designing the ideal practice for population healthcare
TRANSCRIPT
Designing the Ideal Practice for Population Healthcare New Roles for Extenders
HFMA Conference
JR Steinbauer MD
CMO CHI Texas Division Network
Professor of Family Medicine BCM
1
February 16 2018
Objectives
bull Understand the economic drivers of changes to the healthcare system
bull Understand current primary care workforce and most current and common work flow for care delivery
bull Understand value based care
‒ Goals of population health
‒ Challenges to current staffing
‒ Patient Centered Medical homes
bull Consider models for the future and opportunities for advanced practice providers
2
Big Changes in Care House calls
3
Big Changes in Care Home rather than Hospital
4
Hospitals can make older patients sicker Infections incontinence and weakening muscles from bed rest can cascade into delirium frailty and death More than 30 percent of older adults go home from a hospital stay with a minor or major health problem they picked up at the hospital
Early research at Northwestern and other hospitals shows care from geriatrics-trained nurses in the ER can reduce the chances of a hospital stay after a patients emergency visit and for a month afterwardAbout 100 hospitals in the United States have opened geriatric emergency departments or trained ER teams in geriatrics care These teams can arrange home services such as light housekeeping or a break for a caregiver
Big Changes in Care Innovative thinking to decrease costs
5
Whatrsquos Going On
bullKeeping patients OUT of the hospital
bullKeeping patients out of the ER by paying rent
bullMaking money with house-calls
bullHow can these things make sense
ITrsquoS ALL ABOUT A FOCUS ON VALUE
6
What is Value in Healthcare
7
Achieving high value for patients must become the overarching goal of health care delivery with value defined as the health outcomes achieved per dollar spent 1 This goal is what matters for patients and unites the interests of all actors in the system--Porter NEJM Dec 8 2010
What about cost Where are dollars spent
8
The United States spent $29 trillion on health care in 2013 or about $9255 per person according to
a new detailed accounting of the
nations health care dollars
--Washington Post 12-8-14
The United States Spends Morehellip
9
hellipBut Health Outcomes are not the Best
10
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Objectives
bull Understand the economic drivers of changes to the healthcare system
bull Understand current primary care workforce and most current and common work flow for care delivery
bull Understand value based care
‒ Goals of population health
‒ Challenges to current staffing
‒ Patient Centered Medical homes
bull Consider models for the future and opportunities for advanced practice providers
2
Big Changes in Care House calls
3
Big Changes in Care Home rather than Hospital
4
Hospitals can make older patients sicker Infections incontinence and weakening muscles from bed rest can cascade into delirium frailty and death More than 30 percent of older adults go home from a hospital stay with a minor or major health problem they picked up at the hospital
Early research at Northwestern and other hospitals shows care from geriatrics-trained nurses in the ER can reduce the chances of a hospital stay after a patients emergency visit and for a month afterwardAbout 100 hospitals in the United States have opened geriatric emergency departments or trained ER teams in geriatrics care These teams can arrange home services such as light housekeeping or a break for a caregiver
Big Changes in Care Innovative thinking to decrease costs
5
Whatrsquos Going On
bullKeeping patients OUT of the hospital
bullKeeping patients out of the ER by paying rent
bullMaking money with house-calls
bullHow can these things make sense
ITrsquoS ALL ABOUT A FOCUS ON VALUE
6
What is Value in Healthcare
7
Achieving high value for patients must become the overarching goal of health care delivery with value defined as the health outcomes achieved per dollar spent 1 This goal is what matters for patients and unites the interests of all actors in the system--Porter NEJM Dec 8 2010
What about cost Where are dollars spent
8
The United States spent $29 trillion on health care in 2013 or about $9255 per person according to
a new detailed accounting of the
nations health care dollars
--Washington Post 12-8-14
The United States Spends Morehellip
9
hellipBut Health Outcomes are not the Best
10
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Big Changes in Care House calls
3
Big Changes in Care Home rather than Hospital
4
Hospitals can make older patients sicker Infections incontinence and weakening muscles from bed rest can cascade into delirium frailty and death More than 30 percent of older adults go home from a hospital stay with a minor or major health problem they picked up at the hospital
Early research at Northwestern and other hospitals shows care from geriatrics-trained nurses in the ER can reduce the chances of a hospital stay after a patients emergency visit and for a month afterwardAbout 100 hospitals in the United States have opened geriatric emergency departments or trained ER teams in geriatrics care These teams can arrange home services such as light housekeeping or a break for a caregiver
Big Changes in Care Innovative thinking to decrease costs
5
Whatrsquos Going On
bullKeeping patients OUT of the hospital
bullKeeping patients out of the ER by paying rent
bullMaking money with house-calls
bullHow can these things make sense
ITrsquoS ALL ABOUT A FOCUS ON VALUE
6
What is Value in Healthcare
7
Achieving high value for patients must become the overarching goal of health care delivery with value defined as the health outcomes achieved per dollar spent 1 This goal is what matters for patients and unites the interests of all actors in the system--Porter NEJM Dec 8 2010
What about cost Where are dollars spent
8
The United States spent $29 trillion on health care in 2013 or about $9255 per person according to
a new detailed accounting of the
nations health care dollars
--Washington Post 12-8-14
The United States Spends Morehellip
9
hellipBut Health Outcomes are not the Best
10
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Big Changes in Care Home rather than Hospital
4
Hospitals can make older patients sicker Infections incontinence and weakening muscles from bed rest can cascade into delirium frailty and death More than 30 percent of older adults go home from a hospital stay with a minor or major health problem they picked up at the hospital
Early research at Northwestern and other hospitals shows care from geriatrics-trained nurses in the ER can reduce the chances of a hospital stay after a patients emergency visit and for a month afterwardAbout 100 hospitals in the United States have opened geriatric emergency departments or trained ER teams in geriatrics care These teams can arrange home services such as light housekeeping or a break for a caregiver
Big Changes in Care Innovative thinking to decrease costs
5
Whatrsquos Going On
bullKeeping patients OUT of the hospital
bullKeeping patients out of the ER by paying rent
bullMaking money with house-calls
bullHow can these things make sense
ITrsquoS ALL ABOUT A FOCUS ON VALUE
6
What is Value in Healthcare
7
Achieving high value for patients must become the overarching goal of health care delivery with value defined as the health outcomes achieved per dollar spent 1 This goal is what matters for patients and unites the interests of all actors in the system--Porter NEJM Dec 8 2010
What about cost Where are dollars spent
8
The United States spent $29 trillion on health care in 2013 or about $9255 per person according to
a new detailed accounting of the
nations health care dollars
--Washington Post 12-8-14
The United States Spends Morehellip
9
hellipBut Health Outcomes are not the Best
10
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Big Changes in Care Innovative thinking to decrease costs
5
Whatrsquos Going On
bullKeeping patients OUT of the hospital
bullKeeping patients out of the ER by paying rent
bullMaking money with house-calls
bullHow can these things make sense
ITrsquoS ALL ABOUT A FOCUS ON VALUE
6
What is Value in Healthcare
7
Achieving high value for patients must become the overarching goal of health care delivery with value defined as the health outcomes achieved per dollar spent 1 This goal is what matters for patients and unites the interests of all actors in the system--Porter NEJM Dec 8 2010
What about cost Where are dollars spent
8
The United States spent $29 trillion on health care in 2013 or about $9255 per person according to
a new detailed accounting of the
nations health care dollars
--Washington Post 12-8-14
The United States Spends Morehellip
9
hellipBut Health Outcomes are not the Best
10
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Whatrsquos Going On
bullKeeping patients OUT of the hospital
bullKeeping patients out of the ER by paying rent
bullMaking money with house-calls
bullHow can these things make sense
ITrsquoS ALL ABOUT A FOCUS ON VALUE
6
What is Value in Healthcare
7
Achieving high value for patients must become the overarching goal of health care delivery with value defined as the health outcomes achieved per dollar spent 1 This goal is what matters for patients and unites the interests of all actors in the system--Porter NEJM Dec 8 2010
What about cost Where are dollars spent
8
The United States spent $29 trillion on health care in 2013 or about $9255 per person according to
a new detailed accounting of the
nations health care dollars
--Washington Post 12-8-14
The United States Spends Morehellip
9
hellipBut Health Outcomes are not the Best
10
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
What is Value in Healthcare
7
Achieving high value for patients must become the overarching goal of health care delivery with value defined as the health outcomes achieved per dollar spent 1 This goal is what matters for patients and unites the interests of all actors in the system--Porter NEJM Dec 8 2010
What about cost Where are dollars spent
8
The United States spent $29 trillion on health care in 2013 or about $9255 per person according to
a new detailed accounting of the
nations health care dollars
--Washington Post 12-8-14
The United States Spends Morehellip
9
hellipBut Health Outcomes are not the Best
10
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
What about cost Where are dollars spent
8
The United States spent $29 trillion on health care in 2013 or about $9255 per person according to
a new detailed accounting of the
nations health care dollars
--Washington Post 12-8-14
The United States Spends Morehellip
9
hellipBut Health Outcomes are not the Best
10
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
The United States Spends Morehellip
9
hellipBut Health Outcomes are not the Best
10
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
hellipBut Health Outcomes are not the Best
10
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
We Canrsquot Sustain Current Health Care Costs
11
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
What is the focus to improve value
bull Primary Care
‒ Most cost effective point of care
‒ Shown to reduce admissions and improve quality
‒ Ideal venue for population health management
‒ Ideal venue for
Prevention
Disease management
bull So what are the barriers to increasing primary care
‒ Traditional RVU based workflows
‒ Reimbursement ldquoWe donrsquot do things that donrsquot generate revenuerdquo
12
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Primary Care Physician Workforce
13
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Primary Care Workforce
14
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Extenders in 2010
15
-AHRQ ldquoPrimary Care Workforce Stats and Facts 2
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Primary Care Workforce
bull In 2010 there were approximately 209000 practicing primary care physicians in the United States
bull In 2010 approximately 56000 nurse practitioners and 30000 physician assistants were practicing primary care in the US
bull Primary care physicians nurse practitioners and physician assistants are more likely to practice in rural areas than are non-primary care specialists but are still more concentrated in urban areas
16
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
How are Extenders currently used in Primary Care
bull Substitutive (most common)
‒ May have ldquopanelrdquo of patients
‒ Doing acute care
‒ Essentially functioning as a physician
bull Complimentary
‒ Doing focused elements of care
Prevention
Chronic disease
ldquoPhysicalsrdquo
17
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
But Primary Care is in Crisis
18
ldquoPrimary care in the United States is in crisis for a number of reasons An increasing percentage of our workforceis experiencing burnout and reimbursement for primary care is insufficient to provide needed services for patients and adequate compensation for primary care teamsrdquo
ldquoOnly 6--8 percent of health care dollars are spent on primary care services The CMMIrsquos Comprehensive Primary Care (CPC) initiative and Rhode Islandrsquos statewide payment innovation model provide evidence that additional investment in primary care is likely to sustain transformation improve patient outcomes and will be cost neutral or cost saving overallrdquo
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Primary Care Workforce Threats
ldquoThe US primary care system is struggling under increasing demands and expectations diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians nurses and physician assistants into primary care Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care The Council on Graduate Medical Education is concerned that the trend if unchecked will progress to fewer than one-fifth of medical students specializing in primary carerdquo
--AHRQ
19
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Primary Care Workforce Burnout
20
ldquoAfter 38 years in practice Irsquove never felt
more removed from DIRECT interaction with
my patients Lists of lsquoactionsrsquo I must take at
each visit limits on what insurance will pay
for a treadmill of generating RVUrsquos have all conspired to put a
gulf between me and a sense of lsquomaking a differencersquo for my
patientsrdquo
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Primary Care Burnout Possible Solutions
Additional interventions that need further testing but may be able to assist in reducing burnout aremdash
‒ Creating standing order sets
‒ Providing responsive information technology support
‒ Reducing required activities
‒ Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record
‒ Offering flexible or part-time work schedules
‒ Having leaders model and support work-home balance
‒ Hiring floating clinicians to cover unexpected leave
‒ Building workplace teams that address work flow and quality measures
‒ Ensuring values align between clinicians and leaders
--AHRQ
21
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Market Forces in Primary Care
22
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Market Forces in Primary Care
bull More retail organizations getting into ldquoquick carerdquo (Walmart for example)
bull Reasons
‒ldquoYoursquore sick wersquore quickrdquo
‒Physician shortage
‒Physicians occupied with prevention long waits if yoursquore sick
bull Short term solution but doesnrsquot yet offer comprehensive primary care
bull Do patients want ldquofast foodrdquo model for healthcare Or do they prefer a personal health provider
23
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Practice Restrictions for Extenders a Consideration
24
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
What is Population Health
25
ldquoThe art of medicine consists of amusing the patient while nature cures the diseaserdquo - Voltaire
ldquoAmericarsquos health care system is neither healthy caring nor a systemrdquo- Walter Cronkite
ldquo[]because the business of their lives was to cure and they received money for it and had spent the best years of their lives on that business [] Their usefulness did not depend on making the patient swallow substances for the most part harmful but they were useful necessary and indispensable because they satisfied a mental need of the invalid and those who loved her They satisfied that eternal human need for hope of relief for sympathy and that something should be done which is felt by those who are sufferingrdquo
- Leo Tolstoy
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
What is Population Health
26
Population Health Management is
the aggregation of patient data across multiple health information technology resources
the analysis of that data into a single actionablepatient record
and the actions through which care providers can improve both clinical and financial outcomesrdquo
- wwwwellcentivecom
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
CIN Goal the Goal of Population Health
27
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Objectives in Population Health Who is the sickest
28
In all patient populations there is a subset a small percentage that costs the
most and is the most complex current systems
donrsquot address this but newer population health
approaches target these patients
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Traditional Processes in Outpatient Care
Make Appointment
bull Patient calls to make appointment with new problem or follow-up
bull Or patient reminded it is time for appointment due to chronic care
Visit
bull Often acute and chronicprevention not addressed at same visit
bull Limited time competing ldquoagendasrdquo
Post Visit
bull Out of sight out of mind
bull Rare follow-up to assess progress with most recent care plan
29
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Overwhelming Processes in Outpatient Care
bull Calculations show that providing just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2500 patients would take 74 hours per day
bull 191 discrete tasks that physicians accomplish during a typical primary care office visit including twenty-six tasks associated with gathering information from patients and thirteen associated with addressing treatment options
bull Jeffrey Farber and coauthors studied physician work flow and determined that each thirty minutes of scheduled patient visits generates an additional 67 minutes (range17ndash138 minutes) of care outside clinic time Across a variety of primary care settings activities occurring outside scheduled office visits are estimated to result in at least seven to ten hours of work per week for a physician
bull STANDARD WORKFLOWS WILL NOT ACHIEVE POPULATION HEALTH GOALS
30
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Gaps in Current System
bull Data show ‒ Inadequate monitoring of renal disease in diabetes‒ Incomplete immunization data‒Failure to achieve gt40 of CRC monitoring‒Failure to complete annual well visits‒Less than adequate control of diabetes for many patients Lack of understandingNot enough timeresources
DESPITE OUR BEST EFFORTS CURRENT PRACTICE MODELS FALL BEHIND IN QUALITY
31
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Process in Population-based Outpatient Care
Make Appointment
bull Data analysis shows who is due for prevention or monitoring
bull Office reaches out to make appointment
Visit
bull Through standing orders prevention activities accomplished quickly
bull Blended visit may have more time
bull Not every ldquotestrdquo requires a visit
Post Visit
bull Continued monitoring of patient via data systems
bull Engagement through portaleventually tele-med
32
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Transforming Healthcare ndash The Process
33
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Transforming Healthcare ndash Which Problems
34
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Transforming Healthcare ndash How
35
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Population Health ndash Patient Centered Medical Home (PCMH)
36
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Defining the Medical Home
37
Comprehensive Care Whole-person care provided by a team
Patient-Centered
Supports patients in managing decisions and care plans
Coordinated Care
Care is organized across the lsquomedical neighborhoodrsquo
Accessible Services
Care is delivered with short waiting times 247 access and
extended in-person hours
Quality and Safety
Maximizes use of health IT decision support and other tools
Source wwwahrqgov
True Medical Homes have all components
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
PCMHrsquos Impact on Cost and Quality
38
bull The Patient-Centered Primary Care Collaborative (PCPCC) publishes an annual report that highlights recently published clinical quality and financial outcomes of patient-centered medical home (PCMH) initiatives
bull More than 90 commercial and not-for-profit health plans including the nations largest are leading initiatives grounded in the philosophy of patient-centered care and the PCMH
bull Dozens of the nations largest employers including Boeing IBM Intel Safeway and Lockheed Martin are offering advanced primary care and PCMH benefits to thousands of employees
Source The Patient-Centered Primary Care Collaborative ldquoThe Patient Centered-Medical Homersquos Impact on Cost amp Quality An Annual Review of the Evidence 2012-2013
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
PCMH Evaluations and Results
39
PCMH studies continue to demonstrate impressive improvements across a broad range of categories PCMH has been shown to be effective at reducing cost of care emergency department visits inpatient admissions readmissions and at improving access patient satisfaction and preventative services
Recent research finds that the longer a PCMH model of care has been in place the greater the cost savings and improvement in quality and outcomes
The Patient-Centered Primary Care Collaborativersquos recently published PCMHrsquos Impact on Cost amp Quality can be found here PCMH Impact on Cost amp Quality
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Significant Payment Reforms Continue to Incorporate the PCMH
40
bull Many physicians do not realize that their CMS fee- for-service payments are already at
risk and being tracked (January 1 2017) with the potential to have a negative impact on
their 2019 reimbursement
bull CMS is estimating that 47 of physicians across the US will experience a
negative impact to their 2019 payment because they have not been preparing
for this change
bull In addition commercial payers are following the CMS model and increasing the number
of value-based contracts with CINs to submit those contracts models to CMS for 2019
approvals on the APM payment track
bull Aetna has a goal of 75 of its medical spend being in value based higher
risk contracts by the year 2020 They are on track with this goal as 45 of
their 2016 medical spend is aligned with similar CMS models
bull United Healthcare has aligned 45 of its medical spend in value-based risk
contracting in 2016
bull Anthem Blue Cross Blue Shield (in 14 states) has 58 of its medical spend in
value-based contracts in 2017 and continues to work toward a 75 goal
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
PCMH Beyond Recognition
41
bull NCQA Recognition is not synonymous with being a true medical home
ndash For many practices the recognition process provides a useful road map for quality improvement and practice transformation
ndash PCMH is a way of codifying and systematizing primary care improvement efforts The transformation work is never finished as practices embrace continuous quality improvement and use information to refine and improve care for patients and their families
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Primary Care Office Staffing Standard Model
42
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Primary Care Office Staffing Population Health Model
43
Expanded primary care models open new
opportunities for building a real TEAM of providers to
care for patients
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Extender Opportunities in Population Health
44
bullBe a provider in a Quick Care setting‒Hourly employee‒Limited scope‒Goals are access and prescriptions for simple
problems
bullHospital provider in geriatric emergency room
bullHome visit program as alternative to hospitalization
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Extender Opportunities in Population Health
45
bullSeek opportunity in PCMH practice‒Programs of care for prevention and chronic
disease‒Team based approach‒Measurable outcomes improving cost quality and
satisfaction
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Extender Opportunities in Population Health
46
bullWork in some portion of population delivery system‒Employer based clinics‒Administrative work in CIN offices network
coordination‒On site process improvement with member
practices
Questions
47
Questions
47