The Physician s Perspective How the Changing Role of the PCP is Leading Healthcare Reform May 22, 2015 Carman A. Ciervo, DO Chief Physician Executive Our Vision To transform the healthcare To transform the healthcare experience for patients and their families through a culture of caring, quality, and innovation. 1
Clinical Providers September 2010 Primary Care 1 Michael Monte Carlo, DO D.O. Family Medicine West Deptford, NJ 3 Clinical Providers May 2015 Primary Care 29 Hospital Medicine 15 SNFists 2 Vascular Surgery 2 Breast Surgery 1 Cardiothoracic Surgery 1 Total 65 Neurology 5 Endocrinology Pulmonary 3 Radiation Oncology 2 Dermatology 1 2
How the Changing Role of the PCP is Leading Healthcare Reform With accountable care, patient centered medical homes and pay for performance performance gaining momentum, primary care has never been more critical to ensuring quality care and overall system financial success. What has and hasn't worked will be discussed along with an overview of initial results. 5 Reform: The pressure for better upstream care (it s health enhancing & less expensive) Primary & Preventive Care Episodic Outpatient Specialty Care Inpatient Care MOVE CARE UP STREAM THRU FINANCING CHANGE Funding EHRs 30 day Readmission Penalty Chronic Care Management by PCP Medical Home Proficiency 6 3
Patient Centered Medical Home (PCMH) A team based approach to health care that provides comprehensive &integrated medical care to patients in a primary care setting. 6 12 months of intense preparation for certification Three certification designations Only 12 15% of primary care practices in US have achieved a level of PCMH certification thru NCQA. http://www.ncqa.org/portals/0/public%20policy/201%20comment%20letters/the _Future_of_PCMH.pdf 7 Joint Principles of the Patient Centered Medical Home March 2007 Personal physician Physician directed medical practice (team oriented) Whole person orientation Care aes is coordinated and/or integrated Quality and safety Enhanced access Payment 8
1: Enhance Access and Continuity A. *Patient Centered Appointment Access B. 2/7 Access to Clinical Advice C. Electronic Access 2: Team Based Care A. Continuity B. Medical Home Responsibilities bl C. Culturally & Linguistically Appropriate Services (CLAS) D. *The Practice Team 3: Population Health Management A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. *Use Data for Population Management E. Implement Evidence Based Decision Support Pts.5 3.5 2 10 Pts 3 25 2.5 2.5 12 Pts 3 5 20 : Plan and Manage Care A. Identify Patients for Care Management B. *Care Planning and Self Care Support C. Medication Management D. Use Electronic Prescribing E. Support Self Care and Shared Decision Making Pts 3 5 20 5: Track and Coordinate Care Pts A. Test Tracking and Follow Up 6 B. *Referral Tracking and Follow Up 6 C. Coordinate Care Transitions 6 18 6: Measure and Improve Performance A. Measure Clinical Quality Performance B. Measure Resource Use and Care Coordination C. Measure Patient/Family Experience D. *Implement Continuous Quality Improvement E. Demonstrate Continuous Quality Improvement F. Report Performance G. Use Certified EHR Technology Pts 3 3 3 3 0 20 Patient Centered Medical Home 6 standards / 27 elements / 150 factors Patient Centered Medical Home Element 3(D): Use Data for Population Management At least annually practice proactively identifies populations of patients and reminds them, or their families/caregivers, of needed care based on patient information, clinical data, health assessments and evidenced based guidelines including: 1. At least two different preventive care services. 2. At least two different immunizations. 3. At least three different chronic or acute care services.. Patients not recently seen by the practice. 5. Medication monitoring or alert. 5
Patient Centered Medical Home What s notable about it? As the PCMH credential is achieved, your work has just begun. The fully functioning whole is more than the sum of the parts. 11 Patient Centered Medical Home What s notable about it? Sustaining it financially is a very heavy lift Constructing the value revenue cycle reporting system Temptation for backslide to volume based financial success Tension / conflict between finance & physician executives 6
Executing the PCMH Strategy DRIVING REVENUE GROWTH SUPPORT FOR GROWTH & PCMH INFLUENCING CULTURE Grow Volume of Existing Providers Redesign Provider Comp. Plans Adequacy of Support Staff FTEs Mgmt. Develop. Demonstrate PCMH Value to Payers Give Feedback: Timely Data Sets for Managing Improve Support Staff Competencies Consistent Messaging Reduce Process Variation Increase # of Advanced Practitioners Evolve to 5 Providers Per Site Successful reform requires coordinating these roles in a spirit of accountability Patient Hospitalist Primary Care Provider Emergency Mdii Medicine Provider AND A COMMITMENT TO ROBUST COMMUNICATION 1 7
A Physician Retreat Exercise: What s working / what s not? Our Patients, t Our Responsibility, My Role 15 What s working / what s not? Roses Thorns Buds 16 8
How the Changing Role of the PCP is Leading Healthcare Reform Roses (what s working) Rising consciousness of caregivers for what happens beyond their own care sites More timely communication across care sites corresponding with patient transitions Timely and shared discharge summaries Hospital / Sub acute Rehab connections Thorns (what s not working) Medication reconciliation Timely information feedback to the PCP, et. al. about patient Adequacy of information communicated Financing i of reforms 17 Financing Reform: The primary care provider perspective 2000: Independent Practice 2015: Health System Owned Service revenue Practice expenses Physician earnings Net cash flow $ 0 Service revenue Practice expenses Physician earnings Operating loss Hospital subsidy Net cash flow $ 0 9
Evolving Economics of Physician Practice: Cash Flow 2015: Health System Owned By 2018, the financial stress anticipated for hospitals may cause this to diminish. Service revenue Practice expenses Physician earnings Operating loss Hospital subsidy Net cash flow ($ ) Financing Reform: The primary care provider perspective Type of Revenue Payment Simple & Revenue Driver Time Predictable? Fee for service Visits 1 30 days Yes Capitation Panel Size 0 30 days Yes Quality & Outcomes Metrics 30 365 days No (+/ 150) 20 10
Primary Care Practice Economics Type of Revenue % of Payment Revenue Driver Revenue Time To Succeed Fee for service Visit 70% 1 30 days Ramp up visit volume Capitation Panel 20% 1 30 days Diminish visit volume Quality & Outcomes Metrics (+/ 150) 10% 30 365 days Change patient & provider behavior 21 From volume based payments to value based payments Fee for service Value driven care TIME You are here 22 11
1. Execute Payer Contracts That Reward Triple Aim* Performance Financing of Reform: Establishing a third revenue cycle system 2. Track Contract Metrics 3. Set Practice Performance Targets for Contract Metrics: What by when?. Pursue Targets with Resources: Management Providers Support Staff Technology Physical Plant 5. Track Change Results: Outcomes Compliance Patient Satisfaction 2(a). Collect earned revenue Change Methodology Change Agents 6. Set Payer Contract Renegotiation Strategies * Triple Aim = (1) high care quality (2) satisfied patients (3) no wasting of resources Financing Reform: Strategy for Financial Sustainability Are care continuum management contracts in place? Yes No UNSUSTAINABLE Lower revenue due to ineffective care continuum management QUESTIONABLE SUSTAINABILITY Market may no longer reward services provided within unmanaged care continuum No SUSTAINABLE Managing the care continuum and getting paid for it s value. UNSUSTAINABLE Care continuum management expenses go unreimbursed Yes Is care continuum management in place? Many of us are here. 12
So, back down to primary care: What s needed for success? Physician engagement Compensating the primary care physician i to maximize value and earn adequate revenue Payer requirements to pass thru Quality & Outcome Revenues From my care to our care: the challenge of shared accountability From primary care provider to primary care system 25 Physician Engagement Components of a healthy culture Physician engagement beyond employment Readiness for an uncertain future The current economics are too complex to rely on payment models to succeed you need a trusting relationship eato pamong gall caregivers e and hospital administration. 26 13
The Physician Profession & Organizational Culture The profession has had limited experience in organizational hierarchy. Modern professional management practices are new to many physician organizations. Physicians have been slow to adopt modern information technologies, but catching up. 27 Six Components of a Healthy Culture 1. Choosing physicians & midlevel providers Medical care quality Emotional / organizational engagement Historical productivity Diversity / experience distribution 28 1
Six Components of a Healthy KHA Culture 2. Engagement with providers Accessible leadership Primary Care Quality Committee Monthly provider meetings / periodic retreats 29 Six Components of a Healthy Culture 3. Accountability Practice level financial / productivity reviews monthly For providers: Expectations set annually Provider productivity / quality tracked monthly Timely performance evaluations & feedback 30 15
Accountability Provider Dashboard Clinical Indicators 31 Accountability Provider Dashboard Productivity Indicators SAMPLE DOCTOR 32 16
Six Components of a Healthy KHA Culture. Balancing.... Short term expediency with long term success The interests of primary care practice and the health system 5. No bridge burning with physician & hospital competitors 33 Six Components of a Healthy KHA Culture 6. Embracing change Professional development for physician & administrative leaders Tools for change CMS Value based purchasing (hospitalists) Patient centeredmedical home (primary care) 3 17
Our collective success will be highly dependent on patient accountability Easy to have patient come in / hard to have patient do something. I can make a visit happen, but I can t make a patient change. The real opportunity lies with the patient, not us. 35 A final suggestion when engaging physicians: Ask questions & listen to the responses. Don t tfeel lthe need to immediately relieve the stress you hear. Seek first to understand their perspective. What s your opinion of PCMH? How is it better than FFS? How is it worse? 36 18
The work ahead... "The world is going to push us, relentlessly and without mercy, to deliver the highest quality, safest, most satisfying care at the lowest cost." Dr. Bob Wachter University of California at San Francisco How is the PCP Leading Healthcare Reform? With collaboration With data With accountability With tools for change With courage in the face of reform s uncertainties 19