AOA Clinical Assessment ProgramRichard Snow DO, MPHNovember 4th, 2009

• Evaluate changing framework of value based purchasing• How this can strengthen Primary Care

– Discuss models of primary care payment reform– What’s shaping up in Ohio

• Discuss definition of the Patient Centered Medical Home

• Discuss how the AOA-CAP fits into the framework of the PCMH

• Review benefits of adopting the PCMH to your practice from:– Patient care, marketing and payment perspective

• Hospital program from Centers for Medicaid and Medicare Services– Currently hospital reporting on ~ 60 measures

covering:• Process of care

– Evidenced based processes in AMI, HF, Pneumonia, Surgical Care Improvement Program

• Outcomes of care– Mortality, readmission

• Patient Safety– Complications, Patient Safety indicators

• Patient Satisfaction– HCAPS

• Payment tied to Hospital Compare (Since 2005)– Currently, if a hospital does not report they lose

2% of Medicare reimbursement annually• Value Based Purchasing Agenda (2012)

– Next step is to tie payment to performance• Demonstration project suggested methods

– Create distributions on aggregate measures– Reward improvement equally with absolute

performance– Pay more for top decile and less for bottom decile

• Revenue neutral

Ambulatory care has been slower to move forward

Physician Quality Reporting Initiative Movement to measure groups Inclusion of registry

NCQA Physician Recognition Program Patient Centered Medical Home

A principal reason: too little money for too much work. Median income for primary-care doctors was $162,000 in 2004, the lowest of any physician type, according to a study by the Medical Group Management Association in Englewood, Colo. Specialists earned a median of $297,000, with cardiologists and radiologists exceeding $400,000.

What this can mean to primary care? Provide a focus for reimbursement

Co-ordination and management of patients with chronic disease

Primary and secondary prevention Care coordination across multiple providers and

ancillary services Quality improvement focus

A reimbursable event and payment for cognitive care

Picking up where RBRVS fell off

How the concept is perceived among non-health care workers Experience of the Ohio Health Care Quality

and Cost Council Legislative, business and advocacy groups

After a summary and review of over 20 potential avenues of reform the top three and subsequent focus of the summit included Patient Centered Medical Home Payment Reform (to encourage PCMH) Activated Patient

Almost every primary care physician believes they are providing this now

The disconnect is in interpretation Opportunity to redefine your practice as an

Evidenced based Outcomes driven resource for the community That connects with patients and employers And provides care co-ordination

Models to compare to your current practice

Most advanced in setting where incentives can be aligned to achieve patient centered care

Examples From the literature Current Practice

Geisinger Health Care

80 Type 2 diabetic patients with microalbuminuria randomized to: Control

Regular care Intensive intervention

Step-wise introduction of lifestyle and pharmacological interventions aimed at keeping:

glycated hemoglobin <6.5% blood pressure <130/80mmHg total cholesterol <175mg/dl and triglycerides <150mg/dl. reduction in intake dietary fat regular exercise and smoking

cessation.

N Engl J Med 348:383-393,2003

Intermediate Outcomes

Event Rate End Points

death from CVD, nonfatal MI, nonfatal stroke, revascularization, and amputation.

N Engl J Med 348:383-393,2003

Control Group (n=80)

Intensive Treatment Group (n=80)

Glycosylated Hemoglobin < 6.5 3% 15%

Diastolic < 80 mm Hg 60% 70%

Systolic < 130 mm Hg 18% 50%

Total Cholesterol < 175mg/dl 22% 72%

Endpoints after 7.8 years of follow-up 44% of patients in the conventional care arm had

events 24% of patients in the intensive treatment arm

had events (significantly lower) In addition to the 53% reduction in CVD

events the intensive treatment group had a reduction of nephropathy, retinopathy, and autonomic neuropathy by 61, 58, and 63% respectively

N Engl J Med 348:383-393,2003

 Control Group (n=80)

Intensive Treatment Group (n=80)

AOA-CAP for residencies 2004-2009 (n=11,000)

Glycosylated Hemoglobin < 6.5 3% 15%

Glycosylated Hemoglobin < 7.0 46.80%

Diastolic < 80 mm Hg 60% 70%

Blood Pressure < 130/80 32%Systolic < 130 mm Hg 18% 50%

Total Cholesterol < 175mg/dl 22% 72% LDL < 100mg/dL 55.90%

Geisinger Health System One of the best operating models of the

Patient Centered Medical Home Provides a model for what a PCMH would

look like at a system level Take away at the practice level

What can you learn from Geisinger to move your practice to a PCMH model Full transition may take several years

Pending payment reform PQRI

Geisinger operational definition Round-the-clock access to primary and

specialty care services, Enhanced through the use of nurse care

coordinators, care management support, and home-based monitoring

Health Affairs, September/October 2008 27(5):1235–45

Geisinger operational definition Physicians and patients alike have access

to electronic health records (EHRs) For patients, this means they can view lab

results, schedule appointments, receive reminders, and e-mail their providers

Health Affairs, September/October 2008 27(5):1235–45

Geisinger operational definition To encourage physician participation in the

medical home innovation, Geisinger provides practice-based monthly payments of $1,800 per physician

Stipends of $5,000 per 1,000 Medicare patients to help finance additional staff

Health Affairs, September/October 2008 27(5):1235–45

Geisinger operational definition Preliminary data show a 20 percent

reduction in hospital admissions and 7 percent savings in total medical costs

Based on this success, Geisinger is expanding the initiative to additional practice sites.

Health Affairs, September/October 2008 27(5):1235–45

Other Aspects of program – a clinical / epidemiologic perspective Chronic disease care optimization

Coordinated, evidence-based care for patients with chronic diseases, including diabetes, congestive heart failure, and hypertension

Standardize clinical practices, provide doctors with a "snapshot report" of patients' relevant clinical information, and generate automated reminders for patients as well as the clinical team

Other Aspects of program – patient engagement / activation Patients can also self-schedule

appointments and receive an after-visit summary to see how they are doing compared with their goal

Reinforced using care management team

Other Aspects of program – No reason to restructure unless it makes a difference, same for enhanced pay for primary care Physicians may receive financial incentives

linked to patient satisfaction, quality, and value goals.

Initial results from more than 20,000 diabetic patients have shown statistically significant improvements in measures like glucose control, blood pressure, and vaccination rates.

Health Affairs, September/October 2008 27(5):1235–45

Addressing the Problem Based on Geisinger's experience, the authors say

that policymakers nationally should: recognize that EHRs are absolutely necessary but not

sufficient for creating sustainable change in care delivery.

align incentives so that providers are rewarded for enhancing value in health care.

create policies that encourage greater organization of care delivery and payer-provider collaboration.

• Includes employed physicians, owned healthcare facilities and an insurance product (Medicare) thereby allowing alignment of incentives to achieve outstanding results

• How does the previous example apply to a diverse group of primary care settings? What does this mean to your practice.

The concept of the Patient Centered Medical Home is becoming embedded into payment methods. How does this apply locally? Evolution of pay for performance

Becoming more cohesive at practice level Physician Quality Reporting Initiative

Moving from measures to measure groups clustered around chronic disease

NCQA Physician Recognition Program Structural evaluation of your practice

Evolving recommendations Payment for process and outcomes

Similar to endorsed measures in AOA-CAP Improve recognition of contribution of primary

care to the health of populations across the continuum

Improve resources necessary to achieve better outcomes (primary and secondary prevention)

Human (care management) Infrastructure (Information Technology, patient

connectivity)

Key components in all definitions of PCMH include the use of a registry Disease focused, defining current performance

within your practice and patients Developing a systematic approach to improving

care Focused on process or outcomes Using community or other resources to improve care

Re-evaluation of care for evaluation of improvement

Tools your practice needs Registry

AOA-CAP Population management

Management of chronic disease patients to evidenced based goals

Quality improvement Identify opportunities and implementing systematic

change Track improvements in process and outcomes of care

Tools your practice needs Patient education and empowerment

Patient education Time and educator

Group visits Web based resources

Patient communication Traditional visit and exam Phone management Web based management

Tools your practice needs Patient education and empowerment

Self management and engagement Goal setting for control of glucose, lipids and blood

pressure Self measurement

Tools your practice needs Resources / costs

Time with patient Physician Physician extender Educator

Communication and continuity Web based Phone Goal setting and tracking progress to goals

Information on current performance Registry “Synthesized EHR”

Diabetes flow sheets Checklists for preventive care

Focus on treatment intensification (pharmacological) Data from literature and CAP suggest that 30% of

patients not at goal are due to ‘physician inertia’ Rest are system or patient factors

Engage your patients and the community in quality opportunities Employers and patients

EHR is not necessary to create the Patient Centered Medical Home Components of it are helpful

Test and referral tracking, reminders Challenges

Current products do not facilitate registry functions

Operational Costs Productivity

Aligning payment with desired outcomes Moving to close the gap

Challenge of what society wants to pay for Better health early or multiple procedures late

Evolving models in reimbursement CMS

Value Based Purchasing Hospital Based Physician Based

Physician Quality Reporting Initiative

Standards of Medical Home necessary to pass Access and Communications

Ease of access 24/7, continuity, internet enabled, language services Patient Tracking and Registry

Use of templates in chronic disease, most frequently seen diagnosis, risk factors

Care Management Evidenced based diagnosis and treatment guidelines

Patient Self Management Support Group classes, materials, care plan

E-Prescribing

Standards of Medical Home necessary to pass Test Tracking

Track all tests, imaging, abnormal test policy, notification Referral Tracking

Paper or electronic system to track referrals through report from consultant

Performance Reporting and Improvement Clinical process, outcomes, service, safety

Advanced Electronic Communications

Physicians Quality Reporting Initiative (CMS) Pay for reporting 2% bonus payment for

reporting in 2009 153 quality measures

Claims based Registry

Measure Groups

Measure groups as a lead into payment for management of chronic disease

How well are you doing in Diabetes Management, Preventive Care? AOA-CAP is tied to PQRI

2nd year, one of 3 clinical registries originally accepted by CMS for PQRI

30 consecutive charts provide you with info on: Glycemic, blood pressure and lipid control Eye Exam,

Albuminuria screen for diabetes Preventive screenings

Receive a bonus payment of 2% of the physician total charges for 2009