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Patient-Centered Medical Home 2017 Program Performance Report

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Patient-Centered Medical Home 2017 Program Performance Report Patient-Centered Medical Home 2017 Program Performance Report June 27, 2018 CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and BlueShield Association. Contents 1. Program Headlines 2. Overview and Scope of the Model 3. Sustained Favorable Results (2011 – 2017) 4. The Facts that Shape the Landscape 5. Framework of the Patient-Centered Medical Home Model 6. Five Strategies for Medical Home Success 7. Total Care and Cost Improvement Program (TCCI) – Key Supports 8. Providing PCPs with Actionable Data 9. Outcome Incentive Award Patterns 10. Key Insights 2 Program Headlines 2011 -2017 The PCMH Program Has Directly Saved Over $1 Billion in Healthcare Spending, and Contributed to an Even Larger Savings of $5.5 Billion Against Historical Trends Over $440 Million Has Been Paid Out as Additional Performance Based Payments to PCPs Nearly 1 Million Members Have Engaged in Targeted Program Services, with over 250,000 in Clinically Directed Care Plans 3 OVERVIEW AND SCOPE OF THE MODEL 4 Overview of the Commercial PCMH/TCCI Program The CareFirst PCMH/TCCI Program is in its eight year of commercial region-wide operation • Includes over 4,300 participating Primary Care Providers managing care for over 1 million CareFirst Members • Provides financial incentives, clinical supports, and data analytics to PCPs to achieve high levels of quality care and lower total cost of care • Manages $5.5 billion a year in total hospital, non-hospital and drug spending for Members • Generates tens of thousands of nurse-prepared care plans per year for high risk/high cost Members. • Has curbed CareFirst’s overall medical trend to historic lows over the life of the Program • Has decreased costly hospital admissions substantially over the life of the Program • Has led to high levels of sustained member satisfaction that continue to rise as the Program matures 5 SUSTAINED FAVORABLE RESULTS (2011 –2017) 6 Longest Period of Low Trend & Costs Avoided by “Bending the Curve” Combined Medical & Pharmacy Trend – PMPM 10% CareFirst Service Area Book of Business 9% Historical Overall Medical Trend 8% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7% 6% 5% 4% 3% 2% 1% 0% 2010 2011 2012 2013 2014 2015 2016 2017 Source: Medical and Cost Measures that Matter; CareFirst In-Service Area; January 2012-April 2018, Paid Through April 7 2018 Longest Period of Low Trend & Costs Avoided by “Bending the Curve” Combined Medical & Pharmacy Trend – PMPM 10% CareFirst Service Area Book of Business 9% Historical Overall Medical Trend 8% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7.5% 7% 7.5% Costs Avoided by 6.8% Bending Curve: 6% 6% $5.2B+ Actual Medical Trend 5% 5.4% 4% 4.3% 4.3% 3% 3.0% Average Trend (CAGR) 2012-2017: 2.5% 2% 2.5% 3.5% 1.5% 1% 0% 2010 2011 2012 2013 2014 2015 2016 2017 Source: Medical and Cost Measures that Matter; CareFirst In-Service Area; January 2012-April 2018, Paid Through April 8 2018 Improvements in Care Delivery and Care Cost Control: 2011-2018 Total Admissions* Admissions per 1,000* 120,593 2011-2017 118,078 63.9 % Change -16.0% 62.4 108,554 CAGR -2.9% 103,875 102,170 58.5 99,034 2011-2017 56.2 92,864 54.7 54.8 % Change -23.0% 89,980 53.7 CAGR -4.3% 52.5 2011 2012 2013 2014 2015 2016 2017 2018 2011 2012 2013 2014 2015 2016 2017 2018 Total ER Visits* ER Visits per 1,000* 462,953 451,799 2011-2017 244.5 % Change -13.5% 416,127 239.4 408,587 406,648 CAGR -2.4% 224.4 377,803 221.0 217.8 2011-2017 358,030 208.9 207.0 % Change -20.8% 351,350 205.0 CAGR -3.8% 2011 2012 2013 2014 2015 2016 2017 2018 2011 2012 2013 2014 2015 2016 2017 2018 * CareFirst In-Service Area Book of Business, excluding Medicare Primary 9 PCMH Quality Scores Steadily Improved • The Overall Quality Score is an equally weighted average based on the value of the Engagement and Clinical Quality scores. Overall Quality has increase by 35% over 4 years. • Beginning in 2013, Engagement Score rates across all panels have continued to improve by 19.3% each year. Overall Engagement Rate Overall Clinical Measures Performance 90% 90% 76% 77% 80% 80% 72% 67% 66% 69% 69% 70% 70% 59% 62% 62% 60% 53% 60% 17 Percent 50% 103 Percent 50% 38% 40% 40% 30% 30% 2013 2014 2015 2016 2017 2011 2012 2013 2014 2015 2016 2017 Overall Quality Score 90% 80% 72% 74% 68% 70% 61% 35 Percent 60% 55% 50% 40% 30% 2013 2014 2015 2016 2017 10 High Overall Satisfaction for Patients in Care Plans • Ratings from Members in care plans have been very high and have risen as the Program has matured. Member Overall Satisfaction % Scoring at least a 4.0 in Overall Satisfaction (rating of 4 or 5 on a 5-point scale) 91% 91% 91% 90% 90% 89% 89% 89% 89% 88% 85% 86% 83% 85% 81% 81% 81% 81% 80% 79% 79% 77% 76% 75% 71% 70% 1Q13 2Q13 3Q13 4Q13 1Q14 2Q14 3Q14 4Q14 1Q15 2Q15 3Q15 4Q15 1Q16 2Q16 3Q16 4Q16 1Q17 2Q17 3Q17 4Q17 1Q18 Source: CareFirst PCMH Care Plan Survey 11 Member Survey Results • Greater percentages of members are responding year-over-year with a higher level of satisfaction with over 77,000 members surveyed between 2014 and 2017 • Over 4,800 members (87%) completed the survey in the first quarter of 2018, with an average overall score of 4.5 100% 4.5 4.5 90% 4.4 87% 80% 4.4 80% 83% 70% 72% 60% 4.3 4.3 50% 40% 4.2 4.2 30% 20% 4.1 10% 0% 4 2014 2015 2016 2017 Completion Rate Total Average Score 2013 results includes an incomplete year’s worth of data 12 Member Survey Questions 1. You understand the Care Coordination Plan, including the actions you are supposed to take 2. Your Care Coordination nurse and Care Coordination team are helpful in coordinating your care 3. Your doctor or nurse practitioner spends enough time with you 4. After starting your Care Coordination Plan, you have access to information that you need to understand and manage your health better 5. Finally, Overall, your health is more stable and better managed as a result of the Care Coordination Plan 13 THE FACTS THAT SHAPE THE LANDSCAPE 14 The Experience in the CareFirst Region • CareFirst Members account for 41% of the non-government commercially covered population in CareFirst’s service area • The region has had some of the highest hospital admission and readmission rates in the nation – that are now declining • CareFirst customer accounts (often in the services sector) generally have generous benefit designs in the Large Group and FEP (Federal Employee Program) segments and far less generous benefits in the Individual and Small Group segments • Prior to the start of the PCMH program in 2011, CareFirst’s Overall Medical Trend (i.e. rise per Member per month) was regularly between 6% and 9% annually, averaging 7.5% in the 5 – 10 year period preceding the launch of the Program on January 1, 2011 15 Illness Pyramid –The Rosetta Stone 2017 CareFirst, non-Medicare Primary Population –“Population Health” • Health care costs are concentrated at the top of the illness burden pyramid – the top two bands account for less than 13% of the population but over 60% of total costs • PMPM cost for the sickest members (Band 1 – Advanced/Critical Illness) is more than 100 times that of the healthiest members (Band 5) Percent of Percent Cost Admi ts Readmits ER Visits Population Of Cost PMPM Per 1,000 Per 1,000 Per 1,000 Advanced / Critical Illness 80% of 3.0% 35.2% $4,908 880 166 1,150 Band 1 admissions were for Multiple Chronic Illnesses members in Band 2 Bands 1 and 2 9.2% 27.2% $1,216 218 16 585 At Risk Band 3 13.0% 16.4% $522 34 3 325 Stable Band 4 35.0% 16.9% $199 4 0 165 Healthy Band 5 39.8% 4.3% $44 1 0 37 Data from YE 2017 16 Source: HealthCare Analytics - incurred in 2016 and paid thru April 2017 – CareFirst Book of Business, excluding Medicare Primary and Catastrophic members Total Distribution of CareFirst Medical Payments • Spending on prescription drugs is the largest share of the CareFirst medical dollar (including spending in both the Pharmacy and Medical portions of CareFirst benefit plans) • This places increased focus on pharmacy care coordination and utilization 35% 2011 2017 29.6% 30% 27.6% $336 PMPM $439 PMPM 35% 32.3% 25% 30% 20.3% 25.2% 20% 18.4% 25% 18.7% 15% 20% 17.9% 15% 10% 10% 4.1% 6.0% 5% $86.38 $76.68 $17.09 5% $32.82 $115.38 $84.60 $130.75 $137.86 $97.92 $102.30 PMPM PMPM PMPM PMPM PMPM PMPM 0% 0% PMPM PMPM PMPM PMPM Pharmacy Specialists Inpatient Outpatient Primary Pharmacy Specialists Inpatient Outpatient Primary & Others Care & Other Care Physician Prof Physician Medical spending is based on 2011 and 2017 CareFirst Book of Business. Pharmacy % is adjusted to represent typical spend for members with CareFirst’s pharmacy benefit. 17 THE FRAMEWORK OF THE PATIENT-CENTERED MEDICAL HOME MODEL 18 Without Healthcare Cost Control, Not Much Else Matters – CareFirst’s PCMH Program PCMH Five Key Characteristics • Accountability for total cost of care • Incentive only • Information rich • Behavior change based • Uniform model 19 PCP Panels –Small Teams –Performance Units Characteristics of Panels Roles of Panels • Average Panel Size: 10 PCPs • Backup and coverage • The more independent the better • Peer review – shared data • The “buyers” and arrangers of all services • Pooled experience Region PCP Panel 20 Patient Care Account –Illustration of A Scorekeeping System for Panels • A Patient Care Account for each Panel is set up • All expected costs (Credits) and all actual costs (Debits) are recorded in this account Patient Care Account Debits (PMPM) Credits (PMPM) All services paid Global projected care (Allowed Amount) for costs expressed as a every line in every claim PMPM Credits are Calculated as Follows: $9.0M Base Year Costs (2010); 1.26 IB Score for 3,000 members x 1.29 Overall Medical Trend over 6 years at 6.5%, 5.5%, 3.5%, 3.5%, 3.5, 3.5% x 1.079 Illness Burden Adjustment 2017 vs.
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