P4P: Developments and Acceptance In Medicaid and Medicare Disease Mgmt.

P4P: Developments and AcceptanceIn Medicaid and Medicare Disease Mgmt. Gus Geraci, MD Senior Product Manager for Provider Facing Programs McKesson Health Solutions

Agenda • Science and Design of P4PSuccess and FailuresProgress to Date • Questions Disease Management Colloquium

Science of P4P • Defects Exist in Current Payment Systems • Incentive for Volume • Quality May Suffer • Do $$$ Work to Change Behavior? • Mixed Literature and Emotion Disease Management Colloquium

Science of P4P (2) • Evidence is Accruing that Programs Do Work • Many Naysayers • Every Program is Different • How To Avoid “Gaming” Disease Management Colloquium

P4P and Disease ManagementIn Medicaid/Medicare • Challenges: • FFS Environment • No Direct Contractual Relationship With Providers • DM Programs Perceived As Interfering • Misperception of Funding Source for DM Programs • Not From MY Pocket • “Too much paper” • Concerns About Potential Liability Disease Management Colloquium

P4P in Disease Management • We Have Hard Evidence that P4P Achieves Better Results Within a DM program by: • Engaging Providers • Providing an Incentive for Specific Evidence Based Activities • Thereby Improving Clinical and Financial Results Disease Management Colloquium

McKesson’s P4P Approach • Incorporate P4P Market Feedback into Design • Tie P4P Payments to Key DM Program Success Factors • Influenced By Providers • Involve National/State Professional Organizations in Design • Publicize P4P Program Well Disease Management Colloquium

Design Follows AMA P4P Guidelines • Helps ensure quality of care • Yes: based on nationally accepted guidelines • Foster the patient-provider relationship • Yes: provider is key in recruitment and goal-setting Offers voluntary participation • Yes: no penalty or reduction in fees for non-participation • Uses accurate data and fair reporting • Yes: payments based on information received directly from providers, patients or claims • Provides fair and equitable incentives • Yes: providers are paid a fair amount as compensation for the work done Disease Management Colloquium

Market FeedbackProgram Design • Low pt volume per physician • Not statistically significant • Case mix issues Confusing to physicians Difficult to administer • Start with simple participation metrics • Use widely accepted claims-based metrics (HEDIS-like) P4P Design Flaws Model Complexity Data Validity • Payments designed like FFS system Long Lag times between physician behavior, data collection and reporting, and bonus payments Frequent payments: First payment within 6 months after program launch; quarterly payments thereafter Disease Management Colloquium

MS MHS Program Experience – Stormy! • MS MHS Program launched August 22, 2005 • Hurricane Katrina struck MS Gulf Coast August 29th • Practitioners focused on meeting refugee needs • P4P introductory mailing delayed Disease Management Colloquium

Medicare Health Support (MS) CMS-Mandated Services • Development of an individualized, goal oriented care management plan in consultation with each targeted pt, to include: • Point of contact responsible for communications • Self-care education and education for primary caregivers and family members • Education for physicians and other providers as well as collaboration to enhance communication of relevant information Disease Management Colloquium

MS Design Similar to PA • Enroll • Information Exchange • Clinical and Administrative • Evidence Based Clinical Metrics Disease Management Colloquium

How the P4P Program Works Time Physician responsibilities: Disease Management Colloquium

Mississippi - Terminated • Results Not Tracking With Design Disease Management Colloquium

PA Medicaid P4P Program • PA Practitioners More Familiar With P4P Programs (Commercial and Medicaid MCO) • FFS Managed Care Program – EPCCM • Program Continues to Grow in Enrollment • “I actually got a check…” Disease Management Colloquium

Survey of ParticipatingProviders • 56% Agree/Strongly Agree P4P is Useful to Practice • 42% Unsure • 2% Strongly Disagree • 60% Agree Strongly Agree Helps Improve Quality • 38% Unsure • 2% Strongly Disagree Disease Management Colloquium

Clinical Results • P4P participation is shown to increase the average monthly rate of occurrence for a blood test for cholesterol within the diabetes population • P4P participation is shown to increase the average monthly rate of occurrence for a prescription for controller medication within the asthma population • P4P participation is shown to increase the average monthly rate of occurrence for a prescription for cholesterol lowering medication within the CAD population • P4P participation is shown to increase the average monthly rate of occurrence for a prescription for beta-blocker within the heart failure population Disease Management Colloquium

Financial Results • P4P Participation Resulted in Greater Savings in Inpatient Costs Than Non-P4P Disease Management Colloquium

Progress to Date • We’ve Learned a LOT • Getting Out of Medicare in MS • Continuing Strong in PA • Designing Next Two Years for PA • Non-Disease Management P4P • Quality Incentives Aligned with State Initiatives Disease Management Colloquium

Redesigning the Program • Realigning the Program • Reinforcing Success of P4P in Medical Home Model for Primary Care • Success Exists in Specialty and Primary Care P4P • Requests for P4P in New And Current Programs Disease Management Colloquium

Stay Tuned for Next Year! • More Detailed Analysis • More Non-DM Data • P4P Works • Clinical • Financial • Greatest Barriers Are: • Supporting Program • Distrust Disease Management Colloquium

Questions? Gus.Geraci@McKesson.com Disease Management Colloquium

P4P: Developments and Acceptance In Medicaid and Medicare Disease Mgmt.