The Challenges & the Opportunities to Excel in the Urban Multi-Specialty Practice The Manhattan s Physician Group New York, New York Team Dr. Mark Coleman Director of Medical Management Dr. Navarra Rodriguez Chief Medical Officer Steven Vickner Chief Information Officer Lynn Lang Chief Operating Officer MPG Mission Manhattan s Physician Group is a patient centric organization committed to providing outstanding service to our patients in a compassionate culture 1
The Manhattan s Physician Group Focus Areas Creating a culture of accountability Customer Service Process improvement Training Communication Quality Not accepting status quo Challenges Identified for the Practice: Geographic Cultural Operational Clinical 2
Geographic Challenges Manhattan s Physician Group is situated amongst well established & numerically competitive Medical Institutions Collective Medical Institutions & Practices continuously exert authority & control not always in step with our Practice. Care & influence to the patient, management issues to the Practice Easy to utilize for patients Direct access & dependability for service 24/7 Management issues on entry for Hospital Identification issues Limited medical information Communication issues Unnecessary admissions Management issues on discharge Continuity of care Prescription reconciliation Out of group referrals Difficult to acquire medical course, treatments and ressults Management concerns for the Practice Difficulties to work with multiple Medical Institutions Identification Communication: ED utilization, re-admits & length of stay Results and records Continuity of care on discharge Referrals: out of group expenses Erosion of patient base Cultural Challenges Physician Based Historical early Professional Training focused on Diagnosis & Management with limited concern for Necessity or Expense Internship, Residency & Fellowship programs Exaggerated Dependency on Specialist in Primary Care OOG expense out of control Consuming 40% of capitated revenue Patient Based Diversity Spectrum of our practice appeal for maintenance & growth Exaggerated push for Specialist for consults and management of Primary Care in the urban setting Conditioning that was acquired in the last decades Erosion of Primary Care Medicine Leading to bad patient behavior 3
Operational Challenges Internal Communication with PCP & Specialists Limited utilization of EMR throughout practice Access to appointments & care Hours of operation External Communication Informational Navigational Environmental: Location (the East Side vs. the West Side, Downtown vs. Uptown) Clinical Challenges Urban population: large & diverse required our Practice to consider: Medical Services offered: effectiveness & Delivery No Express Care to offer our patients originally Hospital Coordination with our Practice Partnered Arrangement Approach to Acute & Chronic Disease Management Address our patient base Access & deliverables Access & Length of Appointment Time Site & access limits Approach to the Identified Challenges Development of a Medical Management Service Deliver methods & processes that reduce or eliminate barriers considered problematic to the well being of the Practice, the Patient s and the Community Expansion of Information Technologies Service to be able to support the Medical Management agenda s as the Practice moves forward. 4
Three areas of focus needed development to address the identified challenges Referral Management Hospital Management Clinical Management Referral Management The first focus to address the identified challenges of: Geography Cultural Operational Clinical The Referral Culture & the Changes the Practice made Cultural Physician, Patients & Hospitals Resulting in greatest expense to the practice 60-80% of referrals were going outside the practice Need, Benefice, & Approach required overhauling Change occurred through: Openly discussing the Referral issues with our Physicians including the approach, need & benefice Primary Care vs. Specialty Care Retooled EMR: internal defaults, manual external Partnering with Select Hospitals Reduced hospital generated OOG referrals Fostered network of Specialist s as preferred providers Dashboard creation: weekly, monthly, pcp, specialty Identified outliers Identified leakage Allowed monitoring patterns Access Specialty demand outweighed our supply to deliver Increased OOG referrals with increased expense & decreased management control Change occurred through: Recruitment of New Specialty Services & increase Existing Service Lines identified via our Dashboards All physician trained to communicate only through the EMR: improved PCP to Specialist communication Increased appointment availability through increased daily slots: from avg. of 18 to 22 5
Harness Data and Support ACO and Medical Home Initiatives Referral Management Disease Management Hospital Integration Referral Management Report on Who, Where and Why and System Review: Location, MPG referring provider, external provider/specialty, patient, reason Data shared with providers habitually referring outside of MPG to learn trends; re-education in referral patterns and necessity Revamp EMR Clean up internal/external provider drop-downs Standardize and organize Referral To template and Referral Mgmt template Modify referral standards based on NCQA; ex. Referral Priority Enable Self/Supervisory Tracking Tools Provider-based referral tracking within EMR template Trending reports on external referrals Result Dramatic reversal in referral patterns Movement away from external to internal referral OOG referrals dropped to 20-40% Constructed tools to monitor & track activity Direct Physician Engagement Decreased leakage in Specialties we invested in Improved communication internally via uniform use of the EMR Great buy in to change the patient referral culture Improved access Terminated the outside endless referral Based on lack of need, benefice & communication 6
Hospital Management The second area of needed development to address the identified challenges of: Geography Cultural Operational Clinical Complex Urban Landscape Geographic, Cultural, Operational, & Clinical Challenges Create a Kaleidoscope of patient management issues between the Practice & the surrounding Medical Institutions within the medical community Communication Informational Records Undesirable Practice Outcomes for both the Practice & Hospital Continuity of Care Length of Stay Re-admit Rates Consistent Clinical Intervention with Desired Outcomes Source of Out of Group Referrals Frequent Flyers Reduced Practice, Hospital & Patient opportunities & satisfaction Management through Partnership Partner with a limited number of Medical Institutions Ability to work with Share similar geographic landscape Share similar challenges, goals and mantra Management Service Income & Expense 7
Lenox Hill Hospital & Manhattan s Physician Group Embraced the Challenges & Partnership by forging together an Integrated Communication Network Administrative JOC Subgroups Clinical Daily mechanism for patient activity & movement MPG Medical Management Team & LHH Team Physician network ED to PCP to ED Hospitalist to PCP to Hospitalist Specialist to Specialist Informational MPG & LHH I.T. Departments Hospital Partners Phase 1 Identify MPG patients entering hospital ED or straight admit Cull data from hosp systems, print and hard fax to MPG (efax) Track ED/admit data in Excel; scan D/C Summary in EMR Fax from EMR to hard fax located in hospital Phase 2 Full efax transmission Remote access to hospital systems Track ED/admit data in Access; ODBC w/ EMR; scan D/C in EMR Phase 3 Enhance patient identification (HL7 or periodic demo dumps) Advance to real-time alerts when MPG patients arrive Queue data reports and batch transmit via efax RESULTS Manhattan s Physician Group & Lenox Hill Partnership 8
Capitated Patients admitted to LHH 2010 By Quarter 300 264 283 LHH ADMITS BY QTR 200 213 100 122 0 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Jan 2010 vs. Jan 2011 Capitated patients admitted to LHH 100 95 75 50 25 19 0 2010 2011 Capitated Admissions for MPG 2008 vs. 2010 8000 6000 6,085 TOTAL ADMITS LHH ADMITS 4000 3,943 2000 995 1,065 0 2008 2010 9
Results Favorable Outcomes Patronage to LHH has increased throughout the past year & as a historical point has increased in 18 months from 16% to 27% utilization in the care of our capitated patients. Increased Admissions to Lenox Hill Hospital throughout 2010 500% increase from January to December 225% increase from 1 st quarter to 4 th quarter Average Length of Stay for all diagnoses 2008 vs. 2010 (Capitated patients admitted to LHH) 10 LOS BY DAY 8 6 6 4 4 2 0 2008 2010 Results Length of Stay Average MPG Length of Stay 4.0 days in 2010 for all diagnoses National Average Length of Stay 4.8 days for all diagnoses Based on National Hospital Discharge Summary 2007 10
Re-admit Rates for 4 th Qtr 2010 (capitated patients) 20% 17% 15% 10% 5% 0% 1.00% 30 DAYS 72 HRS 24HRS 0 *10% of the 30 day readmit rate are patients who were readmitted with the same diagnosis. Capitated/LHH 4 th Qtr 2010 Re-admit Rate by LOB 50% 48% 40% 38% 30% 20% 14% 10% 0% MEDICAID MEDICARE HMO Results MPG 30 day Mean Readmit Rate 17% overall Medicare population 8% National 30 day Readmit Rate 18% Based on Medicare Agency for Healthcare Research & Quality Annual Conference 2007 11
Summary Structured Partnership Collaboration Communication Development Integrated working networks Significant Achievements Patient Direction & Movement Admissions Length of Stay Readmissions Rates Clinical Management The third focus to address the identified challenges of: Geographic Cultural Operational Clinical Clinical Management Upgrade Participation in HEDIS Your only as good as you can show me Comprehensive group endeavor that embraced most of the clinical staff & helped to shape practice performance expectations for the entire group. Site center teams created for outreach & coordination Creation of dashboards for tracking and completion via I.T. department Cervical cancer screening Breast cancer screening Glaucoma screening Chlamydia screening Comprehensive Diabetic Management Childhood immunization screening 12
HEDIS Current State: Pap, Mammo, Diabetes, Chlamydia, Glacoma, Osteoporosis Regularly run report outline compliance based on: provider and location Providers see patient-level data on missing measures Outreach to patients based on reports As claims and lab results arrive, compliance is updated Future State Integration with 3 rd party app which alerts patients at check-in on treatments they are recommended to have, but have yet to schedule; auto-call back when referrals do not translate to a scheduled appointment, or claims have not been received to confirm treatment has occurred Billing and final sign-off can be halted until a reason is indicated why the patient has not complied with recommended treatments Disease Management Programs Developed in areas to improve both the medical outcome to the patient & the performance outcome to the practice. Review of our clinical practices & outcomes revealed areas for opportunities to improve. Referral pattern: leakage Management Disease Outcomes: elevated Hba1c, BMI,... Hospital Use: increased Frequent Flyer, Readmits Rates, LOS... Structure of Disease Management Programs Operates through the Medical Management Service Supported with our I.T service to develop the means to identify, enroll & track patient & project activity Medical Management Service Restructured into: Administrative branch: operations Clinical branch: medical Navigational branch: outreach, enrollment & coordination Coordinates the Practice, the Partnered Hospital & the Payer Work in synch to identify & provide opportunities for intervention Improve medical condition while decreasing medical expenses Emblem Health Care Sponsors Home disease management programs Sponsors Point of Care team to work within the Practice Integration is required for meaningful use 13
Disease Management Identification and Tracking Reports Patient denominators with chronic conditions MPG targets for HEDIS and NCQA Overlap data collected from hospital partners to ID frequent flyers to ED Patient enrollment in MPG-owned, and payor-sponsored programs Comparative analysis: program attendance vs. reduced hospitalizations EMR Templates Internal referrals for patients who would benefit from programs Track educational material hand-outs to attendees of programs Centralized location for internal/external program membership Transition from Hospital to MPG Educate patient on DM programs during ED/hospital visit Set up first appointments upon D/C Patient outreach to bolster attendance and compliance, using automated phone calls (future enhancement) The Disease Management Programs Range of Programs: Office & Home based, permits more opportunity for positive intervention beyond PCP & Specialist s, Internal Programs: MPG sponsored programs Act as step-up & step-down to that Specialty service & as adjunct service for the PCP & Specialist Office Based programs are in Primary Care COPD Asthma Diabetes HTN Obesity Office Based in Nutritional Care - Diabetes Management & Obesity Management -individual & group sessions External Programs: Home programs sponsored by the medical insurance payor Telephonic & case management resources Results to Date HEDIS participation: 3 rd quarter 2010 completion by %: Cervical Cancer Screening 86% Breast Cancer Screening 77% Chlamydia Screening 81% Glaucoma Screening Exam 81% Comprehensive Diabetic Monitoring Performance of Hba1c 94% Maintenance of Hba1c <9.0 86% Performance of Retinal Exam 54% Increased clinical opportunities for our patients to engage in. Integrated Network of Service s created to connect: Patient, PCP, Specialist, Payer & Partnered Hospitals via the Medical Management Service through its layered Administrative, Clinical & Navigational structure. Improvement in patient care through: Proactive movement into action programs for patient s identified with chronic disease concerns Improvement in Physician access by their patients Improvement in continuity of care between the Practice & the Hospital Increased opportunity to improve a patient s clinical management Increased opportunity to improve patient satisfaction & loyalty to the Practice Improved Referral Practices the smart referral to Disease Management 14
Summary Manhattan s Physician Group, an urban multi-specialty practice located in New York, New York Identified challenges to the practice: Geographic Cultural Operational Clinical Focused on three areas needing development to address identified challenges: Referral Management Hospital Management Disease Management Result is positive & measurable outcomes seen in these focused areas. 15