Pennsylvanias Chronic Care Commission Transforming Primary Care Practice: The Southeast Pennsylvania

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Pennsylvanias Chronic Care CommissionTransformi
ng Primary Care Practice The Southeast
Pennsylvania Rollout

• Status as of May 12, 2008

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The State of Primary Care in the USA

• Research shows patients with PCPs have lower
  costs, but
• Primary care practitioners declining in numbers
  failure to attract new graduates
• Low reimbursement compared to non-PCP peers
• Low satisfaction
• Current primary care practice is reactive, often
  responding to acute episodes, resulting from poor
  self-management by patients with chronic illness
• Access is inadequate
• Emphasis is on issuing referrals and not on
  coordinating care
• Minimal focus on patient education and no support
  staff for patients
• Slow to adopt evidence-based medicine
• Generally lower level of sophistication (EMR,
  support staff, etc.)
• Minimal communication between providers

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Chronic Care Commission Origins

• Pennsylvania Chronic Care Management,
  Reimbursement and Cost Reduction Commission
  created by Governor Rendells Executive Order,
  May 2007.
• First requirement was to develop a strategic plan
  for implementing the Chronic Care Model to
  improve the quality of care while reducing
  avoidable illnesses and their attendant costs.

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Chronic Care CommissionStrategic Direction

• The Commission developed and delivered a
  strategic plan to the Governor and Legislature in
  February 2008 to
• Begin regional rollouts using learning
  collaboratives, practice coaches and provider and
  consumer incentive alignment beginning with
  Southeast PA in May 2008
• The model is an integration of Chronic Care Model
  and the Patient- Centered Medical Home concepts.

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The Chronic Care Model

• Team-based coordinated care, with a focus on
  patients with chronic illness
• Origin Ed Wagner, McColl Institute for
  Healthcare Innovation, Group Health Cooperative
  of Puget Sound
• Improved care coordination
• Cost reductions from averted admissions
• Improved quality of care
• Several existing state and national
  collaboratives, e.g.,
• Vermonts Blueprint for Health
• WA state - based on the IHI Breakthrough Series
  Model
• HRSA implementation through Federally Qualified
  Health Centers across the U.S., including 16 in PA

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What is the Chronic Care Model?
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Decision Support
Self-Management Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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The Patient-Centered Medical Home (PCMH)

• Origin American Academy of Pediatrics
• Now embraced by American Academy of Family
  Physicians, American College of Physicians and
  American Osteopathic Association
• Several pilots in place and emerging around the
  country
• (NY, CO)
• Features
• Open access scheduling
• Use of a registry or EMR to manage a population
• Use of a team Physician, CRNPs, case managers,
  health educators
• Improved communication (telephonic, e-mail)
• Decision support

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Pennsylvanias Chronic Care Commission

• Organization
• 45 Commission members
• Provider, insurer, state government agency,
  organized labor, academic and consumer
  representatives
• Four subcommittees include Commission members,
  plus additional representatives from stakeholder
  organizations
• Practice Redesign
• Consumer Engagement
• Incentive Alignment
• Performance Measurement
• Fifth subcommittee in 6-08 Pooled Claims
  Database
• Staffed and facilitated by the Governors Office
  of Health Care Reform

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Pennsylvanias Chronic Care Commission

• February 2008 strategic plan created a framework
  to guide rollout activities in the Commonwealths
  six region
• Each regional rollout must adhere to the
  framework, but has room to vary its approach
• A Southeast PA Regional Rollout Steering
  Committee crafted the following specific model.
  Other regions of the state need not use this
  specific model.

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Requirements GOHCR

• Funding faculty and expenses for a year-long
  learning collaborative for participating primary
  care practices
• Coordinating the flow of data and funds to
  practices
• Providing ongoing project management support
• Funding cost of registry (first rollout excluded
  due to lack of appropriations)
• Funding data collection, evaluation and reporting
  activities through a contracted 3rd party

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Requirements Primary Care Practices

• Participate in seven days of learning
  collaborative meetings in year 1 initial focus
  on diabetes and pediatric asthma
• Work with an assigned practice coach between
  learning collaborative sessions to transform
  practice
• Use a patient registry to track patients with
  chronic illness
• Achieve Level 1 NCQA PPC-PCMH Recognition within
  12 months
• Report data from the patient registry and other
  sources required for evaluation purposes
• Reinvest funds into the practice site, including
  for case management in those instances where the
  practice does not already have that resource in
  place
• Three-year commitment

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Requirements Primary Care Practices

• Most importantly, implement fundamental redesign
  of the practice for all patients, including, for
  example
• Using the registry to send patient reminders
• Conducting planned visits to address all aspects
  of the patients conditions
• Providing team-based care, using non-physician
  personnel to support the patient (education, care
  coordination, etc.)
• Providing self-management support, involving the
  patient in goal setting, action planning,
  problem-solving and follow-up
• Providing enhanced access to the care team
• Performing population-based data analysis

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What is NCQA PPC-PCMH Recognition?
Must Pass Elements
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Requirements Payers

• Three-year commitment
• Financial support design follows Commission
  framework, but specific to the Southeast rollout.
  Payments proportional to the revenues paid to
  each practice by each of the payers
• Payment to IPIP (Improving Performance in
  Practice) for Practice Coaches (1 for every 15
  practices) _at_130K per coach per year
• Three-part provider payment model
• Infrastructure development
• Enhancement to existing FFS or capitation
  payments
• Pay-for-performance

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Requirements Payers

• Infrastructure development payments
• Licensing fee for registry, support for data
  entry to registry, cost of NCQA survey tool, NCQA
  application fee, and lost revenue for time to
  attend 7 days of learning collaborative meetings
  in the first year
• Enhanced payments to FFS/capitation
• For initial three years, lump sum payments
  aligned with stepwise achievement of the three
  levels of NCQA PPC-PCMH recognition
• Pay-for-performance
• Maintenance of existing program common measures
  across insurers by 2010

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Requirements Payers

• Derivation of infrastructure development
  payments
• Infrastructure Costs to Practice During the First
  Year
• NCQA PPC-PCMH survey tool 80/practice
• Data entry to registry 800/practice
• Office assistant 8,000/practice
• NCQA application fee 360/clinician
• Registry license fee 275/clinician
• Time to attend learning collab
• (7 days/year)
  11,655/clinician

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Requirements Payers

• Derivation of enhancement of FFS/capitation
• Informed by analysis of limited available
  estimates of practice costs to implement CCM/PCMH
  (4-9PMPM range excluding EMR) and of existing
  CCM/PCMH programs and pilots
• Commission recognized that it is likely that
  costs would vary based on practice size and
  configuration. Some existing modeling assumes a
  solo PCP practice, while RI assumes a small group
  practice.
• Southeast PA model provides up to approximately
  4PMPM for NCQA PPC-PCMH recognition, less
  Medicare FFS share of practice
• Per clinician amount decreases as practice size
  increases

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Estimated Practice Costs

1 "The Medical Home Disruptive Innovation for
a New Primary Care Model", Deloitte Center for
Health Solutions, 2008.
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Estimated Practice Costs

• Miscellaneous Notes
• Bridges to Excellences new medical home program
  estimates annual savings of 245 savings per
  patient from a medical home, and has capped award
  payments to providers at 100,000 per year.
• United HealthCare estimates the additional
  reimbursement to a primary care practice for
  implementing a Patient-Centered Medical Home at
  20 above baseline reimbursement.

1 Allan Goroll et. al. "Fundamental Reform of
Payment for Adult Primary Care Comprehensive
Payment for Comprehensive Care", Journal of
General Internal Medicine. 22(3) 410415, March
2007.
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Examples of Other CCM/PCMH Programs

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Examples of Other CCM/PCMH Programs

1 Elbert Huang et. al. The Cost-Effectiveness
of Improving Diabetes Care in U.S. Federally
Qualified Community Health Centers, Health
Services Research, 2007. 2 Bruce E. Landon et.
al. Improving the Management of Chronic Disease
at Community Health Centers, New England Journal
of Medicine, 3569, March 1, 2007.

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Payment Triggered by NCQA PPCPCMH Recognition
Annualized revenue per full-time-equivalent
practitioner from all sources for implementing
the features of the PCMH recognizes economies of
scale and the incremental resources to achieve
full transformation of the practice to include
all features, discounted by the of practice
revenue derived by Medicare FFS and insurers with
low market share.
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Requirements Payers

• Commission is still working on recommendations
  for payer strategies to better engage consumers
  in self-management.
• Currently considering piloting consumer
  incentives. Also looking at benefit design
  changes.

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Participants

• 34 practices
• representing 165 clinician FTEs
• serving 176,000 patients
• internal medicine, family practice, pediatrics
  and NP-led practices
• combination of independent practices and those
  affiliated with one of three academic systems
• almost half have or are implementing an EMR
• size of applicant practice sites
• 3 practices of 1 physician
• 16 practices of 2-4 physicians
• 10 practices of 5-8 physicians
• 3 practices of 10-20 physicians

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Participating Practices

• Ambler Pediatrics
• Buckingham Family Practice
• Childrens Health Center (VNA
• Community Services)
• CHOP Primary Care _at_ South Phila.
• Crozer-Keystone Center for Family
  
  
• Health
• Crozer Medical Associates
• Eagle Family Medicine Center
• Edward S. Cooper Practice
• Family Medicine, Geriatrics Wellness
• Family Practice Counseling Network
• Founders Medical Practice
• Greenhouse Internists
• Holland Medical Associates
• Jefferson Family Medicine Associates
• Kids First Chestnut Hill
• Kids First HighPoint

• Lower Bucks Pediatrics
• Mary Howard Health Center
• Medical Group at Marple Commons
• Mt. Airy Family Practice
• Ninth Street Internal Medicine Assoc.
• North Willow Grove Family Practice
• North Willow Grove Pediatrics
• Penn-Care Bala Cynwyd
• PennCare Internal Medicine at Mayfair
• Pennsbury Medical Practice
• PHMC Health Connection
• Project Salud
• Quality Community Health Care, Inc
• Rising Sun Health Center
• Sayre Health Center
• Temple Pediatric Care
• Penn Medicine at Radnor

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Participants

• 6 payers
• Aetna, AmeriChoice (Medicaid), CIGNA Healthcare,
  Health Partners (Medicaid), Independence Blue
  Cross, Keystone Mercy Health Plan (Medicaid)
• UnitedHealthcare may still join as the 7th
  insurer
• Insurers including commercial (insured and
  self-insured), Medicaid and Medicare Advantage
  business,
• no Medicare FFS

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Supporting Coalition

• The Primary Care Coalition
• The PA Academy of Family Physicians, the PA
  Chapter of the AAP, and the PA Chapter of the
  ACP. Together they are the RWJF IPIP grantee in
  PA.
• IPIP practice coaches will assist with
• transforming the practice
• data collection and reporting
• linking practices to community resources

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Evaluation

• The Commission has approved an evaluation design
  utilized matched pairs of practices as a control
  group.
• The initiative will be evaluated using the
  following measurement domains
• engaged providers
• patient self-care knowledge and skills
• patient function and health status
• primary care practice satisfaction
• appropriate and efficient utilization of services
  
• clinical care quality
• cost

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Evaluation

• As part of the evaluation, the Commission will
  utilize standardized measure sets and performance
  goals for diabetes, asthma and hypertension
  adopted by IPIP.
• These measures are based on national measures as
  defined by AQA/NQF and NCQA/HEDIS.

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Performance Reporting System

• The Commission require practices to submit
  monthly performance data on these measures
  through IPIP.
• The measures apply to the entire practice
  population (e.g., population management).
• Easy to report data from Colorado registry system.

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Anticipated Gains

• Improved quality of care within 1 year
• Reduced admissions and cost in 3 years
• Improved access to care and member satisfaction
• Support for the vulnerable and essential primary
  care professional community
• A robust demonstration of the impact of a
  far-reaching, multi-payer strategy to transform
  care delivery
• Lessons learned to hopefully apply to a broader
  system-wide model application

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Next Steps

• Finalizing contract with evaluation contractor,
  and then completing work on evaluation design.
• Beginning planning for next regional rollout in
  South Central Pennsylvania in the fall of 2008.

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Contacts for Additional Information

• Phil Magistro, PA GOHCR
• pmagistro_at_state.pa.us
• Michael Bailit, consultant to PA GOHCR
• mbailit_at_bailit-health.com