Issue Brief December 2020 The Impact of Federal Value- Based Primary Care Programs on Participating Oregon Practices: A Snapshot Diana Bianco, Chris DeMars, Lisa Miller, and Emilie Sites Policy Points ABSTRACT This analysis examined data on quality, utilization, and cost from the 62 Oregon primary > Participation in the care practices that participated in Comprehensive Primary Care Initiative (CPC Classic) Comprehensive Primary and continued with the Comprehensive Primary Care Plus (CPC+) program in 2017, and Care Initiative and in the compared these with Oregon primary care practices that participated in CPC Classic Comprehensive Primary Care Plus program was only or did not participate in either program. In 2017, practices participating in both associated with positive programs performed better across all payer types than practices in the comparison outcomes in cost, quality, group on 24 of 26 quality measures, including breast and cervical cancer screening and utilization in 62 Oregon and several chronic disease measures. Practices that participated in both programs practices relative to comparison practices. also showed positive trends in emergency department utilization and avoidable emergency department utilization across all payer types. In addition, CPC-participating practices had lower per member per month adjusted claims-based costs among com- > Primary care practices need su icient data on mercially insured members for numerous service types. The results indicate positive quality, utilization, and impacts of CPC program participation and lend continued support for CPC+ and other cost to meet care delivery value-based payment programs in Oregon. requirements, conduct quality improvement activities, and reduce costs. INTRODUCTION Comprehensive Primary Care Plus (CPC+) is a federal initiative that seeks to strengthen primary care through care delivery transformation and multi-payer payment reform. Oregon was one of 18 regions selected by the Centers for Medicare & Medicaid Services (CMS) to join the program, which began in 2017. CPC+ builds upon the Comprehensive Primary Care Initiative (CPCI, or CPC Classic), in which Oregon also participated. CPC+ is consistent with many of Oregon’s delivery — rather than present slices of data from each payer — system innovations, which include greater investments were a more comprehensive approach to performance in primary care along with an emphasis on increased reporting. adoption of value-based payment models. Both the CPC During CPC Classic, Oregon had explored a shared data Classic and CPC+ models require primary care practices aggregation solution but, for a variety of reasons, it to change the way they deliver care, with a focus on key didn’t come to fruition. Under CPC+, payers were eager functions such as care management, population health, to try again. To build consensus for data aggregation, the and comprehensiveness and coordination1. The CPC+ Payer Group undertook a multistep process that included model also aligns with the contractual value-based creating a framework and principles for decision-making. payment requirements for Oregon’s Coordinated Care They outlined a set of agreements and considerations, Organizations. including: The Oregon CPC+ Payer Group1 came together to meet • Recognition that payers were in different stages of the CPC+ participation requirements and to advance collecting clinical and claims data; and spread value-based payment programs in the state. • Agreement that progress required payer commitment Since 2017, participating Oregon payers have met month- and leadership; ly to identify opportunities for alignment, collaboration, and shared learning. The group’s goals are to: • Acknowledgment of the importance of as many payers as possible participating; • Support sustainable primary care transformation; • Understanding of the challenges and opportunities • Identify and share payer and clinic best practices to of collecting clinical and administrative data; and achieve program care delivery and payment model goals; • Affirmation that any solution should support payer evaluation of the payment model and whether/how • Reduce fragmentation, seek simplification, and to sustain and spread it. leverage existing resources; and In 2018, the majority of participating payers committed • Understand and demonstrate the value of CPC+. to aggregating claims data with Comagine Health to help payers and practices learn from the CPC+ experience.2 They wanted Oregon-specific data to help stakeholders The Oregon Health Authority (OHA), the state across the state understand how the model impacted agency overseeing Medicaid, behavioral health, primary care and the potential for spread beyond par- public health, and other programs, has worked with ticipating payers and providers. Comagine Health works its numerous stakeholders to support primary care with Oregon’s largest health insurers plus the Oregon transformation for many years through a variety of Health Authority and CMS to develop a comprehensive programs, initiatives, and reports. Related OHA ini- claims database — the Oregon Data Collaborative — tiatives include the Patient-Centered Primary Care which includes claims from 2015 to present, representing Home program, Primary Care Payment Reform data for over 3 million covered Oregonian lives. Our Collaborative, and Primary Care Spending Report. database includes 80% of the fully insured popula- tion, 23% of the self-insured population, 100% of the Medicaid population, and 87% of the Medicare popula- THE IMPORTANCE OF tion in Oregon. Claims data are submitted quarterly to ANALYSIS AND ROI Comagine Health’s data services vendor, who cleans and The Payer Group recognized that primary care practices aggregates the data, calculates measures, and populates need sufficient data on quality, utilization, and cost results into Comagine Health’s secure online reporting to meet care delivery requirements, conduct quality portal. At no charge, primary care and women’s health improvement activities, and reduce costs. The group provider organizations in Oregon are able to securely knew that reports that synthesize multiple payers’ data access quality, utilization, and expenditure measure Milbank Memorial Fund • www.milbank.org 2 results for their organizations and drill down to practice, participated in CPC Classic only or did not participate in provider, and patient-level results. either program. The practices participating in CPC+ only Aggregated data opened the door to examining whether were not included in either the comparison group or the and how the CPC payment models made a difference for participating practices group because 2017 was the first participating practices on quality, cost, utilization, and year of the CPC+ model. For each measure, Comagine outcomes across payers. The Oregon CPC+ Payer Group, Health took the average of all practices in each group in collaboration with Comagine Health, launched Data where the practice had at least 30 attributed primary Bytes, a series of brief, infographic-heavy publications care patients in the measure denominator. highlighting key analytic findings to share progress CPC-Participating Practices Performed across participants following a multiyear collaborative Better Across All Payer Types on Most process. This report summarizes two Data Bytes pub- Health Quality Measures lished by the Payer Group in 2020 measuring quality, The first analysis shared with practices included 2017 utilization, and cost. results for the quality measures that Comagine Health computes for its adult cost-of-care reporting, across all KEY FINDINGS payers, as well as by payer type: commercial, Medicaid, and Medicare (fee-for-service and Advantage com- Comagine Health examined 2017 data from the 62 bined).3 (Measure descriptions are available in Comagine Oregon primary care practices that participated in Health’s Technical Appendix.) Participating practices CPC Classic and continued with the CPC+ program in performed better on 24 of 26 quality measures (Table 1). 2017 (CPC-participating practices). Comagine Health compared these with Oregon primary care practices that Figure 1. Breast and Cervical Cancer Screening Rates Were Higher in Figure 1. Breast and Cervical CPC-Participating Cancer Screening Rates Were Higher in CPC-Participating Practices Practices Practices participating in both CPC Classic and CPC+ Comparison practices Breast Cancer Screening Cervical Cancer Screening 79%* 73%* 73%* 67%* 73%* 72%* 66%* 65%* 63%* 60%* 57% 64%* 58%* 56% 48% 45% All Payers Commercial Medicaid Medicare All Payers Commercial Medicaid Medicare Notes: * Indicates that the difference is statistically significant (P<0.05). Notes: * Indicates that the difference is statistically significant (P<0.05). Milbank Memorial Fund • www.milbank.org 3 1 WWW.MILBANK.ORG Table 1. Quality Measures Included in This Analysis4  Practices participating in both CPC Classic and CPC+ * Difference was statistically had higher performance rates significant (P<0.05) Quality Measure Results Annual Monitoring for Patients on Persistent Medications – ACE Inhibitors or ARBs  * Annual Monitoring for Patients on Persistent Medications – Diuretics  * Annual Monitoring for Patients on Persistent Medications – Total  * Antidepressant Medication Management: Continuation Phase Treatment  * Antidepressant Medication Management: Effective Acute Phase Treatment  * Appropriate Treatment for Children with Upper Respiratory Infection  Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis  * Breast Cancer Screening  * Cervical Cancer Screening  * Chlamydia Screening in Women  Comprehensive Diabetes Care – Eye Exam Performed  * Comprehensive Diabetes Care – HbA1c Testing  * Comprehensive Diabetes Care – Medical Attention for Nephrology  * Follow-up after Emergency Department Visit for Mental Illness – 7-Day Follow-up  Follow-up after Emergency Department Visit for Mental Illness – 30-Day Follow-up  Generic Prescription Fills: Antidepressants X Generic Prescription Fills: Antihyperlipidemics  Generic Prescription Fills: Antihypertensives  Statin Therapy for Patients with Cardiovascular Disease – Rate 1; Received Statin Therapy  Statin Therapy for Patients with Cardiovascular Disease – Rate 2; Adherence  Statin Therapy for Patients with Diabetes – Rate 1; Received Statin Therapy  * Statin Therapy for Patients with Diabetes – Rate 2; Adherence  * Use of Imaging Studies for Low Back Pain  * Use of Opioids at High Dosage and from Multiple Providers in Persons without Cancer X Use of Opioids at High Dosage in Persons without Cancer  Use of Opioids from Multiple Providers in Persons without Cancer  ACE Inhibitors= angiotensin-converting enzyme inhibitors ARBs= angiotensin II receptor blockers bA1c= also referred to as A1c Milbank Memorial Fund • www.milbank.org 4 Below, we highlight six of the 26 quality measures, • Fit into one of two groupings (preventive screenings starting with the findings that practices participating or care of patients with chronic conditions) that in both CPC+ and CPC Classic performed better than reflect the focus areas of the CPC+ program.5 comparison practices across all payer types on Breast Breast Cancer Screening and Comprehensive Diabetes Cancer Screening and Cervical Cancer Screening quality Care Measures include Medicare fee-for-service data measures (Figure 1). Practices that participated in both that were made available through the Medicare Qualified CPC Classic and CPC+ also had higher performance Entity program, while other measures include Medicare rates than comparison practices across all payers in Advantage data only. Comprehensive Diabetes Care (comprised of three mea- sures) and Annual Monitoring for Patients on Persistent CPC-Participating Practices Showed Medications quality measures (Figure 2). Practices with Positive Trends in Utilization and Costs fewer than 30 patients were excluded from this analysis, The second analysis highlighted utilization and cost which is for the 2017 calendar year. measures. Utilization measures include commercial, Medicaid, Medicare Advantage, and Medicare fee-for- We focused on these six quality measures because they: service data; cost measures include commercial data • Showed statistically significant results (P<0.05) in at only, due to restrictions on sharing noncommercial least the all-payer combined category; cost data.6 For each measure, Comagine Health took • Were selected as priority measures by the CPC+ the average of all practices in each group where the Payer Group as well as by commercial payers and practice had at least 30 attributed primary care patients Medicaid; and in the measure denominator. Practices with fewer than 30 patients were excluded from this analysis. Medicare Figure 2. CPC-Participating Practices Had Higher Performance Rates Figure 2. CPC-Participating Practices Had Higher Performance Rates of Diabetes Care and of Diabetes Care and Monitoring of Persistent Medication Monitoring of Persistent Medication Practices participating in both CPC Classic and CPC+ Comparison practices Diabetes HbA1c Testing^ Diabetes Eye Exam Performed^ 92%* 93%* 91%* 87%* 90%* 87%* 52%* 43% 54%* 46%* 43% 47%* Commercial Commercial Medicare Commercial Commercial Medicare + Medicare + Medicare Diabetes Medical Attention for Nephrology^ Annual Monitoring for Patients on Persistent Medications – Total 78%* 73% 79%* 86%* 85%* 84%* 84% 71%* 71% 72%* 79%* 80%* 81%* 83% Commercial + Medicare Commercial Medicare All Payers Commercial Medicaid Medicare Notes: * Indicates that the difference is statistically significant (P<0.05). ^Indicates diabetes data for 12 months ending June 2017. Data for Notes:Medicaid * Indicateswas that not the difference available isfor statistically this timesignificant period. (P<0.05). Milbank Memorial Fund • www.milbank.org 5 2 WWW.MILBANK.ORG Figure 3. CPC-Participating Practices Had Higher Outpatient Visit Rate Figure 3. CPC-Participating Practices Had Higher Outpatient Visit Rates Outpatient Visits Visits per 1,000 Member-years 9000 8,279* 8000 7,194 7000 6,136* 6000 5,038 5,100* 5000 4,283 4,150* 3,851 4000 3000 2000 1000 0 All Commercial Medicaid Medicare Comparison Group Participating Practices Notes: * Indicates that the difference is statistically significant (P<0.05). Notes: * Indicates that the difference is statistically significant (P<0.05). fee-for-service data were made available through the Participating practices had lower adult emergency depart- Medicare Qualified Entity program. ment (ED) utilization and fewer avoidable ED visits than PPT Presentation Tips Participating practices had significantly more adult comparison practices. Significance varied by payer type 3 WWW.MILBANK.ORG outpatient visits than comparison practices across all (Figure 4). payer types (Figure 3). These findings are consistent with the CPC program emphasis on enhancing primary care and care coordination to improve patient outcomes. Figure 4. CPC-Participating Practices Had Lower ED Utilization Figure 4. CPC-Participating Practices Had Lower ED Utilization Emergency Department Visits Avoidable Emergency Department Visits per 1,000 Member-years Visits 700 652 630* Visits per 1,000 Member-years 600 100 500 459 410 75 70 398* 62 400 340* 300 50 41 41 30* 33* 200 182 157* 25 18 14 100 0 0 All Commercial Medicaid Medicare All Commercial Medicaid Medicare Comparison Group Participating Practices Comparison Group Participating Practices Notes: * Indicates that the difference is statistically significant (P<0.05). Milbank Memorial Fund • www.milbank.org 6 Notes: * Indicates that the difference is statistically significant (P<0.05). Figure 5. Per Member per Month Facility Costs Were Lower for Commercially Figure 5. Per MemberInsured per MonthPatients inWere Facility Costs CPC-Practices Lower for Commercially Insured Patients in CPC-Practices Adjusted Allowed Facility Costs Per Member Per Month (Claims-based) Commercially Insured Patients 150 149 125 128* 100 75 80 67* 50 25 32 25* 0 Emergency Services Inpatient Services Outpatient Services Comparison Group Participating Practices Notes: * Indicates that the difference is statistically significant (P<0.05). Notes: * Indicates that the difference is statistically significant (P<0.05). Practices participating in both CPC Classic and CPC+ IMPLICATIONS had lower per member per month adjusted claims-based PPT Presentation Tips While we cannot claim causation, we found that partici- costs of adult emergency services, inpatient services, 5 WWW.MILBANK.ORG pation in CPC Classic and CPC+ is associated with posi- and outpatient facility costs among commercially in- tive outcomes in cost, quality, and utilization compared sured patients. Differences were statistically significant to nonparticipating clinics. Combining all payer types across all three service areas (Figure 5). frequently resulted in statistically significant differences Although CPC-participating practices receive non-fee- when an individual payer type’s results may not have for-service funds through care management fees and been statistically significant or sometimes showed performance-based incentive payments, Comagine better performance in nonparticipating practices. For Health did not try to compare professional costs be- example, the measure Annual Monitoring for Patients on tween practices because this additional professional Persistent Medications – Diuretics, a subset of the “Total” reimbursement is not captured in available claims data. measure, showed statistically significantly better per- This analysis reflects only claims-based facility costs, formance among participating practices when all payer which are not expected to be directly affected by the types were combined. However, within Medicaid, partic- additional CPC payments. ipating practices performed worse on this measure than Cost measurements were adjusted for practices’ average nonparticipating practices (not statistically significant). risk score. Practices participating in both CPC Classic Also, only the Medicare result was statistically significant and CPC+, on average, had adult patient populations that among payer types when examined alone, but when all were more likely to be hospitalized or become high- payer types were combined, the result was significant. resource users (were sicker) than the comparison group. This is a demonstration of the value of aggregated In the commercial population, the average adjusted risk data; if we were to assess these measures using only of the participating practices was 1.06 and the compari- one payer type, the overall impact on practices’ patient son practices’ average risk score was 0.96. populations would not be visible. Milbank Memorial Fund • www.milbank.org 7 Since the Payer Group published the Data Bytes, stake- models that allow for consistent, flexible payment holders across the state and the nation, including CMS, structures. Understanding the opportunities and chal- have expressed interest in learning more. Payers in the lenges of value-based payment, highlighted through state are considering how this data informs decisions longitudinal data aggregation efforts, is an integral part about value-based payment efforts; a number of regions of this journey. We hope the Oregon experience will have asked about the process the Payer Group used to serve as a launching pad for other states to analyze and get agreement on data aggregation and publication. The evaluate their value-based payment experiences so we policy implications remain to be seen, but we expect that can continue to learn from and share with each other. the results will shore up support for the CPC+ payment model and for the continued shift to implementation of aligned value-based payment models across the state HOW COMAGINE HEALTH and, perhaps, nationally. CONDUCTED THIS STUDY The data source is Comagine Health’s Oregon Data Collaborative, a voluntary all-payer claims database in MOVING FORWARD Oregon. All measures are from calendar year 2017, except During the last 18 months of CPC+, the Oregon Payer the comprehensive diabetes care measures. Due to Group has committed to continue convening regularly, data integrity issues with those three measures in the with a focus on gathering, analyzing, and disseminating calendar year 2017 data, they are based on the 12 months information that demonstrates the benefits of val- ending June 30, 2017. Medicaid data were not available ue-based payments via the CPC+ model. The Payer Group for those measures for that period. will work with Comagine Health to create at least five For each measure, Comagine Health took the average more Data Bytes. Comagine Health and the Payer Group of all practices in each group where the practice had at are exploring the following topics: primary care cost, least 30 attributed primary care patients in the measure quality and utilization trends over time; behavioral health denominator. Analysts used generalized linear model integration; specialty care; care coordination and care regression to compare rate scores and percent scores transitions; and emergency department and inpatient by CPC program participation status (participating vs. utilization. Future reports will include a three-way comparison) for all measures and stratified by payer comparison of practices that participated in both CPC+ type. Statistical significance was set at P<0.05. Mean and CPC classic; practices that participated in CPC+ values were generated by measure for each CPC status. only; and those that participated in neither program. All analyses were conducted using SAS Software 4.0 (SAS In an encouraging development, CMS has expressed Institute Inc., Cary, NC).7 interest in funding additional Data Bytes and will make its decision to do so over the next year. The Oregon Data Collaborative does not have claims information for all the self-insured population in the The COVID-19 pandemic has strained the nation’s health state, national commercial insurers, Tricare, or services care system, especially primary care. The rapid changes provided by the Indian Health Service. This point-in-time in health care utilization have further demonstrated the study did not assess practice performance upon joining inadequacies of a fee-for-service payment environment. a CPC program and cannot rule out selection bias among As a result, many are turning away from fee-for-service practices joining a CPC program. and looking to a system focused on value-based payment Milbank Memorial Fund • www.milbank.org 8 Notes 1 The Oregon CPC+ Payer Group is comprised of: Advanced Health, AllCare Health, CareOregon, InterCommunity Health Network CCO, Moda/Eastern Oregon CCO Oregon Health Authority, PacificSource Health Plans, Primary Health, Providence Health Plan and Providence Health Assurance, Trillium Community Health, UnitedHealthcare, Willamette Valley Community Health, Yamhill Community Care, Centers for Medicare & Medicaid Services. Note: the organizations in italics are not participating in the CPC+ Payer Group as of September 2020. Primary Health and Willamette Valley Community Health no longer operate as coordinated care organizations or payers in Oregon; Trillium Community Health does not contract with any CPC+ providers; and Advanced Health decided not to partici- pate in the final 18 months of the convening contract. 2 Comagine Health is one of the three co-conveners of the Oregon CPC+ Payer Group. Their role as the data aggrega- tor remains separate. 3 Medicare fee-for-service data is available through Comagine Health’s participation in the Medicare Qualified Entity program. 4 In two cases in our overall analysis, the combined rate is in the opposite direction of all the individual payer results. The measures Antidepressant Medication Management: Effective Acute Phase Treatment and Antidepressant Medication Management: Continuation Phase Treatment showed lower rates for every payer type (commercial, Medicaid, and Medicare Advantage) when looked at separately, but higher rates when all payers were combined. This is because CPC-participating practices have a lower proportion of Medicaid members than nonparticipating practices, and Medicaid has a much lower compliance than other payer types on these two measures. Within Medicaid, there was no statistically significant difference on these two measures between CPC-participating prac- tices and nonparticipating practices, although within the commercial payer type the difference was statistically significant. 5 Centers for Medicare & Medicaid Services. CMS.gov. Comprehensive Primary Care Plus. Available at: https://inno- vation.cms.gov/initiatives/comprehensive-primary-care-plus/. Accessed November 2, 2020. 6 Medicare fee-for-service data is available through Comagine Health’s participation in the Medicare Qualified Entity program. 7 CPC+ Payer Group. Resources. http://cpcplusoregon.org/resources. Accessed November 2, 2020. Milbank Memorial Fund • www.milbank.org 9 ABOUT THE AUTHORS Diana Bianco, JD, of Artemis Consulting has supported clients in navigating the changing health care environment for more than 20 years. Ms. Bianco specializes in providing strategic advice and convening diverse stakeholders to help them determine how they can work together to improve the health of their communities. She started her career in health care studying Medicaid law, built expertise working on policies to improve the health care system, and, as a long-time consultant, has worked with government, nonprofit advocacy groups, federally qualified health clinics, business groups, hospital and provider associations, insurers, state boards and task forces, health care providers, and patients to improve the health system. The issues she has focused on include the intersection of health care and public health; implementing value-based payment mechanisms; the challenges and opportunities of Medicaid expan- sion; the importance of an equity lens; the integration of physical and behavioral health; the social determinants of health; and numerous other emerging opportunities. Ms. Bianco has worked on primary care payment reform through the CPC+ Payer Group and Oregon’s Primary Care Payment Reform Collaborative. Chris DeMars, MPH, is the director of the Oregon Health Authority (OHA) Transformation Center and the deputy direc- tor of the Delivery Systems Innovation Office, overseeing programs to support innovation and quality improvement within Oregon’s health system reform efforts. Ms. DeMars also plays a lead role in the agency’s value-based payment and social determinants of health work. Before joining OHA in 2013, she spent eight years as a senior program officer at the Northwest Health Foundation, managing the foundation’s health reform grantmaking. Prior to working for the foundation, Ms. DeMars spent six years as a senior health policy analyst for the U.S. Government Accountability Office, where she authored reports for Congress on Medicaid, Medicare, and commercial payment policy. She has also held positions at Kaiser Permanente Northwest and health-policy consulting firms, including Health Management Associates. Lisa Miller, MPH, manages programs for Comagine Health’s analytic services division, including the Oregon Data Collaborative. The collaborative reports on the quality, utilization, and cost of Oregon’s health care system. In this role, Ms. Miller manages the provider and payer reporting portals; directs CPC+ data aggregation efforts for the Oregon region; convenes two advisory committees providing guidance to the Oregon Data Collaborative; and directs custom projects using collaborative data. Before joining Comagine Health, she led quality improvement efforts at CareOregon and Oregon Health & Science University. Emilie Sites, MPH, joined Comagine Health (formerly Oregon Health Care Quality Corporation/HealthInsight) in 2016. She manages a variety of projects including Total Cost of Care, Healthcare Delivery Systems Analysis, and other affordability and transparency related projects. She is part of the convening team for the Comprehensive Primary Care Plus (CPC+) Payer Group in Oregon and also supports other Comagine Health multi-stakeholder groups. Prior to her time at Comagine Health, Ms. Sites worked in enrollment management and student affairs at Portland State University. She holds a bachelor’s degree in community health education and a Master of Public Health degree in health management and policy, both from Portland State University. Milbank Memorial Fund • www.milbank.org 10 About the Milbank Memorial Fund The Milbank Memorial Fund is an endowed operating foundation that works to improve the health of populations by connecting leaders and decision makers with the best available evidence and experience. Founded in 1905, the Fund engages in nonpartisan analysis, collaboration, and communication on significant issues in health policy. It does this work by publishing high-quality, evidence-based reports, books, and The Milbank Quarterly, a peer-reviewed journal of population health and health policy; convening state health policy decision makers on issues they identify as important to population health; and building communities of health policymakers to enhance their effectiveness. The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan analysis, study, research, and communication on significant issues in health policy. In the Fund’s own publications, in reports, films, or books it publishes with other organizations, and in articles it commissions for publication by other organizations, the Fund endeavors to maintain the highest standards for accuracy and fairness. Statements by individual authors, however, do not necessarily reflect opinions or factual determinations of the Fund. © 2020 Milbank Memorial Fund. All rights reserved. This publication may be redistributed digitally for noncommercial purposes only as long as it remains wholly intact, including this copyright notice and disclaimer. Milbank Memorial Fund 645 Madison Avenue New York, NY 10022 www.milbank.org