Download - Williamson-Chatman 3.23 Symposium
Copyright 2012Ohio State Medical Association 1
Clinical Integration and Quality Improvement
Jay C. Williamson, M.D.CMO, Summa Physicians Inc.
Robin Chatman, MDTrinity Family Medicine
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The Integrated Healthcare Delivery System
Hospitals
Inpatient Facilities• Tertiary/Academic Campus• 3 Community Hospitals• 1 Affiliate Community Hospital• 2 JV Hospitals with Physicians
Outpatient Facilities• Multiple ambulatory sites• Locations in 3 Counties
Service Lines• Cardiac, Oncology, Neurology,
Orthopaedics, Surgery, Seniors, Behavioral Health, Women’s, Emergency, Respiratory
Key Statistics• 2,000+ Licensed Beds• 62,000 Inpatient Admissions• 47,000+ Surgeries• 660,000+ Outpatient Visits• 226,000+ ED Visits• 4,300+ Births• Over 220 Residents
MultipleAlignment Options• Employment• Joint Ventures• EMR• Clinical Integration• Health Plan
Summa Physicians, Inc.• 260+ Employed Physician
Multi-Specialty Group
Summa Health Network• PHO with over 1,000
physician members• EMR/Clinical Integration
Program
Geographic Reach• 19 Counties for Commercial• 18 Counties for Medicare• 60-hospital Commercial
provider network • 41-hospital Medicare
provider network• National accounts in
multiple states
191,000Total Members• Commercial Self Insured• Commercial Fully Insured• Group Process Outsourcing• Medicare Advantage• Individual PPO
Physicians Health Plan Foundation
System FoundationFocused On:• Development• Education• Research• Innovation• Community Benefit• Diversity• Government Relations• Advocacy
Net Revenues: Over $1.5 BillionTotal Employees: Nearly 11,000
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The Next Evolution of the Integrated Delivery System
• We believe that the current healthcare payment system is unsustainable and that payment mechanisms will have to change to better align incentives toward reducing total healthcare costs while continuing to provide high-quality care
• Summa will use its Integrated Delivery System to provide continually improving, value-based, high-quality, transparently accountable care to patients, populations and payers it serves
• Summa will build upon its relationships to continually advance accountability by partnering in a deeper way with patients, populations, and payers toward improving the health of our communities while reducing costs
Summa fundamentally believes that accountability in healthcare is a moral imperative with Integration being a means to that end
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Community Collaborations: Physician Joint Ventures• Summa Health Center at Lake Medina
– Joint venture outpatient surgery center with 2 ORs and 1 procedure room opening in conjunction with the new Summa Health Center at Lake Medina development
– Includes physicians from the following specialties: OB/Gyn, General Surgery, Pain, Podiatry, Ophthalmology, Hand
• Summa Western Reserve Hospital– Joint venture started in June 2009 between Summa Health System
and Western Reserve Hospital Partners– Began the for-profit Summa Western Reserve Hospital at the
current Summa Cuyahoga Falls General Hospital location
• Crystal Clinic Orthopaedic Center (CCOC)– Orthopaedic Hospital Joint venture between Summa Health
System and Crystal Clinic (a local group of approximately 30 orthopedic surgeons)
– Began operations in May 2009 on the Summa St. Thomas Hospital Campus
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Critical IssuesThree critical issues threatening the stability of today’s healthcare system:
1. Uninsured and underinsured populations are increasing.
2. Healthcare costs are escalating.
3. Government regulations are expanding and government reimbursement is not keeping the pace with the cost of providing care.
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Summa Physicians Inc. Governance• 501(c) 3 organization• Independent Board of Directors which include physicians and senior management appointed by system governance committee• Oversee all aspects of SPI operations and finance except compensation• Physician Advisory Council to CMO• Both fully employed and leased models
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SPI Overview • 270 Physicians • 59 Advanced Practice Nurses and Physician Assistants• 671 non-Provider Employees • Summit, Medina, Portage, Wayne, and Stark • Physicians hired based on Community Need, Mission and preventing physician “leakage” from Summa• New planned growth to be based on System needs and focused strategic growth
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SPI Growth as of December 2011 • Summa Physicians, Inc. continues to have success with its model for physician employment
7 8 14 1741
81
187220
255266
0
100
200
300
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Number of Employed Physicians
Satisfied, Engaged, and Aligned Physicians
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SPI – Business Model• Physician Compensation is Productivity Based • Will soon be implementing a model looking at quality
metrics, patient satisfaction and issues such as community service and System performance
• Ancillary Services have transferred to Provider Based Billing under the Hospitals
• Mission focus helps eliminate unnecessary System costs• All physicians are employed under a Hospital or System
approved business plan• Reviewing Leased vs. Employed Model
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2011 SPI ACCOMPLISHMENTS• Outstanding Budget
– Performance through December $3.9 million better than budget. • Vast Improvement in health risk assessment
– Over 1000 this year have been completed leading to better documentation of care provided to Medicare patients and enhanced reimbursement.
• Our newly added 24 physicians • Outstanding performance in light of a year of transition featuring three
different presidents in 2011.• EMR implementation with 113 providers and 37 doctors attested for
Meaningful Use at $18,000 each and 15 more by year end which aids in care coordination and integration.
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The Future - SPI • Implement Strategic Plan
– Enhance Physician Engagement and System Integration
– Expand Market Penetration (selectively and strategically) and Increase our Patient Population
– Achieve superior Operative and Clinical Performance
– Improve Population Health through ACO and Medical Homes
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Patient Center Medical Home (PCMH)
In order to achieve the objectives of reform, we need to transform our current delivery system from high cost, low value to low cost, high value through a strong primary care foundation
Healthy Consumer
Continued Health
Preventable Condition
No Hospitalization Acute Care Episodes
Successful Outcome
High Cost Outcome
Focus on Measurably Improving Population HealthOrganizational Accountability for Capacity, Cost and QualityPayment for Value, Not Volume
Meaningful Measures of System PerformanceRight Workforce
The Affordable Care Act Main Objectives
Complications, Readmissions
Overall Goal is to move healthcare cost from downstream to upstream
PCMHACO
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PCMH Impact on Stakeholders Across Continuum Care
PCMH
Payer
Specialists
Government
EmployerHospital
PCP
Patient
Increased focus on the patient and their healthGreater access to health informationHigher reimbursementMore PCPs
Better, safer, less costly, more convenient care Better overall healthProductive long-term relationship with a PCP
Lower number of chronic care admissions and readmissions Increased focus on procedures.
Lower healthcare costsMore productive workforceImproved employee satisfaction
Lower healthcare costsHealthier population
Better referralsWhole patient care integrationBetter follow up
Improved member and employer satisfactionLower costsOpportunity for new business models
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What is PCMH?A PCMH puts patients at the center of the health care system, and provides primary care that is “accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.”
Features of PCMH
A personal physician who coordinates all care for patients and leads the team.
Physician-directed medical practice – a coordinated team of professionals who work together to care for patients.
Whole person orientation – this approach is key to providing comprehensive care.
Coordinated care that incorporates all components of the complex health care system.
Quality and safety – medical practices voluntarily engage in quality improvement activities to ensure patient safety is always being met.
Enhanced access to care – such as through open-access scheduling and communication mechanisms.
Payment – a system of reimbursement reflective of the true value of coordinated care and innovation.
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How Features of PCMH are Implemented?
Enhanced Access Extended Hours, Open Schedule Internet, e-mail
Quality and Safety Evidence Based Medical care QI projects at the practice level
Coordinated/Integrated Care Registries Proactive care Information Technology Health Information Exchange Chronic care coordination
Internal/external care coordination Part of a patient’s health plan
Physician Directed Medical Practice TeamTeam approach
Low complexity tasks handled by other members of the team
Team members can be internal/externalCollaborative relationship between physician and non-physician practitioners
Personal Physician & Whole Person OrientationFirst contact, continuous and comprehensive careContextual Care
Increased same day access avoids ER and increase continuity
Reduced duplication and improved coordination across the spectrum of care
Having a usual source of care is associated with a greater likelihood that people receive appropriate care, preventive care, better outcomes, lower cost
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Summa PCMH Pilot Project Roadmap
Offered at three level–basic, intermediate and advancedGoal is to obtain Level 3
Measure improvementsSupport ACO Initiatives
Publically report achievements
Highlights of Project6 practices involvedIT and Policy SubcommitteesPCMH Performance Metric TeamNCQA RecognitionTransformation
Gap AnalysisIdentification of PCMH Metrics EHR UpgradesPolicy Creation and Standardization
NCQA Recognition Program
TransformationCultural ChangeRedefining staffing rolesImprove Outcomes
SUMMAPCMH
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PCMH
• ACO paying for part-time physician leader, full-time analyst, and project director.
• PHO will pay for NCQA Certification Fees.
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Accountable Care Organization
Organizational Facts• Start Date – Began operations January 1, 2011• Initial Pilot Population – 11,000 SummaCare Medicare Advantage members that
currently see a participating primary care physician• Legal Entity – Non-profit taxable structure allows for physician majority on the Board• Board Composition – 4 community primary care physicians, 1 medical specialist, 1
surgical specialist, 3 Summa representatives
Our ACO is a clinician-led care collaborativethat partners with communities
to compassionately care for and serve our populationsin an accountable, value- and evidence-based manner.
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PCMH
SpecialtyCare
PrimaryCare Ambulatory
Hospitaland ED
SkilledNursing
NursingHome
HomeHealth
Patients
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Financials:PMPM Target and Results - 2011
Medical Spend PMPM
Shared Savings Annualized
Breakeven $793.62 $0SC Medicare NHC ACO $733.79 $7,400,000
Loosely Managed $752.45 $5,089,600Competitively Managed $639.56 $19,045,513
Well Managed $522.36 $33,534,246
2010 Milliman Benchmarks
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Progress Milestones: 2011
• Began Operations
• Heart Failure Readmission Initiative
• Heart Failure Education
• Discharge-to-Home Care Transition
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Progress Milestones
• Population-based Actuarial Analysis
• ACO Finance Committee
• ACO Clinical Value Committee
• ACO Medical Home Initiative
• Call Center Plan
• Harmony Plan
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PHYSICIAN COMPENSATION PLAN
Summa Physicians, Inc. (SPI)
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PHYSICIAN COMPENSATION PLAN• High Performance Team appointed in late 2011 by new SPI President to
outline a new compensation model by early 2012.• Multispecialty group including representatives from the following areas:
– Family Medicine– Psychiatry– Surgery (Colorectal)– Gastroenterology– Hematology / Oncology– Cardiology– General Internal Medicine– Geriatrics
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PHYSICIAN COMPENSATION PLAN
• Began with weekly meetings with a goal for the new model to be part of new and updated contracts
• Agreement for a one year “shadow” program to see how the model works
• Outlined a set of Guiding Principles and an Incentive Plan Proposal was developed
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GUIDING PRINCIPLESSPI CMO COMPENSATION COMMITTEE
GENERAL CONTRACTING PRINCIPLES
1. All should share in the success of the organization. 2. Incentive plan is calculated on 20% of base compensation. Base compensation is not reduced to
fund incentive plan. 3. A shadowing program will be used the first six months, the new system will start in 2013.
Standardized contract language will be used with an agreed upon compensation plan. 4. Incentive Dimensions required for all. Metrics include Success of SPI/Summa Health System,
Citizenship, Information Management, Quality/Service. (Incentive Plan Proposal attached) 5. Quality metrics for primary care and specialties are different and subgroups may be needed to
work out details. 6. Annual performance review required and passing review will be required to qualify for bonus
distribution. 7. Patient satisfaction review will be part of all metrics. One standardized survey will be used. 8. Changes in base compensation are being considered. 9. Incentives obtained from some bonus dollars and possibly ACO shared savings dollars. 10. MGMA should remain the salary benchmark of choice. 11. Blends of education, teaching, and work productivity will remain part of the contracts.
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INCENTIVE PLAN PROPOSAL TARGET: TOP QUARTILE TOTAL POINTS = 20 Incentive Dimensions: 2/6/12
Success of SPI / Summa (Individual & Group)
Citizenship Information Management Quality / Service
Growth of Established and Loyal Patients - SPI Source: eCW counted charts, billings of unique patients during the prior year vs. next year 2 points
Attendance @ SPI meetings ≥ 75% of meeting Major Conditional Incentive ½ point Source: Attendance sign in and sign out sheets monitored by SPI ops.
Measures of Integration Keep the patient @ home Information Management
within Network In Network Use of Lab/
Radiology/PT-Rehab Source: Referral Tracking in eCW, lab/imagining/pt by ordering physician
3points
Access to Care – Same Day Established Patient and
New Patient (1% Group)
Source: Phone survey for established and new patients 2 points
Profitability of Summa Hospital Operations / Meet or Exceed Budget Expectations - Summa Hospital Source: Summa Financials, booked year end hospitals only 2points
Completion of Records on a timely basis Major Conditional Incentive ½ point Source: eCW “closed files report”, Med Records Procedures
Measures of Coordination Hand off Measures Two-way Communication Satisfaction with
Referring Physicians Info Collegiality / Stellar APR
Source: Referral Sender/Receiver survey 3 points
Inpatient SCIP & Core Measures at 98% attainment Source: CMS/JCHAO List of Top performers 3 points
Patient Satisfaction > 75th percentile Source: Press Ganey OP, C. Natale 2points
Inpatient patient satisfaction with physicians above 50th percentile Source: HCAHPS 2points
6 Dimensions of Quality (IOM) Safe Pt. Centered Effective Timely Efficient Equitable
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PHYSICIAN COMPENSATION PLAN
• Further discussion by specialty of quality metrics
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Example of Quality Metrics for Diabetic Care in Primary Care Practices
B D E F G H I J K L M N O
1 Insurer DOS HbA1c Date LDL Date Urine date Result BP Sys BP DiasEye Exam
DateFoot Exam CPT/ ICD
2 MC 7/ 9/ 11 6.4 7/ 19/ 11 59 3/ 22/ 11 N N 112 62 N N 250.00/ 2143 SC SEC 6/ 30/ 11 9.4 6/ 27/ 11 110 6/ 27/ 11 N N 150 67 5/ 5/ 11 N 250.00/ 2144 MC 3/ 22/ 11 7.3 3/ 16/ 11 94 6/ 16/ 11 1/ 21/ 10 Neg 115 49 9/ 2/ 01 N 250.00/ 2145 SC SEC 5/ 19/ 11 7.2 5/ 19/ 11 92 4/ 21/ 11 N N 149 75 N 8/ 16/ 10 250.00/ 2146 MC 3/ 30/ 11 10.9 8/ 15/ 11 73 8/ 3/ 11 N N 156 12 N 5/ 3/ 10 250.00/ 2147 MC 2/ 3/ 11 6.2 2/ 17/ 11 61 5/ 20/ 11 12/ 30/ 10 POS 153 74 N 12/ 20/ 10 250.41/ 2148 MC 7/ 22/ 11 6 7/ 15/ 11 High Trig 7/ 1/ 11 N N 146 63 11/ 10/ 11 N 250.00/ 2149 MC 7/ 11/ 11 7.5 6/ 9/ 11 67 6/ 9/ 11 N N 113 67 4/ 8/ 11 N 250.00/ 21410 MC 7/ 13/ 11 5.6 7/ 7/ 11 43 7/ 6/ 11 N N 129 61 N N 250.00/ 21511 MC 6/ 15/ 11 6.4 6/ 9/ 11 69 6/ 8/ 11 N N 117 62 8/ 2/ 11 N 250.00/ 21412 MC 4/ 19/ 11 8.4 4/ 19/ 11 74 1/ 11/ 11 4/ 19/ 11 Neg 140 102 N 5/ 11/ 11 250.02/ 20513 SC SEC 8/ 22/ 11 6.4 8/ 8/ 11 51 1/ 3/ 11 N N 150 85 8/ 1/ 11 N 250.00/ 21414 MC 8/ 18/ 11 6.6 10/ 18/ 10 83 1/ 10/ 11 1/ 10/ 11 Neg 133 61 4/ 11/ 11 N 250.00/ 21415 MC 8/ 17/ 11 7.3 8/ 10/ 11 160 8/ 10/ 11 N N 141 61 3/ 17/ 11 N 250.00/ 21416 MC 8/ 9/ 11 8.9 8/ 2/ 11 78 8/ 2/ 11 N N 144 68 11/ 18/ 10 N 250.02/ 21417 MC 2/ 1/ 11 6.5 1/ 26/ 11 78 1/ 26/ 11 N N 123 62 N N 250.00/ 21418 MC 3/ 25/ 11 6.8 3/ 9/ 11 59 6/ 15/ 11 N N 128 66 2/ 24/ 11 N 250.02/ 21419 MC 3/ 25/ 11 6.9 3/ 9/ 11 3/ 9/ 1900 3/ 9/ 11 9/ 15/ 10 Neg 126 73 N N 250.00/ 21420 MC 6/ 16/ 11 5.5 6/ 9/ 2011 42 1/ 25/ 2011 10/ 10/ 2011 Neg 124 3/ 3/ 1900 8/ 18/ 11 12/ 23/ 10 250.00/ 21421 MC 7/ 14/ 11 6.6 2/ 3/ 11 57 11/ 23/ 10 N N 128 65 4/ 27/ 11 N 250.00/ 214
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Example of Quality Metrics for Diabetic Care in Primary Care Practices
B D E F G H I J K L M N O
1 Insurer DOS HbA1c Date LDL Date Urine date Result BP SysBP DiasEye Exam
DateFoot Exam CPT/ ICD
22 MC 3/ 28/ 11 7.3 3/ 21/ 11 34 3/ 21/ 11 N N 140 85 N N 250.00/ 215
23 MC 6/ 29/ 11 6.2 6/ 22/ 11 71 6/ 22/ 11 N N 138 80 3/ 4/ 11 N 250.00/ 214
24 MC 7/ 11/ 11 6.9 7/ 5/ 11 51 3/ 2/ 11 N N 122 64 N N 250.00/ 214
25 MC 5/ 4/ 11 6.2 4/ 13/ 11 89 4/ 13/ 11 N N 95 60 N N 250.00/ 214
26 MC 7/ 27/ 11 5 7/ 20/ 11 126 7/ 13/ 11 7/ 13/ 11 POS 144 88 7/ 11/ 11 N 250.00/ 214
27 MC 8/ 23/ 11 6.4 5/ 13/ 11 102 5/ 13/ 11 9/ 17/ 10 NEG 126 68 10/ 2/ 11 N 250.00/ 214
28 MC 7/ 13/ 11 6.4 7/ 1/ 11 38 7/ 1/ 11 N N 123 66 9/ 8/ 10 2/ 11/ 11 250.00/ 214
29 MC 6/ 22/ 11 5.9 6/ 15/ 11 83 6/ 15/ 11 3/ 7/ 11 POS 138 80 N N 250.00/ 214
30 MC 8/ 23/ 11 7.1 8/ 16/ 11 76 6/ 14/ 11 N N 130 74 N N 250.00/ 214
31 MMO MC 8/ 25/ 11 7.3 6/ 17/ 11 63 8/ 18/ 11 N N 138 78 1/ 11/ 11 N 250.00/ 214
32 MC 2/ 1/ 11 5.8 1/ 4/ 11 55 1/ 4/ 11 N N 111 52 10/ 19/ 10 1/ 19/ 10 250.00/ 214
33 MC 2/ 1/ 11 6.9 6/ 7/ 11 89 1/ 4/ 11 5/ 21/ 10 POS 134 64 2/ 3/ 11 1/ 19/ 10 250.00/ 214
34 MC 1/ 5/ 11 6.5 3/ 2/ 11 87 12/ 30/ 10 N N 166 77 10/ 12/ 10 N 250.00/ 214
35 MC 9/ 6/ 11 7.5 9/ 1/ 11 52 5/ 10/ 11 N N 120 79 8/ 11/ 11 N 250.00/ 214
36 Anthem SR 6/ 15/ 11 6.5 6/ 7/ 11 56 6/ 8/ 11 N N 133 70 N N 250.00/ 214
37 MC 5/ 11/ 11 7.8 5/ 4/ 11 104 8/ 4/ 11 N N 137 75 4/ -/ 11 N 250.02/ 214
38 MC 8/ 3/ 11 6.2 7/ 20/ 11 57 7/ 20/ 11 7/ 20/ 11 Neg 114 63 9/ 13/ 10 N 250.00/ 214
39 MC 8/ 1/ 11 7.3 7/ 6/ 10 N N N N 150 96 1/ 20/ 11 N 250.00/ 203
40 MC 6/ 29/ 11 6.1 7/ 2/ 10 67 7/ 2/ 10 N N 144 82 4/ 9/ 11 N 250.00/ 214
41 SC SEC 7/ 20/ 11 7.4 7/ 6/ 11 97 3/ 8/ 11 3/ 8/ 11 Neg 160 70 6/ 22/ 11 N 250.00/ 214
42 MC 6/ 30/ 11 8.4 6/ 23/ 11 47 6/ 23/ 11 N N 151 81 5/ 12/ 10 N 250.02/ 214
43 MC 6/ 17/ 11 6.1 6/ 10/ 11 63 6/ 10/ 11 N N 126 77 5/ 11/ 11 N 250.00/ 214
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Example of Quality Metrics for Diabetic Care in Primary Care Practices
B D E F G H I J K L M N O
1 Insurer DOS HbA1c Date LDL Date Urine date Result BP Sys BP DiasEye Exam
DateFoot Exam CPT/ ICD
44 MC 5/ 12/ 11 6 4/ 5/ 11 56 4/ 5/ 11 N N 122 66 N N 250.00/ 214
45 MC 4/ 28/ 11 6.4 4/ 25/ 11 77 4/ 25/ 11 N N 134 71 10/ 10/ 11 N 250.00/ 214
46 MC 6/ 16/ 11 7.3 3/ 9/ 11 59 6/ 8/ 11 12/ 9/ 10 POS 122 64 4/ 7/ 11 N 250.00/ 214
SPI Dr.
Total # of Patients Studied 903 45
Average HbA1C 7.1 7.0
Average LDL 91 73
Percentage of Urine Samples collected 43% 29%
Average BP Systolic 133 133
Average BP Diastolic 75 70
Percentage of Eye Exams Performed 35% 67%
Percentage of Foot Exams Performed 21% 18%
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COMPENSATION GUIDELINESA. Base Compensation
– Uses 85% of MGMA Median by Specialty to determine base. – Will be reset each year (WRVU target) based on prior year
WRVU production and market adjustments.– Adjusted upward if WRVU exceeds base target. Based on
tiered compensation formula.– Adjusted downward if WRVU is below base target.– Maximum amount of base compensation to be paid through
bi-weekly payroll = 80% of MGMA national 90% compensation.
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COMPENSATION GUIDELINESB. Excess WRVU Above Base Compensation Targets
– Tiered structure adds a portion of excess WRVU to base compensation (not extra bonus) and a portion to incentive poolTier 1 = Nat Med to Avg Nat Med / Nat 75th
Tier 2 = Avg Nat Med / Nat 75th to national 75thTier 3 = all WRVUs over the Nat 75th
85% of Nat Median +Tier 1 - Base @ 50% of SPI rate +
Tier 2 - Base 45% of SPI rate +Tier 3 - Base 40% of SPI rate +
Total New Base
Tier 1 -Bonus 50% of SPI rate +Tier 2 - Bonus 55% of SPI rate +Tier 3 - Bonus 60% of SPI rate +
SPI added Perf $ (% PCP or % other) +Total Performance Bonus Funding
The level of Physician production utilized in the Tiers = higher of 2 yr avg production or the prior yr production
This component added to Base and paid through bi-weekly payroll
This component held until contract year end and amount to be awarded determined thorough annual
performance review - pre-defined performance metrics.
Base & Performance Bonus WRVU Tier descriptions
1.0 FTE New Base = 85% Nat Median + Tier 1 + Tier 2 + Tier 3 % to payroll For that Physician's specialty
1.0 FTE Performance Bonus Funding = Tier 1 + Tier 2 + Tier 3 + SPI % Perf Bonus Fund
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COMPENSATION GUIDELINESC. WRVU Production Below WRVU Target
– At a certain level may not be eligible for a bonusD. Incentive Plan Pool
– Using tiered approach amount not added to base is placed in incentive pool.
– Physician has ability to add back a comparable amount using different incentives.
– 15% Primary Care addition for recognition of primary care.
– 5% Specialist addition to pool
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COMPENSATION GUIDELINES
• There will always need to be market considerations.
• Outliers will have to be looked at on an individual basis.
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Questions and Discussion