PCMH/ACO IN NEBRASKAAn Experience of

One Rural Family

Physician

Disclaimer This is my perspective I am not speaking for the Nebraska

Academy of Family Physicians I am not speaking for SERPA-ACO I am not speaking for Plum Creek

Medical Group This is the perspective of Joe Miller

MD

Objectives

What were the first 4 steps to establishing Patient Centered Medical Home (PCMH)?

What does a care coordinator do? What is most important to patient

satisfaction and making PCMH work? How does PCMH drive Quality? How does Quality lower costs and

improve true VALUE? Why is payment reform necessary?

FROM FEE FOR SERVICE,

DISEASE BASED, PROCEDURE ORIENTED,

MEDICAL BUSINESS COMPLEX

TO

PATIENT-CENTERED

Value –driven Primary Care Physician led Team-based Accessible Coordinated HEALTH CARE SYSTEM

The Story, the Transformation

September 2008, Ted Epperley March 2009, Charles Dobson, Ivan Abdouch April 2009, Tom Werner, Senator Gloor, PCMH

legislation September 2009, Bob Rauner and Paul Grundy November 2009, Don Klitgaard 2009-2010 the Governors Medicaid Medical Home

Advisory Council on PCMH 2009-present NMA Committee on PCMH Fall 2010 Plum Creek Medical Group applied and

accepted as one of the two Medicaid PCMH pilot project clinics

Story (continued)

2/1/2011-1/31/2013 PCMH Medicaid Pilot Project

May 2012, Harlan, Iowa, summit on PCMH and learn about Co-opportunities

June 2012 opportunity for Advanced Payment, Shared Savings ACO first discussed

SERPA began 1995 September 2012 application submitted to

include 9 practices across Nebraska ~10,000 Medicare patients

Story (continued)

Legislation Senators Gloor and Wightman 2012

Legislative Review Committee on PCMH 2012

1/1/2013-present SERPA-ACO now 14 practices ~75 Primary Care Physicians and 35 mid-levels caring for over 150,000-200,000 patients

SERPA-ACO now has contracts with Medicare, two Medicaid contractors and BC/BS of NE

Lexington, Nebraska Rural independent group of six Family

Physicians Two PA’s Two satellite clinics Lexington

• Population 11,000• Most diverse town in Nebraska• 55% Hispanic, 35% non Hispanic Caucasian, 10%

Somalian• Many languages

PCMH Transformation at the Practice Level: A Case Study of Plum Creek Medical Group

Office

Inpatient

Emergency Room

Nursing Home

Obstetrics

Procedures

Full scope of practice

Allscripts

Eleven years of experience

Attested for third year of meaningful

use

EHR is a must for PCMH to be done

well

Need to collect data and to evaluate

the practice

Electronic Health Record

Payers

30% Self Pay 29% BC/BS (mostly Arkansas

but some Nebraska) 14% Medicaid 12% Medicare 12% Other commercial 3% Work Comp

You don’t have to change, survival is optional

— C. Edwards Deming

We (as a practice) decided to heed Deming’s advice and embrace change; will we as a larger healthcare system…?

It is not a switch to turn on

It takes years

It is a process of continually

evaluating and making

improvements

Transformation

Establish a lead Physician Develop a management team

• Clinic manager• Front office/medical records

manager and EMR software expert• Director of nurses

Select and train a care coordinator Develop the care coordinator position

PCMH Project Details

First Four Steps

Must be imbedded in the practice

New position

Very important

Not paid for except in pilot projects

initially

A pivotal position in transformation

Many hats and tasks

Develop a Nursing Care Coordinator Position

ER utilization• Track and address over utilization of non

emergent visits• Patients contacted and encouraged to use

primary care physician• Use clinic during business hours• Set up appointments after ER visits• Record medication changes

Inpatient discharges Specialty referrals Tracking high acuity patients using the EMR Evidence based standards implemented

What does acare coordinator do?

Encouraged staff to practice to the top of their license

Networking

Help with prior authorizations and patient assistance

programs

Track diabetic patients referred to diabetic educators

Still evolving, community health workers, social

workers, diabetic or health educators, etc

What does a care coordinator do?

MOST IMPORTANT

With the Physician

With the front desk

With the nursing staff

With the whole team

That is what makes primary care, especially

Family Physicians, different

Relationships

Not a group of six independent practitionersStill an ongoing battle but easier and easier

Inertia toward change

Make It a Group Practice

Each physician practices similarly with a different personality

Evidence based approach, Choosing Wisely, USPTF, Up To Date, ACIP

Staff work at the top of their licenseAccess to careMeasure outcomesRegistriesProactive Care

Make It a Group Practice

This is a continuous multifaceted fluid process moving toward one goal

Culture changingPatient Centered Care

• NOT physician centered care• NOT front desk centered care• NOT nurse centered care• NOT insurance (payer) centered care• NOT institution centered care• NOT ______ centered care

PATIENT-CENTERED CARE

Patient-Centered Care

Advanced Access Scheduling Accurate matching supply/demandAccess can be a continually moving target

Access is the single most important driver of patient satisfaction!

Access is an important driver of quality and cost

Improving all three improve VALUE

Access

Set protocols

Every area does it the same

What is important for Patient Care

Cover everything that needs to be done

Do it in an efficient manner for the Patient

Patient flow

Patient safety

Staff Works to Top of License

Physicians communicate at the beginning and throughout the day with the nursing team

Meet with the physician led team periodically to discuss positives and negatives within the processes

If you want something done, explain what you want done and why, but let the staff decide how to do it. IT WILL THEN HAPPEN

Establish Healthcare Team Huddles

Communication within the team

What does the patient need

EHR can help

Lab

Immunizations

Health maintenance

Historical data

Huddles

Check in (where to go next)LabX-rayNursingOtherNursing

• Weight, Height, BMI • History of present illness• Medication reconciliation (every patient, every

medicine, every time)

Rooming

Nursing• Immunizations• Fall assessment• PHQ-9, depression screen• Health Maintenance

Mammogram Colon cancer screen Set up visit for wellness exam ROS if wellness exam VS (BP till last)

Rooming (continued)

Labs

Immunizations (everyone now follows

the ACIP guidelines)

Refills

INR’s (looking at but have not done yet)

Protocols

Patient Surveys

Registries Allows you to measure how well you are doing

As an individual physician

As a practice

In comparison to national figures

Evaluate changes

Make a new plan

Measure

Reevaluate

Measure Outcomes

Use registries to manage your practice not

individuals

Proactive care

Many examples Diabetes (950 diabetics in PCMG practice)

H1N1 flu vaccine to appropriate patient

Drug recalls

Health care maintenance, example colon cancer screening

Population Management

Value =Quality

Cost

TrentonMcCook

Curtis

Ogallala North Platte Lexington

Elwood

Sargent

Broken Bow

Kearney

Hastings Geneva

York

StromsburgShelby

David City

Columbus

Lincoln

Bellevue

Eustis

SERPA-ACO CLINICS

33 QUALITY MEASURES

7 Patient/caregiver experiences6 Care coordination/patient safety

8 Preventive health12 At risk populations: DM, HTN,CHF, CAD and Ischemic Vascular Disease

QUALITY Medicare measured 353 ACO’s nationally

SERPA-ACO is ranked 8th

Diabetes Composite

HTN - BP < 140/90

Pneumococcal Vaccination

Influenza Vaccination

Medication Reconciliation

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

30th Percentile 30th-50th Percentile 50th-90th Percentile 90th Percentile

2013 2014

2013 2014

2013 2014

2013 2014

2013 2014

Quality Measure Alegent/UniNet/CHI

SERPA ACO

MIPPA

ACO 8 – Readmissions 15.1 14.68 15.25ACO 9 – COPD Admits 1.76 0.92 1.06ACO 10 – HF Admits 1.17 0.84 1.06ACO 12 – Med Rec 97.61 98.39 97.19ACO 13 – Fall Risk 43.54 76.81 56.76ACO 14 – Influenza 60.72 78.97 66.78ACO 15 - Pneumovax 62.93 88.25 70.44ACO 18 - Depression 41.3 69.35 54.44ACO 19 – Colon Cancer 48.26 66.43 49.16ACO 20 - Mammography 67.43 71.72 67.89Diabetes Composite 35.21 37.88 31.03ACO 22 – BP Control 72.39 75.5 71.99

Medicare Hospitalizations/1,000

2012 2013 4th Q 2014200

220

240

260

280

300

320

340

360

380

400

325

294280

359

320

295SERPA ACOOther ACOs

Quality systems and measurements built in

Team-based care Enhanced physician leadership Increased partnership with community

resources Comprehensive care Continuous blending high tech AND

high touch elements to optimize patient care while improving the practice’s financial and professional health

Practice Today versusPre-PCMH Transformation

More patient-centered, less physician-centered care

Coordinated, not just episodic care Proactive, not just reactive care Emphasis on prevention as well as

achieving and maintaining wellness…while concurrently developing systematic excellence in treating chronic disease and acute illness

HIT support – EHR, population and chronic disease registries, e-Rx, e-communication, result tracking, patient portal, soon home monitoring……..

Meaning of PCMH Transformation

I’m all for progress. It’s change I object to

— Mark Twain

Major change is hard, and we had (and still have!) a few Mark Twains to contend with during our ongoing transformation!

Strong leaders needed in all areas Physician champion Nursing/office staff Administration IT leader

Ineffective leadership will hamper or halt the ability to make effective changes

The leadership team will shape the new culture of the organization

However strong leadership is absolutely critical!

In addition to better patient care and improved satisfaction, our PCMH efforts have positioned us to take advantage of/influence developing payment changes.• Accountable Care Organization (ACO) - Medicare

(advanced payment shared savings)• ACO - Medicaid contracts with Arbor and Aetna• ACO - Blue Cross/Blue Shield Contract

We are developing increasing levels of sophistication in interpreting and using data in our practice.

The PCMH changes we have made gives us the needed structure to make productive changes in our practice

Next Steps – Payment Changes!

PCMH adds cost to practices• Care coordination• Increased technology• Registries• Population management• Transition of Care• Better Chronic Disease Management

PCMH saves payers• Decreased ER visits• Decreased hospital admissions and readmissions• Decreased duplication of tests and unnecessary

tests

Increased Value Increased Compensation

This is a continuous fight This is why a legislative bill was introduced Payers all agreed to set up some type of

payment system for PCMH and a contract was signed in 2013

United Health Care and Aetna commercial have still not come with a payment system with SERPA-ACO.

We treat all patients the same whether self-pay, Medicare, Medicaid or commercial insurance.

If all the payers will not pay for their benefits we will again push for legislation

All Payers Need to Pay

Enhanced fee for service

Care management fees

Capitated, no risk models

Shared savings

Targeted incentives for quality and efficiency

Global or bundled payments

Accountable Care Organizations

Evolving Payment Methodologies

This is often our approach not just to practice changes but also to changing payment

methodologies

PAYMENT REFORM

Medicare drives the bus Medicaid and commercial will

follow ACA is not going away MACRA is coming Health Care will be Value based

by 2019

Real-time adjudication of claims being explored

Benefit redesign is important New levels of information sharing Shared savings on the table Insurers must transform or face increased

regulation in the private sector Strong motivation to collaborate with

physician practices and healthcare providers

Moving towards value-based purchasing

Payer Reform

Principles for Joint AgreementsSERPA-ACO

Mission/Vision – We are centered on improving the quality of care provided to our patients while helping them reduce their total health care costs.

Partnerships – Joint agreements will be equitable and transparent.

Clinic Level Sustainability – Joint agreements will provide practice level sustainability for Patient Centered Medical Home, clinic-based care coordination and systematic quality improvement efforts.

Shared Rewards – Equitable sharing of achieved savings from contracts.

Patient Choice – Patients and physicians will have the freedom to choose their provider based on the high quality and value

Very important but the needed systems are not built yet and those that are close are extremely expensive.

Medicare closes out their year usually in August or September for the previous 1/1-12/31 year

Blue Cross/Blue Shield claims data always 6 months in the rears for a year of data.

14 clinics with 6 soft wear systems in SERPA-ACO Hospitals all have different systems yet We need to combine clinical data in the office, with

hospital data, with referral data, with claims data We need to be able to pick out PATIENTS at risk

and proactively treat them

IT

The current generation of healthcare providers (and systems) has a diverse set of both unprecedented challenges and exciting opportunities ahead

We must decide how we are going to approach these challenges and opportunities…

What does this mean for the future of Primary Care?

MEDICAL PRACTICE…

The confluence of many broad trends are leading to rapid delivery and payment system changes, offering both unprecedented challenges and opportunities

Practice level changes, as represented by PCMH transformation, can add significant value to both patient and provider experience and outcomes

Many different payment models are being tested nationally, but movement is towards paying for value and accountability

Thoughtful delivery system changes are fundamental in preparing for these evolving payment models

Important Take Home Points

Contact information:

Joe Miller MD FAAFPPlum Creek Medical Group, PC1103 Buffalo BendLexington, NE 68850308-324-6386 ext 622 (office)308-325-7356 (cell)josephmiller@charter.net

Thank you for your attention!Any Questions?