1. Population Management vs. Fee for Service: How To Manage Change In A Time of Change Grant M. Greenberg MD, MA, MHSA

2. Overview Describe the differences between population management and visit-based care Examine the current health care system challenges and rationale for transition to a population-based paradigm. Evaluate challenges in transition from fee- based to population based reimbursement

3. 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)

4. Change is Good https://commons.wikimedia.org/wiki/File%3AJim_Harbaugh%2C_Jake_Rudock%2C_and_Wilton_Speight_in_2015.jpg By Brad Muckenthaler [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons from Wikimedia Commonshttp://creativecommons.org/licenses/by/2.0

5. 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

6. More Money Spent doesn’t mean Better Quality OECD Health Data 2011 www.oecd.org/healthdata

7. 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?

8. Our Current State: Visit Based Care The more you see, and the more complex they are, the higher the payment (UMHS version: wRVU aka 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 Your version: likely quite similar (?)

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 Current State: Payment Highly Correlated with Visits Source: UMHS EHR, Family Medicine Faculty 10/1/14 -9/1/15 Unpublished data

10. 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

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

12. Population Pyramid Source: www.MiPCT.orgwww.MiPCT.org

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

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

15. 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?

16. 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

17. 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

18. 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

19. 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

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