From FFS to VBP: A Journey of a Small Integrated Medical Practice Called KPC

Anna W Leung, PhDDirector of Behavioral Health, Koinonia Primary Care

OBJECTIVES� Introduce KPC1

� FFS2 and PCBH3 co-location

� Value-based care and PCBH integration (or CoCM4)

� Tips and tricks, and challenges in VBP5 preparedness

1. Koinonia Primary Care

2. Fee For Service

3. Primary Care Behavioral Health

4. Collaborative Care Model

5. Value Based Payment

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“Koinonia” /ˌkoinəˈnēə/� 2018 Scripps National Spelling Bee winning word

� A transliterated form of a Greek word “κοινωνία”

� Intimate communion, sharing, association, partnership, often with a spiritual implication;

� The idealized state of fellowship and unity that should exist among believers of Christian faith

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KPC – Our MissionStriving to eliminate health disparity within New York’s Capital

Region by providing compassionate, high quality, patient-centered

healthcare to the underserved in a faith-based environment.

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KPC – Our Team

Our dedicated team of

professionals, staff, and

volunteers

*Caring

*Committed

*Volunteerism

*Respect

*Stewardship

*Community Involvement

*Empowerment

Picture taken in April, 2018 prior to Dr. Corrie Paeglow, our new Executive Director, and Cassie

Flanagan, our new office manager, joined KPC

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KPC – Our Location

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KPC – Our Neighborhood

� West Hill is known for crime– it is the worst in Albany between 2012-2017

� There has been 384 arrests, 3 murders, 6 assaults with a weapon in the first 8 months of 2018 alone

� The first homicide (by shooting) of 2018 took place at the traffic light outside of KPC during lunch time

� News Channel 13 WNYT featured a story in August 2018 titled “Left Behind: Crime in Albany’s West Hill Neighborhood”

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KPC – Our Neighborhood (cont’d)

� Albany is known to be the worst among 100 U.S. metropolitan areas for black non-Hispanic children to be raised

� Source*: The Child Opportunity Index 2015 developed by the Institute for Child, Youth and Family Policy of the Heller School for Social Policy and Management, Brandeis University

� Nationally, an average of 40% of black non-Hispanic children grow up in lowest opportunity neighborhood within their metropolitan area. In Albany, 60% of the children live in such neighborhoods.

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*ICYFP's Child Opportunity Index reveals pervasive racial and ethnic inequities in America’s 100 largest metro areas

https://heller.brandeis.edu/news/items/releases/2015/child-opportunity-index.html

KPC – Our Patients

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� Many patients live in the neighborhood

� 8,964 completed patient visits in the last 12 months

�2,130 active patients currently

Patient Demographics

88%

6%6%

Ethnicity

Non-Hispanic

Hispanic

Unknown

42%

40%

2%

16%

Race

Black/African

AmericanWhite

Asian

Other

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Patient Demographics (cont’d)

1%14%

75%

10%

Age

Infant & Toddler

Ages 3-18

Ages 19-64

Ages 65+

51%49%

Gender

Male

Female

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Patient Demographics (cont’d)

46%

6%10%

9%

23%

6%

Insurance

Commercial Medicaid

Medicaid

Commercial Medicare

Medicare

Private Insurance

None/Not Specified

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Prevalence of Common Chronic Diseases Among KPC Patients

0%

10%

20%

30%

40%

50%

60%

KPC US

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Source: National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)

Fee-For-Service & PCBH Co-location

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Features of FFS:

�Paid for volume

�Quantity over quality - more care not necessarily better care

�Silo work

�Issues- & individual-focused

What’s missing in FFS?

�No measurement of quality or emphasis of evidence-based care

�No emphasis of health of the population

�Even with PCBH co-location, there’s no systematic care coordination; it’s difficult to track sustainable progress or lapse of care

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Value-Based Care &PCBH Integration/CoCM

� At KPC, value-based care and PCBH integration/CoCM (collaborative care model) goes together

� There’s no health without mental health!

� PCBH integration enhances the patient’s experience and treatment outcome and the health among our patient population, save health dollars, and satisfies the providers.

� No idea about the financial implication when KPC first took on CoCM

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The Triple Win

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Is Collaborative Care better?� Greater reduction in depression symptoms is found among patients treated by a collaborative care model than the colocation model (Blackmore et al., 2018)

� From baseline to follow-up, 33% reductions in PHQ9 scores for the collaborative care model versus 14% for the colocation model

� A study of 705 older adults with depression symptoms showed that collaborative care compared with usual care resulted in a statistically difference in depression symptoms at 4 month follow-up (Gilbody et al., 2017)

� We think so!

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Pt quit taking medicine

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1st integrated visit,

with ongoing

medication treatment

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A B C DA – Started antidepressant

B – 1st integrated visit

C – Medication change

D – Dosage adjustment

* EPC is the proprietary name for the CDPHP PCMH;

* Rationale: combined savings associated with better health outcomes and lower utilization will be sufficient to fund enhanced compensation to PCP;

* Shift of focus from volume-based care to value-based care

* Provide care that is right and evidence-based at the right time;

* Monthly capitation payments are calculated based on a severity-adjusted base compensation payment methodology

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* An annual retrospective performance-based bonus is awarded to high performance providers based on value and quality;

* Standard FFS is applied to visits not included in the capitation-style payment billable codes;

* Collaborative care or visits involving both primary care and behavioral health providers do not fall into the billable codes;

* Visit the EPC web page - www.cdphp.com/providers/enhanced-primary-care;

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Is value-based model better?� Data from the Centers for Medicare and Medicaid Services, Medicare accountable care organizations saved more than $460 million in 2015 while improving quality and performance.

� In 2014, CDPHP realized a cost savings of $20.7 million, across all lines of business, directly related to EPC (60% commercial; 20% Medicaid & Medicare)

� $12.8 million more in reimbursements and enhanced bonuses among 193 medical practices, than if those practices had not participated in the program

� KPC’s 2017 Q4 had an increase of profitability of 30% associated with Medicaid patients and 5% with Medicare patients

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Is value-based model better? (cont’d)� Kocher & Chan (2018) – look at one form of VBP model - risk-based payment models with capitation

� What risk? (1) “Upside risk” shares in cost-saving bonuses based on operational efficiencies; (2) “downside risk” loses revenue based on failure to meet clinical performance and/or financial performance thresholds

� Practices that succeed at making the shift from FFS to managing risk are routinely able to increase their practice profitability by at least 25%

� Economic value comes from fewer hospitalization, fewer expensive prescriptions, fewer unnecessary high tech images or diagnostic tests, lower ED use, reducing use of post-acute care facilities

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� Really know the patients

� Acknowledge them as individuals with creative capacity and inherent worth, not only their problems or issues

� Asset-focused versus problem-focused

� The ultimate goal is about human flourishing

Enough about the patients… what about us?� Know one another and the team as a

whole

� Respect and defer to each team member’s gifting

� Remember: None of us is as smart as all of us

� Practice quadruple aim (i.e., satisfaction of the team)

� Make collaboration a true practice within the organization while networking with others (e.g., CBO, MCO) to utilize their resources and expertise

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Continuum based framework for PCBH Integration� Domain #1: Identification of patients and referral to care

� Domain #2: Multi-disciplinary team approach to care

� Domain #3: Continuous care management

� Domain #4: Systematic quality improvement

� Domain #5: Decision support for measurement-based, stepped care

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Continuum based framework for PCBH Integration* (cont’d)�Domain #6: Self-management support that is culturally adapted

�Domain #7: Information tracking and exchange among providers

�Domain #8: Linkage with community and social services

� * Behavioral Health Integration Issue Brief Series, No.2: Advancing Behavioral Health Integration for Small Primary Care Practices: Progress, Emerging Themes, and Policy Considerations (Smali, Goldman, Pincus, & Chung, 2018)

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CHALLENGES

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OVERLOAD� Data overload

� Little overlap among programs seeking for data sharing and/or analytics

�Layers of structured fields can be time-consuming and take away from quality care

�Electronic health records are not readily equipped to record data from multiple programs

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3 TAKEAWAYS

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o VBP practice is a process that needs adaptation through time,

confusion, and perseverance, but it’ll get easier and better.

o Define what value-based care means for you and your

community, upon which you shall develop the workflow and

adopt the logistics

o Help and resources are available more than you think, through

learning, sharing, and reaching out. We’re in it collaboratively!

CONTACT INFORMATION

Anna W. Leung, PhD

aleung@koinoniapc.org

KPC website: www.koinoniapc.org

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