1. Presentation to the QMA Presented by Dr. Jean Clarke
GPSC Fee Incentives
Buy What You Want
Presentation to the QMA
April 2011
Presented by Dr. Jean Clarke

2. $ 4 Priorities Value us Pay us Support us Train us 7 DAN
“Pay us, value us, train us, support us”—For the first time, a Physician voice in planning.
GPSC (General Services Planning Committee):
Value us
Pay us
Support us
Train us

3. Barbara Starfield’s Key Attributes of Primary Care
Access
Co-Ordination
Comprehensiveness
Continuity

4. The Triple Aim Population health outcomes TRIPLE AIM
Patient and provider experience
TRIPLE AIM
Per capita cost

5. Overview Chronic Disease Management Complex Care Conferencing
Palliative Care
Mental Health
Prevention
Maternity
I’m going to speak specifically to the fee incentives introduced by GPSC. Although we now have now consciously decided to keep Barbara Starfield’s key attributes of primary care front and centre in our thinking around fee incentives and use the IHI’s triple aim as a lens, I think it’s fair to say that some of GPSC’s early work was serendipitously supportive of those two things (

6. CHRONIC DISEASE MANAGEMENT
GPSC INITIATIVES
CHRONIC DISEASE MANAGEMENT
Although Barbara Starfield is passionate that a disease focus is anathema to good primary care, I think that our CDM fees as written, actually reward the continuous co-ordinated comprehensive care of patients that constitutes her key attributes.

7. Chronic Disease Management
Diabetes Mellitus - $125.00
Congestive Heart Failure - $125.00
Hypertension - $50.00
COPD - $125.00
COPD Telephone/ follow up - $15.00 (billable up to 4 times in the 12 months)
CHF, DM and COPD – diseases that are associated with significant health care costs, ER visits, hospital admissions. Hypertension chosen because of the potential downstream benefits that early intervention and treatment could bring – decrease in CRF, stroke and so on.

8. Chronic Disease Management
The CDM fee is a management bonus billable annually on the anniversary of the initial billing date.
The CDM fees are for the GP who has accepted responsibility for the ongoing, longitudinal care of the patient.
Must have at least 2 visits with patient in 12 months preceding billing of CDM fee.
FFS billing for office visits continues.
The restriction of the fee to the GP who has accepted responsibility for the ongoing care of the patient is something that you will see for most of the GPSC fee items. This is part of our mandate – to support GPs providing full service primary care.

9. Chronic Disease Management
Diabetes, CHF, and COPD CDM fees may be billed for the same patient.
Hypertension CDM fee is not billable if also billing for Diabetes and/or CHF (but is billable with COPD.)
Use of flow sheets as a tool for tracking care is encouraged but not mandatory provided all required information is included.
One of the things that makes this different from a P4P disease care bonus is that the requirement is to provide guideline informed care, rather than guideline dictated care. We believe that doctors will provide the best care for their patients, individualised to that patient’s personal medical needs – that by not being proscriptive about meeting targets, they can practice the art of medicine while using the best science. Avoids perversities see in QUOF in UK

10. GPSC INITIATIVES
COMPLEX CARE

11. Complex Care
Payment to compensate for the extra time required to provide planned care to complex patients who are living in their home or in assisted living.
Payable only to the General Practitioner who accepts responsibility for the longitudinal, coordinated care of the patient.

12. Complex Care Eligible patients must have two of the following chronic
conditions:
Diabetes mellitus
Chronic kidney disease
Congestive heart failure (CHF)
Cerebrovascular disease (CVD)
Ischemic heart disease (IHD)
Chronic respiratory condition
Chronic neurodegenerative diseases (CND)
Chronic liver disease (CLD)
Because we have a fixed funding envelope we had to restrict the fee to people with certain diagnoses.

13. Complex Care Annual Complex Care Management fee - $315
Minimum 30-minute complex care planning process:
The Complex Care Planning Visit: the development of the care plan is done jointly with the patient. The patient should leave the appointment knowing there is a plan for their care and what that plan is.
Billed in addition to office visit fee on the day of the planning appointment.
Part of the goal is to get away from the treadmill of reactive medical care, and instead focus on proactive planned care for pts with chronic disease, both to improve the patient’s health and hopefully reduce the need for acute episodic visits for exacerbations of chronic disease

14. Complex Care FFS billing for subsequent office visits continues.
CDM fees and Conferencing fees are payable in addition.

15. Complex Care
Complex Care Telephone/ Follow-up Management fee $15
Payable for up to 4 non face to face encounters (telephone, ) in the 18 months following billing of the Complex Care management fee
Telephone/ (2 way) encounters may be provided by the GP or delegated staff. Not for simple appointment reminders or prescription renewals

16. GPSC INITIATIVES
CONFERENCING FEES

17. Conferencing Fees Community Patient Conferencing fee
Facility Patient Conferencing fee
Acute Care Discharge Planning Conferencing fee
Telephone Consultation with a Specialist or GP with Specialty Training

18. Conferencing Fees
Developed to compensate the GP for time spent conferencing with other health care professionals to make a coordinated clinical action plan for the care of patients with more complex needs.
This set of fees, except for the telephone consultation fee, are meant to compensate for the time spent co-ordinating necessary care for patients – the communication necessary with other providers who are also caring for the patient, which is time consuming and very valuable, but previously not remunerated.

19. Conferencing Fees
The Community, Facility and Acute Care Discharge conferencing fees are for the same eligible patient population:
Frail elderly (ICD-9 code V15)
Palliative care (ICD-9 code V58)
Mental illness
Patients of any age with multiple medical needs or complex co-morbidity – pregnancy is considered a co-morbidity in complex maternity patients.
Payable in units of $40.00 per 15 minutes or greater portion. Maximum 4 units/patient/day; 6 units/patient/year.

20. GP Urgent Telephone Conference with a Specialist Fee
Intent is to improve management of the patient with acute needs, and reduce unnecessary ER or hospital admissions/transfers.
Billable when the patient’s condition requires urgent (< 2 hours from time of request) consultation with a specialist or GP with specialty training, and the development and implementation of a care plan within the next 24 hours to keep the patient stable in his/her current environment.
This fee is not restricted by diagnosis or location of the patient, but by the urgency of the need for care.
$40 flat rate fee value.
Billable in addition to visit fee.
This fee recognises that GPs often need access to timely consultative advice and if it is made available, can continue managing their patient without the need for an ER visit or office consultation with a specialist.

21. General Practitioners with Specialty Training Telephone Advice Fees
“General Practitioner (GP) with Specialty Training” is defined as “A GP who has specialty training and who provides services in that specialty area through a health authority supported or approved program.”
“Mirror fees” to the SSC Specialist Telephone Advice fees for FRCP certified Specialists.
Service may be provided when physician is located in office or hospital.
Telephone advice must be related to the field in which the GP has received specialty training.

22. General Practitioners with Specialty Training Telephone Advice Fees
GP with Specialty Training Telephone Advice - Initiated by a Specialist or General Practitioner, urgent (< 2 hours from request for advice) - $60.00.
GP with Specialty Training Telephone Patient Management - Initiated by a Specialist or General Practitioner, one week - $40.00.
GP with Specialty Training Telephone Patient Management / Follow-up - $20.00; maximum 4/year/patient.

23. GPSC INITIATIVES
PALLIATIVE CARE

24. Palliative Care Palliative Care Planning fee - $100
Payable for the development of a Palliative Care Plan for patients who have reached the palliative stage of a life-limiting disease or illness.
Requires a face-to-face visit with the patient or the patient’s representative.
Medical Diagnoses include: end-stage cardiac, respiratory, renal and liver disease, end-stage dementia, degenerative neuromuscular disease, HIV/AIDS or malignancy.
Eligible patients must be resident in the community: at home or in assisted living or supportive housing.

25. Palliative Care
Palliative Care Telephone/ Follow-up Management $15.00
This fee is payable for 2-way telephone or communication with eligible patients or their representative to provide clinical follow-up management
billable by the GP who has developed the patient’s Palliative Care Plan
Billable up to 5 times. .

26. GPSC INITIATIVES
MENTAL HEALTH

27. Community GP Mental Health
Mental Health Initiative compensates the Family Physician who accepts responsibility for the longitudinal care of patients who:
Have an Axis I diagnosis confirmed by DSM IV criteria
With a severity and acuity level causing sufficient interference in activities of daily living that developing a management plan for the rest of the year would be appropriate.
The mental health fee is one of my favourites. It demonstrates the value of co-ordinating fee incentives and physician training – our PSP mental health module teaches practical skills for dealing with patients with mental health issues and the mental health fee then pays you for spending the time to make a proper diagnosis and plan the necessary care.

28. GP Mental Health GP Mental Health Planning fee - $100.00
Paid for the development of a Mental Health Plan for care during the subsequent calendar year for patients who reside in the community.
Requires 30-minute face-to-face visit.
Billable once per calendar year per patient.
Allows billing for 4 additional annual counselling visits

29. Community GP Mental Health
GP Mental Health Telephone/ Management fee - $15
This fee is payable for up to 5 telephone/ services (2-way communication) with eligible patients or their representative via telephone or for the provision of clinical follow-up.
Available for up to 18 months after billing Mental Health fee.
This fee is not to be billed for simple appointment reminders or referral notification.

30. GPSC INITIATIVES
PREVENTION

31. Prevention Fee Personal Health Risk Assessment fee - $50
Billable in addition to an office visit, to undertake a personal health risk assessment visit with “at risk” patients.
Targeted patients include those with:
Smoking
Unhealthy eating
Physical inactivity
Medical obesity.
GP is expected to develop a plan that recommends age- and sex-specific targeted clinical preventative actions of proven benefit.
Billable for up to 100 patients per calendar year per physician.

32. MATERNITY INITIATIVES
GPSC INITIATIVES
MATERNITY INITIATIVES

33. GPSC Obstetric Delivery Bonuses
Delivery bonuses valued at 50% of delivery fee.
Available to GPs who in addition to being paid the delivery fee for the patient are also responsible or share responsibility for providing the patient’s longitudinal primary care.
Maximum total of 25 bonuses claimed per calendar year.

34. Maternity Network Payment
Quarterly payment to encourage shared care of obstetric patients to reduce burnout.
$2100 per quarter.
GPs complete a network registration form for the group.

35. Some Key Findings From the Evaluation
Hollander Analytical Services Ltd.
Fort Street
Victoria, BC V8W 1H7
Tel: (250)
Fax: (250)

36. A Major New Finding
A major, new finding is that there is a clear inverse relationship between the level of attachment to a primary care practice, and costs, for higher care needs patients. Attachment is defined as the percentage of all GP services in one year provided by the practice which provided the most services.

37. Benefits of Attachment
The more patients go to the same practice, the lower the overall, annual costs to the health care system.
Most of the differential in costs between more attached and less attached patients is in hospital costs: costs are higher for less attached patients
Therefore, activities which foster increased attachment of patients to a particular primary care practice have the potential to reduce health care costs i.e. continuity of care is cost-effective.

38. A Major New Finding (cont’d)
Our findings are based on an analysis of diabetes and congestive heart failure patients. A classification system developed by Johns Hopkins University was used to ensure that people in the analysis had similar levels of care need.
Resource Utilization Band (RUB) 4 represents people with a high need for care. RUB 5 represents people with a very high need for care.

39. Major new findings
Annual costs per patient as a function of attachment to practice, for diabetes patients at RUB 4: Fiscal 2007/08
15 BILL
This graph shows the per-capita cost of care for diabetic patients in a high Resource Utilization Band. A RUB is…succinclty
These results show that, for higher-needs patients, increased attachment to a GP results in significantly lower total health care costs, largely from reduced hospitalizations and referrals

40. Major new findings
Annual costs per patient as a function of attachment to practice, for diabetes patients at RUB 5: Fiscal 2007/08
16 BILL
These cost savings are reproducible with different populations of complex patients. This graph shows the highest RUB, RUB 5, of diabetics

41. Major new findings
Annual costs per patient as a function of attachment to practice, for CHF patients at RUB 4: Fiscal 2007/08
17 BILL
And again, reproducible across conditions. This shows Congestive Heart Failure

42. Major new findings
Annual costs per patient as a function of attachment to practice, for CHF patients at RUB 5: Fiscal 2007/08
18 BILL
The data from 2008/2009 look very similar and we expect the cost avoidance to be at similar levels as well.

44. Cost of Care as a Function of Attachment (cont’d)
For the four main groups of patients reported in the study, total cost savings per 5% increase in attachment is estimated as:

45. Incentives RISQY 5% in attachment = $85M in high-RUB costs 20 BILL
Our projections show that a 5% increase in attachment will translate to $85M cost avoidance - for just these two conditions!
What is most interesting is that physicians who bill more incentives, have a higher level of Attachment, and have lower costs for their patients…..
through care: founded in agreed-upon guidelines, formulated through care plans involving the patients, allowing delivery in the community and NOT in the hospitals.

46. Major new findings
Annual costs for CDM patients who did, and did not, receive incentive-based care, standardized for difference in age, gender, RUB and attachment levels: Fiscal 2008/09
Cost categories
Diabetes
incentive
CHF
Hypertension
No $$
With $$
GP, specialist, and diagnostic facilities
1599
1728
2479
2657
1264
1247
Hospital
2339
1999
5706
5019
1486
1272
Pharmacy
1036
1192
1580
1588
526
487
Annual total (average)
4974
4919
9765
9264
3275
3006
19 BILL
In addition to the cost avoidance that results from increased attachment, there is also a net reduction in overall costs for patients of physicians who bill incentives versus those who do not bill incentives, even after adjusting for patient age, gender, RUB and attachment levels – for patients with diabetes, CHF and hypertension.

47. Number of GPs participating in GPSC initiatives
13 BILL
The number of participating GPs has doubled, and now includes 90% of full-service FPs.

48. Uptake of Incentive Billings Over Time: Fiscal 2003/04 to 2009/10
Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.

49. Percentage of GPs Billing for Chronic Disease Management Incentives Over Time: Fiscal 2003/04 to 2009/10
% Using Incentives
Chronic Disease
Diabetes
Heart Disease
Hypertension
Group
Year
Full Service
2003/04
45.6
45.3
25.1
0.0
2004/05
58.8
58.6
29.0
2005/06
76.2
76.0
38.0
2006/07
83.8
82.0
47.4
65.3
2007/08
87.5
85.9
57.9
78.8
2008/09
87.9
86.5
80.3
2009/10
86.1
59.4
81.7
Other
4.1
0.7
5.8
5.6
1.3
10.0
9.6
2.6
12.9
10.1
2.4
7.0
14.9
11.9
3.7
11.0
13.3
9.7
3.3
11.1
7.5
2.2
7.9
Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.

50. MSOC Patients Over Time Based on Care Provided to All Patients for Regular GPs
Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.

51. Diabetes patients receiving 2+ HbA1c tests per year
Quality
RISQY
Diabetes patients receiving 2+ HbA1c tests per year
38 BILL
The most startling contrast was between the patients of doctors who billed the Diabetes Guideline fee and those who did not: the HbAIC rate was 71% for the incented doctors and 32% for those who did not participate!

52. Mean total acute and rehab days per patient by physician
Quality
RISQY
Mean total acute and rehab days per patient by physician
39 BILL
Hospitalization days greatly reduced for doctors with diabetes patients who were incentivized (IP) and significantly worse for those who were not incentivized (NIP).

53. Health Indicators for Diabetes Patients 2002/03 Death Rates For Patients Alive March 31, 2006 Excluding Patients 85 and Over as of March 31, 2002
Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.

54. Professional satisfaction
The Bottom Line
Professional satisfaction
Payer satisfaction
49 BILL
Still a work in progress, but a new culture built on transparent, previously ignored fundamentals…RISQY business!
80% of GPs surveyed in 2010
$$$ cost avoidance