OHLC Progress Report

January 2012

Progress Report–January 2012 The Oregon Health Leadership Council is pleased to announce the launch of a new initiative on acute low back pain and the completion of the Portland area Medicaid Transformation work. We also have updates to share on other key Council initiatives to moderate health care cost increases in the short and long-term. More information is available on our website: www.ORHealthLeadershipCouncil.org

Acute Low Back Pain Pilot Launched Beginning Jan. 1, 2012, the Council launched a two-year initiative to allow direct access to physical therapists for patients with uncomplicated acute low back pain. The pilot is being offered to fully-insured and selfinsured commercial members of Cigna, Lifewise, ODS, PacificSource, Providence, Regence and UnitedHealthcare as well as the employees of other hospital system Council members – Asante, OHSU, Providence, Salem Health and St. Charles Health. The pilot is a community-based approach to a standardized care process for the identification and treatment of patients with acute low back pain. The care process uses a standardized screening tool and offers appointments within 24 to 48 business hours to patients who would benefit from this care. Treatment focuses on exercise, education and self-management tactics. The pilot’s goals of allowing direct access to physical therapists for the quick treatment of uncomplicated, acute low back pain are to: 1. 2. 3. 4.

Reduce time loss from work Improve functional status of the patient Improve patient satisfaction Reduce downstream medical costs

Nineteen physical therapy clinics representing 75 locations with more than 250 therapists were selected to participate. Participating clinics and the areas they represent include: -

Alpine PT and Spine (Bend) C.H. Physical Therapy (Portland) Chehalem (Newberg) Laurelhurst (Portland) Oregon PT/Spine (Eugene)

- Asante (Southern Oregon) - Capitol PT/Hand (Salem) - Eugene PT (Eugene) - Optimal Results (Portland) - Progressive Rehab (Portland)

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OHLC Progress Report

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Providence (Portland, Medford) PT Solutions (Eugene) Salem Health Rehab (Salem) Slocum Ortho (Eugene) Willamette Spine (Salem)

January 2012

- PT Northwest (Salem/Corvallis) - Rebound (Bend) - Sandy PT (Sandy) - Tigard Ortho/Fracture (Tigard)

The clinics provide solid geographic coverage down the Interstate 5 corridor and in Bend. Since our last report, training on the pilot was completed, participating health plans sent out a standardized letter of agreements with physical therapists and the evaluation of the pilot has been developed. Consistent, widespread communication by the plans, employers and others is critical to the pilot’s success. The Council is working with the Oregon Coalition of Health Care Purchasers and through the health plans to get the message out. More emphasis is needed in this area to assure patients, employers and health care providers are aware of this pilot and the availability of direct access to physical therapy for low back pain.

Portland Metro Area Medicaid Transformation In January 2011, the Council recognized that reductions to the state Medicaid budget could have a significant negative impact on commercial payers by shifting the cost to them and organized a small group to look at approaches to redesign and finance care for Medicaid and uninsured populations. In July 2011, the Council reviewed and approved recommendations emerging from that group to further define and explore the concept of a new delivery system for the Portland area that would deliver on the triple AIM for these populations. The concept was envisioned as one that: is community based, with a collaborative and joint mission; is managed with a shared responsibility of risk and funding; uses selective contracting with high performers with sustainable practices; and is responsive to community needs. To further develop this concept and assess the feasibility of the cost savings using benchmark data, the Council hired Health Management Associates (HMA) and Milliman, Inc. This work, which was completed between September and November 2011, was funded and overseen by the Council, Portland-area based managed Medicaid organizations, the

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OHLC Progress Report

January 2012

major Portland-area hospitals and health plans, Multnomah, Clackamas and Washington counties and the Oregon Health Authority. The Oregon Health Leadership Council Board heard the final reports, (available on the OHLC website) from both HMA and Milliman on Dec. 6. The Board concluded that while there were some data limitations (first time use of the State’s All Payer All Claims database and available benchmarks), that the information in the report should be seen as directional, however not be over-generalized. The report did identify a range of cost-saving opportunities that might be helpful to regional efforts across the state. Most importantly, they noted the estimated statewide savings of $117 to $142 million fell significantly short of the $640 million savings needed ($239 million of state funds and $400 million needed to cover federal matching dollars), and that these improvements would take time, financial investments and considerable efforts at the local level, to achieve. The HMA report recommended one new provider-driven, integrated delivery system for the Portland area, with recommendations on how to finance the effort and governance options. The report also identified revenue options that should be pursued to close the budget gap and support the transformation efforts. The Board agreed that: 1) the Medicaid Transformation work for the Portland area needed to transition to a local group; and 2) the role of the OHLC moving forward should be to evaluate statewide revenue options to support transformation and to share best practices on statewide efforts. Since the Board meeting, the Portland-area group has created the TriCounty Medicaid Collaborative led by an Executive Steering Committee which now represents nine major healthcare stakeholders including Legacy, Providence, Kaiser Permanente, OHSU, CareOregon, Multnomah, Washington and Clackamas Counties and the federally qualified health clinics. George Brown, M.D., is chair of that group.

High Value Patient Centered Care Demonstration Oct. 1, 2011 marked the second year of the multi-payer High Value Patient Centered Care (HVPCCM) demonstration initiative for patients with complex and chronic conditions.

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OHLC Progress Report

January 2012

This demonstration project implements a new model of care that integrates intensive care management within primary care, with a specially trained nurse care manager. The nurse acts as a navigator who develops a personal relationship with each patient to understand exactly how best to care for that individual. The care manager also coordinates with other members of the health care team – including the patient’s primary care physician, specialists, other health care professionals, hospitals and health plans. Five health plans, four of the State’s purchasing groups and 14 medical groups are participating in the demonstration. Twenty-three nurse care managers have been working with the 3,600 patients enrolled in the demonstration. The demonstration runs through February 2013 at which time an evaluation will be completed. New Developments New Enrollment Period Under Way. The plans and medical groups are currently in the process of identifying and inviting new patients to enroll in the demonstration. This process accounts for attrition in enrollment that occurred during the year. Through a defined method, the plans identified patients who are candidates to participate in the demonstration and provided these lists to the medical groups for outreach. The medical groups will enroll patients between now and March 15, 2012. This will allow time to collect sufficient data for the evaluation. Data Reporting. Since the last progress report, additional improvements have been made in the utilization reports being provided to the medical groups. The report includes information about their patients on emergency room visits, hospitalizations, prescription drugs, imaging and lab procedures and physician visits. The reports were released in October 2011 and January 2012, with the next report to be released at the end of February. In addition, work continues on the reporting for the Health Plans. Joint Medical Group and Health Plan Meeting. In early January 2012, the health plan and medical groups held another, very successful joint meeting. They discussed the upcoming enrollment period, the new OHLC acute low back pain pilot and how this could be an additional tool for the nurses in helping their patients and shared best practices. The nurses also shared the positive experiences they are having in helping these very complex patients better manage their care and avoid more costly trips to the emergency room.

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OHLC Progress Report

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Administrative Simplification The Administrative Simplification Work Group continues work on key initiatives – increasing the use of electronic data exchange for claims and eligibility, secure single sign on and credentialing. New Developments Health Plans and Providers Using the Secure Single Sign On. We are pleased to report an increase in use of the secure single sign on. This service allows providers to sign on once and use multiple health plans to transact business. Plans currently offering this service for Oregon providers are: Aetna, CIGNA, First Choice Health, LifeWise Health Plan of Oregon, PacificSource Health Plans, Providence Health Plans, Regence Blue Cross Blue Shield of Oregon, HealthNet and Samaritan Health Plans. CareOregon and United Healthcare will be implementing single sign on during the second quarter of 2012. At the end of December 2011, more than 5,500 Oregon provider organizations, with more than 14,700 individual users had registered. Since the initial offering in November 2010 through Dec. 2011, Oregon providers signed on the system over 1,242,700 times. The increased number of plans now offering the service and the value the service provides physician offices have been the driving forces behind the dramatic upswing in use. Electronic Data Transaction Standardization. Last year, the Council completed and submitted companion guides to support the standardization of electronic data exchange for Eligibility and Claims transactions for Oregon. In the fall of 2011, the Department of Consumer and Business Services (DCBS) completed rule making for the implementation of the Oregon Companion Guide for Eligibility. Beginning in January 2012, eligibility requirements are now being implemented. The Council’s work group will help to support implementation as needed and continue to review national industry trends that may require updates to the guides in the future. Advancing Common Credentialing. The committee continues to monitor the progress of credentialing by OneHealthPort (OHP) in the state of Washington. OHP reports that many of the enhancements recommended by Oregon are being made and implemented in Washington. These enhancements were identified by the Administrative Simplification Committee as being required before moving forward in Oregon. The Committee will continue to monitor implementation and

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develop the needed provider adoption strategy with the goal of beginning implementation in Oregon during the first quarter of 2013. Simplifying the Pre-Authorization Process. The Administrative Simplification Executive Committee is advancing an initiative to simplify the prior authorization process. Through a series of work group meetings in the fall of 2011, more than 40 stakeholders outlined the problem statement and vision for an improved prior authorization process. The short-term work, to begin later this quarter, will focus on communication, definitions, tools and development of best practice recommendations. The Administrative Simplification’s Claims and Eligibility work group will inventory existing tools used for prior authorization, develop a list of common terms including types of requests; develop a common education approach to understand the prior authorization process requirements and a checklist of required information by payer.

Evidence-Based Best Practices In addition to the Acute Low Back Pain pilot, the Evidence-Based Best Practices group continues its work with the March of Dimes and the hospitals on reducing elective deliveries before 39 weeks and is exploring a new initiative to support the reduced use of opiates in the emergency room. New Developments More Hospitals Support Policies to Reduce Elective Deliveries before 39 Weeks. Work continues in hospitals around the state to reduce the rate of elective deliveries occurring before 39 weeks. The March of Dimes reports there are now 31 hospitals that have put in place, or have committed to implement, the new community-wide standard to place a ―hard stop‖ on non-medically indicated early deliveries at their institutions. The Oregon hospitals are: Adventist, Asante, Blue Mountain, Harney District Hospital, Kaiser Permanente, Legacy, OHSU, Peace Harbor, PeaceHealth, Providence, Salem Health, Samaritan Health, Sky Lakes, St. Charles Health and Tuality. With a hard stop, elective deliveries will no longer occur unless there is clear medical evidence to the contrary. Research shows that performing these elective procedures before 39 weeks can be harmful to the full development of the child and can result in higher costs from stays in neonatal intensive care units.

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OHLC Progress Report

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To support this effort, the March of Dimes has sent out more than 9,000 pieces of consumer material to the hospitals. In addition, OHSU has been working on ways to measure the effectiveness of this effort. New Work Under Consideration Reducing the Inappropriate Use of Opiates. At the last work group meeting, the committee discussed the high rate of opioid use in Oregon and how ―drug seeking‖ behavior was a driver of high costs and low satisfaction. Some work on standards of care for opioid use has taken place in primary care and by the Oregon College of Emergency Physicians (OCEP); Public Health is also engaged in the issue. At the next meeting, the committee will discuss what role the Council might play in supporting community activities and spreading standards of care for the appropriate use of narcotics.

Value-Based Benefits Value-Based Benefit Designs are now being offered by all health plans that had committed to offer them when this initiative was first launched. The health plans are:    

ODS Providence Regence PacificSource

2+ employees 51+ employees 100+ employees 250+ employees

New Developments Early Results from the Oregon Educator’s Benefit Board. In the fall of 2010, the Oregon Educator’s Benefit Board (OEBB) was the first large employer in the state to implement a version of the Council’s value based benefit design with two of their carriers—ODS and Providence. In looking at the preliminary, first full year impact of the design on ODS enrollees (the plan that has the majority of their members), Joan Kapowich, OEBB Administrator, reported that the new benefit design is clearly making a difference. For those preference sensitive services for which OEBB increased the cost sharing, the overall results showed that members used those services about 10% less often, with cost savings of up to 20%. In some areas, such as imaging and sleep studies they saw overall reduction of use of these services by 15-30% and cost reductions of 15-30%.

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OHLC Progress Report

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Ms. Kapowich stated that she is very pleased with the impact the benefit design appears to be providing and will be tracking the impact moving forward. New Employer Offering a Value-Based Benefit Design. Legacy Health introduced a new value-based benefit design for their 7,700 employees effective Jan. 1, 2012. The design, with the same basic principles as the Council's initial design, has been adapted to align with Legacy's mission of "good health for our people" and with future health care reform. Their benefit plan adds an additional fourth tier that requires pre-authorization for specific services. In 2012, they will include elective spine surgery in that tier. This plan now covers more than 16,000 Legacy employees and their dependents. Small Employer Market. In July 2011, ODS began selling a valuebased benefit design in the small group market. Beginning Feb. 1, 2012, they will have their first small group offering the plan design. The rationale for selecting the design was that there was thought behind benefits that could curb areas of high utilization and better benefits offered for procedures that are less invasive. Coalition of Oregon Health Care Purchasers. To help promote the concept of value based insurance designs, the Coalition of Oregon Health Care Purchasers (OCHCP) held a forum in early December 2011, where representatives from five organizations presented innovative programs they are implementing or piloting. The organizations were the State of Oregon, Legacy Health, H&R Block (Kansas City), CalPERS and Intel Corporation. Common themes among the presentations were the urgent need to change benefit designs, engaging employees/members, shifting the paradigm from the patriarchal world of health benefits to one of personal accountability and health insurance, and changing the way health care is provided to employees/members. Brian DeVore, OCHCP Board Chair and Director of Industry Affairs, Intel Corporation, ended the conference with a call to action for innovation and collaborative efforts by purchasers to help drive system change. We hope that more employers will consider these plans in the future.

For more information: www.ORHealthLeadershipCouncil.org

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