Clinician Pay for Performance. October 31, 2016

Clinician Pay for Performance October 31, 2016

Open Door Family Medical Centers Founded in the basement of a church in 1972 We ve grown a bit since then 5 Primary Care Sites 7 School-based Health Centers Family Medicine Residency program Dental Residency program

Open Door Family Medical Centers By the end of 2015, we had: Over 100 Medical, Behavioral, and Dental clinicians providing care to 47,000 patients in 265,000 visits

Open Door PCP panel sizes Primary care panel size: 1,400/1.0 FTE PCP over 12 months 1,650/1/0 FTE PCP over 18 months 2,100/1.0 FTE PCP over 36 months

Patients by Age and Sex - 2014 (Under age 1) (1-19) (20-49) (50-64) (65 & Up) After childhood, we see a considerable difference between the number of men and women that we see. We attribute this trend to the high number of women that we see during child-bearing age.

Insurance Coverage of Our Patients - 2014 7% 4% 8% Uninsured Medicaid 50% CHIP 32% Medicare Private

Pay for Performance in Focus 2001 - Salary Armageddon 2006 - NP/PA incentive 2007 - eclinicalworks implementation 2009 - Clinical report cards introduced 2011 - Pay for Performance implemented 2013 - Human Resources strengthened 2014 - Tableau database rolled out 2016 - Relevant database rolled out AZARA PVP rolled out

Paying for clinical quality Clinicians of all stripes want to also be judged by the quality of care they give, not just by how many patients they can see. Clinicians are more concerned about how well they are taking care of patients much more than how fast they are moving from patient to patient.

Volume counts, but it s not everything Yes, volume-based reimbursement still reigns supreme. BUT. As healthcare organizations that employ clinicians, shouldn t their quality of care matter more than it currently is represented? We are all patients at some point isn t a clinician who gives good care what matters most?

Pay For Performance 2010 plan devised to incorporate clinical quality metrics as a compensation component 2011 plan rolled-out, first P4P payments HTN bonus trigger set at 60% control rate 2015 metric goals revised HTN bonus trigger set at 66% control rate

P4P magnifies need to define the PCG Using Hypertension control as an example, we only assign the quality of patient s care to the PCG if: 1) Patient is assigned to that PCG 2) Has been diagnosed with Hypertension > 12 months (eliminates concerns about newly diagnosed conditions) 3) Has seen the PCG at least twice in the past 12 months (eliminates the very common and valid concern about not having sufficient face-time with some patients on one s panel)

Open Door P4P Primary Care metrics, 1-6 (of 12) Primary Care P4P 2016 "N" needed Baseline 2016 P4P Hypertension 1 BP < 140/90, adults 18-59 50 70% 66% Diabetes 2 A1c < 9 30 80% 83% Asthma 3 Persistent classes with ICS 10 82% 88% or montelukast Immunizations UTD thru 2 yrs 4 % UTD 25 92% 90% tracks kids 2-4 years of age Immunizations UTD at 15 years 5 % UTD 5 67% 66% 3 HPV, 1 TDaP, 2 Varicella Paps, in last 3 years 6 % done, > 21 yo 100 74% 77% Women age 24-65 HP2020 goal is 66% HP2020 goal is 80% ODFMC goal is 90% HP2020 goal is 50% ODFMC goal is 66%

Open Door P4P Primary Care metrics, 7-12 (of 12) Primary Care P4P 2016 "N" needed Baseline 2016 P4P Mammo, in last 2 years 7 % done, > 50 yo 100 66% 70% Women age 52-75 CRC 8 % done > 50 yo 50 42% 50% Adults age 51-75 Adult Pneumo 9 % done 50 79% 81% Adults age 65 and older Adult Tdap in last 10 years 10 % done 50 64% 65% Age 18 and older Depression screening/treatment 11 Age 12 and older 100 53% 60% Tobacco assessment/cessation 12 Age 13 and older 100 86% 90%

A typical Clinician Report Card A clinician s report card, showing data: 1) By Goal 2) Open Door overall 3) Clinician s site (Mount Kisco) 4) Clinician s data from the most recent 2 quarters He is on track to: Hit P4P metric Miss P4P metric

Pay for Performance breakdown 2016 (2017 breakdown is being revised) Bonus potential is 10% of salary for a clinician who is not in a leadership/managerial position 50% - clinician hits productivity target 25% - clinician site hits productivity 15% - clinician s clinical quality rating (1-4) 10% - individual goals set with clinician s site medical director

Determining Clinical Quality Rating We rate clinical quality on a scale of 1-4. Dr. XXX is on track to hit 10 of 12 P4P metrics. Metrics achieved: Clinical rating: 10-12 4 7-9 3 4-6 2 0-3 1

Summary Clinicians are hard to find, highly-trained, independentminded professionals that you want to nurture, support, and cultivate. Compensation strategies can help or hurt your chances at retention and recruitment. Incentivize what you want to influence (productivity, quality, panel size, satisfaction, camaraderie/citizenship, etc) Make the system as fair and transparent as possible And if at first you don t succeed, try and try again!

Questions??? dwu@odfmc.org 914.373.0419

Who we are Federally Qualified Health Center 24,000 patients with 200,000 units of service in 2015 8 clinical sites plus 3 mobile vans including a health care for the homeless site, dedicated dental, urgent care Joint Commission Accredited PCMH Level 3-2014 Standards Locations in Hudson Valley include Newburgh, New Windsor, Highland Falls (West Point area), Goshen and newest site co-located in housing project in Binghamton

Our Services Primary Care: Internal Medicine, Pediatrics, Ob/Gyn Urgent Care Dental Specialties: Cardiology, Podiatry, ID Behavioral Health Services Care Coordination Audiology Optometry Positive Choices (HIV/AIDS Care) Women, Infants, and Children (WIC) Services Enabling Services Center For Recovery (Methadone and Day Rehab)

Clinical Staff 44 clinicians overall 13 physicians 11 physician extenders (NP/PA) 6 Dentists 6 Dental Hygienists 2 Psych NP and 4 CSW 1 Optometrist 1 Nutritionist

History of Incentive Plan First year of incentive plan 2015; Discussions and Planning began May 2014 Why we started the program: Reflect pay for performance changes in medicine Reward high performing providers, incentivize middle of the road providers, align poor performers Recruitment and retention? Helps align goals of the providers with the practice Previous bonuses were not timely or objective enough to change behavior Guiding principles: Awarding of bonuses is objective & predictable Compensation is timely and reflective of performance Supports the goals of organization Enough skin in the game to change behavior Transparency Getting it off the ground: CEO buy in Provider workgroup meets three to four times per year to define objectives and provide feedback Ongoing meetings with CMO, COO, CFO ( three legged stool meeting) Communication and feedback from Providers

2015 Incentive Plan Focused on 3 elements: productivity (70%) clinical metrics (20%) and cycle time (10%) Two Phases to allow new providers time to build panel Phase 1: 5% Bonus Potential for Physicians; 6.5% for Mid-Level Providers of annual base salary; enter phase I after minimum of 6 months to a year of employment Phase 2: 10% Bonus Potential for Physicians and 11.5% for Mid-Level - with potential of 5% annual withholding; automatic enrollment in Phase 2 after one year. (may elect to enter early) Productivity based on 3 patients per hour and a 32 hour work week ( the 4200 number) Clinical Performance Measures UDS/QARR - agreed upon by CMO and Chief of Dept Cycle Time baseline was 80 minutes goal of 65 minutes

Internal Medicine / Pediatrics / Urgent Care and OBGYN (In Office Providers) Performance Tiers (Percentiles) PRODUCTIVITY STANDARDS Provider Completed Appt. Per Clinical Hour (Approximate) Provider Annual Productivity Provider Quarterly Productivity >110% 3.3 4620 1155 105% 3.15 4410 1103 100% 3.00 4200 1050 95% 2.85 3990 998 90% 2.70 3780 945 85% 2.55 3570 893 <80% 2.40 3360 840 ** Pediatric providers nursery / newborn hospital encounters are calculated on a 1:1 ratio, inpatient admission on a 3:1 ratio ** Performance Tiers (Percentiles) Phase I: Total Bonus % of Annual Salary Phase II: Total Bonus % of Annual Salary >110% 4.20% 8.40% 105% 3.50% 7.00% 100% 2.80% 5.60% 95% 2.10% 4.20% 90% 1.40% 2.80% 85% 0.70% 1.40% <80% -5%

Clinical Outcomes Clinical Outcomes Percent of Annual Salary: Phase I Providers Percent of Annual Salary: Phase II Providers 105% 1.0% 2.0% 100%.75% 1.5% 95%.50% 1.0% 90%.25%.50% Internal Medicine Standard Percentage of patients 18 to 85 years of age with diagnosed hypertension (HTN) whose blood pressure (BP) was less than 140/90 at the time of the last reading 70% Percentage of patients aged 50 to 75 who had appropriate screening for colorectal cancer 40% Family Practice/Highland Falls Percentage of patients 18 to 85 years of age with diagnosed hypertension (HTN) whose blood pressure (BP) was less than 140/90 at the time of the last reading ( UDS) Percentage of patients 3-6 years old who completed an annual well child visit (QARR) Standard 70% 85% OBGYN *( measure of success based on department )* Percentage of women who delivered during the measurement period that were given Tdap (Tetanus, Diphtheria, Pertussis) during their pregnancy. Standard 60% Percentage of woman between the ages of 40 60 seen in the department who had a mammography in the previous 2 years. 62% Pediatrics Standard Percentage of female patients that have three HPV vaccines by age thirteen (QARR) 45% Percentage of patients 3-6 years old who completed an annual well child visit (QARR) 85%

Cycle Time Performance Standards Percent of Achievement 2014 Cycle Time Standard (Minutes) Percent of Annual Salary: Phase I Providers Percent of Annual Salary: Phase II Providers 105% 61.75.50% 1.00% 100% 65.38% 0.75% 95% 68.25.25% 0.50% 90% 71.5.13% 0.25% Percent of Achievement 2015 Cycle Time Standard (Minutes) Percent of Annual Salary: Phase I Providers Percent of Annual Salary: Phase II Providers 105% 57.50% 1.00% 100% 60.38%.75% 95% 63.25%.50% 90% 66.13%.25%

Administrative / Qualifying Metrics: In order to qualify for a bonus all the following standards must be met. If the criteria are not met the provider cannot benefit from quality or productivity bonus, but are still at risk for salary holdback if they do not meet 90% productivity. 1. On the 4 th Friday of every month a report will be generated. All providers must have signed off on any office visit that is more than 48 hours old. 1. Participation in one community event, health screening, health fair or lecture for medical students approval by CMO 1. Peer Review: 5 Peer Review forms will be distributed quarterly. Peer Reviews need to be completed and submitted within 2 weeks of distribution. 1. Provider must write 2 blogs for the health center on a topic of their choice first one due by 6/1/16 and 2 nd one due no later than 12/31/16.

What we learned from 2015? Previous issues with coverage resolved itself departments covered themselves Overall increase in productivity. Some providers respond, some not so much. Not all clinical sites and departments should be held to same standard. Difficult to reconcile this and still appear to be objective and fair. Providers made more money Have not figured out a way to include Ob s who deliver in hospital in plan Cycle Time Improved

2016 Plan Updates Increased weighting of clinical outcomes from 20% to 35% to reflect the shift to Value Based Compensation. Included plan to get to a 50% bonus based on clinical outcomes by 2018 Urgent Care performance tier moved up No more differentiation between mid levels and physicians This was first year providers required to have downside risk (5% holdback for productivity performance < 85%) 3 providers had money held back; 1 recently left organization and cited dissatisfaction with downside risk in exit interview Eliminated Bonus for 90%; Shifted more bonus to high performers ( >100%). Plan included to only bonus for >100% by 2018. Clinical Performance measures based on departmental performance

Value Based Incentives Bronx Lebanon Primary Care Isaac Dapkins MD Outgoing CMO Bronx Lebanon Integrated Services Systems Inc.

Background of BLISS Impetus for Change Measure Alignment Challenges Dashboarding

Background of Bronx Lebanon Integrated Services Systems Inc. YEAR ORGANIZATION 1967-1979 1979-1986 1986-1996 1996- Current MLK Jr Health Center opened its doors the first urban and largest community health center funded by the Office of Economic Opportunity. Bronx-Lebanon Hospital Center (BLHC) was directly funded by a grant from the Bureau of Community Health Services. Bronx Ambulatory Care Network (BACN), a freestanding, not-for-profit corporation, was funded by PHS under the Section 330 Grant Program. BACN contracted with BLHC and Montefiore Hospital Medical Center, as sub-recipients, to provide comprehensive primary care to the residents of the South Bronx. Bronx-Lebanon Integrated Services System Inc. (BLISS) was formed as one of two successor entities to the Bronx Ambulatory Care Network (BACN), and funded as a direct recipient of section-330 funding. 11/4/2016 3

Current status of Bronx-Lebanon Integrated Services Systems Inc. Two subrecipients: MLK Jr HC and Bronx Lebanon Hospital Centers 22 clinical programs at 9 different sites. All 9 sites are PCMH Level 3 (2011 Standards, 2014 application pending) Allscripts Sunrise Clinical Manager since 2008 579 acute care beds Over 1 million ambulatory care visits, 120,000 FQHC patients 330 long-term care beds Part owner of Healthfirst Lead of Bronx Health Access PPS

* Managed Medicaid PCMH Level 3 Healthfirst P4P DSRIP Go Live Click Fees Proposed VBP incentive 1 Year Incentive Review Period 2007 2009 2011 2013 2015 2017 2019 Key: Incentive Changes Programs impacting decision to go to value based 5

Impetus for Change Healthfirst Full- Risk Contract Medicare Access and CHIP Reauthorization Act of 2015 Multiple P4P Programs (DSRIP, UDS, HQIP) Decision to reduce Volume Based incentive for physicians

Measure Alignment Revenue flows based on Number of months patients assigned to a PCP Better quality increases the PMPM value of each client Better documentation increases the PMPM value of each client http://miv42.informatics.stonybrook.edu/

PCMH Establishes a core understanding of population level healthcare Requires provider engagement on a population level Does not take into account cost of care

Healthfirst Quality Incentive Program (HQIP/Medicaid)

DSRIP DSRIP Guaranteed Funds were funneled through Equity Performance Program Revenue flows via Pay for Performance metrics through contracts with Managed Medicaid Companies DSRIP Performance Payments are shifting from Process and Reporting to Performance measures (Domains 2&3) MY3 (July 1, 2016-June 30, 2017) is the highest value year for bonus payments related to performance

DSRIP EPP Measures Children s Access to Primary Care 12 to 24 months Children s Access to Primary Care 7 to 11 years Prenatal and Postpartum Care Postpartum Visits EPP Measures** Children s Access to Primary Care 25 months to 6 years Children s Access to Primary Care 12 to 19 years Prenatal and Postpartum Care Timeliness of Prenatal Care Well Care Visits in the first 15 months (5 or more Visits) Childhood Immunization Status (Combination 3 4313314) Frequency of Ongoing Prenatal Care (81% or more) Follow-up care for Children Prescribed ADHD Medications Continuation Phase Follow-up care for Children Prescribed ADHD Medications Initiation Phase Lead Screening in Children Med. Assist. w/ Smoking & Tobacco Use Cessation Discussed Cessation Strategies Controlling high blood pressure Comprehensive Diabetes screening All Three Tests Diabetes monitoring for persons with schizophrenia Initiation and Engagement in Alcohol and Other Drug Dependence Treatment (IET) within 14 days of substance abuse episode Behavioral Health follow up after hospitalization for mental illness (7 day) Chlamydia Screening (16 24 Years) Med. Assist. w/ Smoking & Tobacco Use Cessation Discussed Cessation Medication Comprehensive Diabetes Care Diabetes screening for persons with schizophrenia or Bipolar Disease who are using Antipsychotic Medication Adherence to anti-psychotic medications for individuals with schizophrenia Behavioral Health follow up after hospitalization for mental illness (30 day) Follow-up on Alcohol and Other Drug Dependence Treatment (IET) within 44 days of initial engagement

Challenges Behavioral Economics Empanelment Measuring Patient Satisfaction Tools for effectuating change in population health

Ann Intern Med. 2016;164(2):114-119.

Empanelment Patients seen in the past 15 months + Patients on Managed Medicaid Panel + Patients are asked to agree on Primary Provider ( Preferred PCP ) as part of the PCMH.

Telephone Survey Questions When visiting your primary care physician or specialist, how long do you usually spend in the waiting room before you see the doctor? Overall, how would you rate the quality of care you received from this doctor? How would you rate this doctor on giving you a clear explanation of tests and treatment options?

Tools for effectuating change How can we increase our panel? How can we get patients to come in to be seen if they need a measure? How can we see what our progress has been?

Bronx Lebanon Incentive Plan Total incentive could result in an increase of reimbursement of approximately 30% Data aggregated for quality across multiple HEDIS measures using RHIO data Patient satisfaction data collected on a daily basis through telephone surveys (Cipher Health) Visit volume will be a component that is phased out over time Panel size based on empanelment

Final Incentive Breakdown Values MEDICINE PEDIATRICS Panel 21% 35% Quality 26% 11% Visit 41% 50% Satisfaction 7% 4% Documentation 6% 0%

Panel Size Providers incentivized to have more 1800 patients in care: Patients seen in the past 15 months + Patients on Managed Medicaid Panel + Patients are asked to agree on Primary Provider ( Preferred PCP )

Quality Component Standard measures that are based on the UDS, EPP and HQIP. Each measure has a threshold above which incentive $ begin to be available and a benchmark when the maximum dollar amount is achieved. We only pay to the benchmark so doing better than benchmark does not benefit provider

Patient Satisfaction Provider specific patient satisfaction responses on a modified CAHPS survey Baseline threshold of >20% positive topline answers Target >55% topline answers

Visit Volume Incentive is a per/visit dollar value for each visit.

Documentation Improvement Providers receive real time alerts at time of visit Provider achieves incentive based on their response to documentation improvement alerts

Dashboarding!

Data Mall

Provider Action List

* Managed Medicaid PCMH Level 3 Healthfirst P4P DSRIP Go Live Click Fees Proposed VBP incentive 1 Year Incentive Review Period 2007 2009 2011 2013 2015 2017 2019 Key: Incentive Changes Programs impacting decision to go to value based 27

Questions Isaac Dapkins MD CMO Lutheran Family Health Center Isaac.Dapkins@nyumc.org