Value-Based Payment Study

Transcription

1 Value-Based Payment Study

2 Page 2 of 133 Value Based Payment Survey TABLE OF CONTENTS EXECUTIVE SUMMARY... 4 METHODOLOGY... 5 DETAILED FINDINGS... 7 Staff at Primary Location... 7 /Health Plans Received in Past 12 Months... 8 Formal Agreements at Primary Location... 9 Medical Home Status Familiarity with Value-Based Payment Strategy Toward VBP by Practice Reasons for No Strategy Toward VBP by Practice VBP Models Available in Area Importance of Factors to Determining VBP Success Attitudinal Statements on VBP Referral Considerations Percent of Compensation Linked to Quality/Cost Measures Participation in Value-Based Payment Key Drivers of Participation in Value-Based Payment Method of VBP Distribution in Practice Preparations to Participate in VBP Accessible Data for Quality Improvement and Population Health Management Source of Data for Quality Improvement and Population Health Management Frequency of Reconciling Reports Due to Inaccurate Data Help for Improving Quality/Cost Reports Identifying High-risk Patients Resources or Personnel Used for Care Management/Coordination Degree of a Barrier to Implementing Value-based Care Delivery Degree of a Barrier to Accepting More Financial Risk Value-based Payment Medicare Payment Pathway Assess Behavioral Health Needs... 33

3 Page 3 of 133 Barriers to Implementing Behavioral Health Services Helpfulness of Adding Pharmacy Services Demographics Appendix A: Historical Trends Appendix B: Open-Ended Responses Appendix C: Cross Tabulations...72

4 Page 4 of 133 EXECUTIVE SUMMARY Practice Characteristics More than seven in 10 (73%) practices include a nurse practitioner or physician assistant while 32% include a care manager/coordinator. Nearly four in 10 (37%) family physicians practices received payments from 10 or more payers during the past 12 months. This number has stayed consistent with 2015 findings. Half of family physicians practices (49%) are recognized as a medical home, which was significantly higher than 40% in Value-Based Payment Familiarity and Utilization Six in 10 (60%) indicated they were either extremely familiar or moderately familiar with the concept of value-based payment (VBP), which was consistent with 57% in Significantly fewer said they were not at all familiar in 2017 than in 2015 (12%). Nearly half (47%) of the practices are actively pursuing VBP opportunities. The remaining practices are developing capabilities but are waiting until results are better known before fully pursuing VBP (23%) or holding off on making changes and focusing on optimizing under feefor service (22%). Factors Important to the Success of VBP Implementation According to family physicians, the most important factors for determining the success of VBP models are clinical outcomes (91%), practice sustainability (90%), and physician/staff morale (91%). There were no significant differences between 2015 and 2017 on any of the success factors. Distribution of VBP When looking at the distribution of payments, four in 10 (37%) indicated payments based on quality measures were distributed to physicians, which was significantly higher than 18% in In 2017, significantly fewer reported payments were funneled through administration than in 2015 (19% versus 26%). Three in 10 still do not know how payments are distributed (consisted with 33% in 2015). Practice Changes Made to Participate in VBP More than half (54%) are updating or adding health IT infrastructure for data management and analysis in preparation to participate in VBP. Significantly more family physicians are hiring care coordinators (43% versus 33%) and behavioral health support (22% versus 15%) in 2017 than in Key Drivers for VBP Participation Based on the binary logistic regression model, the key five drivers of VBP participation are the following: 1) has an ACO agreement, 2) practice is a designated medical home, 3) has made at least one practice change in preparation for VBP, 4) knows their Medicare payment pathway, and 5) finds financial IT investment as a barrier.

5 Page 5 of 133 METHODOLOGY Survey The survey instrument was developed with the Division of Practice Advancement and Humana. The primary purpose of the study was to assess practice characteristics, attitudes towards value-based payment (VBP) models, the current utilization of VBP models, and practice functions related to VBP. In addition, to determine if there are any differences in the results in comparison to the 2015 study. Sample Selection and Survey Invitation A randomly selected sample of 5,000 active members of the American Academy of Family s (AAFP) was invited to complete the survey. A printed copy of the survey was mailed to all invitees (with a postage-paid return envelope). At the same time, an invitation was also sent to the invitees with a link to the online version of the survey. A secondary mailing and were sent to the non-respondents. Survey Responses and Inclusion A total of 482 surveys were completed with identifiable AAFP IDs. The first question on the survey was a screener to identify the family physician s primary role and practice setting. This question identified 386 respondents who spend most of their time in clinical practice and patient care (see Table 1). As a result, the final sample consisted of 386 respondents. Table 1: Which of the following duties account for most of your time during a typical week? n Percent Clinical practice and patient care % Administration or managerial tasks not directly related to patient care % Research 2 0.4% Teaching % Urgent Care % Emergency Room 6 1.2% Other % Direct Primary Care 8 1.7% Total surveys returned = 482

6 Page 6 of 133 Respondent Demographics and Data Weights Compared to the entire population of AAFP active members, the survey sample underrepresents females and new physicians. Table 2: Comparison of Selected Demographics Between Survey Respondents and All Active Members Survey Respondents Active Membership N = 386 N = 70,105 SEX Male 63.2% 56.5% Female 36.8% 43.5% YEARS OUT OF RESIDENCY 1 to 7 years 15.5% 25.1% 8 to 14 years 16.3% 20.0% 15 to 21 years 19.9% 21.7% More than 21 years 48.2% 33.2% To account for difference in the demographic makeup of the survey sample, weights were applied during the calculations of overall results to adjust for gender and years out of residency. Table 3: Data weights used in calculations Years out of Residency Sex Weight 1 to 7 years 8 to 14 years 15 to 21 years More than 21 years Male Female Male Female Male Female Male Female

7 Page 7 of 133 Practice Characteristics Staff at Primary Location DETAILED FINDINGS Nearly three-quarters (73%) of the physicians work in a practice with at least one nurse practitioner (NP) or physician assistant (PA). One-third of physicians (33%) work in a multiple-specialty practice with at least one other primary care specialist (e.g., pediatrics, internal medicine). One-quarter (26%) work in a multiple specialty practice with a specialist physician. Staff at Primary Location Nurse practitioner or physician assistant 73% Other primary care physicians (pediatrics, internal medicine) 33% Care manager/coordinator 32% Behavioral specialist (LSW, clinical psychologist or psychiatrist) 29% Specialist physicians 26% Pharmacist 22% None of the Above 12% Other 5% 0% 20% 40% 60% 80% Q: What types of other clinicians are available at your primary location? (Multiple selection) (n=344)

8 Page 8 of 133 /Health Plans Received in Past 12 Months When respondents were asked approximately how many different payers/health plans have they received payment during the past 12 months, nearly four in 10 physicians (37%) have received payment from more than 10 payers/health plans. The remaining physicians indicated between 7 to 10 payers (21%) or between 1 and 6 payers (15%). One-quarter (24%) are not certain about the number of different payers from which they receive payments. /Health Plans Received in Past 12 Months None 3% 1 to 3 4% 15% 4 to 6 11% 7 to 10 21% More than 10 37% Don't know 24% 0% 5% 10% 15% 20% 25% 30% 35% 40% Q: In the past 12 months, from approximately how many payers/health plans do you receive payment? (n=347)

9 Page 9 of 133 Formal Agreements at Primary Location More than six in 10 physicians (63%) are in a practice associated with an accountable care organization (ACO) or a similar population care arrangement. Nearly four in 10 are affiliated with a clinically integrated network (CIN) (38%) or an independent practice association (36%). Formal Agreements at Primary Location Have Agreement Currently Negotiating an Agreement No Agreement n Accountable Care Organization or similar population care arrangement Clinically Integrated Network (CIN) Independent Practice Association 63% 5% 38% % 4% 60% % 1% 63% 206 Ownership by Insurance Company 7% 1% 94% 191 Q: What type of formal agreements does your primary location have? (Multiple selection)

10 Page 10 of 133 Medical Home Status Nearly half of physicians (49%) are in a practice that is recognized as a medical home. Another 5% are in a practice that has submitted an application for medical home status. Medical Home Status Yes 49% Application submitted 5% No 46% 0% 10% 20% 30% 40% 50% 60% Q: Is your practice designated/recognized as a medical home? (n=333)

11 Page 11 of 133 Attitudes about Value-Based Payment (VBP) Models Familiarity with Value-Based Payment Six in 10 physicians (60%) were either extremely or moderately familiar with the concept of valuebased payment. Three in 10 (31%) were slightly familiar with the concept. The remaining physicians were either not at all familiar (7%) or don t know (3%). Familiarity with VBP Extremely familiar 17% 60% Moderately familiar 43% Slightly familiar 31% Not at all familiar 7% Don't know/no response 3% 0% 10% 20% 30% 40% 50% Q: How familiar are you with the concept of value-based payment? (n=350)

12 Page 12 of 133 Strategy Toward VBP by Practice Nearly half of physicians (47%) are in a practice that are actively pursuing VBP opportunities. The remaining physicians are in a practice that are developing the capabilities for VBP but waiting to determine if VBPs are worth pursuing (21%) or holding off on making change and focus on optimizing under fee-for-service (19%). Strategy Toward VBP by Practice Actively pursue VBP opportunities today 47% Develop capabilities, but wait until the results are better known before fully pursuing 21% Hold off on making changes, focus on optimizing under fee-for-service 19% Other 13% 0% 10% 20% 30% 40% 50% Q: What is your practice s current status or strategy toward value-based payment? (n=335)

13 Page 13 of 133 Reasons for No Strategy Toward VBP by Practice Of the physicians who are currently in a practice that are not actively pursuing value-based payment opportunities, the physicians employer makes the decision of VBP strategies (42%) was the primary reason cited for not implementing a strategy for VBP. Other reasons cited included: being too busy and overwhelmed to think ahead (33%), not enough payment to make practice changes (27%), and VBP is too risky (18%). As indicated in the chart below, other reasons were mentioned with less frequency (15% or less). Reasons for No Strategy Toward VBP by Practice Employer makes the decision of VBP strategies 42% Too busy and overwhelmed to think ahead 33% Not enough payment to make necessary practice changes for VBP 27% Value-based payment is too risky 18% I am able to provide high-quality care under fee-forservice 15% Current rewards are not worth the benefit 13% I don't know where to start 10% Not enough evidence to support VBP 9% Other 20% 0% 10% 20% 30% 40% 50% Q: If your practice does not have a strategy toward value-based payment, why not? (Multiple selection) Base: Those who aren t actively pursuing VBP opportunities. (n=203)

14 Page 14 of 133 VBP Models Available in Area The two most common types of VBP models available to physicians in their market are shared savings (31%) and pay-for-performance (31%). This was followed by per member per month (PMPM) payment (23%), capitation (19%), and CME Comprehensive Care Plus (CPC+) (17%). It should be noted less than half of the physicians (44%) are uncertain about the availability of VBP models in their market. VBP Models Available in Area Shared savings 31% Pay-for-performance 31% Per member per month (PMPM) payment (care management fee) 23% Capitation (global payments) 19% CMS Comprehensive Care Plus (CPC+) 17% Bundled/episode-based payments 16% Don't know/not sure 44% Other 1% 0% 10% 20% 30% 40% 50% Q: Which of the following value-based payment models are available in your market? (Multiple selection) (n=328)

15 Page 15 of 133 Importance of Factors to Determining VBP Success s were asked to rate the level of importance of several factors to determine the success of a VBP program. Based on the top-two box scores combined (very important and somewhat important), several factors surfaced to the top as important. The following four factors were cited most often as important in evaluating the success of a VBP program: clinical outcomes (91%), physician and staff morale (91%), practice sustainability (91%), and coordination of patient care (88%). More than eight in 10 physicians cited savings for the practice (84%) and patient satisfaction (81%) are key factors in determining the success of a VBP program. Lastly, seven in 10 (70%) cited the importance of population health management capabilities. Importance of Factors to Determining VBP Success Very important Somewhat important SUBTOTAL Neutral Somewhat not important Not at all important n Clinical outcomes 75% 16% 91% 7% 1% 2% 317 and staff morale 65% 26% 91% 5% 2% 3% 317 Practice sustainability 75% 16% 91% 6% 1% 2% 316 Coordination of patient care Cost savings for my practice 53% 35% 88% 8% 1% 4% % 36% 84% 13% 1% 2% 313 Patient satisfaction 50% 31% 81% 14% 2% 3% 315 Population health management capabilities 35% 35% 70% 18% 6% 5% 314 Q: Please rate the importance of the following factors for being able to determine whether a value-based payment program has been successful?

16 Page 16 of 133 Attitudinal Statements on VBP As a way to determine physicians perceptions of VBP, physicians were asked to rate their level of agreement (5-point scale) on 10 attitudinal statements. Most of the physicians agreed that practices will have to make substantial investments in technology to be successful in a VBP model (86%). Nearly six in 10 physicians believe VBP models will add more work for physicians with no benefit to the patient (58%) and in a positive note will put family physicians in important central roles within medical groups (56%). Attitudinal Statements on VBP Practices will have to make substantial investments in health information technology to be successful in a VBP model VBP models will add more work for physicians, when there is no benefit to the patient VBP models will put family physicians in important central roles within medical groups VBP models will encourage greater collaboration between primary care physicians and specialists VBP models have the potential to increase practice revenue Strongly agree Somewhat agree SUBTOTAL Disagree Strongly disagree Don t know 53% 33% 86% 4% 1% 10% % 30% 58% 21% 6% 16% % 38% 56% 19% 9% 15% % 35% 51% 22% 9% 19% 322 5% 27% 32% 20% 16% 31% 321 n VBP models will improve patient care 5% 27% 32% 24% 18% 26% 319 VBP models reduce society s overall health care costs VBP models will allow more time with patients Quality expectations are easy to meet in VBP models 4% 22% 26% 20% 18% 35% 322 1% 8% 9% 29% 42% 21% 321 1% 7% 8% 39% 36% 17% 318 VBP models are easy to execute 1% 3% 4% 31% 49% 17% 319 Q: Please rate your level of agreement with the following statements regarding value-based programs?

17 Page 17 of 133 Referral Considerations More than nine in 10 physicians (91%) often consider the location when referring patients to a specialist. More than eight in 10 (84%) consider ease of scheduling patients and nearly eight in 10 (78%) consider the specialist s reputation when referring patients to a specialist. Six in 10 consider ease of record sharing (61%) and the established business relationship (50%). Referral Considerations Often Rarely Never n Location/proximity 91% 7% 3% 333 Ease of scheduling patients 84% 12% 5% 332 Reputation 78% 19% 4% 334 Ease of record sharing 61% 24% 15% 329 Established business relationship 50% 26% 24% 330 Personal relationship 38% 45% 18% 330 Cost of services provided 25% 43% 33% 327 Quality metrics 24% 37% 39% 326 Q: When referring to specialists, how often do you consider the following factors?

18 Page 18 of 133 Percent of Compensation Linked to Quality/Cost Measures Three in 10 physicians (29%) indicated that none of their compensations were linked to their performance on quality and/or cost metrics. Similarly, 30% reported that less than 10% of their compensations were linked to their performance on quality measures. As indicated in the table below, the remaining responses (23%) varied from 11% to 100%. Nearly two in 10 (18%) have no knowledge of what percentage of their compensation was linked to quality/cost measures. Percent of Compensation Linked to Quality/Cost Measures None/0% 29% 1%-10% 30% 11%-20% 12% 21%-30% 5% 31%-50% 3% 23% 51%-75% 1% 76%-100% 2% Don't know 18% 0% 5% 10% 15% 20% 25% 30% 35% Q: What percentage of your compensation is linked to your performance on quality and/or cost metrics? (n=332)

19 Page 19 of 133 Utilization Measures Participation in Value-Based Payment Slightly more than half of the physicians (54%) indicated their practices participate in value-based payments. The remaining half (46%) do not participate in value-based payments. Participation in Value Based Payment Yes 54% My practice does not participate in VBP 46% 0% 20% 40% 60% Q: Does your practice participate in value-based payment? (n=319)

20 Page 20 of 133 Key Drivers of Participation in Value-Based Payment Binary logistic regression analysis was conducted to examine the relationship between value-based payment participation and various potential predictors/drivers. The regression model assessed 22 different predictors (questions listed in the survey) using stepwise selection. The final model consisted of five predictors. All five variables included in the model has a significant positive weight. R-square = Participation in Value-Based Payment Model Adjusted R-squared = Variables in equation: Constant = ACO Agreement (β = 1.051, p-value <0.0001) Medical Home Status (β = 0.651, p-value = 0.009) Medicare payment pathway knowledge (β = 0.949, p-value = 0.003) Practice changes in preparation for VBP (β = 1.294, p-value <0.0001) Financial IT investment barrier (β = 0.450, p-value = 0.018)

21 Page 21 of 133 Percent of s Receiving Care Management Fees Of the physicians that participate in VBP, more than four in 10 physicians (44%) have no knowledge if they are receiving care management fees (PMPM). On other hand, two in 10 physicians (20%) receive care management fees from 1%-10% of their patient population. Percent of s Receiving Care Management Fees None/0% 11% 1%-10% 20% 11%-20% 12% 21%-30% 5% 31%-50% 5% 51%-100% 5% Don't know 44% 0% 10% 20% 30% 40% 50% Q: For what percentage of your patients are you receiving care management fees (PMPM)? Base: Practices participate in VBP. (n=189)

22 Page 22 of 133 Method of VBP Distribution in Practice Less than four in 10 physicians (37%) indicated that value-based payments are distributed to physicians based on achieving quality and/or outcome measure targets. Close behind, one-third (33%) cited payments are distributed to physicians in a transparent manner and two in 10 (22%) said payments are distributed to physicians based on productivity. In contrast, three in 10 (31%) didn t know the method of how payments were distributed in their practices. Method of VBP Distribution in Practice Distributed to physicians based on achieving quality and/or outcome measure targets 37% Distributed to physicians in transparent manner to physicians 33% Distributed to physicians based on productivity (RVUs) 22% Funneled through administration and are not distributed directly to physician; I am unsure how the payments are then being used 19% Funneled through administration and are not distributed directly to physicians; the payments are then reinvested in the practice 13% Distributed to physicians based on achieving patient satisfaction targets 10% Distributed to physicians based on achieving cost reduction targets 6% Don't know 31% Other 5% 0% 10% 20% 30% 40% Q: How are value-based payments distributed within your practice? (Multiple selection) Base: Practices participate in VBP. (n=241)

23 Page 23 of 133 Preparations to Participate in VBP Just over half of physicians (54%) are in a practice that are updating/adding health technology to prepare for VBP. More than four in 10 are in a practice that are hiring care managers/coordinators (43%) and/or are making efforts to improve diagnosis coding (42%) in preparation for VBP. More than one-third are in a practice that has hired staff for quality measure tracking and reporting (35%). More than one in 10 (14%) are in a practice that have not made any efforts to prepare for VBP participation. Preparations to Participate in VBP Updating or adding health IT infrastructure for data management and analysis 54% Hiring/hired care management and care coordinators Making/made efforts to improve diagnosis coding specificity 43% 42% Hiring/hired staff for quality measure tracking and reporting 35% Hiring/hired behavioral health support 22% Making/made connections with local community programs Utilizing external consultants to enhance capabilities 20% 18% Hiring/hired clinical pharmacist 12% Don't know/not sure 19% No changes have been made 14% Other 15% 0% 10% 20% 30% 40% 50% 60% Q: What changes to your practice are you making or have been made to participate in value-based payment? (Multiple selection) (n=332)

24 Page 24 of 133 Practice Functions Related to Value-Based Payment Accessible Data for Quality Improvement and Population Health Management Three-quarters of physicians (74%) have access to their quality measure performance for quality improvement and population health management. Nearly half have access to data on gaps in care (49%) and/or claims (47%) for quality improvement and population health management. Accessible Data for Quality Improvement and Population Health Management Your quality measure performance 74% Gaps in care Claims 49% 47% Integrated EMR 41% Ancillary costs (lab, radiology) 25% Pharmacy costs Hospital costs Attribution list Specialist costs 18% 15% 14% 13% Specialist quality measure performance 7% Don't know 18% Other 8% 0% 20% 40% 60% 80% Q: Which of the following types of data for quality improvement and population health management does your practice have access to? (Multiple selection) (n=337)

25 Page 25 of 133 Source of Data for Quality Improvement and Population Health Management The primary data source used by physicians for quality improvement and population health management is information stored within their electronic health record (70%). Four in 10 physicians are in practices where they have access to insurance company reports (44%) and/or their health systems data (36%). Source of Data for Quality Improvement and Population Health Management Electronic health record 70% Insurance company reports (public and private) 44% Health system 36% Outside data vendor 12% Free standing registry 6% Don't know 29% Other 2% 0% 20% 40% 60% 80% Q: What is the source of data your practice uses for quality improvement and population health management? (Multiple selection) (n=329)

26 Page 26 of 133 Frequency of Reconciling Reports Due to Inaccurate Data When physicians were asked how often they reconcile the quality/cost reports received from outside sources due to inaccurate data, nearly half (49%) didn t know the answer to the question. Of those aware of the frequency, 17% cited always and 19% cited sometimes. In contrast, nearly two in 10 (14%) said they never reconcile their quality/cost reports due to inaccurate data. Frequency of Reconciling Reports Due to Inaccurate Data Always 17% Sometimes 19% Never 14% Don't know 49% 0% 10% 20% 30% 40% 50% 60% Q: How often do you need to reconcile the quality/cost reports received from outside sources (i.e. insurance companies) due to inaccurate data? (n=313)

27 Page 27 of 133 Help for Improving Quality/Cost Reports As a way to improve the quality and cost reports, nearly two-thirds of physicians (65%) cited it would be helpful if there were standardized reports across all insurance companies and their products. More than five in 10 physicians (54%) recommended to make the reports easier to understand. More than four in 10 (46%) said to provide tangible steps to improve metrics as being helpful for improving quality/cost reports. Help for Improving Quality/Cost Reports Standardize reports across all insurance companies and their products 65% Make the reports easier to understand and actionable 54% Provide tangible steps towards improving the metrics 46% Prioritize patients based on highest risk 42% Reduce the length of reports 35% Other 10% 0% 10% 20% 30% 40% 50% 60% 70% Q: What would help improve the usefulness of these reports to you and your clinic staff? (Multiple selection) (n=301)

28 Page 28 of 133 Identifying High-risk Patients One-third of physicians (32%) said they work in a practice that provide ongoing care management and coordination to all high-risk patients. Similarly, one-third (32%) work in a practice that will provide this service to high-risk patients if the necessary resources and capacity are available. Identifying High-risk Patients We provide ongoing care management/coordniation services to all high-risk patients 32% We provide care management/coordination services to some high-risk patients, but not all are identified due to resources and capacity 32% We identify high-risk patients, but we do not have the resources or capacity to provide care management/coordination services We provide care management/coordination services for only those high-risk patients for which we receive a care management fee (PMPM) 7% 6% Our practice does not identify high-risk patients 10% Don't know 12% Other 1% 0% 10% 20% 30% 40% Q: Which of the following best describes your process to provide care management/coordination services to the patients you identify as high-risk? (n=330)

29 Page 29 of 133 Resources or Personnel Used for Care Management/Coordination Nearly four in 10 (37%) are in a practice with a full-time care manager/coordinator, while nearly half (48%) are in practice that have not hired a coordinator and are using existing staff to care out this service. Two in 10 (19%) are in a practice that has a care manager/coordinator provided by an insurance company in their area. Resources or Personnel Used for Care Management/Coordination We use existing staff to carry out care management/coordnination functions 48% We have a full-time care manager/coordinator dedicated to care management/coordination funcation 37% We do not have the resources or capacity to hire a care manager/coordinator 22% Insurance companies in our area provide a care manager/coordinator 19% Don't know 9% Other 3% 0% 20% 40% 60% Q: Which of the following describes your practice with regard to the resources or personnel use for care management/coordination? (Multiple selection) (n=332)

30 Page 30 of 133 Degree of a Barrier to Implementing Value-based Care Delivery The biggest barrier to implementing value-based care delivery is lack of staff time as two-thirds of physicians (69%) indicated this as a major barrier. Other barriers cited with less frequency included the lack of standardization of performance measures (48%), lack of uniform insurance reports on performance (46%), and the financial investment required by IT (41%). Degree of a Barrier to Implementing Value-based Care Delivery Major Barrier Minor Barrier Not a Barrier Don t know n Lack of staff time to implement care functions that support value-based payment Lack of standardization of performance measures and metrics No uniform insurance company reports on performance 70% 20% 3% 7% % 30% 9% 14% % 29% 7% 19% 317 Financial investment required by IT PMPM is too low to support care/management/coordination functions Data is not available in a timely manner to improve care and reduce costs Lack of evidence that using performance measures results in better patient care Insufficient training on advanced care delivery functions 41% 26% 20% 13% % 18% 5% 39% % 31% 13% 17% % 29% 22% 16% % 35% 20% 17% 317 Q: How much of a barrier are each of the following statements to implementing value-based care delivery?

31 Page 31 of 133 Degree of a Barrier to Accepting More Financial Risk Valuebased Payment Nearly six in 10 physicians see items related to the uncertainty of the financial risk/reward as barriers to accepting more financial risk value-based payments: lack of transparency between payers and providers (58%), unpredictability of revenue stream (57%), and administrative complexity and cost need to understand financial risk (56%). Degree of a Barrier to Accepting More Financial Risk Value-based Payment Major Barrier Minor Barrier Not a Barrier Don t know n Lack of transparency between payers and providers Unpredictability of revenue stream Administrative complexity and cost needed to understand financial risk Lack of resources to report, validate, and use data Lack of information available on cost of health care services provided for appropriate referrals Lack of interoperability between types of health care providers Current rewards are not worth the risk Need for integration (e.g., clinical, financial) to participate in VBP 58% 20% 5% 17% % 20% 4% 20% % 19% 4% 21% % 21% 12% 15% % 24% 8% 19% % 25% 6% 21% % 22% 9% 25% % 25% 8% 23% 317 Limited referral options 26% 25% 30% 20% 314 Q: How much of a barrier are each of the following statements on accepting more financial risk value-based payment?

32 Page 32 of 133 Medicare Payment Pathway More than one-third of physicians (36%) work will be participating in merit-based incentive payment system (MIPS) during the 2017 performance year. About two in 10 physicians will be participating in Medicare Shared Savings Program (18%) and/or Comprehensive Primary Care Plus (CPC+) (17%) during the 2017 performance year. Half of physicians (49%) cited they didn t know which Medicare payment pathway they are planning on participating in during the 2017 performance year. Medicare Payment Pathway Merit-based Incentive Payment System (MIPS) 36% Medicare Shared Savings Program 18% Comprehensive Primary Care Plus (CPC+) 17% Advanced Alternative Payment Model (AAPM) 10% Don't know 49% 0% 20% 40% 60% Q: Which Medicare payment pathway are you planning to participate in during the 2017 performance year? (Multiple selection) (n=321)

33 Page 33 of 133 Behavioral Health and Pharmacy Needs Assess Behavioral Health Needs More than half of physicians (56%) screen all patients for behavioral health conditions. Four in 10 (41%) selectively screen for behavioral health conditions. Only 3% do not screen for behavioral conditions. Assess Behavioral Health Needs Screen all patients for behavioral health conditions 56% Selectively screen (i.e., limited conditions, risk, clinical judgement) 41% Do not screen for behavioral conditions 3% Other 10% 0% 20% 40% 60% Q: Which of the following best describes your ability to assess patient behavioral health needs? (Multiple selection) (n=330)

34 Page 34 of 133 Barriers to Implementing Behavioral Health Services The biggest barrier to implementing behavioral health services is the lack of access to behavioral health specialists in the community (71%). Nearly six in 10 physicians (59%) find patients being unwilling or unable to follow up as a barrier to implementing behavioral health services. Other barriers included: lack or inadequate payment (38%), difficulty in finding behavioral health specialists to hire (25%), difficulty in adding behavioral health in the workflow (24%), and lack of training for existing staff and physicians (19%). Barriers to Implementing Behavioral Health Services Lack of access to behavioral health specialists in community 71% Patients are unwilling or unable to follow up 59% Lack or inadequte payment 38% Difficulty in finding behavioral health specialists to hire 25% Difficulty in adding behavioral health in our workflow 24% Lack of training for existing staff and physicians 19% Other 6% 0% 20% 40% 60% 80% Q: What barriers do you face in implementing/providing behavioral health services? (Multiple selection) (n=327)

35 Page 35 of 133 Helpfulness of Adding Pharmacy Services When asked to rate the helpfulness of several pharmacy services in achieving quality metrics and cost for VBP, the two most popular services included understanding their patient s out-of-pocket costs (77%) and the point-of-care formulary status (77%). Two-thirds (66%) indicated they would find helpful having reports on multiple prescribers medication guideline compliance and six in 10 said the nurse and pharmacist consult at the transition of care (62%). Helpfulness of Adding Pharmacy Services Very helpful Somewhat helpful SUBTOTAL Slightly helpful Not helpful n Understanding patient out of pocket costs 54% 23% 77% 13% 10% 299 Point-of-care formulary status 55% 22% 77% 11% 13% 309 Reports on multiple prescribers medication guideline compliance, adverse events, etc. (not available in your EMR) Nurse + pharmacist consult at transition of care Onsite clinical pharmacist hired by your practice 35% 34% 69% 20% 11% % 31% 62% 25% 14% % 23% 53% 21% 26% 304 Onsite retail pharmacy location 22% 20% 42% 27% 31% 304 Onsite clinical pharmacist provided by insurance company 18% 22% 40% 25% 35% 294 Q: How helpful would each of the following pharmacy services be in achieving quality metrics/cost for VBP?

36 Page 36 of 133 Demographics Active Membership Survey Respondents* Count 70, Gender Male 56.5% 63% Female 43.5% 37% Years Since Residency 1 to 7 years 25% 16% 8 to 14 years 20% 16% 15 to 21 years 22% 20% More than 21 years 33% 498% Practice Ownership Sole Owner 12% 18% Partial Owner 16% 19% 100% Employed 68% 63% Not Applicable 2% <1% *Data is not weighted

37 Page 37 of 133 Appendix A: Historical Trends What types of other clinicians are available at your primary location? (Multiple Selection) n = 626 n = 344 Nurse practitioner or physician assistant 71% 73% Other primary care physicians (pediatrics, internal medicine) 36% 33% Care manager/coordinator 28% 32% Behavioral specialist (LSW, clinical psychologist or psychiatrist) 25% 29% Specialist physicians 22% 26% Pharmacist 21% 22% None of the above n/a 12% Other 9% * 5% n/a = question was not asked in the 2015 VBP survey In the past 12 months, from approximately how many payers/health plans do you receive payment? n = 601 n = 347 None 4% 3% 1 to 3 4% 4% 4 to 6 9% 11% 7 to 10 23% 21% More than 10 38% 37% Don t know 22% 24%

38 Page 38 of 133 Is your practice designated/recognized as a medical home? n = 602 n = 333 Yes 40% * 49% Application submitted 12% * 5% No 49% 46%. How familiar are you with the concept of valuebased payment? n = 593 n = 350 Extremely familiar 17% 17% Somewhat familiar 40% 43% SUBTOTAL 57% 60% Slightly familiar 30% 31% Not at all familiar 12% * 7% Don t know/no response 1% * 3% What is your practice s current strategy toward value-based payment? 2015^ 2017 n = 438 n = 335 Actively pursue VBP opportunities today 44% 47% Develop capabilities, but wait until the results are better known before fully pursuing Hold off on making changes, focus on optimizing under fee-for-service 23% 21% 22% 19% Other 10% 13% ^ Data from 2015 included a Don t know option. To be comparable with 2017 s data, all don t know responses were excluded from this comparison.

39 Page 39 of 133 If your practice does not have a strategy toward value-based payment, why not? (Multiple Selection) n = 427 n = 203 Employer makes the decision of VBP strategies n/a 42% Too busy and overwhelmed to think ahead 21% * 33% Not enough payment to make necessary practice changes for VBP 16% * 27% Value-based payment is too risky 7% * 18% I am able to provide high-quality care under fee-forservice 2% * 15% Current rewards are not worth the benefit 22% * 13% I don t know where to start 16% * 10% Not enough evidence to support VBP 17% * 9% Other 24% 20% n/a = question was not asked in the 2015 VBP survey Which of the following value-based payment models are available in your market? n = 570 n = 328 Shared savings 27% 31% Pay-for-performance 46% * 31% Per member per month (PMPM) payment (care management fee) 29% 23% Capitation (global payments) 28% * 19% CMS Comprehensive Care Plus (CPC+) n/a 17% Bundled/episode-based payments 20% 16% Don t know/not sure 32% * 44% Other 2% 1% n/a = question was not asked in the 2015 VBP survey

40 Page 40 of 133 Please rate the importance of the following factors for being able to determine whether a value-based payment program has been successful Clinical outcomes n = 552 n = 317 Very important 74% 75% Somewhat important 17% 16% SUBTOTAL 91% 91% Neutral 6% 7% Somewhat not important 2% 1% Not at all important 1% 2% and staff morale n = 549 n = 317 Very important 64% 65% Somewhat important 23% 26% SUBTOTAL 87% 91% Neutral 9% * 5% Somewhat not important 2% 2% Not at all important 1% 3% Practice sustainability n = 547 n = 316 Very important 79% 75% Somewhat important 13% 16% SUBTOTAL 92% 91% Neutral 6% 6% Somewhat not important 1% 1% Not at all important 1% 2%

41 Page 41 of 133 Please rate the importance of the following factors for being able to determine whether a value-based payment program has been successful Coordination of patient care n = 548 n = 318 Very important 54% 53% Somewhat important 32% 35% SUBTOTAL 86% 88% Neutral 11% 8% Somewhat not important 2% 1% Not at all important 1% * 4% Cost savings for my practice n = 547 n = 313 Very important 50% 48% Somewhat important 33% 36% SUBTOTAL 84% 84% Neutral 13% 13% Somewhat not important 2% 1% Not at all important 1% 2% Patient satisfaction n = 550 n = 315 Very important 54% 50% Somewhat important 28% 31% SUBTOTAL 82% 81% Neutral 13% 14% Somewhat not important 3% 2% Not at all important 2% 3%

42 Page 42 of 133 Please rate the importance of the following factors for being able to determine whether a value-based payment program has been successful Population health management capabilities n = 545 n = 314 Very important 34% 35% Somewhat important 38% 35% SUBTOTAL 72% 70% Neutral 20% 18% Somewhat not important 6% 6% Not at all important 3% 5% Please rate your level of agreement with the following statements regarding value-based payment programs. Practices will have to make substantial investment in health information technology to be successful in a VBP model n = 557 n = 321 Strongly agree 50% 53% Somewhat agree 38% 33% SUBTOTAL 87% 86% Disagree 5% 4% Strongly disagree 1% 1% Don t know 7% 10% VBP models will add more work for physicians, when there is no benefit to the patient n = 554 n = 321 Strongly agree 28% 28% Somewhat agree 31% 30% SUBTOTAL 59% 58% Disagree 20% 21% Strongly disagree 8% 6% Don t know 16% 16%

43 Page 43 of 133 Please rate your level of agreement with the following statements regarding value-based payment programs. VBP models will put family physicians in important central roles within medical groups n = 555 n = 320 Strongly agree 18% 18% Somewhat agree 37% 38% SUBTOTAL 56% 56% Disagree 20% 19% Strongly disagree 8% 9% Don t know 16% 15% VBP models will encourage greater collaboration between primary care physicians and specialists n = 555 n = 322 Strongly agree 16% 16% Somewhat agree 35% 35% SUBTOTAL 52% 51% Disagree 22% 22% Strongly disagree 10% 9% Don t know 16% 19% VBP models have the potential to increase practice revenue n = 321 Strongly agree n/a 5% Somewhat agree n/a 27% SUBTOTAL n/a 32% Disagree n/a 20% Strongly disagree n/a 16% Don t know n/a 31% n/a = question was not asked in the 2015 VBP survey

44 Page 44 of 133 Please rate your level of agreement with the following statements regarding value-based payment programs VBP models will improve patient care n = 551 n = 319 Strongly agree 6% 5% Somewhat agree 25% 27% SUBTOTAL 31% 32% Disagree 20% 24% Strongly disagree 15% 18% Don t know 33% 26% VBP models reduce society s overall health care costs n = 322 Strongly agree n/a 4% Somewhat agree n/a 22% SUBTOTAL n/a 26% Disagree n/a 20% Strongly disagree n/a 18% Don t know n/a 35% VBP models will allow more time with patients n = 556 n = 321 Strongly agree 2% 1% Somewhat agree 9% 8% SUBTOTAL 11% 9% Disagree 31% 29% Strongly disagree 38% 42% Don t know 21% 21% n/a = question was not asked in the 2015 VBP survey

45 Page 45 of 133 Please rate your level of agreement with the following statements regarding value-based payment programs Quality expectations are easy to meet in VBP models n = 552 n = 318 Strongly agree <1% 1% Somewhat agree 13% * 7% SUBTOTAL 13% * 8% Disagree 40% 39% Strongly disagree 30% 36% Don t know 17% 17% VBP models are easy to execute n = 551 n = 319 Strongly agree 0% 1% Somewhat agree 5% 3% SUBTOTAL 5% 4% Disagree 34% 31% Strongly disagree 46% 49% Don t know 14% 17% For what percentage of your patients are you receiving care management fees (PMPM)? n = 556 n = 189 None/0% 29% * 11% 1-50% 26% * 42% % 3% 5% Don t know 42% 44%.

46 Page 46 of 133 How are value-based payments distributed within your practice? (Multiple Selection) n = 514 n = 241 Distributed to physicians based on achieving quality and/or outcome measure targets Distributed to physicians in transparent manner to physicians 18% * 37% 12% * 33% Distributed to physicians based on productivity (RVUs) 14% * 22% Funneled through administration and are not distributed directly to physicians; I am unsure how the payments are then being used Funneled through administration and are not distributed directly to physicians; the payments are then reinvested in the practice Distributed to physicians based on achieving patient satisfaction targets Distributed to physicians based on achieving cost reduction targets 16% 19% 16% 13% 10% 10% 4% 6% Don t know 33% 31% Other 15% * 5%

47 Page 47 of 133 What changes to your practice are you making or have been made to participate in value-based payment? (Multiple Selection) n = 551 n = 332 Updating or adding health IT infrastructure for data management and analysis 54% 54% Hiring/hired care management and care coordinators 33% * 43% Making/made efforts to improve diagnosis coding specificity Hiring/hired staff for quality measure tracking and reporting n/a 42% n/a 35% Hiring/hired behavioral health support 15% * 22% Making/made connections with local community programs n/a 20% Utilizing external consultants to enhance capabilities n/a 18% Hiring/hired clinical pharmacist n/a 12% Don t know/not sure 14% 19% No changes have been made 26% * 14% Other 4% * 15% n/a = question was not asked in the 2015 VBP survey

48 Page 48 of 133 Which of the following types of data for quality improvement and population health management does your practice have access to? (Multiple Selection) n = 556 n = 337 Your quality measure performance n/a 74% Gaps in care n/a 49% Claims 50% 47% Integrated EMR n/a 41% Ancillary costs (labs, radiology) 36% * 25% Pharmacy costs 22% 18% Hospital costs 25% * 15% Attribution list n/a 14% Specialist costs 18% 13% Specialist quality measure performance n/a 7% Don t know 16% 18% Other 3% * 8% n/a = question was not asked in the 2015 VBP survey What is the source of data your practice uses for quality improvement and population health management? (Multiple Selection) n = 549 n = 329 Electronic health record 79% * 70% Insurance company reports (public and private) 34% * 44% Health system 21% * 36% Outside data vendor 12% 12% Free standing registry 5% 6% Don t know 14% * 29% Other 4% 2%

49 Page 49 of 133 Which of the following best describes your process to provide care management/coordination services to the patients your identify as high-risk? n = 529 n = 330 We provide ongoing care management/coordination services to all high-risk patients We provide care management/coordination services to some high-risk patients, but not all are identified due to resources and capacity We identify high-risk patients, but we do not have the resources or capacity to provide care management/coordination services We provide care management/coordination services for only those high-risk patients for which we receive a care management fee (PMPM) 23% * 32% 33% 32% n/a 7% 3% * 6% Our practice does not identify high-risk patients 17% * 10% Don t know 11% 12% Other 3% * 1% n/a = question was not asked in the 2015 VBP survey Which of the following describes your practice with regard to the resources or personnel use for care management/coordination (Multiple Selection) n = 551 n = 332 We use existing staff to carry out care management/coordination functions We have a full-time care manager/coordinator dedicated to care management/coordination function We do not have the resources or capacity to hire a care manager/coordinator Insurance companies in our area provide a care manager/coordinator 48% 48% 25% * 37% 23% 22% 14% 19% Don t know 12% 9% Other 5% 3%

50 Page 50 of 133 How much of a barrier are each of the following statements to implementing value-based care delivery? Lack of staff time to implement care functions that support value-based payment n = 527 n = 321 Major barrier 73% 70% Minor barrier 18% 20% Not a barrier 2% 3% Don t know 7% 7% Lack of standardization of performance measures and metrics n = 526 n = 317 Major barrier 43% 48% Minor barrier 31% 30% Not a barrier 14% * 9% Don t know 11% 14% No uniform insurance company reports on performance n = 523 n = 317 Major barrier 49% 46% Minor barrier 26% 29% Not a barrier 9% 7% Don t know 16% 19% Financial investment required by IT n = 312 Major barrier n/a 41% Minor barrier n/a 26% Not a barrier n/a 20% Don t know n/a 13% n/a = question was not asked in the 2015 VBP survey

51 Page 51 of 133 How much of a barrier are each of the following statements to implementing value-based care delivery? PMPM is too low to support care/management/coordination functions n = 521 n = 311 Major barrier 38% 38% Minor barrier 23% 18% Not a barrier 7% 5% Don t know 31% * 39% Data is not available in a timely manner to improve care and reduce costs n = 523 n = 317 Major barrier 33% 39% Minor barrier 30% 31% Not a barrier 17% 13% Don t know 20% 17% Lack of evidence that using performance measures results in better patient care n = 529 n = 319 Major barrier 37% 33% Minor barrier 25% 29% Not a barrier 24% 22% Don t know 13% 16% Insufficient training on advanced care delivery functions n = 520 n = 317 Major barrier 27% 29% Minor barrier 35% 35% Not a barrier 21% 20% Don t know 17% 17%

52 Page 52 of 133 How much of a barrier are each of the following statements on accepting more financial risk value-based payment? Lack of transparency between payers and providers n = 527 n = 317 Major barrier 57% 58% Minor barrier 20% 20% Not a barrier 8% 5% Don t know 15% 17% Unpredictability of revenue stream n = 526 n = 320 Major barrier 60% 57% Minor barrier 20% 20% Not a barrier 5% 4% Don t know 14% * 20% Administrative complexity and cost needed to understand financial risk n = 524 n = 318 Major barrier 57% 56% Minor barrier 23% 19% Not a barrier 4% 4% Don t know 16% 21% Lack of resources to report, validate, and use data n = 522 n = 318 Major barrier 58% 53% Minor barrier 23% 21% Not a barrier 8% 11% Don t know 11% 15% Lack of information available on cost of health care services provided for appropriate referrals n = 517 n = 319 Major barrier 46% 49% Minor barrier 30% 24% Not a barrier 5% 8% Don t know 19% 19%

53 Page 53 of 133 How much of a barrier are each of the following statements on accepting more financial risk value-based payment? Lack of interoperability between types of health care providers n = 521 n = 319 Major barrier 53% 48% Minor barrier 23% 25% Not a barrier 8% 6% Don t know 16% 21% Current rewards are not worth the risk n = 529 n = 319 Major barrier 48% 44% Minor barrier 22% 22% Not a barrier 8% 9% Don t know 22% 25% Need for integration (e.g., clinical, financial) to participate in VBP n = 528 n = 317 Major barrier 50% 44% Minor barrier 25% 25% Not a barrier 10% 8% Don t know 15% * 23% Limited referral options n = 314 Major barrier n/a 26% Minor barrier n/a 25% Not a barrier n/a 30% Don t know n/a 20% n/a = question was not asked in the 2015 VBP survey

54 Page 54 of 133 Appendix B: Open-Ended Responses Other Comments Specified What types of other clinicians are available at your primary location? Other Comments: RN Residents. R.D.; Acupuncture. Podiatrists, dentists Podiatrist Physical Therapy Physical Therapy Optometry. OB/GYN Nutritionist Sports medicine. Dietician, respiratory therapist, radiology technician. Dietician CDE Diabetes Manager

55 Page 55 of 133 What is your practice s current status or strategy toward value-based payment? Other Comments: Would like to explore. We are grant based, thank God. Got out of that mess. Do fill Medicaid fee for service, thank God. We are doing VBP but don't want the paperwork hassle so we don't bother trying to prove it VA practice VA VA This is determined by high-level administration. Skeptical (very) Rural health with country hospital Rural Health Clinic. Rural health clinic No emphasis on any of this. Military clinic Just joined. New ACO. It's a behavioral health facility. It will not apply. I will stop practicing if this happens. I have no idea. I don't know. I have a private practice where we make house calls. I work full time as a hospitalist. Government clinic Frequently accept cash from patients without insurance. FQHC not in this, but acting as if we are. Fee and cash pay. focused on patient care and quality not the government Do not know Directly contract with employer. Can't stand it. As an employee, I get paid RVUs. Employer has some insurers that do VBP and others that do not. Already in this model.