Re-Defining a Paradigm of Care: Transforming Payment Models to Better Match With Physician Time and Effort Grant M. Greenberg, M.D., M.A., M.H.S.A. Joel J. Heidelbaugh, M.D., FAAFP, FACG David C. Serlin, M.D. University of Michigan Department of Family Medicine

Disclosures None to Report for any of the presenters

26,000 faculty, staff, students, trainees, & volunteers 3 hospitals with 990 beds, 45,000 stays annually 40 outpatient locations, 120 clinics, 1.9 million outpatient visits annually Research – $453 million annually Affiliations – AAVA, ACOs, state-wide collaboratives, others Department of Family Medicine: 6 Clinics, 90+ Faculty, 75,000+ patients

BURNING PLATFORM You/We are going out of business! Shifting Payer Mix: demographics and Medicare No Quick Fix- ongoing changes (effectiveness, efficiency) Physicians are a key part of the problem, and solution (apprentice model: do what I do vs change what I do)

Change is Good By Brad Muckenthaler [CC BY 2.0 ( via Wikimedia Commons from Wikimedia Commonshttp://creativecommons.org/licenses/by/2.0

Average Health Spending Per Capita ($US): a non-sustainable cost curve K. Davis et al. Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data

More Money Spent doesn’t mean Better Quality OECD Health Data

What will Fix the Problem? Socialized Medicine (e.g. National Health Service in the UK)? “Obamacare” aka Patient Protection and Affordable Care Act (PPACA)? Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)? Sequestration (e.g. just cut payments across the board to reduce costs)? Patient Centered Medical Home Model? Accountable Care Organizations?

PCMH, Population Management Home Care Services Sub-acute Care Public Health Safety Net Clinics Hospital Care Specialty Care Patient Centered Medical Home Primary Care

Population Pyramid Source:

Our Current State: Clinical Payment Model wRVU (work-Relative Value Units) –Based on Patients Seen –Accounts for Complexity –$ Amount per wRVU paid from Medical Group to Department, reflecting payment from Payer to Medical Group –The more you see, and the more complex they are, the higher the payment

Other Relevant Models: Concierge/Direct Primary Care Cash Only Pure Capitation (Per Member Per Month) Performance Payment (Quality, Efficiency)

Current Payment Model GAPS for Population Management Based on Visits, not population based (Passive System) Driven by individual productivity, not team No inherent incentive to improve quality No direct accounting for asynchronous work

HOW CAN WE DO BETTER? Better equate reimbursement to effort –“Panel” Management –Complexity Based –Quality Based –Asynchronous Care –Reward for reducing utilization

Patient Panel How do we determine attribution? (Activity based? Patient selection? Insurance Card ID?) What is the right number? How do we account for and define complexity across patients?

Attribution Models Activity Based (current) –2 visits in past 2 years, one within past 13 months Assignment Based (proposed) –PCP “ID” in EHR –Seen within 3 years

Panel Size UM Fam Med Source: University of Michigan Medical Group Unpublished Data, September 2015

Current State: Payment Highly Correlated with Visits Source: UMHS EHR, Family Medicine Faculty 10/1/14 -9/1/15 Unpublished data

Current State: Patient Calls Loosely Related to Office Visit Volume Source: UMHS EHR, Family Medicine Faculty 10/1/14 -9/1/15 Unpublished data

Current State: Follow up Work Correlates with Office Visits Source: UMHS EHR, Family Medicine Faculty 10/1/14 -9/1/15 Unpublished data

Payment for Quality Based on clinic-level performance and number of eligible patients for select chronic disease & preventive care measures Focuses on measures that are clinically relevant and/or are tracked by external organizations (e.g., HEDIS, BCBSM, BCN)

Visit Sensitive Quality Metrics Activity that requires PCP contact Activity based attribution more likely to accurately reflect performance Examples: Diabetic Foot Exams Blood Pressure Measurements Lipid Screening

Visit Insensitive Quality Metric Activity that does not require a PCP visit Assignment (population) based attribution more likely to accurately reflect performance Examples: Mammograms Immunizations Adding medications (statin, ACEI / ARB)

Transition Plans How do we transition care models in coordination with the uncertain transition of payment models? Many commercial payors continue in a fee for service model with plans to change “in the future” CMS plans to have 50% of payments in alternative formats by 2018 (APM, MIPS)

Transition Plans-Payment Model Begin to relatively “devalue” the volume incentives in place (RVUs), but on a gradual pace to maintain financial viability Increase incentives for quality and value Move toward a capitated model of care Use of Advanced Practice Providers and pharmacists to optimize outcomes

Transition Plans- Care Model Start to decrease physician time in face to face visits Use Advance Practice Providers to maintain access Reallocate physician time to work with support staff –Panel Managers: gaps in care –Care Navigators: transition care/complex care Reallocate time for alternative patient contacts –Phone visits –Electronic/virtual visits

Transition Plans Metrics: -Financials -Patient Satisfaction (CAHPS) -Faculty Satisfaction -Quality -?Primary Care Sensitive ED utilization -?Hospital Readmission Rates

Discussion What are you doing?

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