Prescription for Pennsylvania The Pennsylvania Multi-Payer Statewide Medical Home Model

Transcription

1 Prescription for Pennsylvania The Pennsylvania Multi-Payer Statewide Medical Home Model Robert Gabbay MD, PhD Director, Penn State Institute for Diabetes and Obesity Professor of Medicine Penn State College of Medicine

2 Today Development of the PA initiative Key aspects Early outcomes Unique features Questions to ponder 2

3 Origin and Purpose of the Governors Chronic Care Commission Established May 2007 by Executive Order with Commissioners appointed in their individual capacity. Purpose: to design the informational, technological and reimbursement infrastructure needed to implement and support widespread dissemination and implementation of the Chronic Care Model throughout Pennsylvania. 3

4 The Chronic Care Model Most widely accepted evidencebased model for Improving Chronic Care 4

5 The Chronic Care Model Community Health System Resources and Policies Self- Management Support Health Care Organization Delivery System Design Decision Support Clinical Info Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes 5

6 Why Diabetes? 6

7 It s Where the Money is! 7

8 Avoidable Hospitalization Costs for Pennsylvanians with Chronic Disease Cost in $ Billions Heart Disease Lung Disease Diabetes Asthma Chronic Disease 8

9 Why Diabetes? High Morbidity and Mortality High Cost for preventable complications Consensus evidence based goals An epidemic is ahead Diabetes will double in next 20 years

10 The PA Chronic Care Commission Strategic Plan The Commission presented its Strategic Plan to the Governor and the Speaker of the House on February 13, 2008 The Plan provides a business case and framework for implementing the Chronic Care Model across the Commonwealth Implementation is incremental Diabetes (with co-morbidities) and lesser extent asthma primary focus of the initial rollout with spread to other chronic illnesses 10

11 The Intervention 1. Learning collaboratives 2. Practice coaches 3. Registry Reporting 4. Patient Centered Medical Home implementation 5. Reimbursement/infrastructure payments 11

12 Implementation of the Chronic Incremental rollout Care Model in PA Southeastern PA was the first regional rollout May 2008 Rollouts in South Central PA followed by Western, NW and NE PA and throughout the State Rollouts persist for at least three years To date- 780 providers across the state involved with population of 1 million patients 12

13 Partner Organizations Governors Office for Health Care Reform Governor s Chronic Care Commission Payers Independence Blue Cross, Highmark, Capital Blue Cross, Aetna, Keystone Mercy, Health Partners, Geisinger, Cigna, others (17 Total) Professional Organizations/Societies Improving Performance in Practice (IPIP) ABIM ACP PAFP 13

14 One of the Largest Multi- Payer PCMH Initiative in US 14

15 Goals Change processes of care Improve clinical outcomes (diabetes is the target disease but untimely spread to other diseases) Cost containment 15

16 Overall Framework 1. Learning collaboratives 2. Registry reporting 3. Practice coaches 4. Patient Centered Medical Home 5. Reimbursement/incentives changes 16

17 1. The Breakthrough Series Learning Collaborative 2 days each 3 months for One-year then every 6 months for next 2 years Sharing across teams facilitated by conference calls between sessions, listservs, websites for materials 17

18 PDSA Cycle 18

19 2. Registry Reporting Use your own otherwise State provides one free (RMD) Monthly reporting of outcomes along with narrative reports 19

20 3. IPIP Practice Coaches IPIP : Improving Performance in Practice piloted in Colorado and North Carolina RWJ supported Help practices problem solve during PDSA cycles Implement Registry 20

21 4.PPC-PCMH Content and Scoring Standard 1: Access and Communication A. Has written standards for patient access and patient communication** B. Uses data to show it meets its standards for patient access and communication** Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information (mostly non-clinical data) B. Has clinical data system with clinical data in searchable data fields C. Uses the clinical data system D. Uses paper or electronic-based charting tools to organize clinical information** E. Uses data to identify important diagnoses and conditions in practice** F. Generates lists of patients and reminds patients and clinicians of services needed (population management) Standard 3: Care Management A. Adopts and implements evidence-based guidelines for three conditions ** B. Generates reminders about preventive services for clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans, assessing progress, addressing barriers E. Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities Standard 4: Patient Self-Management Support A. Assesses language preference and other communication barriers B. Actively supports patient self-management** Pt Pt Pt Pt s s s s Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety checks C. Has electronic prescription writer with cost checks Standard 6: Test Tracking A. Tracks tests and identifies abnormal results systematically** B. Uses electronic systems to order and retrieve tests and flag duplicate tests Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic system** Standard 8: Performance Reporting and Improvement A. Measures clinical and/or service performance by physician or across the practice** B. Survey of patients care experience C. Reports performance across the practice or by physician ** D. Sets goals and takes action to improve performance E. Produces reports using standardized measures F. Transmits reports with standardized measures electronically to external entities Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support **Must Pass Elements 21 Pts Pts PT 4 4 Pts Pts

22 Focus on Chronic Care Model But reimbursement based on PCMH certification 22

23 5.Reimbursement 17 leading insurers initially involved and expanding GOHCR convener for negotiations Goal is to support implementation of the CCM 23

24 Reimbursement Reimburse for time away from practice at learning collaboratives Benchmark payments based on NCQA PCMH Certification (requires care management) Per FTE prorated by Carrier contribution of Practice s total revenue In NEPA- savings shared with practices Can be ~$30-50 K /FTE/ yr 24

25 Strengths of the PA Approach Government Convener Multi-Payer (17) Teaching practices to change Chronic Care Model Focus Lots of small practices All Practices Reporting Monthly Scope 780 Providers and 1 Million Patients 25

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27 Implementation of the Chronic Care Model in PA 27

28 A Look at the Numbers Region Number of Practices Total Providers FTE'S Total Reported Patients Average FTE's/Practice Average Patients/FT E Year 1 Payments Total Estimated Payments By Insurers SEPA , ,391 $1,965,982 $13,599,231 SCPA , ,081 TBD $4,711,210 SWPA , ,413 TBD $6,219,842 NEPA , ,428 TBD $6,159,615 Total , ,941 $1,965,982 $30,689,898 NWPA , ,026 $192,000 NCPA , $168,000 SEPA , ,434 $276,000 Total , ,364 $636,000 Grand Total ,093, ,694 $2,601,982 $30,689,898

29 Charecteristics of reimbursed practices SEPA SCPA SWPA NEPA Number Participating Practices Number Participating Providers Percent Urban Practices 52% 0% 50% 0% Percent At-risk Populations African American Hispanic Percent of Practice Type FQHC Resident Family Medicine Internal Medicine 12% 37% 32% 16% 28% 24% 2% 2% 0% 0% 80% 20% 13% 1% 9% 0% 86% 5% 3% 3% 0% 7% 86% 7% Percent Practices with Providers 1 to 3 4 to 10 Greater than 10 20% 76% 4% 24% 68% 8% 50% 45% 5% 67% 26% 7% 29

30 Government-Payer-Provider Partnership

31 Outcomes Measures Clinical Patient centered Utilization Costs 31

32 Preliminary Results: Southeastern PA 25 practices working on Diabetes 143 providers and 10,000 patients Improvement in complication screening, evidence based medication use, and clinical outcomes NCQA certification 32

33 Evidence Based Treatment Baseline Mean Value at One Year Aspirin Statin* ACE/ARB* SM Goal

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35 Early Cost Data From One Major Insurer in SE First year of SEPA practices saw: 26% decrease in hospital admissions 30% decrease in emergency room visits 16% decrease in overall costs 35

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39 Questions How is Success Determined and Who Defines Success? What parts of the intervention are most important Spreading to all Chronic illness Care 39

40 It Takes a Team.. Governor s Office of Health Care Reform Ann Torregrossa, Phil Magistro, Brian Ebersole, Gregory Howe and of course the Governor Ed Wagner, Michael Bailit, Connie Sixta, the brave practices, and many, many more PA Association of Family Practice/Improving Performance in Practice (IPIP)- Pat Bricker

41 Prescription for Pennsylvania Questions?