Transcript AOA Clinical Assessment Program Interface with Pay for

HOW CAN THE CAP HELP YOU DEVELOP A
PATIENT CENTERED MEDICAL HOME AND
INCREASE PRACTICE REIMBURSEMENT
AOA Clinical Assessment Program
Richard Snow DO, MPH
November 4th, 2009
GOALS
•
Evaluate changing framework of value based purchasing
•
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Discuss models of primary care payment reform
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•
•
•
How this can strengthen Primary Care
What’s shaping up in Ohio
Discuss definition of the Patient Centered Medical
Home
Discuss how the AOA-CAP fits into the framework of the
PCMH
Review benefits of adopting the PCMH to your practice
from:
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Patient care, marketing and payment perspective
VALUE BASED PURCHASING
WHERE IS IT NOW?
•
Hospital program from Centers for Medicaid and
Medicare Services
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Currently hospital reporting on ~ 60 measures
covering:
•
Process of care
–
•
Outcomes of care
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•
Mortality, readmission
Patient Safety
–
•
Evidenced based processes in AMI, HF, Pneumonia, Surgical Care
Improvement Program
Complications, Patient Safety indicators
Patient Satisfaction
–
HCAPS
VALUE BASED PURCHASING
WHERE IS IT NOW?
•
Payment tied to Hospital Compare (Since 2005)
–
•
Currently, if a hospital does not report they lose 2% of
Medicare reimbursement annually
Value Based Purchasing Agenda (2012)
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Next step is to tie payment to performance
•
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Create distributions on aggregate measures
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Demonstration project suggested methods
Reward improvement equally with absolute performance
Pay more for top decile and less for bottom decile
•
Revenue neutral
VALUE BASED PURCHASING
WHERE IS IT NOW?
Ambulatory care has been slower to move
forward
 Physician Quality Reporting Initiative

 Movement
to measure groups
 Inclusion of registry

NCQA Physician Recognition Program
 Patient
Centered Medical Home
THE DEATH OF PRIMARY CARE?

A principal reason: too little money for too
much work. Median income for primary-care
doctors was $162,000 in 2004, the lowest of
any physician type, according to a study by the
Medical Group Management Association in
Englewood, Colo. Specialists earned a median
of $297,000, with cardiologists and
radiologists exceeding $400,000.
PATENT CENTERED MEDICAL HOME

What this can mean to primary care?
 Provide
a focus for reimbursement
 Co-ordination
disease
and management of patients with chronic
Primary and secondary prevention
 Care coordination across multiple providers and ancillary
services
 Quality improvement focus

A
reimbursable event and payment for cognitive
care
 Picking
up where RBRVS fell off
PATIENT CENTERED MEDICAL HOME
HOW DOES THIS RESONATE AMONG NON-CLINICIANS

How the concept is perceived among nonhealth care workers

Experience of the Ohio Health Care Quality and Cost
Council
 Legislative,

business and advocacy groups
After a summary and review of over 20
potential avenues of reform the top three and
subsequent focus of the summit included
Patient Centered Medical Home
 Payment Reform (to encourage PCMH)
 Activated Patient

PATIENT CENTERED MEDICAL HOME
HOW DOES THIS RESONATE AMONG CLINICIANS
Almost every primary care physician believes
they are providing this now
 The disconnect is in interpretation

 Opportunity
 Evidenced
to redefine your practice as an
based
 Outcomes driven resource for the community
 That connects with patients and employers
 And provides care co-ordination
EXAMPLES OF PATIENT CENTERED MEDICAL
HOME
Models to compare to your current practice
 Most advanced in setting where incentives can
be aligned to achieve patient centered care
 Examples

 From
the literature
 Current Practice
 Geisinger
Health Care
THE EFFECT OF CO-ORDINATED CARE ON
DIABETICS
EARLY EVIDENCE OF THE EFFECT OF A PATIENT CENTERED MEDICAL HOME

80 Type 2 diabetic patients with microalbuminuria
randomized to:

Control


Regular care
Intensive intervention

Step-wise introduction of lifestyle and pharmacological interventions
aimed at keeping:

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
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glycated hemoglobin <6.5%
blood pressure <130/80mmHg
total cholesterol <175mg/dl
and triglycerides <150mg/dl.
reduction in intake dietary fat regular exercise and smoking cessation.
N Engl J Med 348:383-393,2003
RESULTS OF THE STENO STUDY

Intermediate Outcomes

Event Rate

End Points

Control Group Inte nsive T re a tme nt
(n=80)
Group (n=80)
Glycosyla te d
H e moglobin < 6.5
3%
15%
D ia stolic < 80 mm H g
60%
70%
S ystolic < 130 mm H g
18%
50%
T ota l Chole ste rol <
175mg/ dl
22%
72%
N Engl J Med 348:383-393,2003
death from CVD, nonfatal
MI, nonfatal stroke,
revascularization, and
amputation.
RESULTS

Endpoints after 7.8 years of follow-up



44% of patients in the conventional care arm had events
24% of patients in the intensive treatment arm had events
(significantly lower)
In addition to the 53% reduction in CVD events the
intensive treatment group had a reduction of
nephropathy, retinopathy, and autonomic neuropathy
by 61, 58, and 63% respectively
N Engl J Med 348:383-393,2003
WHAT’S ACHIEVABLE IN DIABETES CARE?
Intensive
Control Group Treatment Group
(n=80)
(n=80)
Glycosylated
Hemoglobin < 6.5
3%
15%
Diastolic < 80 mm Hg
60%
70%
Systolic < 130 mm Hg
Total Cholesterol <
175mg/dl
18%
50%
22%
72%
AOA-CAP for residencies 2004-2009
(n=11,000)
Glycosylated Hemoglobin
< 7.0
Blood Pressure < 130/80
LDL < 100mg/dL
46.80%
32%
55.90%
CURRENT EXAMPLE OF PATIENT CENTER
MEDICAL HOME

Geisinger Health System
 One
of the best operating models of the Patient
Centered Medical Home
 Provides a model for what a PCMH would look like
at a system level
 Take

away at the practice level
What can you learn from Geisinger to move
your practice to a PCMH model
 Full
transition may take several years
 Pending

PQRI
payment reform
PATIENT CENTERED MEDICAL HOME
GEISINGER EXAMPLE

Geisinger operational definition
 Round-the-clock
access to primary and specialty
care services,
 Enhanced through the use of nurse care
coordinators, care management support, and
home-based monitoring
Health Affairs, September/October 2008 27(5):1235–45
PATIENT CENTERED MEDICAL HOME
GEISINGER EXAMPLE

Geisinger operational definition
 Physicians
and patients alike have access to
electronic health records (EHRs)
 For patients, this means they can view lab results,
schedule appointments, receive reminders, and email their providers
Health Affairs, September/October 2008 27(5):1235–45
PATIENT CENTERED MEDICAL HOME
GEISINGER EXAMPLE

Geisinger operational definition
 To
encourage physician participation in the medical
home innovation, Geisinger provides practice-based
monthly payments of $1,800 per physician
 Stipends of $5,000 per 1,000 Medicare patients to
help finance additional staff
Health Affairs, September/October 2008 27(5):1235–45
PATIENT CENTERED MEDICAL HOME
GEISINGER EXAMPLE

Geisinger operational definition
 Preliminary
data show a 20 percent reduction in
hospital admissions and 7 percent savings in total
medical costs
 Based on this success, Geisinger is expanding the
initiative to additional practice sites.
Health Affairs, September/October 2008 27(5):1235–45
PATIENT CENTERED MEDICAL HOME
GEISINGER EXAMPLE

Other Aspects of program – a clinical /
epidemiologic perspective
 Chronic
disease care optimization
 Coordinated,
evidence-based care for patients with
chronic diseases, including diabetes, congestive heart
failure, and hypertension
 Standardize clinical practices, provide doctors with a
"snapshot report" of patients' relevant clinical
information, and generate automated reminders for
patients as well as the clinical team
PATIENT CENTERED MEDICAL HOME
GEISINGER EXAMPLE

Other Aspects of program – patient
engagement / activation
 Patients
can also self-schedule appointments and
receive an after-visit summary to see how they are
doing compared with their goal
 Reinforced
using care management team
PATIENT CENTERED MEDICAL HOME
GEISINGER EXAMPLE

Other Aspects of program – No reason to
restructure unless it makes a difference, same
for enhanced pay for primary care
 Physicians
may receive financial incentives linked
to patient satisfaction, quality, and value goals.
 Initial results from more than 20,000 diabetic
patients have shown statistically significant
improvements in measures like glucose control,
blood pressure, and vaccination rates.
RESULTS
Health Affairs, September/October 2008 27(5):1235–45
SUMMARY

Addressing the Problem

Based on Geisinger's experience, the authors say that
policymakers nationally should:
recognize that EHRs are absolutely necessary but not sufficient for
creating sustainable change in care delivery.
 align incentives so that providers are rewarded for enhancing value
in health care.
 create policies that encourage greater organization of care delivery
and payer-provider collaboration.

GEISINGER IS UNIQUE
•
•
Includes employed physicians, owned healthcare
facilities and an insurance product (Medicare) thereby
allowing alignment of incentives to achieve
outstanding results
How does the previous example apply to a diverse
group of primary care settings?

What does this mean to your practice.
FOLLOW THE PAYMENT TO BUILD CAPACITY

The concept of the Patient Centered Medical
Home is becoming embedded into payment
methods.
How does this apply locally?
 Evolution of pay for performance

 Becoming

more cohesive at practice level
Physician Quality Reporting Initiative
 Moving
from measures to measure groups clustered around
chronic disease

NCQA Physician Recognition Program
 Structural
evaluation of your practice
FOLLOW THE PAYMENT TO BUILD CAPACITY

Evolving recommendations
 Payment
 Similar
for process and outcomes
to endorsed measures in AOA-CAP
 Improve
recognition of contribution of primary care
to the health of populations across the continuum
 Improve resources necessary to achieve better
outcomes (primary and secondary prevention)
 Human
(care management)
 Infrastructure (Information Technology, patient
connectivity)
USING CAP AS A START TO DEVELOPMENT OF
PATIENT CENTERED MEDICAL HOME

Key components in all definitions of PCMH
include the use of a registry
 Disease
focused, defining current performance
within your practice and patients
 Developing a systematic approach to improving
care
 Focused
on process or outcomes
 Using community or other resources to improve care
 Re-evaluation
of care for evaluation of improvement
USING CAP AS A START TO DEVELOPMENT OF
PATIENT CENTERED MEDICAL HOME

Tools your practice needs
 Registry
 AOA-CAP
 Population

management
Management of chronic disease patients to evidenced based
goals
 Quality
improvement
Identify opportunities and implementing systematic change
 Track improvements in process and outcomes of care

USING CAP AS A START TO DEVELOPMENT OF
PATIENT CENTERED MEDICAL HOME

Tools your practice needs
 Patient
education and empowerment
 Patient

education
Time and educator


 Patient
Group visits
Web based resources
communication
Traditional visit and exam
 Phone management
 Web based management

USING CAP AS A START TO DEVELOPMENT OF
PATIENT CENTERED MEDICAL HOME

Tools your practice needs
 Patient
 Self
education and empowerment
management and engagement
Goal setting for control of glucose, lipids and blood pressure
 Self measurement

USING CAP AS A START TO DEVELOPMENT OF
PATIENT CENTERED MEDICAL HOME

Tools your practice needs

Resources / costs

Time with patient




Communication and continuity




Physician
Physician extender
Educator
Web based
Phone
Goal setting and tracking progress to goals
Information on current performance


Registry
“Synthesized EHR”
WHAT CAN YOUR PRACTICE DO NOW?

Diabetes flow sheets


Checklists for preventive care
Focus on treatment intensification (pharmacological)

Data from literature and CAP suggest that 30% of patients
not at goal are due to ‘physician inertia’


Rest are system or patient factors
Engage your patients and the community in quality
opportunities

Employers and patients
A WORD ABOUT ELECTRONIC HEALTH RECORD

EHR is not necessary to create the Patient
Centered Medical Home
 Components
 Test
of it are helpful
and referral tracking, reminders
 Challenges
 Current
products do not facilitate registry functions
 Operational
Costs
 Productivity

PATIENT CENTERED MEDICAL HOME
HOW DOES IT GET PAID FOR?

Aligning payment with desired outcomes

Moving to close the gap

Challenge of what society wants to pay for


Better health early or multiple procedures late
Evolving models in reimbursement

CMS

Value Based Purchasing



Hospital Based
Physician Based
Physician Quality Reporting Initiative
PATIENT CENTERED MEDICAL HOME
NCQA PHYSICIAN PRACTICE CONNECTION – PATIENT CENTERED MEDICAL HOME

Standards of Medical Home necessary to pass

Access and Communications


Patient Tracking and Registry


Evidenced based diagnosis and treatment guidelines
Patient Self Management Support


Use of templates in chronic disease, most frequently seen diagnosis, risk factors
Care Management


Ease of access 24/7, continuity, internet enabled, language services
Group classes, materials, care plan
E-Prescribing
PATIENT CENTERED MEDICAL HOME
NCQA PHYSICIAN PRACTICE CONNECTION – PATIENT CENTERED MEDICAL HOME

Standards of Medical Home necessary to pass

Test Tracking


Referral Tracking


Paper or electronic system to track referrals through report from consultant
Performance Reporting and Improvement


Track all tests, imaging, abnormal test policy, notification
Clinical process, outcomes, service, safety
Advanced Electronic Communications
PATIENT CENTERED MEDICAL HOME
HOW DOES IT GET PAID FOR?

Physicians Quality Reporting Initiative (CMS)
 Pay
for reporting 2% bonus payment for reporting in
2009
 153 quality measures
 Claims
based
 Registry

Measure Groups
 Measure
groups as a lead into payment for
management of chronic disease
WHAT CAN YOUR PRACTICE DO NOW?

How well are you doing in Diabetes
Management, Preventive Care?
 AOA-CAP
is tied to PQRI
 2nd
year, one of 3 clinical registries originally accepted by
CMS for PQRI
 30 consecutive charts provide you with info on:
Glycemic, blood pressure and lipid control Eye Exam,
Albuminuria screen for diabetes
 Preventive screenings

 Receive
a bonus payment of 2% of the physician total
charges for 2009