1. Northeast August 6, 2013

2.  My thanks to Lou for presenting this talk.  Please complete the required IPHIT participant form for our HRSA grant.  Please complete the evaluation form at the end or email me any feedback you have about this presentation so we can continue to improve upon it. Thanks. Jennifer & The Integrating Public Health Inquiry and Transformation (IPHIT) team

3.  Review Northeast Clinic demographics, geo- maps and quality metrics  Look at different ways data can be asked and presented  Explore examples of how to data can inform future investigations and interventions  Share the state of clinic finances  Provide examples of your own individual data

4.  As you look at this data, formulate your own questions:  What else do you want to know?  What seems to be missing?  What assumptions are we making?  In preparing this presentation, I have inserted black slides followed by my own questions and thoughts as examples of how data can move us to inquiry and, hopefully, ultimately to action.

5.  In May 2013 12,075 patients were assigned to a PCP at Northeast clinic. From this we have panel-based data.  From 7/1/12 to 6/30/13 (FY13) ◦ 7,704 patients were actually seen at Northeast at least once during this year. From this we have service-based data. ◦ There were 30,650 visits including lab, xray and nurse visits ◦ There were 23,428 visits with NE providers  Thus every patient who had >0 provider visits in FY13 was seen an average of 3 times (23,428/7,704)

6. Panel: patients assigned to a PCP at NE on May 2013 Service: patients seen at NE during 7/1/12-6/30/13 Not NE assigned: patients not assigned to a PCP at NE Panel Service Not NE assigned This is how it looks:

7.  Which questions are best answered with panel data?  Which questions are best answered with service data?  Which questions are best answered with visit data?

8. The following slides are based on panel-based data unless noted

10. Children 65+

13.  Includes lab and xray encounters (30650 encounters)  61% female, 39% male

14.  * Includes lab and xray encounters (30650 encounters)

15.  Ten percent of the FMP patient visits must be with patients less than 10 years of age.  Ten percent of the FMP patient visits must be with patients 60 years of age or more  So what is the visit mix for the NE residents?

16.  Includes only residents’ visits (6389 visits)

17. By PanelBy Service Notice how insurance status affects access/utilization data.

18. As you develop QI and community medicine projects here at Northeast, start by sifting through the data. Here’s what caught my eye…

19. ◦ Our data shows 14.9% of our patients are black ◦ According to the U.S. census bureau, Blacks make up  5.4% of the population in Dane County  6.5% in WI  13.6% in the U.S. http://quickfacts.census.gov/qfd/states/55/55025.html http://quickfacts.census.gov/qfd/states/55/55025.html ◦ Did you know that we are caring for a relatively large percentage of black patients in our clinic relative to their prevalence in our community?

20. Where are our patients?

22.  We have adopted Lake View Elementary School  We overlaid the census tract data of the Northeast Clinic population ages 5-11 years old with the Lake View Elementary School district map  Then we added data about BMI %ile

23. This shows most NE obese elementary school-age children don’t live in the Lake View Elementary school district (in light green).

24. (Some) Northeast Diagnostic Codes

25. Condition# Patients % Patients % Female % Male Obesity262829.460.439.6 Hyperlipidemia199516.547.552.5 Hypertension191815.953.246.8 Diabetes6615.552.347.7 CAD2221.836.064.0 CHF780.664.135.9 Chronic Kidney Dis2402.063.836.2 Asthma11229.362.737.3 Cancer3042.552.347.7 Chronic back pain150112.462.237.8 Opioid126810.561.338.7 Gender identity disorder 750.652.048.0 Chronic diseases at Northeast 7/1/12-6/30/13

26. Condition # Patients % Patients % Female % Male Depression218018.569.630.4 Anxiety145612.167.332.7 Schizophrenia1251.047.252.8 Smoking183117.550.849.2 Alcohol disorder5204.335.464.6 Substance use disorder 3462.951.448.6 And more 7/1/12-6/30/13

27. Maybe. But how about: how are we doing compared to Dane County, WI and the nation?

28. Condition # Patients % Patients Dane county % WI % U.S. % Obesity262829.4242925 Smoking183117.5151913 Alcohol disorder5204.324 7 Diabetes6615.5688.3 Another look at chronic diseases at Northeast 7/1/12-6/30/13 www.countyhealthrankings.org ??? Christina Lightbourn would likely disagree with this. Remember data is limited by what you input. What diagnosis code(s) are we using here?

29. We have developed some great interventions around diabetes at Northeast, but look at back pain and opiods…

30. Condition# Patients % Patients % Female % Male Obesity262829.460.439.6 Hyperlipidemia199516.547.552.5 Hypertension191815.953.246.8 Diabetes6615.552.347.7 CAD2221.836.064.0 CHF780.664.135.9 Chronic Kidney Dis2402.063.836.2 Asthma11229.362.737.3 Cancer3042.552.347.7 Chronic back pain150112.462.237.8 Opioid126810.561.338.7 Gender identity disorder 750.652.048.0 Chronic diseases at Northeast 7/1/12-6/30/13

31. Condition Panel-BasedService-Based # Patients% Patients# Patients% Patients Obesity262829.4211631.8 Hyperlipidemia199516.5172024.3 Hypertension191815.9169023.9 Diabetes6615.56449.1 CAD2221.81982.8 CHF780.6741.0 Chronic Kidney Dis2402.02313.3 Asthma11229.388712.5 Cancer3042.52553.6 Chronic back pain150112.4118716.8 Opioid126810.5128418.2 Gender identity disorder 750.6380.5 And yet another look: panel vs service data 7/1/12-6/30/13

32.  Carrie Stoltenberg and Ann O’Connor have founded and led our Chronic Controlled Substance Work Group at Northeast. This group ◦ Uses a pain registry ◦ Meets regularly and review our top users ◦ Develops QI tools and protocols such as our CCS contracts

33. What the data showsWhat ideas do you have?  Pain patients are high utilizers of health services.  Almost twice as many women as men have back pain and chronic opioid use  Group visits (e.g. yoga) for chronic pain patients?  A smoother process for refill of chronic controlled substances? ……

34. Some data you can access immediately from your EPIC dashboard

35. NE % UWMF goal % Breast CA screening 70.7>70 Colon CA screening 66.9>70 % A1c testing 97.9>67.6 % LDL testing 89.8>76.7 % A1c control 54.3>47.7 % LDL control 54.4>57.5 % BP control 46.9>48.0 Pneumococcal vaccine 83.7>75

36. NE % UWMF goal % SCHEDULING % Template Filled 67.5>85 % Slot Utilization 74.3>85 % No-Show 9.5<4 PATIENT EXPERIENCE % appt available when needed 66.9>77 % Explanations that I understand 89.3>92.2 Looks like we need to work on access issues.

37.  Clinic level data ◦ Avatar % top box ◦ Diabetes registry performance ◦ Immunizations ◦ Pay for performance

38. Although these metrics are important to track and work on, there are others you could search out.

39. It’s in the data

40. “Of all the forms on inequality, injustice in health care is the most shocking and inhumane.” Rev. Martin Luther King, Jr

41. Asthma

42.  UWMF has no quality incentives to encourage the health care community to focus upon asthma parameters But consider the following slides (and remember about 1 in 6 patients at NE are black ) :

43. A dult Asthma Prevalence, 2008 Child Asthma Prevalence, 2008 http://www.cdc.gov/asthma/stateprofiles/Asthma_in_WI.pdf

44. Age-adjusted asthma mortality by race, 2007 http://www.cdc.gov/asthma/stateprofiles/Asthma_in_WI.pdf

45. Condition# Patients % Patients % Female % Male Obesity262829.460.439.6 Hyperlipidemia199516.547.552.5 Hypertension191815.953.246.8 Diabetes6615.552.347.7 CAD2221.836.064.0 CHF780.664.135.9 Chronic Kidney Dis2402.063.836.2 Asthma11229.362.737.3 Cancer3042.552.347.7 Chronic back pain150112.462.237.8 Opioid126810.561.338.7 Gender identity disorder 750.652.048.0 Chronic diseases at Northeast 7/1/12-6/30/13

46. At NE, 1122 patients have asthma

47. The % afflicted with asthma within each racial/ethnic grouping

49. They’re mostly in our backyard.

50.  This is an example of the kind of data that you can request of our DFM data warehouse from which could stem future projects ◦ Jennifer Edgoose can help you focus your question to request data from Wen-Jan Tuan, database administrator, at the DFM

51. Next you’ll see data that shows ways to follow the money

56. Relative Value Units for Selected Services, 2008 (HCPCScode)Total Physician Work Practice Expense Professional Liability Insurance Brief Office Visit (99213)1.90.971.90.05 Intermediate Office Visit (99214)2.531.421.060.05 Diagnostic Colonoscopy (45378)5.643.691.650.3 Total Hip Replacement (27130)37.6621.6112.543.51

57. visits per hour EdgooseOrielPattersonRabagoSannerSchragerSchwabavg Jul 10 - Dec 10 2.322.572.492.842.802.722.752.64 Jan 13 - Jun 13 2.242.522.212.502.312.602.632.43 change-0.07-0.05-0.29-0.34-0.48-0.12-0.11-0.21 RVUs per hour EdgooseOrielPattersonRabagoSannerSchragerSchwabavg Jul 10 - Dec 10 3.234.143.214.124.113.844.453.87 Jan 13 - Jun 13 3.704.343.393.934.264.114.534.04 change0.470.200.18-0.190.150.270.090.17  Does NOT include procedure-only visits Notice how NE faculty visits per hour have declined while RVU’s per hour have increased

58.  “What do you NEED to address today?” (limited agenda each visit, comprehensive care via a series of visits or at periodic “physicals”)  Now “ every visit is about everything” ◦ Comprehensive review/action expected at every visit:  Immunizations at every visit  Health maintenance at every visit  Chronic disease metrics (e.g. Diabetes) reviewed at every visit  Complete medication reconciliation ◦ Higher copays – pt’s want to avoid visits ◦ Mychart used instead of visits? ◦ Patient satisfaction higher with comprehensive care each time? ◦ Higher provider satisfaction with fewer longer more comprehensive visits?

60. A long-view of charges at NE (2008 to 2013) see next slide 7/2012-6/2013

61. Type of Service2008-20092012-2013 Charges $% % Inpatient Hospital903,82612792,0708 ED13283220 Home Health11574410 Independent Lab593,0438 Office5,918,666798,726,87991 Outpatient Hospital45,195185,8791 SNF9,76025,315 Assisted Living Fac288 7,472,9759,638,061 When you make comparisons you see that operations evolve. This is something we don’t have now. This shows more care/charges in the office over time.

62. RevenueActual %Rev/ %Exp BudgetVariance Patient fee revenue 4,297,79358%4,392,564(94,771) Hospital revenue 1,491,43120%1,578,269(86,838) State revenue1,538,52521%1,538,526(1) Other revenue81,9501%117,964(36,014) TOTAL REVENUE 7,409,699100%7,627,33(217,624)

63. Actual RevenueBudgeted Revenue

64.  GHC (including GHC MA) per-member-per-month (PMPM) direct to DFM ◦ “converted” to charges/payments for internal analysis  Unity (all) and PPlus (not MA)– PMPM to UW Health ◦ Split between UWH (and Meriter) and UWMF ◦ UWMF $ internally allocated by charges  If we bill less then specialists get more…  Dean is fee-for-service (FFS)  Medicare and Medicaid FFS except GHC-MA

65. 2009/2013“The work we do”“The money we get” “Money/ Work" PayorCharges% of chgsPayments% of paysCollection % GHC 1,228,466 1,519,633 16 891,989 1,075,844 23 24 73 71 Medicaid 1,296,999 1,878,035 17 19 445,153 542,811 11 12 34 29 Medicare 1,298,233 2,185,700 17 23 417,127 688,925 11 15 32 Physician Plus 1,155,628 944,555 15 10 507,223 342,287 13 8 44 36 Unity 876,334 1,475.370 12 15 529,038 828,358 14 18 60 56 Workers Comp 38,412 37,343 1010 35,885 31,610 1111 93 85 All other & self pay 1,578,903 1,597,425 21 17 1,064,809 970,644 27 22 67 61 TOTAL 7,472,975 9,638,061 100 3,891,224 4,480,479 100 52 46

66. 20092013 Look at Physician Plus vs Unity over the years

67. Salaries & Benefits Actual %Rev/ %Exp BudgetVariance Physician1,650,51022%1,684,353(33,834) Resident821,28411%773,96047,334 PA and NPs458,4906%473,660(15,170) Staff1,696,30523%1,861,057(164,752) SUB-TOTAL4,626,60862%4,793,030(166,422)

68. Non- Personnel Actual %Rev/ %Exp BudgetVariance Facilities469,0536%461,5387,515 Supplies389,1325%312,89576,237 Purchased services 111,7181%92,21319,505 Lab118,9682%100,83718,131 Other operating expenses 950,06313%1,044,131(94,068) Assessment755,70510%758,857(3,152) R&D41,6811%44,627(2,946) Sub-total2,836,32038%2,815,09821,222

69. Actual ExpensesBudgeted Expenses

70. ActualBudgetVariance TOTAL REVENUE 7,409,6997,627,323(217,624) TOTAL EXPENSES 7,462,8287,608,128(145,200) NET BALANCE(53,229)19,195(72,424)

71. Clinic% of 99213%99214-5 Belleville50.146.3 Northeast4055.3 Verona65.329 Wingra55.241.6 Fitchburg2670.4 Odana Atrium49.744.6 GO NORTHEAST!

72.  While we want to acknowledge the unique individuals who make up each data point, we wanted to share with you a bird eye’s vantage of Northeast.  Our clinic is growing and has room to continue to improve on many different metrics.  We have reviewed Northeast data through ◦ Demographics ◦ Geo-mapping ◦ Chronic conditions ◦ Finances  We will provide you with some examples of your own personal data.

73. Questions?

75.  Document what you do  Code what you document  Yes… knowing how to code does effect how you document

76. ◦ You ARE doing the work (complex management) ◦ Reflects your specialty’s value  To your health system and group practice partners  To insurers  To patients ◦ Effects payment, $ to pay yourself and…  Pays for your nurse, receptionist, heat, electricity  Higher coding helps pay for services we don’t get paid for (phone calls, mychart, letters…) ◦ Effects “production” expectations – would you rather have many short visits or fewer longer visits each day?  Higher coding justifies a comprehensive care model

77. ◦ In many group practices (e.g. UW Health) with capitated insurance (e.g. Unity and PPlus) if you code low then the subspecialists get a larger slice of the pie ◦ So how much do you want to pay the ***ologists?

78.  Better to document and code appropriately and then deal with discounting the bill than to undercode. ◦ Undercoding is actually fraud in Medicare ◦ … as is overcoding  Programs to forgive/discount bills ◦ UWMF Community Cares ◦ Various prescription drug programs

79. CODEDESCRIPTION Work RVU Total RVU OFFICE VISIT,NEW PATIENT,EVAL AND MANAGEMENT 99202 LEVEL 2 0.93 1.96 99203 LEVEL 3 1.42 2.83 99204 LEVEL 4 2.43 4.39 99205 LEVEL 5 3.17 5.47 OFFICE VISIT,ESTABLISHED PATIENT,EVAL AND MANAGEMENT 99213 LEVEL3 0.97 1.90 99214 LEVEL 4 1.50 2.82 99215 LEVEL 5 2.11 3.81 99381PREVENTIVE MEDICINE, NEW PATIENT,<1 YEAR 1.19 2.45 99382 AGE 1-4 YEARS 1.36 2.69 99383 AGE 5-11 YEARS 1.36 2.69 99384 AGE 12-17 YEARS 1.53 2.93 99385 AGE 18-39 YEARS 1.53 2.93 99386 AGE 40-64 YEARS 1.88 3.42 99387 65 YEARS AND OVER 2.06 3.77 99391PREVENTIVE MEDICINE,ESTABLISHED PT,AGE <1 YR 1.02 2.11 99392 AGE 1-4 YEARS 1.19 2.35 99393 AGE 5-11 YEARS 1.19 2.34 99394 AGE 12-17 YEARS 1.36 2.58 99395 AGE 18-39 YEARS 1.36 2.59 99396 AGE 40-64 YEARS 1.53 2.83 99397 AGE 65 AND OVER 1.71 3.19

80.  In summer 2010 I started a series of “revival meetings” at NE and other clinics to more appropriately code visits at a level reflecting our actual work: ◦ 99214 vs 99213 ◦ Preventive visits with carve outs  How are we doing? (data review)  Simplified (but accurate) rules for coding 99214 and carve outs

81. SannerSchwabRabagoOrielSchraegerJWNMVDPattersonO'Connor Jul 09 - Dec 09 26%35%28% 25%60%14%33%2% Jan 10 - Jun 10 34%47%41%39%25%69%24%31%4% Jul 10 - Dec 10 60%64%58%48%39%66%42%16% Jan 11 - Jun 11 70%66%62%57%35%66%43%47%21% Jul 11 - Dec 11 78%69%51%66%42%62%54%45%28% Jan 12 - Jun 12 78%69%55%65%63%61%48%47%39% Jul 12 - Dec 12 86%80%58% 60%56%57%44%43% Jan 13 - Jun 13 85%75%68%64%60%57%53%33%29% We got religion… 99214 & 99215 coding as % of all established E&M visits Aug 2010 rivival!

82. So did the residents…

83. And the new recruits…

84.  Coding level 99214 (detailed established office visit) simplified ◦ See separate sheet ◦ It may change how you structure progess notes, but not make them longer  Rules for carve outs  Other “high value” codes

85. Example 1 66yo male SUBJECTIVE: Here with several concerns: 1) 1 week of nasal congestion green, cough green mucous. 2 days R ear itch but not painful. L jaw ache. Chills but no fever measured. 2) DM lab f/u: Taking lantus 10u/d since 12/22/10. FBGs checked 3-4x/week and have been 100s-130s. None <80 in 6 mo. ROS: Occas chest pain unchanged in > 1 year. No nausea or diarrhea. No numbness, weakness or tingling all extemeties. Pertinent PSFH:: Wife had URI symptoms resolved last week. Stress echo neg in Dec 2010. No hx sinus surgery. Last abx >6 mo ago. OBJECTIVE: Nurses note and vital signs reviewed Head; normocephalic, atraumatic. ENT- both TM normal without fluid or infection, throat normal without erythema or exudate and frontal sinus tender. Lungs clear to auscultation. Good air movement bilaterally without rales, wheezes, or rhonchi. COR: Regular rate and rhythm. S1 and S2 normal, no murmurs, clicks, gallops or rubs. Recent labs reviewed. ASSESSMENT: Sinus congestion - possible sinusitis given duration and sinus area tenderness DM in control. Lipids in control PLAN: zpack Refilled chronic meds - no change Return in 4 mo for fasting labs (see orders) with F/U visit with me 1-2 weeks later

86. Example 2 75yo male SUBJECTIVE: Here with several issues: 1) HTN. BPs have been good at home (100-130/60s). 2) DM. BGs at home checks TID, fastings 93-140s, preprandials 80-170. 3) Lipids. Taking lovastatin 40 only QOD Pertinent PSFH: Lives alone. Retired. Son comes to visit approx 3x/wk, also has a friend who visits. Pt does own grocery shopping, drives himself. Wakes at 1-2am every day (used to this from lifelong work routine). Known CAD. ROS: No CP, diarrhea, nausea, recent fevers. Mild nasal congestion. No dysuria. Stream good. Nocturia x 1 stable. No lower extremity numbness or pain. No myalgias or weakness. OBJECTIVE: Vital signs and nurse's note reviewed. Chest: Clear; no wheezes or rales. Cardiac: Regular rate and rhythm. S1 and S2 normal; no murmurs, clicks, gallops or rubs. Extremities: 2+edema L, 1+ R ASSESSMENT: DM in good control LDL near goal (<80) at 88. HTN in control PLAN: No change meds He may be getting set up with VA to get a better deal on medication costs Return to me in 6 mo for fasting labs (see orders) with F/U visit with me 1-2 weeks later

87. Example 3 36 yo male SUBJECTIVE: Here with new problem: Dentist noted increasing pigmentation of gingiva over last year and wondered if pt has hemachromatosis. Patient has noted darkening gingival and buccal mucosal pigment, bilateral symrtric, blotchy distribution, slowly progressing over few years not associated with pain or bleeding. No tooth pain or loosening. Had sores inside lower lip early this mo - now resolved. ROS: No fevers, cough, congestion, sore throat. No nausea/diarrhea. No abdominal pain. Wt stable. Denies arthralgias, joint swelling, myalgias. Pertinent PSFH: No recent foreign travel (last was June 2009 to Mali). No family history arthritis or mouth sores. OBJECTIVE: Vital signs and nurse's note reviewed. Diffuse variably dark pigmentation buccal mucosa and gingiva. No other skin rash or lesions. Abdomen: Normal BS. No HSM/masses. Nontender. ASSESSMENT: Hyperpigmented oral mucosa new per pt and dentist. No other signs hemachromatosis or connective tissue disease. PLAN: Check labs (see orders) - letter with results. If labs normal no further f/u needed at this point. Due for CPE April

88.  If you see a patient for a preventive visit AND you deal with one or more problems you should bill a “carve out” E&M code  Preventive visits include ”physicals”, WWE, WCC.  A carve out is billed using exactly the same rules as a regular E&M visit ◦ E.g. if the patient has 3 stable problems (e.g. DM, DJD, depression) and you refill meds = 99214 carve out  EPIC example

89. RBRVS 2010 High value codes… 2010 Madison charge Work RVU Total RVU example of a carve out: 99397 AGE 65 AND OVER $ 2381.713.19 99214 LEVEL 4 $ 1941.502.82 3.216.01 Internal UW Health "credit for work done"3.21RVUs if insurance ONLY pays for prevention visits then pt gets bill for $ - if insurance ONLY pays for E&M (illness) visits then pt gets bill for $ 44 Transition Care Management (TCM) codes implemented 1/1/2013 99495 (moderate complexity):2.114.82 99496 (high complexity): 3.056.79

90.  Thus we rarely have a 1:4 staffer:resident ratio  The quick “tag in” interruption is welcomed  Tell me what you want me to say… and we can discuss more later  Other visit types need staffer to lay eyes on pt: ◦ R1s in 1 st 6 months ◦ Procedures ◦ Preops billed as consults

92.  RRC requires 1650 visits over 3 years with minimum 150 in first year  The class that graduated June 2013 (Fox, Schaefer, Marty, Dhanoa) averaged total 1709 visits

96.  Clinic level data ◦ Avatar % top box ◦ Diabetes registry performance ◦ Immunizations ◦ Pay for performance  Individual provider data ◦ Clinician profile ◦ Opioid registry ◦ Diabetes registry ◦ Avatar data