A Close Look at Care Coordination Within Patient-Centered Medical Homes: West Virginia's Experience

A Close Look at Care Coordination Within Patient-Centered Medical Homes: West Virginia's Experience

Event Date: 
Thursday, May 9, 2013

On May 9, 2013, the Innovations Exchange held a Web event titled A Close Look at Care Coordination Within Patient-Centered Medical Homes: West Virginia's Experience.

This was the second Web event in a three-part series designed to share novel experiences and lessons learned in putting accountable care organization (ACO) and patient-centered medical home (PCMH) principles into practice.


Judi Consalvo, Program Analyst at AHRQ Center for Outcomes and Evidence

James B. Becker, MD, Medicaid Medical Director, West Virginia Bureau for Medical Services

Dr. James Becker is currently Medical Director of the West Virginia Offices of the Insurance Commissioner and Medical Director in the Bureau for Medical Services at the West Virginia Department of Health and Human Resources. He is an Associate Professor in the Department of Family and Community Health at Marshall University Joan C. Edwards School of Medicine where he continues in clinical practice. Dr. Becker is also a clinical professor at West Virginia University, Department of Community Medicine, serves on the Resident Advisory Committee for Occupational Medicine and lectures for the Master in Public Health program. For the last six years, he has been involved in creating and promoting models of care coordination and patient-centered medical homes. He is currently engaged in the development of the West Virginia Health Homes for Chronic Conditions State Plan Amendment. In his role at the Insurance Commission, Dr. Becker is a lead team member developing a multi-payer model for medical homes and care coordination.

William Golden, MD, Medical Director, Arkansas Medicaid Enterprise at Arkansas Department of Human Services

Dr. Golden is the Medical Director of the Arkansas Medicaid Enterprise at the Arkansas Department of Human Services. He is also Professor of Medicine and Public Health at the University of Arkansas for Medical Sciences (UAMS) where he served as Director of the Division of General Internal Medicine for nearly 20 years. Prior to his current position, he served for 16 years as Vice President for Clinical Quality Improvement of the Arkansas Foundation for Medical Care where he designed numerous statewide quality improvement and health technology projects for Medicare and Medicaid. Among his awards and recognitions, he received the National James Q. Cannon Award for Physician Leadership in Clinical Quality Improvement (2001), a special citation from UAMS for innovations in medical education related to his statewide quality improvement efforts (2005), Mastership in the American College of Physicians (2008), and the Alfred Stengel Memorial Award for Service to the American College of Physicians (2011).

David Meyers, MD, Director of the Center for Primary Care, Prevention, and Clinical Partnerships, AHRQ

Dr. Meyers has served as the Director of AHRQ’s Center for Primary Care, Prevention and Clinical Partnerships since February 2008. He leads the Agency’s work in support of the primary care patient-centered medical home and currently is serving on U.S. Department of Health and Human Services teams charged with implementing Affordable Care Act provisions related to primary care and prevention. Prior to becoming Center Director, he helped to direct the Center's Practice-Based Research Network initiatives, served as a Medical Officer for the U.S. Preventive Services Task Force and was a Project Officer for AHRQ’s Health Information Technology portfolio. Before joining AHRQ in 2004, he practiced family medicine, including maternity care, in a community health center in southeast Washington, D.C. and directed the Georgetown University Department of Family Medicine's Practice-Based Research Network, CAPRICORN.

Additional Information

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Slide 1

A Close Look at Care Coordination within Patient-Centered Medical Homes: West Virginia's Experience

Web Seminar
May 9, 2013
Follow this event on Twitter Hashtag: #AHRQIX

Slide 2

Using the Webcast Console and Submitting Questions

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Slide 3

Accessing Presentations

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Slide 4

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Slide 5

Innovations Exchange Web Event Series

Archived Event Materials
Available within two weeks under Events & Podcasts at http://www.innovations.ahrq.gov

Next Events
Thursday, June 5, 2013 1-2 pm ET
Building Health Information Exchanges to Support Accountable Care Organizations and Medical Homes: Delaware's Experience

Slide 6

Today's Event Moderator

James Becker, MD
Medicaid Medical Director,
West Virginia Bureau for Medical Services

Slide 7

How Rural Are We?

  • We are a state of 1.8 million individuals
  • Yet, our two largest cities approach 50 K in number
  • Many parts of the State are geographically isolated and medically underserved
  • Medicaid currently serves 410,000 individuals
  • Over 200,000 individuals are uninsured
  • Many patients cross borders to receive care

Slide 8

What Are Our Health Challenges?

  • Chronic diseases
  • Mental health, substance abuse
  • Aging population
  • Poverty, unemployment
  • Low educational achievement
  • Lifestyle issues
  • Health literacy issues

Slide 9

What's Working?

  • Prevention programs and wellness, especially for selected conditions
  • Federally Qualified Health Centers and the rural health network meet much of the region's need and are widely accepted in their communities
  • Comprehensive behavioral health system
  • University outreach networks with satellite services, technology and grant support

Slide 10

What Is Our Direction?

  • In 2009 we adopted the “Triple Aim” and began building Patient-Centered Medical Homes (PCMH) around the state with grant support
  • The legislature endorsed PCMH and a state plan for health improvement
  • Since then, each private health carrier has adopted some elements
  • No central payment methodology is established

Slide 11


  • West Virginia has a series of state plan amendments (SPAs) in development related to Health Homes (ACA 2703)
  • The first will involve bipolar individuals with/or at risk of hepatitis
  • Future SPAs expected for diabetes, obesity, asthma, mental illness, Alzheimer's, congestive heart failure, chronic obstructive pulmonary disease
  • SPAs broadly define care coordination, care managers and care coordinators

Slide 12

In Our Experience…

  • Care coordination is a highly individual skill
    -  Flexibility and creativity
    -  Sense of “mission”
    -  Experience-based
  • Best delivered “face-to-face”
    -  Shared coordinators and telephonic care
  • Best in the setting of team care

Slide 13

In Our Experience…

  • Requires leadership and resources
  • Is effective when there is data to guide decisions
    -  Electronic health records and care coordination
    -  Information technology for population management
  • We've found no single credential or skill set that best identifies a care coordinator

Slide 14

Care Coordination Models

  • The ‘Health Home'
  • Patient-Centered Medical Home
  • Targeted Case Management
  • Managed Care Organizations
  • Community Health Workers
  • Other community services…

Slide 15

Payment for Care Coordination

  • Under the state plan amendments, Medicaid will use a fee-for-service plus per member per month model
  • A private carrier is promoting a move to an Accountable Care Organization with pay for performance (P4P) and pay for value features
  • Another insurer is adopting a comprehensive payment model with a P4P shared savings
  • A network in the state operates under grant-based payment
  • So you see…..

Slide 16

Everyone likes care coordination, but we're not sure how we should pay for it!

Slide 17

A Bit of Strategy…

  • Adopt consistent or similar payment models
  • Capture similar measures in similar ways
  • Allow flexibility within practices as long as they are moving toward accepted standards
  • Recognize the unique features of practices and communities

Slide 18


William Golden, MD
Medical Director, Arkansas Medicaid Enterprise
at Arkansas Department of Human Services

Slide 19

Rural Challenges

  • Workforce variation; team, alternatives, access
  • Practice infrastructure; capitalization
  • Socioeconomics, health literacy
  • Perverse incentives

Slide 20

Evolving Environment

  • Workforce
  • Practice ownership, management
  • Health Information Technology

Slide 21

Arkansas Payment Reform

  • Harmonize economic incentives: multi-payer, promote local innovation, care coordination
  • Episodes of care
    -  Gain sharing for total cost of care, quality metrics
    -  Reward more effective providers; break cycle of payment regardless of practice variation
  • Medical home: New per member per month for transformation/care coordination; gain sharing for total cost of care, quality metrics

Slide 22

Quality Standards and Shared Savings

The figure shows providers in order from highest to lowest average cost and demonstrates that PAPs (Principal Accountable Providers) that meet quality standards and have average costs below the commendable threshold will share in savings up to a limit.

Slide 23

Upside Only Gain-Sharing

Image of the two ways PCPs receive upside only gain-sharing in the PCMH model: 1) receive gain-sharing based on your own performance improvement, 2) receive gain-sharing based on being a high performer in the state. For both options: quality metrics must be met for gain-sharing and costs to calculate fain-sharing are risk-adjusted and exclude high-cost outliers.

Slide 24

Concepts: Medical Home versus Health Home

Medical Home: The Clinical Game Plan

  • Care coordination/coaching for high priority patients; medically frail, complex psychosocial, literacy concerns

Health Home: Community Coordination for Select Populations

  • Developmental disability
  • Significant mood disorder

Slide 25

Payment Initiative

Venn Diagram displaying that payment incentives have an overlap between a service episode and care coordination within a health home. Service episode includes: $300 Million for Adult Developmental Disability Expenditures, which ensures care provision is efficient and based on client needs including aligning resources provided with level of need and expanding plan customization options for clients. This minimizes resources and time not focused on delivering client care. Care Coordination within health home includes $35 Million for Halo expenditures such as medical, behavioral expenditures for adults. This includes increased care coordination through integrating care across medical, behavioral, health services, reducing unnecessary medical and behavioral health spending, and promoting wellness activities.

Slide 26

New Activities

  • Provider report cards; data supported change
  • Health Information Technology (HIT) expansion
  • Vendor options for care coordination

Slide 27


  • Engaging all practices; not just early adopters
  • Engaging patients
  • Pooling practice data; statistical, actuarial necessity
  • Diverse installed electronic medical record base; limitations of data extraction
  • Accountability for use of per member per month

Slide 28

Unknowns: Value, Pricing of New Services

  • Avoid new economic silos
  • Telemedicine
  • Care coordination; for whom, how intensive

Slide 29

Brighter Future

  • Providers and payer agree that change is needed
  • Pain of change becoming less than pain of status quo
  • Opportunity window to create smarter, more effective health care

Slide 30

Today's Event Moderator

David Meyers, MD
Director of the Center for Primary Care,
Prevention, and Clinical Partnerships, AHRQ

Slide 31

AHRQ Resources


Slide 32

PCMH Basics

  • Defining the PCMH
  • Evidence and evaluation
  • Tools and resources: care coordination, quality and safety, patient-centeredness, and more
  • Implementation: A How-To Guide on Developing and Running a Practice Facilitation Program, new case studies

Slide 33

White Papers and Briefs on Care Coordination

  • The Roles of Patient-Centered Medical Homes And Accountable Care Organizations in Coordinating Patient Care
  • Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms
  • Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions

Slide 34

Measuring Care Coordination

Slide 35


Consumer Assessment of Healthcare Providers and Systems (CAHPS) program https://www.cahps.ahrq.gov/Surveys-Guidance/CG/PCMH.aspx

  • Released in late October 2011
  • Built on existing, well-validated clinician and group survey
  • Covers topics such as provider-patient communication, coordination of care, and shared decision making
  • Available in English and Spanish; adult and child versions

Slide 36


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Slide 37

The Innovations Exchange

Visit our Web site: http://www.innovations.ahrq.gov/

Follow us on Twitter: @AHRQIX

Send us email: info@innovations.ahrq.gov


Judi Consalvo: Good afternoon. On behalf of the Agency for Healthcare Research and Quality's Innovations Exchange, I’d like to welcome you to our Web event entitled, A Close Look at Care Coordination within Patient-Centered Medical Homes: West Virginia’s Experience. I’m Judi Consalvo and I’m with AHRQ's Center for Outcomes and Evidence. We’re very excited about today’s topic and glad to see that you share our enthusiasm. We have over 800 registered for this event today.

Next slide. Before we begin, I would like to introduce you to our webcast console. The console can be resized to fit your entire browser window. All the components on the console can be resized, moved and minimized into the menu dock at the bottom of the console. If the slides are too small, click on the lower right-hand corner of the slide window and drag your mouse down to make it larger. Twitter functionality is available in the console for today’s webcast. Feel free to participate using the hash tag #AHRQIX. We are pleased to offer closed captioning on this Web seminar. To access the close captioning, please click on the link called Close Captioning that is on the lower right-hand of your screen. After you click the link, a new window will display the captioning.

I would also like to remind you that if you experience any technical problems, you may click on the question mark button at the bottom of the screen to access the help guide or click on the Q&A button at the bottom of your screen to contact us with your question. Our technical staff will work with you to resolve any issues.

The last portion of this Web seminar is reserved for a discussion based on questions that you submit. Questions may be submitted at any time during the presentation. Simply click on the Q&A button at the bottom of your screen then type your question into the Q&A box and select Submit. We welcome your questions and comments on the upcoming presentation and we look forward to an engaging dialogue that will promote the spread of health care innovations.

Next slide, please. Today’s slides are available by clicking on the widget at the bottom of your screen that says Download Slides. This will generate a PDF version of the presentation that you can download and save as desired.

Next slide, please. What is the Health Care Innovations Exchange? This Web event series is sponsored by AHRQ’s Health Care Innovations Exchange. For those of you who are new to the Exchange, I’ll take just a minute to give you an overview. AHRQ created the Innovations Exchange to speed the implementation of new and better ways of delivering health care. The Exchange offers busy health professionals and researchers a variety of opportunities to share, learn about, and ultimately adopt evidenced-based innovations and tools suitable for a range of health care settings and populations.

The Exchange Web site includes a searchable database of QualityTools and service delivery and policy innovations. The Exchange also contains both successes and attempts, innovator stories and lessons learned, and expert commentaries. To assist you in implementing these innovations, AHRQ also supports learning and networking opportunities such as Web seminars, TweetChats, and podcasts. We post new content to the Web site every two weeks on a range of topics and hope that you will sign up to stay connected with us if you have not done so already.

Next slide. We have a number of upcoming events to share innovative health care strategies and promote the spread of innovations. Our next learning and networking event is our upcoming event on June 5th from 1:00 PM to 2:00 PM Eastern Time called Building Health Information Exchanges to Support Accountable Care Organizations and Medical Homes: Delaware’s Experience. To register for this event or receive more information, please visit our Web site at www.innovations.ahrq.gov. The Web site also holds an archive of our past Web events, podcasts and TweetChats and we also invite you to take a look and download materials that may be useful to you in your practice.

Next slide. So let’s turn to our agenda for today. It is my pleasure to introduce our first presenter, Dr. James Becker. Dr. Becker is currently Medical Director of the West Virginia Offices of the Insurance Commissioner and Medical Director in the Bureau of Medical Services at West Virginia Department of Health and Human Resources. For the last six years, he has been involved in creating and promoting models of care coordination in patient-centered medical homes. He is currently engaged in the development of the West Virginia Health Homes for chronic conditions state plan amendment and a lead team member developing a multi-payer model for medical homes and care coordination. Jim?

James Becker: Thank you. Good afternoon. I would particularly like to thank AHRQ this afternoon for giving us an opportunity to talk about the challenges of developing care coordination models in a rural health setting. West Virginia is a state that has embraced the concept for at least five years, but it’s still in the process of developing its care coordination models. And as you’ll see, we’re still working to develop the right model for payment. I hope that this program will give us an opportunity to share our experience, and then based on this webinar, obtain some additional ideas that will help move us forward.

Before I really get into the discussion of care coordination, I would like to set a little background for you. Our state is very rural and diverse. West Virginia is a state of 1.8 million individuals with only two cities that approach 50,000 in population. Many parts of our state are geographically isolated and medically underserved.

Currently, our Medicaid program in West Virginia covers about 410,000 individuals, but there were over 200,000 individuals who have been uninsured. As anyone knows who’s worked around care coordination, the uninsured population poses particular unique problems in terms of care coordination as they move in and out of insurance coverages. Just last week, our governor made the decision to allow West Virginia to participate in the Medicaid expansion, which is exciting news for us, in that it creates a lot of opportunities and a lot of work.

In addition to that, many patients in West Virginia cross borders to receive medical care. This again becomes an important issue when it comes to care coordination. In West Virginia, we face all of the same challenges that everyone else faces related to health. We have the problems of chronic diseases and diabetes and coronary artery disease, COPD, Alzheimer’s, asthma, mental health, substance abuse, and all of that in the context of a population demographic that’s generally aging. Complicating factors, poverty and unemployment, are an important factor in the health of our population as well as the issues of low educational achievement for some individuals, lifestyle issues, and bad habits and bad choices and then the issues of health literacy and access to health care. We face these challenges and see that in the rural setting they pose some unique problems for us but at the same time they create situations in rural setting in which unique solutions are found.

I’d like to talk now about some things that have worked for us in West Virginia. In West Virginia, here are some examples of things that have been particularly successful in my experience with the state systems. Our prevention programs and our wellness programs have been quite successful for selected communities and for selected conditions. We have a fairly robust network of federally qualified health centers and we have a rural health network which meets the needs of the regions that they serve and they’re widely accepted by their communities, particularly they are places that can provide people access to care and contacts and evaluations that put them in touch with the right specialists when specialized care is needed.

We have an elaborate comprehensive behavioral health system that’s pretty well distributed across the state and takes care of a great percentage of the needs for mental health care. In addition, we have several universities that have robust outreach programs particularly around their satellite services, technologies like telemedicine and they operate under grant support and obtain information and collect data and collect measures. There are three medical schools in the state that also provide a lot of support and one dental school.

In 2009, West Virginia adopted the “Triple Aim” of quality of care, quality of the health care experience, and cost efficiency, and began building patient-centered medical homes, grant support throughout the state. Its fairly broad acceptance of the concepts of patient-centered medical home in our legislature endorsed the idea of patient-centered medical homes, and a state plan was developed for health improvement. Since then, this concept of patient-centered medical home, care coordination, care management, and the “Triple Aim” have really been taken up by many elements of the health care community.

Despite the broad acceptance, one challenge has been the lack of a central payment methodology. And so, that’s one of the things that I want to talk about today a little. I want to talk also about patient-centered medical homes and health homes, because they are terms that will crisscross around care coordination today and it’s important to understand the distinctions, bearing in mind that care coordination looks pretty much the same whether it’s in a PCMH or whether it’s in a health home.

Currently, West Virginia Medicaid has a series of state plan amendments in development related to the Affordable Care Act Section 2703, which gives us an opportunity to create health homes for patients with chronic conditions. We have decided that the first health home that we’re going to create is going to be around a relatively small population of individuals who suffer from bipolar disorder and also have either risk of or are infected with hepatitis, chronic hepatitis. We chose that particular state plan amendment and that population because it’s population that is high risk and at the same time it’s population that does not receive a great deal of centralized care coordination services. That is the beginning of a number of steps in developing a series of state plan amendments for those with chronic conditions that’s really planned in West Virginia. We will be eventually developing state plan amendments that will create care coordination for diabetes, obesity, asthma, mental illness and so on. Pediatric populations, elderly populations are all included in the plan and all coverage of Medicaid individuals including those in fee-for-service care and those in managed care would be included.

One of the important components of the state plan project is the state plan amendment defines care coordination, and we follow the six general care coordination services that are usually associated with care coordination programs, and at the same time we create care managers and care coordinators.

This is not the first time we’ve been there with care coordination. As I said, we’ve had a number of years of experience with the patient-centered medical home model. We have models in some of the universities; we have models in standalone clinics, large groups, FQHCs and so on. What we’ve learned a lot from the experience of care coordination and in some general terms I’d like to describe what we believe to be important in the area of care coordination. Care coordination really requires a system that has some flexibility and creativity; it requires that the team develop a sense of mission and share that mission about the importance of spreading good health. It also benefits a great deal from experience-based individuals.

We’ve noticed that in practices where individuals have a broad range of experiences throughout the health system, those individuals bring a great deal of skill to the team when it comes to care coordination. In several of the pilot projects that were conducted earlier in the development of our patient-centered medical homes, we experimented with shared care coordinators and we experimented with telephonic care. And the conclusion that we came to on that was that care coordination for us in West Virginia is best delivered face to face. Not necessarily on every visit, but occasionally enough to keep the patient and the coordinator closely engaged and understanding each other.

We also know that care coordination is best delivered in the setting of team care and we can’t emphasize enough how important it is to have a good solid team. Our health home state plan amendment that’s in development right now defines the minimum team has a primary care physician, a behavioral health specialist, a care manager, who usually would be a registered nurse, and then a care coordinator who might be someone with a bachelor’s degree in social science or health science.

The other elements that we’ve identified from our experience are that care coordination really does require leadership and people who step up in the various areas of need and people understand the resources that are available. One challenge that we’ve encountered is finding data to guide the decisions of our care teams. Most of the state is adopting electronic health records but many of those electronic health records don’t contain the capacity to really do the kind of diary and dialogue that might be necessary to guide care coordination. And so, those working with electronic health record systems are finding ways to do that through tasking and through other ways to build diaries onto their system.

The other thing that is missing in many electronic health records in our state is the information technology to do population management; something that is eventually going to be key to this once we move past the point of obtaining process measures and really getting into outcome measures.

In conclusion, we found that there is no single credential that really identifies a care coordinator and no single skill set. In our opinion, it has to be viewed in context; and that might be the context of the behavioral health center, the context of a primary care center, a context of a specialty population like the frail elderly.

In our state we’ve had quite a bit of experience with care coordination models that share features consistent with what we’re doing in our health home. We’ve obviously had five years at least of experience with a patient-centered medical home. In the behavioral health world, we’ve had targeted case management. In the managed care organizations we’ve had a level of care coordination that has been very successful when focused around certain conditions. We have communities that have taken on the challenge of care coordination using community health workers and even programs that have done an excellent job using self-management services. So there are a wide range of things that I think can enable good care coordination and you don’t find it all in any single model.

I’d like to give you some examples of payment issues that we’re seeing in our state related to care coordination, and these are just four of many that are going on but these are good examples of how people share the same concept about care coordination but believe that it ought to be paid for differently. Under our state plan amendments that we’re currently developing with Medicaid, we’ll be using fee-for-service plus per-member-per-month payment model for those care coordination services.

At the same time in West Virginia, there is a private carrier in the state that is promoting a move to an accountable care organization model that we have a pay for performance feature and a pay per value feature that would be developed. This is early in development in the state and providers are moving in the direction of trying to figure out how to do the proper kind of care coordination to meet those needs. At the same time, we have another insurer that is adopting a comprehensive payment model with a pay for performance feature and shared savings. At the same time, we have a program that’s reported good outcomes in managing a select population through a network that concentrates on emergency department visits, hospitalizations and things, but it’s funded under a grant-based payment.

So this is certainly not the end of the story on what we have currently going on in the state and what you see in conclusion is that everyone seems to like care coordination, but we’re not exactly sure how we would be paying for it. So we find ourselves with a system that we all believe is good and helpful and we need to move in the direction of adopting some standards and some consistent practices to make it easier for providers to get in line. Our state has been the recipient of a technical assistance grant to help us work on a multi-payer project with our Patient-Centered Medical Homes and our Health Homes. And so, some of the strategies that we’re hoping to adopt with that would be simply to work toward consistent or similar payment models so that providers are not confused by the payment system that they’ll be participating in. We also think that it’s really critical that we capture similar measures in similar ways and we want to allow the practices enough flexibility that they can move to the standards that we expect them to hit because not everything is about meeting the standards, at the same time you have to be giving health care. And finally, we want to recognize the unique features of these practices in the communities because that’s one of the strengths of rural healthcare is that you have communities frequently willing to step up.

So that concludes my comments and I look forward to talking with Dr. Golden and with some folks on the line about some of the ideas around this. Thank you.

Judi Consalvo: Great. Thank you so much, Jim.

It is now my pleasure to introduce Dr. William Golden. Dr. Golden is a Medical Director of the Arkansas Medicaid Enterprise at the Arkansas Department of Human Services. Prior to his current position, he served for 16 years as Vice President for Clinical Quality Improvement of the Arkansas Foundation for Medical Care, where he designed numerous state-wide quality improvement and health technology projects and for Medicare and Medicaid. Among his awards and recognitions, he received the National James Q. Cannon Award for Physician Leadership in Clinical Quality Improvement; a special citation from UAMS for innovations in medical education related to his state-wide quality improvement efforts; a Mastership in the American College of Physicians; and the Alfred Stengel Memorial Award for service to the American College of Physicians. Dr. Golden?

William Golden: Thank you very much and thank you everybody for calling in. I think Jim gave an excellent overview of the options, challenges, and really complexity of designing care coordination. I think Jim shares with me the thought that these days if you are a plan manager or you’re involved with a program like Medicare or Medicaid, besides managing benefits and payment, it’s all about population health as well; how do you use the system to maximize the value for the participants and the patients in the system with the resources you have available.

Next slide. Like West Virginia, Arkansas is a rural state, about 3 million people, very much spread out though and we have, as any rural state has, great variation in the work force in terms of quality and quantity. You have challenges in primary care access, behavioral health access, and times getting access to folks with diabetic education skills. So it is always something to look at how you can get services to educate patients. We have challenges of practice infrastructure. We have a really large number one, two, and three-person practices, very much limited in terms of group practice integration and a lot of these primary care practice is because of the challenges in primary care reimbursements and the problems with underinsurance in many of these communities, they are undercapitalized and they are difficult to make innovative changes.

The patients have socioeconomic challenges, health literacy issues, and over the years that results in a lot perverse incentives, people have learned to survive in a practice environment by doing high volume acute care visits where preventive services and chronic care management often becomes not a secondary thought and not a primary driver.

Next slide. As we move forward and we’re starting talking about expansion to care and the need to replicate our primary care workforce, which is aging and not being replaced, we have now thoughts on the way to expand the use of nurse practitioners. We have two new physician assistant programs developing. Practices are increasingly being owned by hospitals or managed by hospitals, which gives them new infrastructure and economic support.

And then, finally, we have the growth in health information technology, challenges in terms of the functionality of electronic medical records but also the linkages through health information exchange and other techniques such as e-prescribing to really start leveraging the creation of registries and better population health.

Next slide. Arkansas was challenged by the – we were one of the last Medicaid programs to remain solvent and we were going to be challenged this year. Our governor said – let’s move forward and try to harmonize financial incentives to reform our health care system; get away from high volume pay for event to payment per outcome and episodes approach. And we have actually been able to do a multi-payer initiative over the last two years with the private payers including Blue Cross and QualChoice with the support of Medicare to begin this process. Likely, since I’ve written these slides, we’ve also agreed, our legislature at the last week of the legislature, passed a private option of ACA expansion which will bring new insurance programs into the state to expand care for nearly half a million people who right now do not have insurance in the state.

Our episodes of care approach involve gain sharing and total cost of care for people doing acute management events like hip replacement, pregnancy, acute hospitalization for heart failure. And we are finding that by paying people for their average per episode cost risk adjusted that we are incentivizing innovation to provide efficient health care that meets quality metrics. It rewards better providers who are doing interesting things to provide value-based care.

We’re also working on medical homes, which we’ll be rolling out later this year where we give new per member per month support for care coordination and care transformation to build up the infrastructure practices and to either have care coordination in their office setting or to a pooled arrangement with the end result of having gain sharing for total cost of care manage and for hitting quality metrics.

Next slide. So you see on this next little graphic we have an example of what the episode care looks like; people see patients during the year. Everybody gets paid fee for service whether you’re a surgeon, a pathologist, a physical therapist or a radiologist, at the end of the year the principal accountable provider, which would be a surgeon for a hip and knee or an obstetrician for a delivery or a doctor, an ER doctor or a primary care doctor for treating colds, gets all of their episode for an episode rolled up, averaged in cost and then they get put in this kind of normalized graphic so that everyone sees where they are in terms of their average cost per episode. And if you’re below the commendable line and in that green zone, you get 50% of the gain sharing of your cost per episode below the commendable line to a maximum gain sharing at the gain sharing limit. We obviously don’t want to incentivize care at the lowest possible cost regardless of quality and output.

On the other hand, if you are on the pink zone and you’re above the acceptable zone, you are at risk for 50% risk sharing up to 10% of your total reimbursements for the year from that payer. We have different people there; the data from the previous years, so we hope people can adjust their practice style and under ideal circumstances there will be nobody in the pink zone. And if we pay for lots of folks in the green zone, it means that we have successfully bent the cost curve.

Next slide. The medical home approach, we will have two approaches, one would be if your per member per year cost risk adjusted is already lean and mean, we will give you the maximum gain sharing below a certain threshold. We clearly admit that our primary care environment is quite diverse. We have some sophisticated medical homes or people on the way to having sophisticated medical home qualities. We have others that are still doing high volume paper-based practices that need to start on the journey. So we’re hoping people would envision what their journeys looks like, identify their high-priority patients that need additional coaching and additional activities so that they can engage their patients, enhance adherence and create more coordinated care with the other providers in the community.

So the folks that are on that journey and are successful beside getting the enhanced per member per months fees will get a reduced gain sharing approach if they can show that they are meeting quality metrics and bending the cost curve or beating the trend lines for expected cost into the future. Practices that get the per member per month fees down the road and do not make enhancement, do not show signs of becoming if you will, have stronger medical hominess and better care coordination, will eventually be asked to either show a corrective action plan or to perhaps lose their per member per month support. We are not requiring certification to be a black belt fifth level medical home, but rather to assume the attributes of a good medical home and achieve functional outcomes. We are not requiring an EMR at the start but rather they should have one at least by the end of two years of the program.

Next slide. I would like to distinguish though in our program the difference between health homes and medical homes. Medical homes will be the clinical game plan, often the primary care doctor, where they have care coordination coaching for the high priority patients. So they’ll find the medically frail, the complex psychosocial conditions, people with health care literacy who need greater support to achieve adherence to good care plans, reduction of acute care events.

The health home on the other hand is a different structure where we’re going to be looking for entities to do community coordination for select populations. So folks who are managing our clients with developmental disabilities who need support to be effective living in their communities either at home or in group homes, who have a good work environment, the health home would help them navigate the healthcare system but the health home would be responsible for a variety of metrics involved with their life in the community. Likewise, people who have serious mood disorders, not just mild depression or ADHD, but significant mood disorders will most likely relate most of their care to a mental health provider who will then be accountable for helping that client to engage with medical homes for their other medical issues.

Next slide. This slide kind of gives you kind of an overview of how the payments would split. You have the service episode for the folks with developmental disability where most of the spend is in the health home for the disability and there would be some halo spend which would be smaller for their medical care where they would get the preventive services and the services that would be specifically tailored to that person that relate to their medical conditions and perhaps the unique medical complications of their disabilities.

Next slide. All of this requires new activity for our program and new resources to get our provider community up to speed and oriented. And as we said, we’re trying to harmonize financial incentives across payers so that more of their book business is impacted by these new incentives. So it’s not enough for just one payer to make changes. We’re doing it across a larger swap of the economic book business of our providers. But to get them to respond to these incentives, we’re creating new provider report cards so that they can see not only how their practice performs on quality metrics and cost but how their patients are being cared for throughout the journey in their healthcare. So the principal accountable for providers and the medical homes will be getting relative performance of their practice for all of the spending related to their patients, not just the bills generated by the medical home or the principal accountable provider him or herself.

Likewise, we’re expanding health information technology. We’re having our Health Information Exchange develop quick information to medical homes for patients who have been in the hospital and in the emergency room, so we can hold practices accountable to make sure that patients get followed up by someone in the community after an acute event. We are also identifying vendors to make services available to small practices who may not know how to navigate this transformation process so they can become – get coaching for their medical home process as well as to have care coordination support if they have a small practice with limited resources and the ability to hire a care coordinator within their four walls.

Next slide. All of that brings up issues, new kinds of issues. We want to engage all practices not just the early adopters. We’re going to have volunteers in the beginning, but as I’ve said we have great diversity in our primary care and provider population. We want this to engage and get providers throughout the state in all aspects, in all corners of our geography so that the system truly transforms. This may stress some providers; on the other hand its innovative opportunity for greater payment will perhaps allow the better providers to expand their operations, get new associate providers with them, and create a new environment to have services in communities that up until this time were not able to attract this kind of entry because of the economic incentives as well as the expansion of health insurance.

We want to engage the patient. We have lots of providers who warned us that this system could fail because the patients just don’t comply. And our response back is to tell them that better care coordination and patient-centeredness would help to get patient adherence to improve that the day of the answering machine at night or on weekends needs to be in the past and we need to have greater access to these patients, both after hours, but particularly live voice access at night on a weekend. We’re going to have to pool practice data for gain sharing. That’s an unfortunate necessity because of statistical and actuarial concerns. We have concerns about a limited electronic medical record base. We have about 50% in place, just like in West Virginia, and we have limitations on their ability to extract data. And then finally we’re going to have new metrics to make people accountable for their per member per month fees so that they can show that they are actually doing something with the new dollars.

Next slide. As we move forward in practice reform and expansion, we want to avoid new economic silos. Everybody is offering us opportunities, but we don’t want to create new per event payments every time someone sees a pharmacist and a pharmacy or an educator. We want to integrate that into a more umbrella organization through the care coordination process. We have telemedicine in the state and the question is, “What is its best use and what is the most economic way of creating that to reduce care transportation cost to the patient and to expand access to specialty services?” And then, finally, just like as Jim outlined, when is care coordination best used? What’s the best price? What’s the best effectiveness? How intense? How often do you use it? What’s the best yield in terms of getting it in place?

So finally on the last slide, this is a new opportunity. We have a brighter future. Providers and payers and to a great extent patients as well realize that change is needed. We cannot continue to raise copays, insurance premiums or taxes to keep our health system going the way it is. The pain of change is becoming less than the pain of the status quo, particularly as the status quo goes into the future and the economic challenges grow. This is a great opportunity window to create a smarter, more effective health care system by changing the economic incentives in concert with greater data and greater practice support.

So thank you for listening.

Judi Consalvo: Great. Thank you, Bill. Now, it is my pleasure to introduce today’s event moderator, Dr. David Meyers. Dr. Meyers is the Director of AHRQ’s Center for Primary Care, Prevention, and Clinical Partnerships. He leads the agency’s work in support of the primary care patient-centered medical home; and currently is serving on the US Department of Health and Human Services Teams charged with implementing Affordable Care Act provisions related to primary care and prevention. We are pleased to have David with us today to share some AHRQ resources and lead us through the question-and-answer portion of this Web seminar.

David Meyers: Thanks so much, Judi, and thank you all for joining our call today. I especially want to offer thanks to Drs. Becker and Golden for sharing their experiences in West Virginia and Arkansas as well as to the dynamic team at AHRQ’s Health Care Innovations Exchange for bringing us all together.

At this time, if you haven’t already done so, feel free to go to the bottom of your screen and submit any questions you have for our question-and-answer period. While you’re doing this, I’d like to take a few moments to share some resources from AHRQ about the PCMH and care coordination in particular.

Next slide, please. At AHRQ we’ve put together a one-stop browsing and shopping PCMH extravaganza. And the Web site is there for you right now, pcmh.ahrq.gov. And this Web site was designed with researchers and policy makers in mind. And recently has expanded to include newer resources targeting those who are in the trenches actually implementing the PCMH and primary care transformation.

Next slide. In addition to providing some background and definitions of this PCMH and some foundational white papers and briefs, a great deal of AHRQ’s work has been focused on understanding the outcomes of implementing improved primary care and finding ways to help folks improve how we assess, measure, and determine whether the medical home or any other complex healthcare intervention improves all the dimensions of quality.

Next slide. Specifically I wanted to highlight for you that the Web site host a series of in-depth foundational white papers mostly targeted to researchers and those who want in-depth background information as well as shorter policy focused briefs that are shorter for policy makers but also really cut to the chase of ideas and issues to keep in mind as we move forward when implementing change in primary care. And on the slide now you can see some of those that are focused on care coordination.

Next slide. The final two resources I wanted to bring to your intention deal with the question of measurement specifically, one, AHRQ has been challenged by the community to help move forward how can we measure whether a care coordination is happening and it’s a many year process unfortunately to move this field forward, but we are making progress. And right now you can find on our website an Atlas, which is a series of tools that are available and it catalogs each of the different tools that we found so far and puts them in a theoretical framework of what is care coordination and what are the different domains and maps for you, hence the term Atlas, which different measures focus on which different domains and which different populations. So you can go in in the next – very soon this will become a searchable database as well as a PDF. But you can go in and look for things based on I’m looking to understand care coordination for children from the patient and family perspective and I have a real interest in understanding how information flow or communication is happening. And then that’ll take you to which tools currently focus on that.

There are so many tools though available. People said, “Which is the best one? If I just need one, make this simple for me.” And we tried to do that. This is not as scientific but it is our community effort to say, “Of the given measurement tools available, which ones are doable and therefore feasible for which populations and how they work.” But the caveat as it says at the bottom of the slide is, at the moment the best way we found to measure care coordination is by asking patients and families and so that means surveys and that definitely does have a measurement burden and cost associated with it.

Final slide, please. Also, this wouldn’t be an AHRQ session if we didn’t highlight that we have a new PCMH CAHPS tool. These are tools for understanding patient experience and this tool is developed specifically for focusing on the domains of primary care and the patient-centered medical home, which does, of course, include care coordination. This is available for free with all the technical assistance that our CAHPS tools come with and you can find that on the AHRQ website on your screen right now.

With that conclusion, next slide please, I am ready to turn it over to our speakers to answer some of your questions. Thank you, everybody, who’s already submitted them and feel free to keep them going on. Let’s start, well, since I just mentioned measurement, Jim and Bill, for both of you, let’s start with a number of folks in the audience ask, “How are you specifically, in the initiatives used to describe in West Virginia and Arkansas thinking about measuring care coordination or whether or not it’s taking place and the outcomes that you’re associating with it and how with these new payment models are you going to be – have you thought about ways that you’re actually going to be paying for value or performance specifically around care coordination.

William Golden: Why don’t you start, Jim? I can chime in after.

James Becker: Sure. Yeah, obviously that’s a very complex issue and a very important issue in adopting something like the health homes for chronic conditions. We have a number of different measures that we need to connect that collect some of the measures that we collect or are measures to prove the performance of the care coordination process and to begin looking at outcomes. But the question as I understand is a question of how are we actually going to measure care coordination activity. In the model that we’ve created, care coordination is available to anyone who meets the target population criteria and care coordination describes a minimum level of primary care coordination services, which are defined in the state plan amendment.

They’re based on an assessment that’s done by the health home and a planned around care coordination subject to audit. Centers that are doing this have to certify with us by going through a process through our division of primary care. Audits will be looking at the record keeping on the care coordination services but there has to actually be documentation of services delivered.

We are really working on the idea of a two-tiered per member per month payment. The higher tier of payment would be for intensive care coordination services. Those services would require some significant documentation in the form of a prior authorization. We’re also asking for reporting on the performance of the care coordinators. And though it hasn’t been finally determined, one thing that we would like to see is documentation of the level of activity of care coordinators and care managers in their involvement in each individual patient’s care. That would be something in the form of an Excel spreadsheet that would capture every telephonic or face-to-face encounter, every review of the record in just a very simple quick documentation of how much time was spent on this activity. One of the things we hope to get out of this is a better understanding of how much time it takes to do care coordination and how it compares in population to population.

So we think that it’ll generate information of that type. And those are the kind of measures around care coordination we’ll be looking for. So I think I’ve touched on as many as I can think of off the top of my head.

William Golden: In Arkansas, let me, it’s obviously a multipronged kind of thing as Jim mentioned. But in our total cost of care management for acute episodes, obviously, if you have readmissions or repeat ER visits after discharge, which can be directly impacted by care coordination at discharge and into the home setting, that would alter your average cost per episodes, so people are going to be motivated to have a reduction in those kinds of outcomes.

Likewise, on the health home side, the health home provider is going to be measured on things such as adherence to their medication, achievement of the office visits for preventive services. So there are a number of things that the health home will be accountable for in terms of making sure the client is getting the appropriate volume and timeliness of services.

And then, likewise, with the medical home, we’re going to be looking at things – has the practice identified high priority patients. Do they have care plans for those patients? Are those patients being seen at least twice a year and what exactly have they been doing with those high priority patients in terms of reaching out and managing their acute care episodes as well as adherence. So there are a number of things that we will look at. Some of it will be process and structure as opposed to the actual outcomes of patients, but it’s going to be a mixture of all of that.

David Meyers: Okay, well, thank you both. We have so many amazing questions right now. So folks, feel free to keep them in, but I’m going to have to say we probably won’t get to all of them but I do want to keep going now. So, one question that has come up from several folks is that some of these efforts appear to really be focused on transforming the whole state and really developing a whole system for the majority of folks. But in some of our pre-materials we talked about how West Virginia and Arkansas were going after some of the hardest reach folks including, for example, children in foster care. So, could you explain to the audience briefly any efforts about how your work in PCMH, health homes, new payment models, specifically is going to try to reach the hardest to reach and the most needy in your communities?

James Becker: Bill, do you want me to go first here?

William Golden: Go ahead.

James Becker: David, the population that we’ve chosen for this health home state plan amendment that involves bipolar individuals is a perfect example of that. This is a high-risk group that seldom gets care coordinators and they have a very – not only do they have very high medical cost and complications but they have great breaks and service and multiple sources of medical care that they wind up accessing and then long periods without care. Care coordination is perfect for that kind of population but bear in mind that you – and this is directly from our discussions with CMS, you have to set the bar a little low on your threshold for success.

In the bipolar population if they’re hospitalized three times a year for unstable conditions, if you can get them to two a year or if you can reduce on one expensive service, that’s an important good outcome for that population. So that’s an example and I like to comment about foster care. One of our groups that we’re most interested in is foster care children and behavioral health medicines, we know a great deal about that nationally. And so we’re anxious to move on eventually to a state plan amendment that does that. We have a lot of private providers who come to us on a regular basis and say, “Hey, I have a great tool for coordinating the care because these kids do have gaps in their care for immunizations and such.”

So I really appreciate that point. That’s in our mind as we do both PCMH and health homes.

David Meyers: Okay, and so – thank you so much and so the state plan amendments for health homes are one answer of how states are focused on these harder to reach populations and really wrapping as we heard earlier that the health home model really brings in community resources and ties that with primary care.

So a couple of folks have asked pretty much the same question in different ways and they want you guys to get down to dollars and cents. What is a valuable or appropriate PMPM for care coordination services to a primary care practices that gets you good results but also gives the practice enough to build the needed infrastructure and the new staffing to make this model work. So do you have a range or a figure that you want to share with the group just to help them in their thinking?

William Golden: Well, let me start here as we have some numbers. And I think everybody is taking their best estimates/guess at these things. And I can tell you that in some of the health home models that’s being, I think, run by HRSA. I’ve seen some health homes getting $75 per member per month which I’m a little concerned as not sustainable. We’re looking at a risk adjusted approach that’ll vary from $1 for a real healthy kid to perhaps $25 or $30 for a very complex kid. So we think it’s going to average out at least when we’re starting off here at $4 per member per month.

Our practices are already getting a $3 per member per month for being – our PCCM program because we’re not a managed care state, which I should have mentioned during my original talk. So that’s where we’re looking at right now. It’s not going to take care of 100% of the patients in the process but it will force folks to prioritize which patients need the additional attention and we think that’s the way to get it started on their way to manage these patients. In addition, that the carrot of the total cost of care management gain sharing, which would then potentially motivate additional investments in care coordination.

David Meyers: I really appreciate that. I’ll add that from our work here at AHRQ, what we’ve seen as on the lower end folks are in the $5 to $6 range, at the average seems to be in the $10-ish; and so your $3 plus $4 or $7 is right in there. Medicare for its large demonstration of advanced primary care, which is care coordination plus a number of other things is gone all the way up to over $20, and they do have a risk adjustment as well but their average fee is $20 per Medicare beneficiary, but recognizing these are some of the most needy and folks needing care coordination service. So hopefully, we’re soon going to see data from many of these models playing out and we’ll have better information for folks.

Another question that’s come up has to do with the data and you both talked about the importance that this only really works, care coordination works when information really flows. And so the need for good health IT systems was brought up by both of you. But then on another side, on the measurement side, folks were really curious about two things, one, how have you gotten the clinicians, the physicians and nurses in your states to buy into being measured. They note especially recognizing some of the small numbers problems and that the measures may not be the right measures or risk stratification. They may be very wary to put their finances on the line. So how have you built their buy-in to come along with you on this journey?

And then another group asked, how are you – to get all this data, are you entering into data use agreements? Are there data governance issues that people need to be thinking if they want to follow in your footsteps as they try to get all the data that’s necessary both for the providers but also for you all to understand your programs?

James Becker: Bill, I think Arkansas is further along on this. Do you want to take that and then I could comment?

William Golden: Sure. Okay. We have been doing data projects with our population for a long time. So I have been working in the state 15, 20 years. So we understand the tyranny of small numbers. At the same time, we also know how to present data on a fair basis. We don’t obviously profile people unless they have at least five cases. And so, we have a pretty good track record of being reasonable. We have a very rich data warehouse. We went all electronic claims in the mid-90s. And we have a couple of good data contractors that have been crunching numbers like mad. So this is just an enhancement of what we’ve been doing over time.

So there is no new data use agreement. On some of our quality metrics we do have that do some portals where people are entering some data and we’re trying to minimize that burden. Down the road, we’re looking at how you do data aggregation, how do you do cross-payer data; that’s more of an ambitious schedule. But as it is right now each payer is running their own data and we have sufficient sources and databases that we’re running most of the stuff on administrative clients.

James Becker: And just to add a couple of comments from West Virginia, I’ve done this work with providers in the past in a different chapter in my life and have done report cards for providers. And there is a great deal of initial resistance from providers and it’s very difficult to bring them in. One of the things that I have found to be most useful as you tackle the issue of report carding and actually sharing that with the providers is to – I would just advise anybody who’s doing it, collect data that the doctor can in some way validate in their own practice setting. That goes a long way toward acceptance of the data and engaging in dialogue about that, because every provider believes they take care of the highest risk population. Every provider feels their patients are the sicker and have the worst outcome.

So that’s a piece of just general advice about it. West Virginia is not very centralized in its current data collection systems for Medicaid or for other insurance, but we are in the process of obtaining of an all payer claims database which will be helpful, and our Medicaid program and it’s acquiring a new data warehouse, data support system. We have some data that we’re very comfortable with but we have a difficult time pulling it together. Sometimes it resides in two pools and we feel like the man with two watches who doesn’t know what time it is.

David Meyers: You all have been quite nimble and just provided excellent additional details. I have so many that I’d like to ask you. I have a feeling that they’re about to tell me time’s up. So with that I will just say thank you and turn it back over to our host.

Judi Consalvo: Thank you, David, and thank you very much. This has been a great sharing of a wealth of information and I’m sure our listeners have a lot more questions. And so what I can say to you is to visit the Health Care Innovations Exchange Web site at www.innovations.ahrq.gov and you can learn more information about our presentations today as well as there is a comment section where you can submit your questions and perhaps engage our presenters in more dialogue. Also follow us on Twitter and you can also send us any emails, questions on info@innovations.ahrq.gov.

And again, thank you all for this wonderful presentations and that’s it for today from AHRQ’s Health Care Innovations Exchange. Thank you.

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