This webinar discusses primary care as part of a value-based plan and how to promote primary care through benefit design and employee engagement.

1. High Value Primary Care:
How Can Employers Identify and
Promote It?
SEPT 27, 2017

2. Agenda
• Primary Care as Part of a Value-Based Plan—Robert (20 mins)
• Promoting Primary Care Through Benefit Design and Employee Engagement—Diane (20 mins)
• Q&A (20 mins)
Diane Stewart
Senior Director, Redesign Care Delivery
PBGH
Robert Smith,
Executive Director
CBGH

3. Logistics
• Line muted.
• Questions in chat box throughout.
• Email kklaas@pbgh.org for slides.

4. Primary Care as Part of a Value-Based Plan
Robert Smith, Colorado Business Group on Health
robert.smith@cbghealth.org

5. What We’ll Cover
• About Prometheus: Patient-Centric Accounting (vs Site of Care)
• The Treatment of Chronic Disease: Observed Variation
• Trends in Chronic Disease: Observed Trends
• Conclusions

6. 1. Identify Relevant Costs 2. Separate/Segment PACs
Use clinical guidelines to sort
RELEVENT claims into those
associated with...
Charges that are
RELEVENT
to the disease
and associated with any
co-morbid
conditions.
“Potentially”
Avoidable
Complications
(and costs)
Charges that are
IRRELEVENT
to the disease
and any co-morbid
conditions.
Examine every claim for every
eligible patient and sort as....
Prometheus: A Clinically-Based Model for Supporting…
Continuous Quality Improvement
“Typically”
Provided
Services
(and costs)
$ $

7. PACs* in Chronic Care
for Six Health Plans in Colorado
PAC
Percentage CHF COPD DM Asth. HTN CAD GERD
Plan A 65% 47% 33% 34% 23% 18% 29%
Plan B 62% 45% 25% 32% 21% 15% 31%
Plan C 58% 45% 38% 35% 23% 33% 42%
Plan D 56% 44% 30% 36% 20% 13% 25%
Plan E 73% 47% 42% 45% 25% 11% 36%
Plan F 65% 49% 36% 37% 27% 25% 26%
CO Ave.* 63% 46% 34% 37% 23% 19% 32%
US Ave. 56% 45% 29% 29% 17% 14% 35%
US Max 69% 61% 36% 41% 25% 23% 43%
US Min 40% 26% 21% 22% 14% 9% 17%
*Potentially Avoidable Costs as a % of Total Spend:
“Every system is perfectly designed for precisely the results it gets.” Don Berwick, MD

8. 436
1043
306
765
366
739
0
200
400
600
800
1000
1200
$-
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
Asthma CAD COPD DM GERD HTN
ALL_TYP_AMT ALL_PAC_AMT N
Assessing Potentially Avoidable Costs for three
Colorado Springs Employers

9. What We’ve Observed Over 5 Years
1. Incidence of chronic disease has increased quarterly entire period
• For each of six chronic diseases with hypertension, coronary artery diseases & diabetes leading the
way – by a lot
• For each and every one of seven employers
• Approximately 1/3+ of the employee population has one of these six chronic diseases
2. Delivery of “typical” (e.g., expected) primary care has been decreasing annually for six of
the seven employers
• In general, 10-15% of patients receive >90% and <10% of expected care
• Overall, 70-80% receive only about 50% of recommended, evidence-based care
• Variation consistent across employers and primary care groups
• Majority of catastrophic cases (e.g., >$50k) were patients with an underlying chronic disease who
had not seen a physician in >3 years. Highest cost patients incurred $250-500k.

10. Observed….Cont’d
3. Less spending on “Typical”
services consistently correlates
with greater spending on ”PACs.”
4. Patients with more co-morbid
conditions have increased PACs.

11. Conclusions
1. Employers and primary care physicians are most aligned parties in the
healthcare market place.
2. Spending 5-7% of premium on primary care when 50-70% of costs are driven
by chronic conditions seems wholly inadequate and illogical.
3. Working with primary care physicians on an inclusive basis makes most
sense given importance of continuity of care and need for a holistic approach
to treating patients with multiple co-morbid conditions..
4. Reducing the clinical and financial burden of chronic disease requires:
1. Clinically-based reporting (versus actuarially-based) for physicians.
2. Value-based insurance designs to encourage the use of primary care.

12. Primary care as foundational strategy:
How It Might Look:
Preventative &
Primary Care
Procedures &
Episodic Care
Underlying Issues
• Underuse/Gaps in Care
• Compliance
• Underspending
Issues
• Overuse
• Inappropriate demand
• Over-spending
Issues
• Misuse/medical error
• Variation in Outcomes
Catastrophic
Care
Comp. Solutions
• Centers of Excellence
• Case Management
Comp. Solutions
• Transparency Tool
• Help Line
Component Solutions
• Risk Assessments/Screenings
• Nat’l Diabetes Prevent Prgm.
• PCP Relationship
• Advance Primary Care Value-Based Benefit Design

13. Promoting Primary Care Through Benefit Design
and Employee Engagement
Diane Stewart, Pacific Business Group on Health
dstewart@pbgh.org

14. Employer Primary Care Action Guide
1. Change your benefit
design to encourage
stronger relationship
between patients and
a primary care
physician
2. Work with your carrier
or TPA to change
provider payment
3. Engage your
employees by promoting
transparency among
primary care practices
4. Support state and
federal policies that
strengthen primary care

15. Promote Primary Care through
Benefit Design
1. Ensure employees, even those in a
PPO, select a Primary Care Provider
during open enrollment
1. Incentivize primary care use
• Defined number of free visits
• Waived copays

16. Promote Primary Care through
Employee Engagement
1. Ensure performance data
available, accessible and
visible in online provider
directories
2. Encourage employees to
choose high value primary
care providers by asking a set
of questions…

17. Questions to Ask When Choosing a New Primary
Care Provider: Signals of High Value Primary Care
E-access to records
and care team
• Will I be able to see my
medical record online?
• Can I message my
doctor or care team
through email/online
portal?
Team-based care
• Is there someone other
than the doctor who
can help me with tasks
like refilling
medications, learning
about a condition, or
managing a chronic
disease?
In-office procedures
• Can the doctor and
care team do the
following in the office:
freeze a wart, inject a
knee with cortisone,
conduct women’s
health procedures,
such as inserting an
IUD?
Population health
management
• Will someone from the
care team contact me
to help remind me
when screenings or
regular blood tests are
due before my next
appointment?
24/7 access
•Is there a doctor, nurse
or other person
available to speak to
me after hours? Does
that person have the
ability to access my
medical record?
Care coordination
•Do you have a method
of staying informed
when I receive care
outside of the clinic,
such as care received
from the Emergency
Department or
specialists?
Appointment access
•Do you hold
appointments in your
schedule every day for
same day visits?
Mental health services
•Do you have onsite
counseling services to
help patients who are
experiencing stress or
emotional problems, or
ways to help patients
with referrals to a
counselor?

19. Contact Us:
Robert Smith, Executive Director, CBGH
robert.smith@cbghealth.org
Diane Stewart, Senior Director, PBGH
dstewart@pbgh.org
Kelly Klaas, Purchaser Value Manager, PBGH
kklaas@pbgh.org
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