Anecdotal practice‐level successes and challenges identified throughout the state
a
To view a comprehensive video about AHCPII, visit http://www.achi.net/pages/OurWork/Project.aspx?ID=81. PCMH Enrollment data provided by Arkansas DHS, pulled from PCMH Q4 reporting as of December 10, 2014. Includes practices that enrolled for 1/1/14 and 7/1/14 start dates. b
Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
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Preliminary 2015 enrollment totals show increases in provider participation and beneficiaries served. Through the state’s Health Care Independence Act, qualified health plans operating in the Health Insurance Marketplace will join Arkansas Medicaid in supporting PCMH practices in 2015. Episodes of Care During the first phase of the payment initiative, the state Medicaid program, Arkansas Blue Cross and Blue Shield (AR BCBS) and QualChoice of Arkansas (QCA) agreed on design parameters and initially introduced five episodes of care: 
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
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
Upper respiratory infections (URIs)
Total hip and knee replacements
Congestive heart failure (CHF)
Attention deficit hyperactivity disorder (ADHD)
Perinatal (pregnancy)
Episodes of Care Highlights 
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
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A 17% drop in unnecessary antibiotic prescribing for non‐specific URI
Across the board improvements in perinatal screening rates
AR BCBS hip/knee replacement costs were reduced by 1.4% (7% below projected costs)
73% of Medicaid and 60% of AR BCBS Principal Accountable Providers (PAPs) improved
costs or remained in a commendable or acceptable cost range
AHCPII System Infrastructure Development The episode and PCMH models have been enabled through development of advanced analytic infrastructure allowing the state to identify areas of improvement and support improved clinical outcomes. After agreeing
on common performance measures and report designs, participating payers each conducted analysis of
provider performance independently using either internal capabilities or independently contracted vendors. Medicaid, QCA, and other payers worked with AR BCBS to facilitate provider reporting through their Advanced Health Information Network (AHIN). This has enabled a multi‐payer provider portal on a common platform to support episode and PCMH data entry, and access to reports produced by each payer or their vendors. Providers now receive both historical and performance reports for each episode type (e.g., perinatal), including summarized and detailed cost and quality information, patient names, and patient‐level episode ID numbers for each individual episode. A large and increasing number of providers have accessed their reports: 

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For the first wave of episodes, 15,600 quarterly performance reports distributed to nearly 2,000 PAPs
PAPs
Approximately 227 million claims were processed
2.8 million episodes were generated before exclusions
Today, the state’s Medicaid growth rate is reduced to 2‐3 percent, private payers have reported 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. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
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Introduction
In 2011, facing an increasingly fragmented health care system with system costs exceeding available revenue, and growing concern regarding the value of health care expenditures in both the public and private sector, 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 of Arkansas (QCA)c—to transform the Arkansas health care 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 QCA have worked collaboratively with hundreds of physicians, hospital executives, patients, families, and advocates in designing, building, and implementing Arkansas’s new payment and delivery system. The result is a bold initiative 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 support to enable 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 chronic disease management as well as increased information and responsibility for the total experience of care, the PCMH is positioned to optimize the patients’ appropriate utilization of services and guide referrals to the highest‐value specialty providers. With design and implementation led by Medicaid, the expansion of the PCMH model throughout the state has already exceeded enrollment expectations. Complementing the PCMH model is the second major component—Arkansas’s episode of care model for conditions that require care coordination and a more intensive use of resources. In an episode of care, a principal accountable provider (PAP) is identified to manage the quality and minimize treatment variations. Through identified opportunities to improve quality and reduce complications for the entire episode, established performance expectations enable the PAP to benefit from system efficiencies. Improvements in Quality of Care 
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Reduction in use of
unnecessary antibiotics
Improved prenatal screening
rates
Reduced infection rates in joint
replacements
Increased 24/7 access to care
through medical homes
A third component utilized by Arkansas DHS is that of a health home—a client‐based support strategy for individuals with needs exceeding the traditional medical home model. The health home strategy optimizes coordination services to those individuals, including the frail elderly, the severe and persistently mentally ill, and the developmentally disabled. This AHCPII Statewide Tracking Report is the first of an anticipated series of updates on the progress and penetration of the state’s system transformation effort. Included are reports on provider uptake in the PCMH model and on the first performance reports for initial episodes launched in 2012‐2013. Information contained in this report represents aggregate results provided by individual payers for descriptive purposes. More details and additional graphical representations of results can be found in Appendix B. The state’s health system has already been impacted by the AHCPII in several ways. Enrollment in the state’s PCMH model is widespread, having over half of all eligible Medicaid primary care providers enrolled, with the vast majority successfully completing practice transformation activities. Approximately 82 percent of eligible c
QCA is committed to reporting their two initial episodes’ progress after the end of their performance period (12/31/2014); results will be included in the second year report in 2015. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
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beneficiaries are now receiving care under the state’s program, far exceeding the initial year‐one goal of 40 percent. For the episode of care model, we have seen meaningful impacts on quality and efficiency, and providers either have received enhanced payments for commendable performance or have been subject to required payments for not achieving acceptable performance. For example, AR BCBS results showed that quality of perinatal (pregnancy) care was improved, and 58 percent of PAPs had decreased perinatal costs compared to projected estimates. For total knee or hip replacements, costs were 1.4 percent below previous year costs. Across all AR BCBS PAPs, 60 percent either improved to a lower cost range or remained in an acceptable or commendable cost range, while 40 percent of PAPs shifted to a higher cost range or remained in an unacceptable cost category. For Medicaid, just one of several areas that showed improvement was in antibiotic prescribing rates, which were reduced by approximately 17 percent. Across all Medicaid PAPs, 73 percent either improved to a lower cost range or remained in an acceptable or Financial Impact and Cost Containment commendable cost range, with 296 PAPs receiving gain‐
 Medicaid growth rate reduced to 2‐3%
sharing payments, while 27 percent of PAPs shifted to a higher cost range or remained in an unacceptable cost  AR BCBS hip/knee replacement costs were
reduced by 1.4% (7% below projected)
category, with 231 PAPs owing risk‐sharing payments. 
73% of Medicaid and 60% of AR BCBS PAPs
improved costs or remained in a
commendable or acceptable cost range
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 will be a requirement in 2015. In addition, some commercial carriers are extending the PCMH model to their fully insured, non‐exchange products. Self‐insured interest continues to grow, with both public and private sector expansions anticipated. New episodes have been launched and others are under development, which continues to accelerate the proportion of surgical, specialty, or intensive care under value‐based purchasing strategies. The largest challenge to the AHCPII remains the lack of full participation of Medicare with the care needs of its eligible participants and their volume of care consumed. Continued demonstration of progress will be utilized to solicit the Centers for Medicaid and Medicare Services’ full participation. The 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. System Infrastructure Development
One of the greatest areas of success in the first operational year has been the progress made in establishing the system infrastructure, which has allowed Arkansas to identify areas of improvement within the AHCPII, and support the clinical outcomes reached by providers. After agreeing on common performance measures and report designs,
participating payers each conducted analysis of provider performance independently using either internal capabilities
or independently contracted vendors. Medicaid, QCA, and other payers worked with AR BCBS to facilitate provider reporting through their Advanced Health Information Network (AHIN), enabling a multi‐payer provider portal on a common platform to support episode and PCMH data entry and access to payers' reports. The analyses contained in this report were produced and made possible in part by GDIT, Medicaid, and AR BCBS.
Providers now receive both historical and informational reports for each episode type (e.g., perinatal), including summarized and detailed cost and quality information, patient names, and patient‐level episode ID numbers for each individual episode. A large and increasing number of providers have accessed their reports. In order to generate and report on the first wave of episodes, approximately 226.5 million claims have been processed Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
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through the episode engine, resulting in just fewer than 2.67 million episodes before exclusions. More than 15,600 quarterly performance reports have been distributed to nearly 2,000 distinct PAPs.d Patient-Centered Medical Homee
The PCMH model is best described as a model of primary care that is patient‐centered, comprehensive, team‐
based, coordinated, accessible, and focused on quality. Through improved care coordination and communication, the goal of the medical home is to help patients stay healthy, increase the quality of care they receive, and reduce costs. PCMH transformation has been underway in Arkansas since October 2012, with 69 practices initially selected to participate in the Comprehensive Primary Care (CPC) initiative—a multi‐payer PCMH program sponsored by the Center for Provider Spotlight: Dr. Stacy Zimmermane
Medicare and Medicaid Innovation (CMMI).1 Wave‐
“Our numbers have gotten better every year since we two expansion of the PCMH model began in started the program, but there is always room to January 2013, and builds upon the efforts of the improve.” CPC initiative. For this expansion, Medicaid ‐‐Dr. Stacy Zimmerman of Ozark Internal Medicine and developed a medical transformation model with Pediatrics
particular attention given to the pediatric population. Arkansas’s long‐term goal is for most primary care practices in the state to transition to the PCMH model.  44% Reduction in Hospital Admissions
Currently, detailed information about system wide  25% Reduction in ER Costs
cost and quality impacts of the PCMH model and  29% Decrease in Total Costs of Care
the Medicare‐led CPC initiative is not readily  9% Increase in Prescribing of Generic Drugs
available. Inclusion of this information is anticipated in subsequent reports. Information is available regarding provider and beneficiary enrollment and practice transformation progress. 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 gain sharing based on performance improvements, or based on high performance compared to statewide averages. Quality metrics must be met in both options. Unlike episodes, there is no downside financial risk to the current PCMH models operating in Arkansas. The Arkansas PCMH model has exceeded initial expectations for both provider enrollment and number of beneficiaries served under the model at this stage of implementation. Key findings on current enrollment and participation include: 
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123 PCMHs enrolledf in the state’s Medicaid‐led, multi‐payer PCMH program. Nine of these
practices are also enrolled in the CPC initiative;
61 practicesg enrolled in the Medicare‐led CPC initiative;
d
Arkansas has 6,340 active, licensed physicians and 93 hospitals For a full PCMH case study on Ozark Internal Medicine and Pediatrics (OIMP), please see Appendix B. An early adopter of the PCMH model in Arkansas, OIMP is located in Clinton, AR, in Van Buren County, and serves a panel of approximately 5,700 active patients. e
f
Data provided by Arkansas DHS, pulled from PCMH Q4 reporting as of December 10, 2014. Includes practices that enrolled for 1/1/14 and 7/1/14 start dates. g
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
Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
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
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Approximately 780 primary care
Table 1: Patient‐Centered Medical Homes Milestones providers are participating,
representing 73 percent of all
eligible providers;c
Approximately 309K Medicaid
beneficiaries are covered,
representing 80 percent of all
eligible Medicaid beneficiaries;c
Multi‐payer participation in either
the CPC initiative or the Arkansas
PCMH program includes Medicaid,
Medicare, AR BCBS, QCA, Humana,
Arkansas Public School Employees
Plan, Arkansas State Employees Plan,
Federal Employees Plan, Walmart,
and Fort Smith Physicians Alliance
(Medicare shared savings program
accountable care organization (ACO)
in alignment with PCMH);
The first wave of PCMHs enrolled in the Medicaid‐led PCMH program started in January 2014. For those
practices, the six‐month practice transformation milestones have required attestation most recently.
Currently, milestone attestation is available for 105 PCMHs that began their enrollment on January 1,
2014; and
Through the state’s Health Care Independence Act, known as the Private Option, QHPs operating on the
Health Insurance Marketplace will join Medicaid in supporting PCMH practices in 2015.
Table 2: Attestation to PCMH Practice Transformation Milestonesh
PCMH 3 Month Activities PCMHs that Identify the should have Identify team top 10% of lead(s) for attested high‐priority care (Total = 105) patients coordination Number 105 105 Percent 100% 100% PCMH 6 Month Activities Develop and Identify and Assess record reduce medical Track same‐
Make operations of strategies to neighborhood day available practice and implement care barriers to 24/7 access appointment opportunities coordination coordinated to care requests to improve and practice care at the transformation practice level 88 87 84 86 72 84% 83% 80% 82% 69% Episodes of Care
An episode of care is the collection of care provided to treat a particular condition for a given length of time.2 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. PAPs are given quarterly reports that outline their overall performance across the entire episode, including quality targets, utilization variation, and aggregate costs. Upon completion of a performance period (usually one year), each PAP may be eligible for gain sharing if their overall performance has achieved commendable status. If the overall performance is not acceptable and exceeds the acceptable threshold, the PAP may be required to refund a portion of his payments. h
Data provided by Arkansas DHS on 11/6/2014. The PCMH attestation validation process is underway to ensure attestation is accurate. Any PCMHs that do not meet attestation validation must complete remediation in a timely manner or will be subject to termination from the PCMH program. Validation of milestones will be provided in subsequent statewide tracking reports. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
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During the first phase of the payment initiative, Medicaid and the private insurers selectively introduced five episodes of care: upper respiratory infections (URI), total hip and knee replacements, congestive heart failure (CHF), attention deficit hyperactivity disorder (ADHD),i and perinatal.2 For these episodes, payers agreed upon the following strategies to align financial incentive to improve care: 
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Upper Respiratory Infections (URI)—the trigger is the first diagnosis of a URI; the PAP is the diagnosing
clinician; the time period is 21 days; quality targets include appropriate testing prior to antibiotic use;
costs include all associated therapeutic costs. Currently, Medicaid is the only participating payer.
Perinatal—the episode trigger is the delivery of a live infant; the PAP is the delivering provider; the time
period is the prenatal period and 60 days postpartum; quality targets 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 preoperatively to 90 days postoperatively; quality targets
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 index hospital for
the admission; the time period is the admission day plus 30 days; quality targets include appropriate
cardiac medication management and follow up; all facility services, inpatient professional services,
emergency department visits, observation, and post‐acute care; any CHF‐related outpatient labs and
diagnostics, outpatient costs, and medications are 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 is 12
months; complexity and quality assessments are through provider attestation; costs include all ADHD‐
related charges (ADHD results are not reflected in this year’s report due to length of performance period
and ongoing analyses of results). Currently, Medicaid is the only participating payer.
In the multi‐payer effort, payers in collaboration with practicing providers jointly developed the definitions above.j 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 performance year are reported below for Medicaid and AR BCBS. QCA will report their two initial episodes’ progress after the end of their performance period (December 31, 2014). 1. Perinatal
The perinatal episode aims to ensure healthy pregnancy and follow‐up care for the mother and new baby, which requires months of care provided by many different providers ranging from obstetricians, family practice physicians, and nurse midwives to hospitals, emergency departments, obstetric specialists, and others.3 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.4 There are five additional quality metrics that PAPs are tracked on in the perinatal episode i
This report does not include ADHD episode data due to significant changes in the algorithm and this episode had a short performance period of only one quarter (any comparison would be flawed). j
Specific details are available at http://www.paymentinitiative.org/episodesOfCare/Pages/default.aspx. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
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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 QCA are participating in the perinatal episode. Key findings from this episode include the following: 
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Screening rates improved across the board for both AR BCBS and Medicaid. The Chlamydia‐screening
rate showed the most improvement for both payers.
Medicaid’s C‐section rate improved from 38.6 percent in the baseline year to 33.8 percent in the
performance year. However, the C‐section’s average length of inpatient stay increased from 2.2 days in
the baseline year to 2.6 days in the performance year, which may signify a shift to more appropriate C‐
sections.
AR BCBS’s C‐section rate increased from 38.0 percent in the baseline year to 38.5 percent in the
performance year.
2. Total Joint Replacement (TJR): Hip and Knee
Previously, multiple providers have been involved at each stage of total hip and knee replacements without optimal care coordination. This leads to duplication of efforts, increased costs, and 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.5 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.6 TJR includes all care related to the procedure in the period 30 days prior to the surgery to 90 days after.5 This episode has four metrics in place to track quality of care and improvement opportunities: 30‐day all‐cause readmission rate;k 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. Medicaid, AR BCBS, and QCA are participating in the TJR episode. Key findings for the episode include: 
For AR BCBS, all TJR quality metrics from baseline period to performance period showed improvement,
with wound infection rates decreasing by nearly eight‐fold from 8.5 per 1,000 in the baseline year to 1.1
per 1,000 in the performance year. The 30‐day all‐cause readmission rate improved from 2.55 percent in
the baseline year to 2.09 percent in the following performance year. The 90‐day post‐op complication
rate improved from 3.40 percent in the baseline year to 2.63 percent in the performance year.

For Medicaid, the TJR episode is the single most costly episode, with procedures for the knee being
more costly than hip. For TJR, there was improvement in the 30‐day all‐cause readmission rate. While
costly, Medicaid’s limited adult coverage is reflected in the limited number of episodes, thus limiting the
interpretation of results.
3. Upper Respiratory Infection (URI)
Upper Respiratory Infections (URIs) are one of the most common illnesses suffered by Arkansans, leading to more doctor visits than any other ailment each year.7 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 retrospective 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. Key results from the URI episodes include: k
The 30‐day all‐cause readmission rate is for patient readmissions occurring between 30‐90 days post‐surgery o related only to the TJR procedure count toward the episode. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
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
All three of the URI (pharyngitis, sinusitis and non‐specified URI) episode metrics for antibiotic
prescribing rates improved from the baseline to performance period.l,m
 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 37.1 percent in the performance year.
This decrease is an improvement toward the CDC recommendation that antibiotics should not be used
to treat non‐specific URI in adults since antibiotics do not improve URI.8
 Across all three URI episode types, there were more PAPs with performance year costs in either the
commendable and acceptable range than the unacceptable cost range.
4. Congestive Heart Failure (CHF)
In Arkansas, 24 percent of hospitalized Medicare patients with congestive heart failure (CHF) will be re‐admitted within 30 days annually.9 CHF affects a significant number of older 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, with a focus 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.9 The 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 7 and 14 days after discharge; proportion of patients matching hyper dynamic, normal, mild dysfunction, moderate dysfunction, 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).10 Medicaid and AR BCBS are participating in the CHF episode. Key findings include: 
For Medicaid, the CHF episode saw a decrease in the 14‐day observation rate, improving from 42.67
percent in the baseline period to 40.09 percent in the performance period. Medicaid excludes dualeligible from it's episodes. For this reason, the number of cases is low. With only thirteen valid PAPs and
the low volume of valid episodes in the analysis, the results for this episode must be cautiously observed.

For AR BCBS, the 30‐day all‐cause readmission rate worsened from 10.42 percent in the baseline year to
13.51 percent in the performance year. However, the CHF episode’s volume was so low that any
statistical significance is questionable.
Additional Episodes
Additional episodes deployed or under development are increasing the proportion of surgical, specialty, or intensive care under value‐based purchasing strategies. The consistent definition of the episode, identification of the PAP, and articulation of quality expectations across payers will 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 quality improvement and practice variation. Table 3 below illustrates the additional episodes deployed or under development. l
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. m
Having consistent start and end dates for baseline and performance effectively removes seasonality associated with URI rates. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
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Table 3: Episodes Deployed or Under Development Episode Payer Participation Upper Respiratory Infection (URI) Medicaid Perinatal Medicaid, AR BCBS, QCA Congestive Heart Failure (CHF) Medicaid, AR BCBS Total Joint Replacement (TJR) Medicaid, AR BCBS, QCA Attention Deficit Hyperactivity Disorder (ADHD) Medicaid Cholecystectomy (Gall Bladder Removal) Medicaid, AR BCBS, QCA Colonoscopy Medicaid, AR BCBS, QCA Tonsillectomy Medicaid, AR BCBS Oppositional Defiant Disorder (ODD) Medicaid Coronary Artery Bypass Grafting (CABG) Medicaid, AR BCBS Asthma Medicaid, AR BCBS Chronic Obstructive Pulmonary Disease (COPD) Medicaid, AR BCBS Percutaneous Coronary Intervention (PCI) Medicaid, AR BCBS, QCA Neonatal Medicaid ADHD/ODD Comorbidity Medicaid Conclusion
The AHCPII is a statewide, permanent initiative, not a small scale or short‐term demonstration project. Enhanced multi‐payer participation is anticipated, and some of the state’s largest self‐insured employers are already participating, having seen the potential opportunities for better, and more efficient health care for their employees. The total transformation of Arkansas’s health system will be strengthened if every payer in the state operates under the new system. 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. As Arkansas moves forward with an increasing proportion of care being delivered under the value‐based models of the AHCPII, subsequent annual statewide tracking reports will capture future system impacts, including more detailed information on PCMHs, episodes of care, and health homes. REFERENCES
1
“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/medicalHomes/Pages/default.aspx
2
“Episodes of Care.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. Accessed on November 4, 2014 at http://www.paymentinitiative.org/episodesOfCare/Pages/default.aspx. 3
“Episode Summary: Perinatal.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. Accessed on November 4, 2014 at http://www.paymentinitiative.org/referenceMaterials/Documents/perinatalEpisode.pdf. 4
“Perinatal Care Algorithm Summary”. Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited: November 17, 2014.]. http://www.paymentinitiative.org/referenceMaterials/Documents/2012_1011%20Perinatal%20codes.pdf 5
“Episode Summary: Total Hip and Knee Replacement.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. Accessed on November 4, 2014 at http://www.paymentinitiative.org/referenceMaterials/Documents/hipKneeEpisode.pdf. Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
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6
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 December 15, 2014 at http://www.arkansasbluecross.com/providers/manual/manual_default.asp?page=870&SectionID=3 7
“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 8
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. 9
“Episode Summary: Acute/Post‐acute Congestive Heart Failure.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. Accessed on December 11, 2014 at http://www.paymentinitiative.org/referenceMaterials/Documents/CHF%20Episode%20Descript_7‐2014.pdf. 10
“Congestive Heart Failure Algorithm Summary.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited: November 24, 2014]. http://www.paymentinitiative.org/referenceMaterials/Documents/CHF%20codes.pdf Arkansas Health Care Payment Improvement Initiative Statewide Tracking Report (January 2015)
Page 11 of 11
Appendix A
Case Study
Patient-Centered Medical Homes:
Improving Quality in a
Fragmented System
Case Study
Patient-Centered Medical Homes:
Improving Quality in a
Fragmented System
ACHI is a nonpartisan, independent, health policy center that serves as a catalyst to improve the health of Arkansans.
Ozark Internal Medicine and Pediatrics
October 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 primary
focus of the initiative has been payment innovation and restructuring the system to incentivize quality
outcomes. The three main strategies are episodes of care, which focus on improving quality and
reducing waste and inefficiencies in common procedures and the treatment of acute conditions;
behavioral health and long-term services and support; and patient-centered medical homes. This study
is part of a series of case studies spotlighting practice transformation to patient-centered medical homes,
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.
This case study was produced in partnership with the Arkansas Department of Human Services.
“Our numbers have gotten better every year since we started the program, but there is always room to improve.” ‐‐Dr. Stacy Zimmerman of Ozark Internal Medicine and Pediatrics An early adopter of the patient-centered medical home (PCMH) model in
Arkansas, Ozark Internal Medicine and Pediatrics (OIMP), is located in
Clinton, AR, in Van Buren County, and serves a panel of approximately
5,700 active patients. Led by Dr. Stacy Zimmerman, OIMP employs a staff
of nine, with one advanced practice nurse (APN), two licensed practical
nurses (LPNs), two administrative personnel, two X-ray technicians, and
one full-time information technology (IT) specialist. OIMP began the PCMH
transformation process in 2010—first as one of five practices in the PCMH
Pilot Project sponsored by Arkansas Blue Cross and Blue Shield, then by being one of 69 Arkansas
practices originally selected to participate in the Centers for Medicare and Medicaid Services Innovation
Center’s Comprehensive Primary Care (CPC)
Improvements Reported By Dr. Zimmerman initiative, followed by their enrollment in the
Since OIMP Became a PCMH Arkansas PCMH program.
•
•
•
•
44% Reduction in Hospital Admissions
25% Reduction in ER Costs
29% Decrease in Total Costs of Care
9% Increase in Prescribing of Generic Drugs
Implementing a team-based approach to patient
care is a primary goal of the PCMH model. By
involving the entire staff in care coordination
activities, OIMP has been able to provide more
efficient, higher quality care. According to Zimmerman, “Everybody contributes to care coordination, from
the time the front office checks in the patient…. We do a lot of team huddles before we see patients and
throughout the day so the nurses anticipate any lab tests, shots, or other things that need
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
VAN BUREN COUNTY PROFILE
Overall County Health Ranking: 25 (of 75)
Uninsured: 22% (AR: 20%)
Primary Care Physicians: 8,542:1 (AR: 1,586:1)
Diabetic Screening: 84% (AR: 82%)
Mammography Screening: 55% (AR: 58%)
Social & Economic Factor Ranking: 43 (of 75)
Poor or Fair Health: 23% (AR: 19%)
Mental Health Providers: 1,548:1 (AR: 696:1)
Low Birth Weight: 8.6% (AR: 9.0%)
Unemployed: 8.9% (AR: 7.3%)
*http://www.countyhealthrankings.org/app/#!/arkansas/2014/rankings/van-buren/county/outcomes/overall/snapshot
to be done—this helps us save time.”
The PCMH program also provides resources and incentivizes practices to adopt an electronic medical
record (EMR) system. By using their own customized EMR system, the OIMP team has been able to
greatly reduce or eliminate care gaps for their patients. Zimmerman researched which EMR system
would suit her clinic’s needs before deciding on a platform that now allows her to run automated
reminders and care-gap analyses. These tools help OIMP proactively manage chronic conditions. “Our
EMR reminders tell the staff where the needs are for each of our patients. We design the rules in our
system to track things like hemoglobin A1C checks for all of our diabetic patients,” said Zimmerman. The
EMR system also supports a patient portal where OIMP staff can share lab results, prescription details,
or follow-up reminders directly with patients. Zimmerman said, “When I get results, I can immediately
send the patient a portal message indicating lab results and appropriate follow-up. I get confirmation
when they receive the message, and then we have a perfect circle—with no care gaps.”
In addition to the patient portal, the OIMP team has improved other aspects of patient engagement and
experience of care. Patients at OIMP now benefit from improved access and an after-hours call line—
features that Zimmerman credits in helping reduce unnecessary emergency room (ER) admissions for
her patients. Zimmerman said, “Patients love timely
“It comes down to care management. Before
turnaround and professional service. Having that, they are
patients
leave, we go through their care gaps
more apt to lean on us before they go to the ER.” For
with them. They have a follow-up date, and all
OIMP, the PCMH model has facilitated and reinforced a
of their medicines are taken care of. We are
shift towards greater patient responsibility. “It builds
reducing the chance of problems before followconfidence and trust and guides patients to use the system
up. We’re keeping our patients healthy.”
in the right way. The PCMH is outside of our walls, it’s a
change in the culture of our practice, in the methodology,”
--Stacy Zimmerman, MD, OIMP
said Zimmerman.
The staff and patients at OIMP have benefited from the PCMH program in numerous ways. However, Dr.
Zimmerman’s team is still challenged with issues such as managing transitions of care for their patients
who visit hospitals or other providers. OIMP is participating in the state’s health information exchange—
the State Health Alliance for Records Exchange (SHARE)—and the team is capable of securely
exporting information to other providers. However, obtaining bi-directional communication from hospitals
either using a different EMR platform or not connected to SHARE has been difficult. “It’s so hard to track
inpatient admissions and ER discharges; my patients may go to three or four different hospitals. Right
now, I’m dependent on discharge summaries, faxes, or patient emails. Receiving results from the
SHARE interface will fulfill so many of our transitions of care goals and milestones that we have to meet
for the PCMH program,” said Zimmerman.
Like all PCMH practices in Arkansas, OIMP receives up-front financial support from participating payers.
These funds have helped Dr. Zimmerman transform her practice and maintain care-coordination
activities. While there is a requirement for qualified health plans to offer financial support to PCMH
practices beginning in 2015, it is unclear to what extent all payers will support Arkansas’s PCMH
program in the future. “I would like to see Medicare come to the table. Trying to stretch the $3 permember per-month payment from Medicaid doesn’t go very far,” said Zimmerman.
The goal of improved quality is one shared by OIMP and all PCMH practices in the state. While OIMP
has made improvements in areas such as care coordination and EMR implementation that have
impacted key quality and cost indicators, Dr. Zimmerman still acknowledges, “It’s a work in progress.”
This report was composed using information obtained during an in-person interview and discussion with Dr. Stacy Zimmerman
of Ozark Internal Medicine and Pediatrics. The Arkansas Center for Health Improvement was granted written permission to use
this information. Additional information included 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 © October 2014 by the Arkansas Center for Health Improvement. All rights reserved.
Case Study Patient-Centered Medical Homes: Improving Quality in a Fragmented System
Page 2
Appendix B
Arkansas Health Care Payment
Improvement Initiative:
Detailed Statewide
Tracking Report
APPENDIX B
TABLE OF CONTENTS
Background & Purpose ...................................................................................................................................................... 2 Report Overview ................................................................................................................................................................ 3 PATIENT‐CENTERED MEDICAL HOME (PCMH) ............................................................................................................... 3 PCMH Implementation Update.................................................................................................................................. 4 EPISODES OF CARE ......................................................................................................................................................... 6 Perinatal ..................................................................................................................................................................... 7 Total Joint Replacement (TJR): Hip and Knee ............................................................................................................ 9 Upper Respiratory Infection (URI) ........................................................................................................................... 11 Congestive Heart Failure (CHF): ............................................................................................................................... 14 Additional Episodes .................................................................................................................................................. 16 Conclusion ........................................................................................................................................................................ 16 Appendix B: AHCPII Detailed Statewide Tracking Report 1 Background & Purpose
In 2011, facing an increasingly fragmented health care system with system costs exceeding available revenue, and growing concern regarding the value of health care expenditures in both the public and private sector, 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 of Arkansas (QCA) a—to transform the Arkansas health care 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. Together, Arkansas Medicaid (Medicaid), AR BCBS, and QCA have worked collaboratively with hundreds of physicians, hospital executives, patients, families, and advocates in designing, building, and implementing Arkansas’s new payment and delivery system. The result is a bold initiative 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 support to enable 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 chronic disease management as well as increased information and responsibility for the total experience of care, the PCMH is positioned to optimize the patients’ appropriate utilization of services and guide referrals to the highest‐value specialty providers. Complementing the PCMH model is the second major component—Arkansas’s episode of care model for conditions that require care coordination and a more intensive use of resources. In an episode of care, a principal accountable provider (PAP) is identified to manage the quality and minimize treatment variations. Through identified opportunities to improve quality and reduce complications for the entire episode, established performance expectations enable the PAP to benefit from system efficiencies. A third component utilized by Arkansas DHS is that of a health home—a client‐based support strategy for those individuals with needs exceeding the traditional medical home model. The health home strategy optimizes coordination services to those individuals, including the frail elderly, the severe and persistently mentally ill, and the developmentally disabled. This AHCPII Statewide Tracking Report is the first of an anticipated series of updates on the progress and penetration of the state’s system transformation effort. Included are reports on provider uptake in the PCMH model and on the first performance reports for initial episodes launched in 2012‐2013. Information contained in this report represents aggregate results provided by individual payers for descriptive purposes. The state’s health system has already been impacted by the AHCPII in several ways. Enrollment in the states’ PCMH model is widespread, having over half of all eligible primary care providers enrolled, with the vast majority successfully completing practice transformation activities. Approximately 76 percent of eligible beneficiaries are now receiving care under the state’s program, far exceeding the initial year‐one goal of 40 percent. For the episode of care model, we have seen meaningful impacts on quality and efficiency, and providers either have received enhanced payments for commendable performance or have been subject to required payments for not achieving acceptable performance. For example, AR BCBS results showed that quality of perinatal (pregnancy) care was improved, and 58 percent of PAPs had decreased perinatal costs compared to projected estimates. For total knee or hip replacements, costs were 1.4 percent below previous year costs. Across all AR BCBS PAPs, 60 percent either improved to a lower cost range or remained in an acceptable or commendable cost range, while 40 percent of PAPs shifted to a higher cost range or remained in an unacceptable cost category. For Medicaid, just one of several areas that showed improvement was in antibiotic prescribing rates, which were reduced by approximately 17 percent. Across all Medicaid a
QCA is committed to reporting their two initial episodes’ progress after the end of their performance period (12/31/2014); results will be included in the second year report in 2015. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 2 PAPs, 73 percent either improved to a lower cost range or remained in an acceptable or commendable cost range, with 296 PAPs receiving gain‐sharing payments, while 27 percent of PAPs shifted to a higher cost range or remained in an unacceptable cost category, with 231 PAPs owing risk‐sharing payments. 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 will be a requirement in 2015. In addition, some commercial carriers are extending the PCMH model to their fully insured, non‐exchange products. Self‐
insured interest continues to grow, with both public and private sector expansion anticipated. New episodes have been launched and others are under development, which continues to accelerate the proportion of surgical, specialty, or intensive care under value‐based purchasing strategies. The largest challenge to the AHCPII remains the lack of full participation of Medicare with the care needs of its eligible participants and their volume of care consumed. Continued demonstration of progress will be utilized to solicit the Centers for Medicaid and Medicare Services’ full participation. 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. This statewide, cross‐payer tracking report is funded in part through a grant to ACHI from Wal‐Mart Stores, Inc. (Walmart), a participant in and major supporter of the AHCPII. Through the state’s Employer Advisory Council (EAC), leaders at Walmart have provided input on design and implementation of AHCPII alongside other participating public and private payers. Report Overview
The following report contains an update on the PCMH model, which includes current enrollment status, as well as progress towards practice‐transformation milestones and quality indicators. In an effort to monitor the statewide diffusion of AHCPII and the overall amount of care that is being delivered under a value‐based system, this report also includes a section on overall penetration of AHCPII components across providers and beneficiaries. In addition, the report contains a section for the episodes of care model that includes a summary of how the model works and a description of each episode, including assignment of a PAP, episode timeframe, and patient journey for each type of episode. The section also contains key quality metrics for each episode, as well as summary information on episode providers’ cost impact as reflected in provider movement across episode‐specific cost thresholds. Here are some of the key highlights presented in this report: 






Approximately 76 percent of eligible Medicaid beneficiaries are receiving care under the Arkansas PCMH model,
greatly exceeding the initial expectation of 40 percent of beneficiaries covered by the first year of the initiative.
PCMH provider enrollment exceeded initial expectations, with encouraging reports of practice‐level
improvements already underway.
Approximately 659 primary care providers are enrolled in the Arkansas PCMH model.
Medicaid saw an improvement in upper respiratory infection (URI) episodes, with a large reduction in antibiotic
use.
Both Medicaid and AR BCBS improved in the perinatal episode, with an increase in screening rates.
The total joint replacement (TJR) episode’s 30‐day readmission rate for Medicaid and AR BCBS showed
improvement with reductions in readmission rates.
Both Medicaid and AR BCBS experienced some variation in the congestive heart failure (CHF) episode. Both
payers did see an improvement with reductions in hospital readmissions.
PATIENT‐CENTERED MEDICAL HOME (PCMH) The PCMH is best described as a model of primary care that is patient‐centered, comprehensive, team‐based, coordinated, accessible, and focused on quality. Through improved care coordination and communication, the goal of Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 3 the medical home is to help patients stay healthy, increase the quality of care they receive, and reduce costs. The patient is a part of a care team that is led by a designated primary care doctor who communicates with other clinical and administrative professionals to better coordinate responsibilities of the patient’s care. PCMH transformation has been underway in Arkansas since October 2012, with 69 practices initially selected to participate in the Comprehensive Primary Care (CPC) initiative, a multi‐payer PCMH program sponsored by the Center for Medicare and Medicaid Innovation (CMMI).1 Wave‐two expansion of the PCMH model began in January 2013, and builds upon the efforts of the CPC initiative. Arkansas’s long‐term goal is for most primary care practices in the state to transition to the PCMH model. Participating PCMH practices receive up‐front payments to enable them to more proactively meet patient needs and practice transformation milestones, including 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, there are two ways for a primary care physician to achieve gain sharing: 1. Gain sharing based on performance improvements
2. Gain sharing based on high performance compared to statewide averages
Quality metrics must be met in both options. Unlike episodes of care, there is no downside financial risk to the current PCMH model operating in Arkansas. PCMH Implementation Update Beginning with the CPC initiative in 2012, the state embarked on a multi‐payer PCMH implementation, with participation from Medicare, Medicaid, AR BCBS, QCA, and Humana. Development of an EAC helped facilitate further self‐insured participation, including Walmart, Arkansas State Employees Plan, and Arkansas Public School Employees Plan. Currently, detailed information about system‐wide cost and quality impacts of the PCMH model and the Medicare‐led CPC initiative is not readily available. Inclusion of this information is anticipated in subsequent annual reports. However, information is available regarding provider Table 1: Patient‐Centered Medical Homes Milestones
and beneficiary enrollment and practice transformation progress for PCMHs enrolled in the Medicaid‐led PCMH program, as well as anecdotal, practice‐level information.b The Arkansas PCMH model has exceeded initial expectations for both provider enrollment and number of beneficiaries served under the model at this stage of implementation. Arkansas’s PCMH rollout is inclusive of the initial 69 practices selected for the CPC initiative, and the 143 practices now enrolled in the state’s Medicaid‐led, multi‐payer PCMH program. Current PCMH Enrollment 
123 PCMHs enrolled in the state’s
Medicaid‐led, multi‐payer PCMH
program. Nine of these practices are
also enrolled in the CPC initiative.

61 practicesc enrolled in the Medicare‐led CPC initiative.
b
For a full PCMH case study on Ozark Internal Medicine and Pediatrics (OIMP), see Appendix A. An early adopter of the PCMH model in Arkansas, OIMP is located in Clinton, AR, in Van Buren County, and serves a panel of approximately 5,700 active patients. c
Practices are enrolled individually in the CPC initiative, and current enrollment numbers are tracked by Centers for Medicaid and Medicare Services: http://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/Arkansas.html
Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 4 

Approximately 780 primary care providers are participating, representing 73 percent of all eligible providers.c
Approximately 309K Medicaid beneficiaries are covered, representing 80 percent of all eligible Medicaid
beneficiaries.c
Current Payer Participation 









Arkansas Medicaid
Medicare
Arkansas Blue Cross and Blue Shield
QualChoice of Arkansas
Humana
Arkansas Public School Employees Plan (73K beneficiaries)
Federal Employees Plan (approximately 50K employees in Arkansas)
Arkansas State Employees Plan (55K beneficiaries)
Walmart (approximately 50K employees in Arkansas)
Fort Smith Physicians Alliance (Medicare shared‐savings program accountable care organization (ACO) in
alignment with PCMH)
Current PCMH Practice Transformation Progress The first wave of PCMHs enrolled in the Medicaid‐led PCMH program starting in January 2014. For those practices, the six‐month practice transformation milestones have required attestation most recently. Table 2 below illustrates the rate of attestation for the six‐month PCMH milestones for the first round of practices enrolled in the Medicaid‐led PCMH program. The table displays the rate of attestation among the practices that began the Medicaid‐led PCMH program on January 1, 2014. The PCMH attestation validation process is underway to ensure that attestation is accurate, and that any PCMHs that do not meet attestation validation must complete remediation in a timely manner, or will be subject to termination from the PCMH program. Validation of milestones will be provided in subsequent statewide tracking reports. Table 2: Attestation to PCMH Practice Transformation Milestonesd
PCMH 3 Month Activities PCMHs that should have attested (Total = 105) Number Percent 



PCMH 6 Month Activities Identify and Develop and Assess reduce medical Track same‐
record strategies Make Identify team Identify the top operations of neighborhood day to implement available 24/7 lead(s) for 10% of high‐
practice and barriers to appointment care coordination care priority patients opportunities coordinated access to care
requests and practice to improve coordination care at the transformation practice level 105 105 88 87 84 86 72 100% 100% 84% 83% 80% 82% 69% Milestone attestation is currently available for 105 PCMHs that began their enrollment on January 1, 2014.
The 105 PCMHs whose transformation timeline began on January 1, 2014, are part of the 193 total PCMHs
currently recognized in the state.
70 of 71 practices with deficiencies in six‐month milestones submitted quality improvement plans (QIPs).
PCMHs have a calendar quarter following submission of QIPs to complete remediation. The PCMH quality
assurance team is in the attestation validation process (e.g., site visits, phone calls, etc.) to confirm PCMH
activity attestation. PCMHs that do not remediate any inaccurate attestations are subject to termination from
the program.
Future Payer Participation d
The PCMH attestation validation process is underway to ensure attestation is accurate. Any PCMHs that do not meet attestation validation must complete remediation in a timely manner or will be subject to termination from the PCMH program. Validation of milestones will be provided in subsequent state tracking reports. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 5 Through the state’s Health Care Independence Act, known as the Private Option, qualified health plans (QHPs) operating on the Health Insurance Marketplace will join Medicaid in supporting PCMH practices in 2015. Additional payer participation is anticipated, and QHPs will be required to increase the incentives of the PCMH program for providers to transition to the PCMH model in 2015. To be implemented by Arkansas Insurance Department (AID) rule, new payer requirements include a minimum average of $5 PMPM care payment for care coordination and practice transformation. The payment is tied to performance on practice support activities and metrics. This additional financial support to participating practices will reinforce the value of practice transformation activities, which are aimed at things like achieving more coordinated care and increasing the use of health information technology and the State Health Alliance for Records Exchange (SHARE). The AID rule also requires payers to develop a shared savings model (to be implemented in future years of the PCMH program) for practices to achieve a per‐issuer enrollee cost of care that is below a benchmark cost. Finally, the rule requires that payers provide performance reports in a pre‐specified, standardized format, and share statistics in the form of analyzed claims data for potential multi‐payer use. Expanded Payer Participation Beginning January 1, 2015 





Arkansas Blue Cross and Blue Shield**
Blue Cross and Blue Shield Multi‐state Plan**
QualChoice of Arkansas**
Arkansas Health and Wellness (Ambetter)**
United Healthcare
Additional Self‐Insured Purchasers
**Via QHP Requirements
Upcoming Additional Support for PCMH 



PMPM payments will begin on April 1, 2015, for QHP beneficiaries attributed to Medicaid‐designated PCMHs
that are in good standing. Attribution will be updated on a quarterly basis.
QHP PCMH attribution will be based on marketplace enrollment. Excluding those deemed medically frail and
enrolled in traditional Medicaid, there are 188Ke individuals enrolled in the Private Option, and another45Kf
individuals enrolled in the Health Insurance Marketplace.
Five carriers are offering plans for Dual‐Eligible Special Needs Plans (D‐SNPs) and must adhere to the same QHP
requirements to support PCMHs for program eligible individuals.
The first PCMH shared‐savings payments will be issued to providers beginning in July 2015.
EPISODES OF CARE An integral component of the AHCPII is the creation and implementation of an episode‐based care delivery model. The episode of care model is designed to reduce or control costs, and improve quality of care. An episode is the collection of care provided to treat a particular condition for a given length of time.2 For each episode of care identified, a principal accountable provider (PAP) is designated.3 This 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 mid‐level provider. In others, it will be a hospital or facility.4 Payers provide quarterly data reports to providers outlining quality, cost, and utilization patterns associated with specific episodes of care. These reports provide PAPs with information they have not had in the past, which allows them to better understand which areas they are excelling or may need improvement as compared to their peers. They also support PAPs operating in a PCMH model to better account for the entire continuum of care their patients encounter across the health care system. e
Total number enrolled in private plans through the Health Care Independence Program (Private Option) per Arkansas DHS report run on December 3, 2014. f
Total number of Health Insurance Marketplace enrollees actively covered, excluding enrollment cancellations, as reported by the Arkansas Insurance Department as of December 15, 2014. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 6 During the first phase of the payment initiative, Medicaid and the private insurers initially introduced five episodes of care: upper respiratory infections (URI), total hip and knee replacements, congestive heart failure (CHF), attention deficit hyperactivity disorder (ADHD),g and perinatal. All payers do not participate in all types of episodes developed under the model.2 Quality metrics are built into each episode in order for providers to qualify for gain sharing. There are two types of quality metrics for episodes: “to pass” and “to track.” The “to pass” metrics are linked to payment.4 The provider must meet required threshold levels to be eligible for incentive payments, known as gain sharing. “To track” metrics are key to understanding overall quality of care and quality improvement opportunities. The tracking metrics are shared with providers, but are not linked to payment.4 At the end of an episode’s performance period, each PAP’s average cost of care for each type of episode will be calculated by each payer. Only valid episodes, as determined by episode‐specific algorithms and inclusion criteria, will count towards a PAP’s average. The PAP’s average cost will be compiled and compared with other providers. Based on results, PAPs will fall into threshold categories that determine whether they qualify for risk or gain sharing. Episode cost thresholds are set separately by each participating payer, and are based on historical Arkansas cost data. Threshold categories are commendable, acceptable, and unacceptable. PAPs that meet quality targets with average episode costs below the commendable threshold, or “green zone,” will share half the savings up to a limit. To ensure that appropriate and high‐quality care is maintained, there is a threshold for maximum gain sharing for each episode, known as the gain‐sharing limit. PAPs that experience average costs within the acceptable, or “grey zone,” will not be subject to risk sharing, but will not receive any gain‐share payments. PAPs that have average costs above the unacceptable threshold, or “red zone,” will be responsible for a share of costs above this threshold. Perinatal The perinatal episode aims to ensure a healthy pregnancy and follow‐up care for the mother and new baby, which requires months of care provided by many different providers, ranging from obstetricians, family practice physicians, and nurse midwives to hospitals, emergency departments, obstetric specialists, and others. Episode Definition: The perinatal episode includes all pregnancy‐
related care provided during the course of the pregnancy.5 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.9 It encompasses the full range of services provided during this time period (e.g., labs, imaging, specialist consultations, and inpatient care).5 The initial episode design excludes neonatal care. Figure 2: Perinatal Care Screening Rates – MEDICAID g
This report does not include ADHD episode data due to significant changes in the algorithm and the short episode performance period of only one quarter; any comparison would be flawed. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 7 PAP: The PAP for the perinatal episode is the physician or nurse midwife (provider or provider group) who performs the delivery.5 This provider must also perform the majority of the prenatal care for the patient identified by claims with the appropriate global OB bundle procedure, prenatal care bundle procedure, or office visit procedures.6 Participating Payers: Medicaid, AR BCBS, and QCA.h Performance & 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. These measures are for HIV, Chlamydia, and Group B streptococcus (GBS)
screenings. Each screening must meet the minimum threshold of 80 percent to pass.7 There are additional quality metrics that are tracked in the perinatal episode for quality of care and improvement opportunities including the following screenings: asymptomatic bacteriuria, hepititis B
specific antigen, ultrasound and gestational diabetes. Cesarean (C‐section) rate is also tracked in the
perinatal episode. Payer Overall Performance (AR BCBS and Medicaid): Screening rates improved across the board for both AR BCBS and Medicaid. The Chlamydia screening rate showed the most improvement for both payers. (Please see individual findings below.) 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‐sections. The C‐section rate improved from 38.6 percent in the baseline year to 33.8 percent in the performance year. However, the C‐section’s average length of stay worsened, moving from 2.2 days in the baseline year to 2.6 days in the performance year.i PROVIDER COST MOVEMENT: PAP Perinatal Performance (Medicaid) For example, in 2012, 13 PAPs were in the unacceptable category. In 2013, 9 of those PAPs moved to the acceptable category. Figure 3: 2013 Provider Cost Movement/Shift: Perinatal (Medicaid)
2012 PAP Baseline Range
At the start of 2012, PAPs began in one range, and may have shifted to another range in 2013. Commendable: 10 PAPs
Acceptable: 73 PAPs
4
6
2
Unacceptable: 13 PAPs
4
57
14
9
0
20
40
60
80
2013 PAP Movement Range Distribution
Unacceptable
Acceptable
Commendable
Figure 3 displays PAP movement for Medicaid perinatal episodes across cost categories from the baseline year through the performance year. There were a total of 96 PAPs who had 5,845 valid episodes of care in the baseline year, and 5,712 valid episodes in the performance period. Of the 10 PAPs who experienced costs within the commendable range, 4 moved to the acceptable range, and 6 remained in the commendable range in the performance year. Of the 73 PAPs who experienced costs in the acceptable range in their baseline year, 2 moved to the unacceptable category, 57 remained in the acceptable category, and 14 improved to the commendable category. Of the 13 PAPs who experienced average perinatal episode costs in the unacceptable range in the baseline year, 4 remained in the unacceptable category, and 9 improved to the acceptable category in the performance year. h
QCA is committed to reporting their two initial episodes progress after the ending of their performance period (12/31/2014); results will be included in the second year report in 2015. i
Medicaid’s baseline period was 3/1/2012 through 9/30/2012, while the performance period (initial for payment) was 3/1/2013 through 9/20/2013. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 8 AR BCBS Summary: As mentioned above, all AR BCBS perinatal quality metrics (for screenings), from baseline period to performance period, showed improvement. Figure 4: Perinatal Care Screening Rates – AR BCBS The AR BCBS C‐section rate worsened, from 38.0 percent in the baseline year to 38.5 percent j
in the performance year. 2012 PAP Baseline Range
Figure 5: 2013 Provider Cost Movement/Shift: Perinatal (AR BCBS)
Commendable: 92 PAPs
6
Acceptable: 30 PAPs
30
15
Unacceptable: 12 PAPs
9
56
6
8 22
0
20
40
60
80
2013 PAP Movement Range Distribution
Unacceptable
Acceptable
Commendable
100
PROVIDER COST MOVEMENT: PAP Perinatal Performance (AR BCBS) There were a total of 134 PAPs who had 2,871 valid episodes of care in the baseline year and 2,725 valid episodes in the performance period. Figure 5 displays PAP movement across cost categories from the baseline year to the performance year. Of the 92 PAPs who experienced costs within the commendable range, 6 moved to the unacceptable range, 30 moved to the acceptable range, and 56 remained in the commendable range in the performance year. Of the 30 PAPS who experienced costs in the acceptable range in their baseline year, 15 moved to the unacceptable category, 9 remained in the acceptable category, and 6 improved to the commendable category. Of the 12 PAPS who experienced average perinatal episode costs in the unacceptable range in the baseline year, 8 remained in the unacceptable category, 2 improved to the acceptable category, and 2 improved to the commendable category in the performance year. Total Joint Replacement (TJR): Hip and Knee Previously, multiple providers have been involved at each stage of total joint replacement procedures without optimal coordination.8 This leads to duplication of efforts, increased costs and decreased quality of care. The hip and knee j
AR BCBS baseline period was 1/1/2012 through 12/31/2012, while the performance period was 1/1/2013 through 12/31/2013. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 9 episode includes all services related to elective hip and knee replacement procedures, from the initial consultation to post surgery follow‐up care.9 Hip and knee replacements resulting from joint degeneration and osteoarthritis are among the top five elective procedures performed.10 Each operation involves pre‐surgery diagnostics and testing, hospitalization, the procedure itself, and post‐surgery rehabilitation. Episode Definition: The hip and knee TJR episode includes all care related to elective hip and knee replacements.11 A hip or knee replacement episode includes all services in the period from 30 days prior to the surgery through 90 days after surgery, including all‐cause readmissions within 30 days of Figure 7: Total Joint Replacement: Hip and Knee – AR BCBS
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. PAP: The PAP for the hip and knee TJR episode is the orthopedic surgeon who performs the surgical replacement procedure.11 Participating Payers: Medicaid, AR BCBS, and QCAh Performance & Results: Post‐operative 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 pre‐operative 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. These improved outcomes are aimed at the overall goals of improving quality and lowering costs. No quality metrics that require PAPs to pass to participate in shared savings have been selected.12 Yet, TJR has four quality metrics in place that PAPs are tracked on for quality of care and improvement opportunities. These are the following quality metrics: 30‐day all‐cause readmission rate;k 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. Medicaid Summary: The TJR episode is the single most costly episode for Medicaid, with procedures for the knee being more costly than hip. For TJR, there was improvement in the 30‐day all‐cause readmission rate. This is an episode particularly susceptible to having low volume for Medicaid.l 


30‐day wound infection: The infection rate increased from 1.42 percent in the baseline year to 1.98 percent in
the performance year. 30‐day all‐cause readmission rate: The hospital readmission rate decreased from 3.55 percent in the baseline
year to 0.00 in the performance year; a lower rate is desired and indication of no readmissions in performance
period.
90‐day post‐op complication rate: The complication rate worsened from 6.38 percent in the baseline year to
7.92 percent in the performance year.
k
The 30‐day all‐cause readmission rate is for patient readmissions only related to the TJR procedure, between 30‐90 days post‐surgery count toward the episode. l
Medicaid’s baseline period was 2/1/2012 through 12/31/2012, while performance period (initial for payment) was 2/1/2013 through 12/31/2013.
Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 10 PROVIDER COST MOVEMENT: PAP Total Joint Replacement Performance (Medicaid) There were a total of 3 separate PAPs for the TJR episode with 141 valid episodes of care in the baseline year and 101 valid episodes of care in the performance year. Two PAPs’ baseline year costs fell within the “commendable” green zone. Of the 2 PAPs, 1 PAP remained with “commendable” range, and the other PAP moved from “commendable” average cost to the “acceptable” range. One PAP had a baseline cost within the acceptable range, and remained in that range for the performance period. AR BCBS Summary: All total joint replacement quality metrics, from baseline period to performance period, showed improvement.m 

30‐day wound infection: The infection rate improved from 0.85 percent in the baseline year to 0.11 percent in
the performance year. 30‐day all‐cause readmission rate: The hospital readmission rate improved from 2.55 percent in the baseline
year to 2.09 percent in the performance year.
90‐day post‐op complication rate: The complication rate improved from 3.40 percent in the baseline year to
2.63 percent in the performance year.
PROVIDER COST MOVEMENT: PAP Total Joint Replacement Performance (AR BCBS) There were a total of 27 PAPs who had a total of 823 valid episodes of care in the baseline year and 911 valid episodes in the performance period. Figure 8 displays PAP Figure 8: 2013 Provider Cost Movement/Shift: Total Joint Replacement ̶ AR BCBS
2012 PAP Baseline Range

Commendable: 12 PAPs
Acceptable: 13 PAPs
Unacceptable: 2 PAPs
2
1
10
5
7
2
movement across cost categories from the baseline 0
2
4
6
8
10
12
14
year through the performance 2013 PAP Movement Range Distribution
year for the TJR episode. Of the Acceptable
Commendable
Unacceptable
12 PAPs who experienced costs
within the commendable range, 2 moved to the unacceptable range, while the remaining 10 PAPs remained in the commendable range in the performance year. Of the 13 PAPS who experienced costs in the acceptable range in their baseline year, 1 moved to the unacceptable category, 5 remained in the acceptable category, and 7 improved to the commendable category. Of the 2 PAPS who experienced average TJR episode costs in the unacceptable range in the baseline year, both remained in the unacceptable range. Upper Respiratory Infection (URI) 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.13 Most URIs are viral infections that resolve m
AR BCBS baseline period was 1/1/2012 through 12/31/2012, while the performance period was 1/1/2013 through 12/31/2013. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 11 themselves within 10 days.14 These infections are typically unaffected by antibiotics; therefore, antibiotics are rarely needed to treat these infections, but are still regularly prescribed in Arkansas. This retrospective episode encourages efficient treatment and consultation with the physician, including follow‐up appointments, as well as urging physicians to better manage prescribing antibiotics.13 Episode Definition: Three types of episodes are covered—nonspecific URIs, acute pharyngitis, and acute sinusitis. These share common characteristics, but are treated as separate episode types.14 PAP: The PAP for the URI episode is the first provider to see the patient in an in‐person setting, even if other providers see the patient during the Figure 10: Antibiotic Prescribing Rate for URI Episodes – MEDICAID
episode. Participating Payers: Medicaid 100.0
90.12 89.48
Performance & Results: 80.0
57.70
One of the primary goals of 49.29
44.58
60.0
the URI episode is to improve 37.13
Baseline
quality of treatment by 40.0
Performance
reducing the rate of unnecessary antibiotic 20.0
prescribing. Although 0.0
patients often expect an URI (Non‐specific) URI (Sinusitus) URI (Pharyngitis)
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.15 URI has one quality metric that PAPs must pass in order to participate in upside savings.16 In the pharyngitis episode, providers must have carried out a strep test for patients for whom an antibiotic was prescribed at a minimum threshold of 47 percent. PAPs were tracked on two quality metrics for URI quality of care and improvement opportunities. The first tracked metric was the antibiotic prescribing rate for all URI episodes. The second metric was the multiple antibiotic prescribing rates for the URI episodes, sinusitis and non‐specific URI. Medicaid Summary: There are three types of episodes within the URI episode that are covered—non‐specified URIs, acute sinusitis, and acute pharyngitis. All three of the URI (pharyngitis, sinusitis, and non‐specified) 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 37.1 percent in the performance
year. 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.17
Sinusitis URI: Of the valid episodes of sinusitis URI, the antibiotic prescribing rate decreased from 90.1 percent in
the baseline year to 89.5 percent in the performance year.
Pharyngitis URI: For pharyngitis patients, a strep test is necessary to indicate whether antibiotics should be
prescribed. Among the valid episodes of pharyngitis URI, the strep test‐to‐prescribing rate improved from 49.3
percent in the baseline year to 57.7 percent in the performance year.
n
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. o
Having consistent start and end dates for baseline and performance effectively removes seasonality associated with URI rates.
Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 12 Figure 11: 2013 Provider Cost Movement/Shift: URI – Non‐specific (Medicaid) 2012 PAP Baseline Range
PROVIDER COST 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. Commendable: 82 PAPs 3 29
Acceptable: 286 PAPs
50
41
204
41
56
31 4
Unacceptable: 91 PAPs
Figure 11 illustrates PAP movement for Medicaid non‐specific URI episodes 0
50
100
150
200
250
300
350
across cost categories from 2013 PAP Movement Range Distribution
the baseline year to the Unacceptable
Acceptable
Commendable
performance year. There were a total of 459 PAPs who had 55,069 valid episodes of care in the baseline year, and 51,198 valid episodes in the performance period. Of the 82 PAPs who experienced costs within the commendable range, 3 moved to the unacceptable range, 29 moved to the acceptable range, and 50 remained in the commendable range in the performance year. Of the 286 PAPS who experienced costs in the acceptable range in their baseline year, 41 moved to the unacceptable category, 204 remained in the acceptable category, and 41 improved to the commendable category. Of the 91 PAPs who experienced average non‐specific URI episode costs in the unacceptable range in the baseline year, 56 remained in the unacceptable category, 31 improved to the acceptable category, and 4 improved to the commendable category in the performance year. 2012 PAP Baseline Range
Figure 12 displays PAP Figure 12: 2013 Provider Cost Movement / Shift: URI – Pharyngitis (Medicaid)
movement for Medicaid pharyngitis URI episodes across cost categories from the baseline year to the performance year. There Commendable: 46 PAPs 1 24 21
were a total of 505 PAPs who had 40,428 valid episodes of care in the Acceptable: 357 PAPs
52
272
33
baseline year and 36,481 valid episodes of care in the Unacceptable: 101 PAPs
performance period. Of the 63
38
46 PAPs who experienced costs within the 0
100
200
300
400
commendable range, 1 moved to the unacceptable 2013 PAP Movement Range Distribution
range, 24 moved to the Commendable
Unacceptable
Acceptable
acceptable range, and 21 remained in the commendable range in the performance year. Of the 357 PAPS who experienced costs in the acceptable range in their baseline year, 52 moved to the unacceptable category, 272 remained in the acceptable category, and 33 improved to the commendable category. Of the 101 PAPS who experienced average pharyngitis URI episode costs in the unacceptable range in the baseline year, 63 remained in the unacceptable category, and 38 improved to the acceptable category in the performance year. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 13 2012 PAP Baseline Range
Figure 13 displays PAP
Figure 13: 2013 Provider Cost Movement / Shift: URI – Sinusitis (Medicaid)
movement for Medicaid sinusitis URI episodes across cost categories from the baseline year to the Commendable: 182 PAPs 11
47
124
performance year. There were a total of 331 PAPs who had 22,696 valid Acceptable: 113 PAPs
23
58
32
episodes of care in the baseline year and 22,852 valid episodes of care in Unacceptable: 36 PAPs
20 12 4
the performance period. Of the 182 PAPs who 0
20
40
60
80
100
120
140
160
180
200
experienced costs within 2013 PAP Movement Range Distribution
the commendable range, Acceptable
Commendable
Unacceptable
11 moved to the unacceptable range, 47 moved to the acceptable range, and 124 remained in the commendable range in the performance year. Of the 113 PAPs who experienced costs in the acceptable range in their baseline year, 23 moved to the unacceptable category, 58 remained in the acceptable category, and 32 improved to the commendable category. Of the 36 PAPs who experienced average sinusitusURI episode costs in the unacceptable range in the baseline year, 20 remained in the unacceptable category, 12 improved to the acceptable category, and 4 improved to the commendable category in the performance year. Congestive Heart Failure (CHF): In Arkansas, 24 percent of hospitalized Medicare patients with congestive heart failure (CHF) will be re‐admitted within 30 days annually.18 CHF affects a significant number of Arkansans and represents an opportunity to improve quality, patient experience, and efficiency.19 Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 14 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, with a focus on improved care coordination and effectiveness among hospital care providers. Patient education and post‐discharge follow up are key ingredients to preventing readmission.18 Increased use of evidence‐based therapies could save the lives of up to 700 Arkansans each year.19 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.19 All facility services, inpatient professional services, emergency department visits, observation, and post‐acute care as well as any CHF‐related outpatient labs and diagnostics, outpatient costs, and medications are included. PAP: Given the hospital’s critical role in discharge education and planning, the hospital for the initial inpatient admission will be the PAP for the CHF episode. In the case where 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 & Results: The CHF episode aims to improve coordination and effectiveness by extending the hospital’s accountability beyond discharge.20 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.21 In the CHF episode, one of these guidelines has been adopted as a quality metric that PAPs must pass in order to participate in the upside of savings. The metric is that, in patients with left ventricular systolic dysfunction (LVSD), PAPs are to prescribe an ACE‐inhibitor or angiotensin II receptor blocker (ARB) therapy at hospital discharge to 85 percent of patients (minimum threshold).22 Six other quality metrics are in place for PAPs to be tracked for quality of care and improvement opportunities. The quality metrics are frequency of outpatient follow‐ups within 7 and 14 days after discharge; proportion of patients matching hyper dynamic, normal, mild dysfunction, moderate dysfunction, 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 Summary: CHF saw a decrease in the 14‐day observation rate from the baseline to the performance period. The results for this episode must be cautiously observed because of the low volume of valid episodes in the analyses.p There was a slight decrease in valid episodes from baseline to performance period (225 to 212), which compounds the problems with small numbers for this analysis and drawing strong conclusions. 


30‐day CHF readmission rate: The rate worsened from 7.56 percent in the baseline year to 8.49 percent in the
performance year. 30‐day all‐cause readmission rate: The hospital readmission rate worsened from 16.00 percent in the baseline
year to 18.87 percent in the performance year.
14‐day observation rate: The 14‐day observation care’s rate improved from 42.67 percent in the baseline year to
40.09 percent in the performance year.
PROVIDER COST MOVEMENT: PAP Congestive Heart Failure Performance (Medicaid) There were a total of 13 separate PAPs for the CHF episode who had 225 valid episodes of care in the baseline year and 212 valid episodes of care in the performance year. All 9 PAPs whose baseline year cost fell within the “commendable” green zone remained in the commendable zone in the performance year. Among the remaining 4 PAPs who had costs within the acceptable range in the baseline year, 3 stayed in that range in the performance year, while 1 PAP improved to the commendable range. p
Medicaid’s baseline period was 2/1/2012 thru 12/31/2012, while performance period (initial for payment) was 2/1/2013 thru 12/31/2013. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 15 AR BCBS Summary: Overall, the CHF episode generally showed small improvements from baseline to performance period on all metrics except for the 30‐day all‐cause readmission rate. q 
For AR BCBS, the 30‐day all‐cause readmission rate worsened from 10.42 percent in the baseline year to 13.51
percent in the performance year. However, the CHF episode’s volume was so low that any statistical significance
is questionable.
PROVIDER COST MOVEMENT: PAP Congestive Heart Failure Performance (AR BCBS) There were a total of 2 separate PAPs for the CHF episode, with 48 valid episodes in the baseline year and 74 valid episodes in the performance year. Overall, both PAPs baseline year costs fell within the “commendable” green zone. While there was a split in their performance year, one PAP remained with “commendable” average cost and the other PAP moved from “commendable” average cost to the “acceptable” gray zone of average cost. Additional Episodes Additional episodes deployed or under development are increasing the proportion of surgical, specialty, or intensive care under value‐based purchasing strategies. The consistent definition of the episode, identification of the PAP, and articulation of quality expectations across payers will 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 quality threats and practice variations. The table below represent the additional episodes deployed or under development. Table 3: Episodes Deployed or Under Development Episode Payer Participation Upper Respiratory Infection (URI) Medicaid Perinatal Medicaid, AR BCBS, QCA Congestive Heart Failure (CHF) Medicaid, AR BCBS Total Joint Replacement (TJR) Medicaid, AR BCBS, QCA Attention Deficit Hyperactivity Disorder (ADHD) Medicaid Cholecystectomy (Gall Bladder Removal) Medicaid, AR BCBS, QCA Colonoscopy Medicaid, AR BCBS, QCA Tonsillectomy Medicaid, AR BCBS Oppositional Defiant Disorder (ODD) Medicaid Coronary Artery Bypass Grafting (CABG) Medicaid, AR BCBS Asthma Medicaid, AR BCBS Chronic Obstructive Pulmonary Disease (COPD) Medicaid, AR BCBS Percutaneous Coronary Intervention (PCI) Medicaid, AR BCBS, QCA Neonatal Medicaid ADHD/ODD Comorbidity Medicaid Conclusion
The AHCPII is a statewide, permanent initiative, not a small scale or short‐term demonstration project. Enhanced multi‐
payer participation is anticipated, and some of the state’s largest self‐insured employers are already participating, having seen the potential opportunities for better, and more efficient health care for their employees. The total transformation of Arkansas’s health care system will be strengthened if every payer in the state operates under the new system. 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 q
AR BCBS’s baseline period was 1/1/2012 thru 12/31/2012, while the performance period was 1/1/2013 thru 12/31/2013. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 16 www.paymentinitiative.org. As Arkansas moves forward with an increasing proportion of care being delivered under the value‐based models of the AHCPII, subsequent annual statewide tracking reports will capture future system impacts, including more detailed information on PCMHs, episodes of care, and health homes. REFERENCES
1
“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/medicalHomes/Pages/default.aspx
2 “Episodes of Care.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. Accessed on November 4, 2014 at http://www.paymentinitiative.org/episodesOfCare/Pages/default.aspx. 3
“Provider Manual: Arkansas Health Care Payment Improvement Initiative (AHCPII).” Arkansas Blue Cross and Blue Shield. http://www.arkansasbluecross.com/providers/manual/manual_default.asp?page=865&sectionID=3 4
“Episodes of Care: Provider Manual ‐ Section II.” Arkansas Medicaid. [Online 2012]. [Cited: November 4, 2014]. https://www.medicaid.state.ar.us/InternetSolution/Provider/docs/episode.aspx. 5
Provider Manual: Arkansas Health Care Payment Improvement Initiative (AHCPII). “Perinatal Episode Reimbursement Program.” Arkansas Blue Cross and Blue Shield. [Online] 2012. [Cited: November 17, 2014.] http://www.arkansasbluecross.com/providers/manual/manual_default.asp?page=871&sectionID=3. 6
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, 2014.]http://www.arkansasbluecross.com/doclib/forms/manual/Algorithm_Perinatal_V1.3.pdf. 7
Perinatal Care Algorithm Summary. AR Health Care Payment Improvement Initiative. [Online] 2012. [Cited: November 17, 2014.]. http://www.paymentinitiative.org/referenceMaterials/Documents/2012_1011%20Perinatal%20codes.pdf. 8
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, 2014.] http://www.arkansasbluecross.com/providers/manual/manual_default.asp?page=870&SectionID=3. 9
“Episodes of Care: Hip and Knee Replacement.” Arkansas Payment Improvement Initiative. [Online] 2012. Accessed on November 19, 2014 at http://www.paymentinitiative.org/episodesOfCare/Pages/Hip‐and‐Knee‐Replacement.aspx. 10
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, 2014.] http://www.arkansasbluecross.com/providers/manual/manual_default.asp?page=870&SectionID=3. 11
“Episode Summary: Total Hip and Knee Replacement.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited: November 19, 2014.] http://www.paymentinitiative.org/referenceMaterials/Documents/hipKneeEpisode.pdf. 12
“Total Joint Replacement Algorithm Summary.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited: November 19, 2014.]. http://www.paymentinitiative.org/referenceMaterials/Documents/TJR%20codes.pdf. 13
“Episodes of Care: Upper Respiratory Infection Arkansas Payment Improvement Initiative. [Online] 2012. [Cited: November 21, 2014.] http://www.paymentinitiative.org/episodesOfCare/Pages/Upper‐Respiratory‐Infection‐(URI).aspx. 14
“Episode Summary: Upper Respiratory Infection (URI).” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited: November 21, 2014]. http://www.paymentinitiative.org/referenceMaterials/Documents/upperRespiratoryEpisode.pdf. 15
“Get Smart: Know When Antibiotics Work.” Centers for Disease Control and Prevention (CDC). [Online] 2013. [Cited: December 15, 2014]. http://www.cdc.gov/getsmart/campaign‐materials/about‐campaign.html. 16
“URI Algorithm Summary.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited: November 21, 2014.]. http://www.paymentinitiative.org/referenceMaterials/Documents/2012_1011%20URI%20codes.pdf. 17
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. 18
“Episode of Care: Congestive Heart Failure (CHF).” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited: November 24, 2014.] http://www.paymentinitiative.org/episodesOfCare/Pages/Congestive‐Heart‐Failure.aspx. 19
“Acute/post‐acute Congestive Heart Failure Episode Summary.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited: December 11, 2014]. http://www.paymentinitiative.org/referenceMaterials/Documents/CHF%20Episode%20Descript_7‐2014.pdf. 20
“Provider Manual: Arkansas Health Care Payment Improvement Initiative (AHCPII). Congestive Heart Failure Episode Reimbursement Program.” Arkansas Blue Cross Blue Shield. Online] 2012. [Cited: November 24, 2014.] http://www.arkansasbluecross.com/providers/manual/manual_default.asp?page=875&sectionID=3. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 17 21
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.ncbi.nlm.nih.gov/pubmed/21641346 22
“Congestive Heart Failure Algorithm Summary.” Arkansas Health Care Payment Improvement Initiative. [Online] 2012. [Cited: November 24, 2014.] http://www.paymentinitiative.org/referenceMaterials/Documents/CHF%20codes.pdf. Appendix B: AHCPII Detailed Statewide Tracking Report (January 2015) 18