how the changing role of the pcp is healthcare may...
TRANSCRIPT
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The Physician’s Perspective
How the Changing Role of the PCP isHow 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 healthcareTo transform the healthcare experience for patients and their families through a culture of caring, quality, and innovation.
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Clinical Providers
September 2010
Primary Care 1Primary Care 1
MichaelMonteCarlo D O
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Carlo,D.O.FamilyMedicineWestDeptford,NJ
Clinical Providers
May 2015
Primary Care 29
Hospital Medicine 15
SNFists 2
Vascular Surgery 2
Breast Surgery 1
Cardiothoracic Surgery 1
Neurology 5
Endocrinology 4
Pulmonary 3
Radiation Oncology 2
Dermatology 1
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Total 65
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How the Changing Role of the PCP is Leading Healthcare Reform
With accountable care, patient centered medical homes and pay for performance gaining momentumhomes and pay‐for‐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.
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Episodic Outpatient Specialty Care
Episodic Outpatient Specialty Care
Primary & Preventive Care
Primary & Preventive Care
Inpatient Care
Inpatient Care
Reform: The pressure for better upstream care (it’s health enhancing & less expensive)
MOVE CARE UP‐STREAM THRU FINANCING CHANGE
Funding EHRsFunding EHRs
30‐day Readmission Penalty
Chronic Care Management by PCP
Medical Home Proficiency
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Chronic Care Management by PCP
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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
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in US have achieved a level of PCMH certification thru NCQA.
http://www.ncqa.org/Portals/0/Public%20Policy/2014%20Comment%20Letters/The_Future_of_PCMH.pdf
Joint Principles of the Patient Centered
Medical Home March 2007
Personal physician Care is coordinated Personal physician
Physician‐directed medical practice
(team oriented)
Whole person orientation
a e s coo d a edand/or integrated
Quality and safety
Enhanced access
Paymentorientation Payment
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1: Enhance Access and Continuity A. *Patient‐Centered Appointment AccessB. 24/7 Access to Clinical AdviceC. Electronic Access
Pts4.53.52
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2: Team‐Based CareA. Continuity
d l b l
Pts32 5
4: Plan and Manage Care A. Identify Patients for Care ManagementB. *Care Planning and Self‐Care SupportC. Medication ManagementD. Use Electronic PrescribingE. Support Self‐Care and Shared Decision‐Making
Pts44435
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5 Track and Coordinate Care PtsB. Medical Home Responsibilities C. Culturally & Linguistically Appropriate
Services (CLAS) D. *The Practice Team
2.5
2.54
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3: Population Health Management
A. Patient Information B. Clinical Data C Comprehensive Health Assessment
Pts3445
5: Track and Coordinate CareA. Test Tracking and Follow‐UpB. *Referral Tracking and Follow‐UpC. Coordinate Care Transitions
Pts666
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6: Measure and Improve PerformanceA. Measure Clinical Quality PerformanceB. Measure Resource Use and Care CoordinationC. Measure Patient/Family ExperienceD. *Implement Continuous Quality Improvement E D C i Q li I
Pts33443C. Comprehensive Health Assessment
D. *Use Data for PopulationManagementE. Implement Evidence‐Based Decision‐
Support
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E. Demonstrate Continuous Quality ImprovementF. Report PerformanceG. Use Certified EHR Technology
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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 ofAt 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.
4. Patients not recently seen by the practice.
5. Medication monitoring or alert.
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Patient Centered Medical HomeWhat’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.
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Patient Centered Medical HomeWhat’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 tiexecutives
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Executing the PCMH Strategy
Redesign Provider Comp.
Plans
Grow Volume of Existing Providers
Adequacy of Support Staff
FTEs
DRIVING REVENUE GROWTH SUPPORT FOR GROWTH & PCMH
INFLUENCING CULTURE
Mgmt. Develop.
Increase # of Advanced
Practitioners
Plans
Reduce Process Variation
Give Feedback: Timely Data Sets for Managing
Demonstrate PCMH Value to
Payers
Providers
Improve Support Staff Competencies
FTEs
Consistent Messaging
Evolve to 5 Providers Per
Site
Successful reform requires coordinating these roles in a spirit of accountability
Patient
HospitalistPrimary Care
Provider
Emergency M di i
Patient
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Medicine Provider
AND A COMMITMENT TO ROBUST COMMUNICATION
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A Physician Retreat Exercise: What’s working /
what’s not?what’s not?
O P ti t
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Our Patients, Our Responsibility, My Role
What’s working / what’s not?
RosesTh
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ThornsBuds
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How the Changing Role of the PCP is Leading Healthcare Reform
Roses (what’s working)
Rising consciousness of care‐
Thorns (what’s not working)
• Medication reconciliationggivers for what happens beyond their own care sites
More timely communication across care sites corresponding with patient transitions
Timely and shared discharge
Medication reconciliation
• Timely information feedback to the PCP, et. al. about patient
• Adequacy of information communicated
Fi i f fsummaries
Hospital / Sub‐acute Rehab connections
• Financing of reforms
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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 subsidyHospital subsidy
Net cash flow $ ‐0‐
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Evolving Economics of Physician Practice:Cash Flow
2015: Health System Owned
Service revenue
Practice expenses
Physician earnings
Operating loss
Hospital subsidy
By 2018, the financial stress anticipated for hospitals may cause this to diminish.
Hospital subsidy
Net cash flow ($‐‐)
Type of Revenue Payment Simple &Revenue Driver Time Predictable?
Financing Reform:The primary care provider perspective
Revenue Driver Time Predictable?
Fee‐for‐service Visits 14‐30 days Yes
Capitation Panel Size 0‐30 days Yes
Quality &Quality & Outcomes Metrics 30‐365 days No
(+/‐150)
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Primary Care Practice Economics
Type of Revenue % of PaymentType of Revenue % of PaymentRevenue Driver Revenue Time To Succeed
Fee‐for‐service Visit 70% 14‐30 days Ramp up visit volume
Capitation Panel 20% 1‐30 days Diminish visit volume
Quality &
Outcomes Metrics 10% 30‐365 days Change patient &(+/‐150) provider behavior
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From volumeFrom volume‐‐based payments based payments to valueto value‐‐based paymentsbased payments
Fee‐for‐service Value‐driven care
TIME
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You are here
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Financing of Reform: Establishing a third revenue cycle system
1. Execute Payer Contracts That Reward Triple Aim* Performance
4. Pursue Targets with Resources:‐ Management‐ Providers ‐ Support Staff ‐ Technology‐ Physical Plant
‐ Change Methodology
5. Track Change Results:‐ Outcomes‐ Compliance‐ Patient Satisfaction
2. Track Contract Metrics
3. Set Practice Performance Targets for Contract Metrics:What by when?
‐ Change Agents
6. Set Payer Contract Renegotiation Strategies
2(a). Collect earned revenue
* Triple Aim = (1) high care quality (2) satisfied patients (3) no wasting of resources
Yes UNSUSTAINABLE Lower revenue due to ineffective care continuum
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SUSTAINABLE Managing the care continuum and getting paid for it’s l
Financing Reform: Strategy for Financial Sustainability
M fAre care
continuum management contracts in
place?
QUESTIONABLE SUSTAINABILITY Market may no longer reward services provided within unmanaged care
management value.
UNSUSTAINABLE Care continuum management expenses go unreimbursed
Many of us are here.
No
Is care continuum management in place?
YesNo
unmanaged care continuum
unreimbursed
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So, back down to primary care:What’s needed for success?
Physician engagement
C ti th i h i i t Compensating the primary care physician 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 biliaccountability
From primary care provider to primary care system
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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 among all caregivers and hospital e at o s p a o g a ca eg e s a d osp taadministration.
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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.
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Six Components of a Healthy Culture
1. Choosing physicians & midlevel providers Medical care quality
Emotional / organizational engagement
Historical productivity
Diversity / experience distribution
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Six Components of a Healthy KHA Culture
2 Engagement with providers2. Engagement with providers
Accessible leadership
Primary Care Quality Committee
Monthly provider meetings / periodic retreats
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Six Components of a Healthy Culture
3. Accountability/ Practice level financial / productivity reviews
monthly For providers:Expectations set annuallyProvider productivity / quality tracked monthlyTimely performance evaluations & feedback
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Provider DashboardClinical Indicators
Accountability
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Provider DashboardProductivity Indicators
Accountability
SAMPLE DOCTOR
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Six Components of a Healthy KHA Culture
4 Balancing4. 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 competitorscompetitors
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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‐centered medical home (primary care)Patient centered medical home (primary care)
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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.”
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A final suggestion when engaging physicians:
Ask questions & listen to the responses.
D ’t f l th d t i di t l li th t Don’t feel the 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?
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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