Jennifer Lochner, MD Brian Arndt, MD Beth Potter, MD Moving away from the RVU: Care delivery changes with implementation of physician compensation reform Jennifer Lochner, MD Brian Arndt, MD Beth Potter, MD

Disclosures We have no conflicts of interest to disclose

Learning Objectives Describe pros and cons of physician compensation plans based on RVU productivity as compared to panel size. Adopt new metrics to assess changes in care delivery over time. Consider local forces related to payer mix and department culture in decision making around changes to physician compensation plans.

This report includes 18 DFMCH clinics in and around Dane County, WI: 4 residency training sites, 10 community clinics and 4 regional clinics

Revenue Sources for our Clinics Capitation Fee for service 2011 34.7% 65.3% 2015 41.5% 58.5%

UW Health Primary Care Job Description Formalized across primary care disciplines Emphasis on team based care including panel management and population health as well as caring for individual patients Defines work week as 27 hours face to face care, 13 hours non face to face care Care model redesign implemented – new tools to address screening and chronic disease management during and outside of office visits

Key changes to the clinical compensation plan Primarily based on panel size rather than RVU productivity – for 1.0 clinical FTE target panel size was set at 1800 Link to national benchmarks for FM clinical compensation Maintain some aspect of RVU productivity in the calculation For residency faculty minimize or remove any incentive to move patients onto faculty panels Implemented for residency and community clinics but not for regional clinics Residency clinics: 80% panel based, 20% RVU based Community clinics: 50% panel based, 50% RVU based

What happened next? RVU trends Panel size trends

Trends in RVU per clinical FTE   2011 RVUs per FTE 2012 RVUs per FTE 2013 RVUs per FTE 2014 RVUs per FTE RVU variance 2011-2014 National FM RVU benchmarkb 4796 4878 4901 4828 +0.01% Residency clinics  6099 6252  4786  4723  -22.6% Residency clinics percentage of FM benchmark 127 128 98 Community clinics 3513  4335  4597   4307 +22.6% 73 89 94 a New compensation plan started January 2013, retroactive to July 2012 b National family medicine Relative Value Unit benchmarks were obtained from data from the Medical Group Management Association, the American Medical Group Association, and McGladrey & Pullen

Trends in panel size January 2012 January 2013 January 2014 January   January 2012 January 2013 January 2014 January 2015 January 2016 Community Panel size 72,681 75,012 78,261 82,632 84,687 Clinical FTE 51.83 45.77 41.96 44.9 41.7 Panel size per 1.0 FTE 1402 1639 1865 1840 2031 Residency 33,475 33,588 33,608 34,321 35,447 20.28 21.02 18.71 18.23 17.43 1650 1598 1796 1883 2034 a New compensation plan started January 2013, retroactive to July 2012 b This includes physician clinical FTE, not including resident, fellow and APP FTE. For faculty this number reflected both direct patient care and resident precepting.

Any predictions on what happened to office visits per panel member over time? How about non face to face patient encounters over time?

Residency clinics – Office visits and non face to face encounters Slope= 0.68 p<0.001 Non FTF encounters per panel Avg 0.545 Avg 0.429 Slope= -0.245 p=0.001 Avg 0.219 Avg 0.188 FM office visits per panel

Community clinics – Office visits and non Face to Face encounters Slope= 0.236 p<0.001 Non FTF encounters per panel Avg 0.458 Avg 0.530 Avg 0.178 Slope= -0.578 p<0.001 FM office visits per panel Avg 0.136

Regional Clinics – Office visits and non face to face encounters Slope= 0.257 p=0.001 Non FTF encounters per panel Avg 0.477 Avg 0.577 Slope= 0.154 p=0.46 FM office visits per panel Avg 0.141 Avg 0.155

Why is this important? Implications for job descriptions and expectations for time spent in various activities for physicians and other care team members Implications for staffing ratios for care team members such as MA, RN Implications for appropriate panel size for physicians

More work to do… Comprehensiveness of care Patient satisfaction Are we maintaining comprehensiveness or are we referring more things out to either urgent care or specialty care? Patient satisfaction Are patients happy to have more care over the phone and electronic messaging or are they feeling like they cannot get in when they need to? Quality of care Are we still able to give high quality care with fewer face to face visits?

Goal = Triple Aim

Many thanks! Wen-Jan Tuan Michelle Riley Kathy McCain

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