1) Claims data provides limited and inaccurate information about patient quality and health outcomes, as it primarily reflects billing practices rather than clinical data. 2) BCBSND launched the MediQHome project to obtain comprehensive clinical data directly from providers to better measure quality, risk adjust outcomes, and support care management and the patient-centered medical home model. 3) Over 1,200 primary care providers are participating in MediQHome, providing data on over 82 quality metrics across various chronic conditions, which is risk adjusted and used for benchmarking and practice transformation.

1. Point-of-Care Clinical Data Support & Care Management Integration. David S. Hanekom, M.D., F.A.C.P., C.M.P.E. October 6, 2009

2. Outline Claims data – accuracy and validity Quality Measurement and claims data Clinical data and quality measurement Patient-Centered Medical Home Benefits of clinical data

3. Medical Management Activities at BCBSND Uniform Participation Agreement Near-universal participation Specific Provider Performance standards in PAR Agreement Performance Standards enforceable via Corrective Action Policy Correction Action Policy transparent and available at www.bcbsnd.com All member/provider complaints of fraud/quality-of-care issues are formally investigated. Original source documentation is obtained. Medical director and formal coding review of all source documents.

4. Claims data Claims data represent: Billing practices of Provider Medical and billing requirements of payers Coding conventions and rules of organizations Reimbursement strategies of various groups Methodology for getting reimbursed to Providers and Patients.

5. Lessons Learned Claims data represent payment policy and reimbursement strategies and not clinically useful quality information. Claims data have huge gaps and is not useful for quality measurement or reporting.

6. Paradigm Shift Quality Measurement and Reporting will be: Clinical data supported by claims data Outcomes measures supported by process measures Clinically meaningful measures to clinician/patient/payer Comprehensive , multiple measures across multiple clinical conditions Clinical quality benchmarking that is condition specific and regionally relevant to North Dakota Clinical measures must be co-morbid condition risk-adjusted Performance reporting must reflect patient preference and fairly reflect clinician controlled/influenced quality of care.

7. Obtaining Clinical Data No single, uniform information technology platform available that would meet PCMH need. Contracted with vendor for custom-designed product that meets the following functionalities: Technology platform/vendor agnostic Allow for natural language processing Patient-centric data gathering Data gathering automated with option for manual entry modification Rigorous quality assurance and complete transparency of data Automatic risk-adjustment of metrics based on multiple clinical criteria Intuitive ease of use for front-line clinical staff Automated attribution process for clinical condition and personal physician Near “real-time data” at point of care via web-portal Complete transparency of all data, metrics, performance standards to all parties involved

8. MediQHome Quality Project Patient-Centered Medical Home 2 Large IHDS and 8 smaller clinical groups (Proof of Concept) MDInsight PCMH information technology platform (Free to providers) 1,200 PCP’s enrolled and acting as Personal Physicians 9 Chronic Condition Clinical Suites, 4 Wellness Suites 82 metrics tracked and displayed to Providers Metrics are risk-adjusted automatically Comparative quality reporting with benchmarking Quality reporting risk-adjusted for patient preferences and legitimate medical contra-indications to testing or treatment Quality reporting contextually adjusted for patient and clinical factors All data exportable by provider for additional data uses. Sponsor Portal with powerful auditing and reporting capabilities. www.thorconnect.org/nd/mediqhome

9. Lessons Learned Design of MDInsight Complex and challenging Data acquisition much less complex than anticipated. Clinical data resides in multiple places and originate from multiple sources (known and unknown to Provider) Significant variability in IT resources in front-line offices Resourcefulness of rural/smaller offices impressive Urgent need for quality data and comparative quality reporting Need and willingness to do practice transformation Acceptance of quality data as basis for transformation Recognition and embracement of prospective population management based on accurate data .

10. Disease Burden Disease burden much higher than that reflected by claims experience. Member’s have higher burden of complex co-morbid conditions than reflected in claims data. Claims data financial risk profiling e.g. ERG’sdo not reflect clinical risk as defined in clinical data. Patient preferences play major role in clinical risk and future financial risk.

11. Benefits of clinical data Benefit Design Disease burden more precisely defined Gaps in benefit design identified. Value-based design based Underwriting Disease burden and clinical risk well defined. Case Management Earlier and more targeted risk identification and intervention. Intervention targeted and customized to Member’s needs Disease management FEP members targeted with various programs Medical Policy Clinical data informs and guides medical policy generation and adjustment to support PCMH and population management.

12. Benefits of Clinical Data Quality Reporting Accurate, continuous, comparative and transparent Clinically and contextually adjusted. Locally , regionally, and nationally benchmarked. Provider Relations Cooperative, transparent Quality Initiative Provides Six Sigma, lean principles process support via consultant Employers Better product and program design for Self-funded Groups Customized wellness offerings based on clinical risk. Other External relations with other stakeholders

13. Summary Contacts Petrice Balkan MediQhome program Director petrice.balkan@bcbsnd.com David Hanekom, M.D., F.A.C.P., C.M.P.E. Medical Director david.hanekom@bcbsnd.com