Medicare Physician Group Practice Demonstration

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1 Medicare Physician Group Practice Demonstration Heather Grimsley Medicare Demonstrations Program Group Center for Medicare and Medicaid Innovation Centers for Medicare & Medicaid Services April 2011

2 PGP Demonstration Overview Section 412 of BIPA 2000 (P.L ) 10 physician groups representing 5,000 physicians & 220,000 Medicare FFS beneficiaries Initially approved as a 3 year demonstration Extended to 5 performance years Performance period: April March 2010 Currently finalizing the PGP Transition Demonstration that was authorized in the Affordable Care Act

3 PGP Goals & Objectives Encourage coordination of Medicare Part A & Part B services Reward physicians for improving quality and outcomes Promote efficiency

4 PGP Demonstration Sites

5 PGP Design PGPs continue to receive Medicare FFS payments Physician practices have broad flexibility to redesign care processes to achieve specified outcomes Performance on 32 quality measures Lower spending growth than local market

6 Assigned Patient Population No lock-in or enrollment Retrospective annual assignment Plurality of allowed charges for office or other outpatient E&M services Accountable for total Part A & Part B expenditures Incentives to standardize care processes across all patients and all payers

7 Patient Population Characteristics Patient populations range from 10,184 to 35,148 per PGP Assign 46% to 71% of patients with visit at PGP Assigned patients average five to seven visits PGP accounts for 64% to 86% of total office or other outpatient E&M allowed charges 20% to 27% of assigned patients are hospitalized 21% to 33% of assigned patients have three or more HCCs Diabetes, CHF, COPD, heart arrhythmias most common

8 Shared Savings Model No upfront payment or insurance risk Business risk for PGP Total Medicare risk adjusted expenditure growth rate for assigned patients is more than 2 percentage points below target growth rate Share up to 80% of savings 50/50 based on quality and financial performance Local market area used to set target growth rate Counties with 1% or more of assigned patients 91% of assigned patients live in local market area Maximum performance payment capped at 5% of Part A and Part B target expenditures

9 Quality Measures Diabetes Mellitus Congestive Heart Failure Coronary Artery Disease Hypertension & Cancer Screening HbA1c Management LVEF Assessment Antiplatelet Therapy Blood Pressure Screening HbA1c Control LVEF Testing Drug Therapy for Lowering LDL Cholesterol Blood Pressure Control Blood Pressure Management Weight Measurement Beta-Blocker Therapy Prior MI Blood Pressure Plan of Care Lipid Measurement Blood Pressure Screening Blood Pressure Breast Cancer Screening LDL Cholesterol Level Patient Education Lipid Profile Colorectal Cancer Screening Urine Protein Testing Beta-Blocker Therapy LDL Cholesterol Level Eye Exam Ace Inhibitor Therapy Ace Inhibitor Therapy Foot Exam Influenza Vaccination Warfarin Therapy Influenza Vaccination Pneumonia Vaccination Pneumonia Vaccination Claims based measures in italics

10 Quality Performance Targets Performance targets = the lowest of (A) or (B) or (C): (A) The higher of 75% compliance OR the Medicare HEDIS mean for the measure (B) the 70th percentile Medicare HEDIS level for the measure (C) the quality improvement target, which is defined as a 10% reduction in the gap between the base year level for the measure and 100% compliance

11 PGP Performance Year 4 Quality Results All 10 groups achieved benchmark performance on at least 29 of the 32 measures Three groups achieved benchmark performance on all 32 measures Increased quality scores from baseline to PY4 an average of: Diabetes: +10 percentage points HF: +13 percentage points CAD: +6 percentage points Cancer screening: +9 points Hypertension: +3 point No HF or CAD benchmarks missed

12 Lessons Learned: Quality Measurement Determining quality measures is difficult and requires much development Clearly defined goals, measure specifications and reporting methodology Consistent with clinical practice and high quality care physician/provider buy-in Changing measures frequently creates provider angst Processes more readily moved than outcomes Ceiling effect may render some measures obsolete Are we measuring the right things?

13 Lessons Learned: Quality Reporting Increases awareness and documentation of care processes Outreach and education are important for provider understanding and accurate and consistent reporting Measuring/reporting quality creates opportunity for providers to standardize care processes and redesign workflows to improve delivery at point of care

14 Additional Information Additional information on Medicare Demonstrations: Heather Grimsley

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