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)

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Panel Size UM Fam Med Source: University of Michigan Medical Group Unpublished Data, September 2015

urrent State: Payment Highly Correlated with Visits

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State: Patient Calls Loosely Related to Office Visit Volume Source: UMHS EHR, Family Medicine Faculty 10/1/14 -9/1/15 Unpublished data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

Transition Plans How do we transition care models in coordination with the uncertain transition of payment models? https://www.flickr.com/photos/subhroclicks/4398675024/in/photostream/ Creative commons license. Photo by Subhro Ganguly

Payment Reform Cost Containment Link payment to evidence and outcomes Bundle payments by episode/condition Reimburse for coordination of care in a medical home Accountability for Results Transparency Accountability No Outcome/No Income

Discussion What are you doing to get “there”? -culture changes, less reliance on “autonomy” -evidenced based practice -reduction in variation -continuous measurement/feedback -patient engagement

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