Evaluation Options for Oregon’s Primary Care Transformation Initiative
Who we are and why we’re here John McConnell Christina Charlesworth Stephanie Renfro Center for Health Systems Effectiveness (CHSE) Our mission is to provide the analyses, evidence, and economic expertise to build a more sustainable health care system.
Who we are and why we’re here John McConnell Christina Charlesworth Stephanie Renfro Center for Health Systems Effectiveness (CHSE) Our mission is to provide the analyses, evidence, and economic expertise to build a more sustainable health care system. Contract with OHA to develop PCTI evaluation options
Oregon is pursuing ambitious reform efforts under SB934 Use value-based payment methods to: » Increase investment in primary care - Without increasing costs to consumers - Without increasing total cost of care » Align primary care reimbursement by all purchasers of care » Continue to improve reimbursement methods, including by investing in the social determinants of health
Considerations for evaluation design
Payment reform is a tool to support broader change Payment model design and recommendations
Payment reform is a tool to support broader change Payment model design and recommendations Adoption of recommendations “Did this actually happen?”
Payment reform is a tool to support broader change Payment model design and recommendations Adoption of recommendations Improved Increased primary Aligned reimbursement care investment reimbursement methods (+ SDOH) “If this actually happened- what were the effects?”
Payment reform is a tool to support broader change Particular interest in: » Integration of behavioral health » Reduced administrative burden » Comprehensive patient-centered care » Better quality and patient outcomes
What evidence is needed? $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption Did spending on primary care services increase? By how much?
What evidence is needed? $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption Did the total cost of care increase? Were consumer costs affected? What was the role of prices vs utilization?
What evidence is needed? $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption Did payers increase their use of Collaborative-recommended payment methods? For example, did contracts including comprehensive population- based payments (HCP-LAN category 4B) increase?
What evidence is needed? $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption What progress was made towards aligning reimbursement methods across payers?
What evidence is needed? $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption Did service use patterns change? For example, did avoidable ED visits decrease? Did quality of patient care change? For example, did rates of chlamydia screening, adolescent well-care visits, or follow-up after hospitalization for mental illness increase?
What evidence is needed? $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption Did payment methods facilitate clinic investment in social determinants of health?
What evidence is needed? $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption Did clinics integrate behavioral and primary care practice? For example, did use of Collaborative-recommended billing codes to support integrated health clinics increase? Did clinic workflows change? For example, are there more warm hand-offs between primary care and behavioral health providers?
Evaluation options
How we got here Challenges » What questions do we really care about answering? » What can we measure? Limits of administrative data » Constructing a treatment variable » Implementation vs participation » Hard to get at clinic-level
How we got here With a little help from our friends » PCTI Evaluation Workgroup » Collaborative meetings » OHA staff, Diana Bianco » Supplementary feedback from payers, providers
How we got here What we bring you today » Four evaluation options » Complementary » Not mutually exclusive » Evaluation Workgroup most interested in Options 1-3 (to start!)
Option 1 Option 2 Option 3 Option 4 Describe Cross-state Cross-clinic Qualitative payment Commercial Medicaid clinic sample arrangements comparison comparison Increased investment in X primary care Containment of total costs $ X of care & costs to consumers Adoption of value-based X X X payment methods Alignment of value-based X X payment methods Improvement on utilization X X and quality measures Adoption of payment X methods to address SDOH Integration of physical and X X X behavioral health
1 Describe payment arrangements Big-picture description of payment model adoption, and alignment of contracting arrangements over time
1 Describe payment arrangements Big-picture description of payment model adoption, and alignment of contracting arrangements over time $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption
1 Describe payment arrangements Big-picture description of payment model adoption, and alignment of contracting arrangements over time » Includes all payers » Actionable information about implementation » Updates possible annually » Important context for interpreting other results » Hinges on payer-reported data $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption
2 Cross-state commercial comparison Compare commercial patient outcomes in Oregon to control states before and after the Initiative
2 Cross-state commercial comparison Compare commercial patient outcomes in Oregon to control states before and after the Initiative $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption
2 Cross-state commercial comparison Compare commercial patient outcomes in Oregon to control states before and after the Initiative » Strong design and methods will yield high quality evidence » Disentangles role of service use and price in total costs » Can inform return on investment question » Stakeholders do not need to report any data $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption
3 Cross-clinic Medicaid comparison Compare Medicaid contracting arrangements and patient outcomes for Oregon PCTI vs. non-PCTI clinics
3 Cross-clinic Medicaid comparison Compare Medicaid contracting arrangements and patient outcomes for Oregon PCTI vs. non-PCTI clinics $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption
3 Cross-clinic Medicaid comparison Compare Medicaid contracting arrangements and patient outcomes for Oregon PCTI vs. non-PCTI clinics » Leverages CCO data on patient-clinic assignment & attribution » Study design weaker than Option 2 (eg, no control state) » Some implementation information, but for Medicaid only » CCOs and OHA need to report data $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption
4 Qualitative clinic sample Survey a sample of clinics about microsystem changes related to VBP, behavioral health integration and SDOH
4 Qualitative clinic sample Survey a sample of clinics about microsystem changes related to VBP, behavioral health integration and SDOH $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption
4 Qualitative clinic sample Survey a sample of clinics about microsystem changes related to VBP, behavioral health integration and SDOH » Rich information about clinic-level changes that is not available elsewhere » Relevant to all payers » Primary data collection is resource-intensive $ Primary care Cost VBP Payment Service use & Payment for Behavioral health investment containment alignment quality SDOH integration adoption
Timeline Implementation Collaborative convenes through 2027 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 YR 1 YR 2 YR 3 CPC+ CPC+ Others Track 2 Track 1, FQHCs, etc
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