The Michigan Primary Care Consortium and its Initiatives

1
The Michigan Primary Care Consortium and its
Initiatives

• March 2009

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Presentation Outline

• Origin of the MI Primary Care Consortium
• The MPCC Organization
• Current Priorities and Plans of the MPCC
• The Patient-Centered Medical Home
• Improving Performance in Practice (IPIP)
  Program
• Vision for a Healthy Michigan

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Broken Health Care System

• Rising costs of health care
• Rising rates of uninsured, underinsured
• Flat or worsening health status indicators
• Significant health disparities
• Unimpressive quality indicators
• Rising dissatisfaction
• Aging population greater demands on health
  care system

4
Primary Care System in Crisis

• Fragmented, uncoordinated patient care
• Inconsistent delivery of evidence-based care,
  especially preventive and chronic care
• Misaligned reimbursement system
• Increasing expectations/demands by payers,
  purchasers
• Shrinking primary care workforce (i.e.,
  physicians, mid-level providers, others)
• Survival of primary care is questioned

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Why Is Primary Care Important?
Better health outcomes Lower costs Greater equity
in health
Source Barbara Starfield, October 2006
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MI Primary Care Consortium

• BACKGROUND
• In 2005-06, 134 Michigan professionals developed
  strategic recommendations to resolve key primary
  care system barriers
• Five barriers to effective primary care
• Under-use of community resources
• Under-use of patient registries, other HIT
• Under-use of evidence-based guidelines
• Inappropriate reimbursement system
• Practices not well designed to deliver chronic
  care

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MI Primary Care Consortium

• MISSION
• The Michigan Primary Care Consortium is a
  collaborative public/private partnership created
  to improve the system of delivery of prevention
  and chronic disease services and other conditions
  in primary care settings throughout the state, by
  aligning existing quality improvement
  initiatives, addressing gaps, and engaging in
  problem-solving strategies to assure a
  patient-centered medical home for everyone.
• 2008

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Michigan Primary Care Consortium

• The Organization

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MPCC Membership

• Professional Trade Associations
• Insurers and Payers
• Health Systems
• Businesses
• Regional QI Initiatives
• Public Health Organizations
• Consumer Organizations
• Others

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MPCC MembershipDiverse Stakeholders

• Professional/Trade Associations
• American College of Physicians, MI Chapter
• MI Academy of Family Physicians
• MI Academy of Physician Assistants
• MI Association for Local Public Health
• MI Association of Health Plans
• MI Association of Osteopathic Family Physicians
• MI Chapter, American Academy of Pediatrics
• MI Council of Nurse Practitioners
• MI Health and Hospital Association

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MPCC MembershipDiverse Stakeholders

• Professional/Trade Associations (continued)
• MI Osteopathic Association
• MI Pharmacists Association
• MI Primary Care Association
• MI State Medical Society
• Insurers
• Aetna
• Blue Cross Blue Shield of Michigan
• Medicaid

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MPCC MembershipDiverse Stakeholders

• Health Systems
• Genesys Health System
• Henry Ford Health System
• Karmanos Cancer Institute of Wayne State
  University
• University of Michigan Health System
• Consumer Organizations
• MI Consumer Health Coalition
• MI Council for Maternal and Child Health

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MPCC MembershipDiverse Stakeholders

• Regional Health Initiatives
• Alliance for Health, Western MI
• Detroit/Wayne County Health Authority
• Greater Detroit Area Health Council
• School Community Health Alliance
• Public Health Organizations
• Detroit Dept of Health and Wellness Promotion
• MI Department of Community Health

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MPCC MembershipDiverse Stakeholders

• Businesses
• Automotive Industry Action Group
• Chrysler LLC
• Ford Motor Co.
• General Motors, Inc.
• GlaxoSmithKline Pharmaceuticals, Inc.
• Merck Company, Inc.
• Pfizer, Inc.
• Pyper Products, Inc.

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MPCC MembershipDiverse Stakeholders

• Others
• Gratiot Family Practice
• Integrated Health Associates
• Medical Network One
• MI Health Council
• MI Peer Review Organization
• MI State University Institute for Healthcare
  Studies

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MPCC Committees

• Steering and Executive Chair, Janet Olszewski,
  MDCH
• Priorities Chair, Kim Sibilsky, MPCA
• Communications Chair, Rebecca Blake, MSMS
• Governance Chair, Dennis Paradis, MOA
• Funding Chair, Lody Zwarensteyn, AFH
• Strategic Planning Chair, Larry Wagenknecht, MPA

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White Paper Work Groups

• Primary Care in Crisis Lead Kevin Piggott, MD
  and Dennis Paradis, MOA
• Consumer Engagement Lead Stacey Hettiger,
  MSMS
• Rebuilding Primary Care Workforce Teresa
  Wehrwein, MSN, PhD-MSU and Robert Burack, MD- WSU
• Practice Transformation and Payment Reform
  Lead Joseph Fortuna, MD-AIAG

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2009-2010 MPCC Action Groups

• Consumer Engagement and Empowerment Lead
  Stacey Hettiger, MSMS
• Rebuilding the Primary Care Workforce Lead
  Robert Yellan, MPRO
• Practice Transformation Lead Ernie Yoder, MD
  (SJHS) and Larry Abramson, DO, POMC
• Payment Reform Lead TBD

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Other MPCC Work Groups

• Multi-Payer Group working on MI consensus on PCMH
  definition, metrics, recognition, payment
• Task Group drafting PCMH Definition Lead
• Self-Management, Trissa Torres, MD, Genesys
• Provider Language, Kim Sibilsky, MPCA
• Payment Language, Paul Ponstein, MD, Priority
  Health
• Task Group drafting PCMH Metrics Lead
• Ernie Yoder, MD, St. John Health System
• Task Group working on collaboration between MPCC
  and
• the MI Health Information Technology Commission
• Primary Care Summit Planning Group

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Michigan Primary Care Consortium

• Priorities for 2009-2010

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Michigan Primary Care Consortiums Priority
Projects for 2009/2010

• Increase transparency for consumers regarding
  health care quality and cost, improve self-
  management and empowerment, and increase health
  literacy.
• Address primary care workforce shortages.
• Implement transformation of primary care
  practices to create Patient-Centered Medical
  Homes that provide efficient and effective
  preventive and chronic care management.
• Work toward payment reform concurrent with
  transformation.
• Support and evaluate the MPCCs Improving
  Performance in Practice (IPIP) program.

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MPCC Recommendations to its Action Group

• 1. Consumer Empowerment focus on
• Transparency
• Self Management
• Health Literacy

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CONSUMER ENGAGEMENT Transparency

• The MPCC should support and encourage efforts to
  provide transparent information on health care
  costs, quality of services, and what insurance
  covers.
• The MPCC should promote that payers provide
  eligibility and coverage information at
  point-of-service through a smart card or a web
  portal in order to reduce administrative logjams
  and paperwork, improve transparency, and help
  prevent fraud and abuse. (Information minimally
  should include the patients deductibles and
  co-pays, what their insurance policies cover, and
  what portion of the cost may be borne by the
  patient).

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CONSUMER ENGAGEMENT Self-Management

• The MPCC should urge medical schools and other
  health care professional training programs to
  develop and utilize educational programs that
  include patient self-management, motivational
  interviewing, and patient-centered primary health
  care in their curricula.
• The MPCC should evaluate methods to engage
  patients in self-management (e.g., PAM,
  Motivational Interviewing), assess their
  feasibility for use by diverse primary care
  practices in Michigan, and communicate results to
  MI practices statewide.

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CONSUMER ENGAGEMENT Health Literacy

• The MPCC should encourage updates to the
  statewide Michigan Model for Comprehensive
  School Health Education to improve health
  literacy of Michigan youth (K-12).

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MPCC Recommendations to its Action Group

• 2. Primary Care Workforce focus on
• State Plan
• Incentives for Expansion
• Financial Help for Students
• Mentoring New Practitioners

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PRIMARY CARE WORKFORCE State Plan

• The MPCC should support development of a State
  Plan based on analysis of workforce data to
  address the gap between projected workforce needs
  and the projected number of primary care workers
  (all disciplines) who will be employed in the
  State, paying special attention to geographically
  and economically underserved areas.

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PRIMARY CARE WORKFORCE Incentives for Expansion

• The MPCC should advocate for granting State
  funding preference to health professional schools
  that meet or exceed target numbers of graduating
  students in designated primary care specialties.
• The MPCC should encourage endowments and capital
  campaigns to assist in expanding the numbers of
  medical, nurse practitioner and physician
  assistant students recruited from and trained in
  Michigan who choose to become primary care
  providers in Michigan.

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PRIMARY CARE WORKFORCE Financial Aid to Students

• The MPCC should advocate for academic
  institutions giving financial aid preference,
  including loans and scholarships, to medical
  residents and NP and PA students that commit to
  practice in primary care settings in Michigan
  with bonuses to those who choose to practice in
  rural and other underserved areas.
• The MPCC should advocate for the expansion and
  wide communication of loan forgiveness programs
  and other incentives to professionals who agree
  to provide primary care services in designated
  underserved areas in Michigan.

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PRIMARY CARE WORKFORCE Mentoring New
Practitioners

• The MPCC should encourage expansion of programs
  to reimburse providers who assume primary care
  mentoring roles.

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MPCC Recommendations to its Action Group

• 3. Primary Care Transformation focus on
• Convener Role for MPCC
• Practice Transformation
• Health Information Technology

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PRIMARY CARE TRANSFORMATION Convener Role

• The MPCC should assume the role of umbrella
  organization and champion for statewide primary
  care transformation and implementation of PCMH,
  including
• Convening stakeholders with interest in promoting
  integration of the principles of the PCMH into
  Michigan primary care practices
• Developing a clear definition of the PCMH
• Identifying meaningful metrics that can
  distinguish the PCMH from other practices

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PRIMARY CARE TRANSFORMATION Convener Role
(continued)

• Identifying how PCMH practices will be recognized
  in Michigan
• Promoting payment models that adequately support
  creation and sustainability of PCMH
• Developing action plans for the MPCCs priorities
  that MPCC members can reasonably expect to
  execute
• Conducting ongoing evaluation to identify which
  modifications increase value and should be
  promoted as greater experience with PCMH evolves

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PRIMARY CARE TRANSFORMATIONPractice
Transformation

• The MPCC should support and promote assessment
  and analysis of practice culture and process flow
  in Michigan practices by qualified professionals
  skilled in the use of validated quality
  management systems and process-improvement tools.
  Objectives of process are
• Improvements in quality and patient safety
• Improvements in patient care coordination
• Reductions in waste
• Improvements in patient, staff and provider
  satisfaction
• Adoption and effective use of all relevant
  modalities of health information technology

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PRIMARY CARE TRANSFORMATIONHealth Information
Technology

• The MPCC should promote the effective use of
  patient/population registries and other useful
  health information technology in primary care
  practices.

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MPCC Recommendations to its Action Group

• 4. Payment Reform focus on
• Payment Policies for PCMH
• Practice Infrastructure Support

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PAYMENT REFORM Payment Policies - PCMH

• The MPCC should review payment policies tested in
  Michigan and elsewhere and develop
  recommendations for change in Michigan payment
  policies that support the PCMH (e.g., increased
  direct payments through fee for service and
  primary care capitation models supplemental
  incentives and/or payment models to sustain PCMH
  including, but not limited to, bundled
  arrangements and risk models).

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PAYMENT REFORMPractice Infrastructure Support

• The MPCC should encourage all potential private
  and public funding sources to invest in
  practice-level infrastructure for the PCMH.
  Initial direct funding is needed for
• Practice redesign
• Information technology
• Additional personnel to provide team care
• Education and training for all providers to
  create and sustain a PCMH

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PAYMENT REFORMPractice Infrastructure Support
(continued)

• The MPCC should advocate for financial
  arrangements that enable primary care practices
  to purchase and to staff important health
  information infrastructure including
• Population-Patient Registries
• Electronic Medical Records
• E-prescribing
• Web portals for patients and providers

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World Health Org Acute vs Chronic Care

• Health care systems throughout the world
  evolved around the concept of infectious disease,
  and they perform best when addressing patients
  episodic and urgent concerns. However, the acute
  care paradigm is no longer adequate for the
  changing health problems in todays world.
• Both high- and low-income countries spend
  billions of dollars on unnecessary hospital
  admissions, expensive technologies, and the
  collection of useless clinical information.
• As long as the acute care model dominates health
  care systems, health care expenditures will
  continue to escalate, but improvements in the
  populations health status will not.
• World Health Organization. Innovative care for
  chronic conditions building blocks for action
  global report. (Geneva WHO 2002.)

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Outcomes
Improved Outcomes
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The Patient-Centered Medical Home (PCMH)

• What is this?
• Why has MPCC identified PCMH as THE
  SOLUTION to the Primary Care Crisis?

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Patient-Centered Medical Home

• PCMH is an approach to providing comprehensive
  primary care for children, youth, adults and
  seniors based on the Chronic Care Model
• PCMH is a health care setting that facilitates
  partnerships between patients and their personal
  physicians and, when appropriate, the patients
  family or caregivers
• A PCMH makes effective use of community resources
  and supports to assist patients and families
  become activated and achieve their health goals

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PCMH Practices

• Organize the delivery of team-based care for all
  patients, consistent with the Chronic Care Model
• Use evidence-based medicine and clinical decision
  support tools
• Use secure health information technology to
  promote quality and safety
• Coordinate care in partnership with patients and
  families
• Provide enhanced and convenient access to care
• Identify and measure key quality indicators
• Participate in programs that provide feedback to
  practices on performance and accept
  accountability for process improvement and for
  health outcomes

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PCMH IS AN OPPORTUNITY FOR

• Improving health of patients and their
  satisfaction with their care
• Improving purchaser and payer satisfaction with
  outcomes of care
• Improving reimbursement for primary care
• Improving physician satisfaction with their
  choice to specialize in primary care
• Improving recruitment of medical residents, NPs
  and PAs into primary care
• Slowing the rise in health care spending

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2007 Joint Principles for PCMH

• Personal physician
• Physician-directed medical practice
• Whole person orientation
• Care is coordinated and/or integrated
• Quality and safety
• Enhanced access to care
• Payment that supports a PCMH

• Jointly approved by
• American Academy of Family Physicians
• American Academy of Pediatrics
• American College of Physicians
• American Osteopathic Association

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PCMH Definition in Michigan

• Same as Joint Principles with footnotes to
  further define
• Patient-Centered
• Personal Physician
• Quality and Safety
• Payment

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Patient-Centered MI Footnote

• This model of care recognizes the central role of
  patients and when appropriate their families,
  as stewards of their own health. In the
  Patient-Centered Medical Home, the team of health
  professionals guides and supports patients and
  their families to help them achieve their own
  health and wellness goals.

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Personal Physician - MI Footnote

• A personal physician may be of any specialty but
  to be considered a Patient-Centered Medical Home,
  the practice must meet all Patient-Centered
  Medical Home requirements. It shall be recognized
  that there may be situations in which a physician
  is not on-site and the patients relationship is
  with a certified nurse practitioner (NP) or
  physician assistant (PA) who provides the
  principal or predominant source of care for a
  patient. 

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Personal Physician (continued)

• In those instances, the NP or PA provider, in
  collaboration with a physician, may perform the
  responsibilities of first contact, continuous and
  comprehensive care if he or she is otherwise
  qualified by education, training, or experience
  to perform the selected acts, tasks, or functions
  necessary where the acts, tasks, or functions
  fall within the certified nurse practitioners or
  the physician assistant's scope of practice.

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Quality and Safety MI Footnote

• Clinical outcomes, safety, resource utilization
  and clinical and administrative efficiency are
  consistent with Best Practices.

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Payment MI Footnote

• Transformational change in healthcare financial
  incentives should occur simultaneously with,
  proportionally to, and in alignment with
  Patient-Centered Medical Home adoption.

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NCQA Practice Connections Patient Centered
Medical Home Certification
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BCBSMs Physician Group Incentive Program (PGIP)

• For Enhanced Payments as a Patient-Centered
  Medical Home
• Performance reporting
• Patient-Provider agreement
• Extended access
• Individual care management
• Test tracking and follow-up
• Coordination of care
• Preventive services
• Specialist referral process
• Linkage to community services
• Self-management support
• Patient registry
• Patient portal

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Systemness as a Community Property

• Community entity provides
• Leadership and integration via coalition
• Performance measurement
• Financial incentives
• Models of change
• Programs for learning and dissemination
• Shared infrastructure
• Guidelines
• IT software and support
• Care management
• Consumer education

Health Systems in a Community
Widespread Practice Change
Improved Community Outcomes
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Michigan Primary Care Consortium

• Improving Performance in Practice (IPIP) Program

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Improving Performance in Practice Program

• American Board of Medical Specialties
• Created IPIP to support new physician
  recertification requirements
• 7 states were provided with program materials and
  support Michigan was 3rd state selected
• Funded by RWJF, grant provides 2 years of seed
  money to states, with states adding additional
  funds

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Improving Performance in Practice Program in
Michigan

• Objective
• Improve chronic disease management in primary
  care practices
• Methodology
• Chronic disease Learning Collaborative
• - 2-day learning sessions each quarter
• - Monthly phone calls
• - Focus Adult Diabetes and/or Pediatric Asthma
• On-site coaching from volunteers who are
  industry-trained process improvement engineers

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Key IPIP Interventions

• Use a Patient Registry
• Initiate Team Care
• Implement Planned Visits
• Provide Self-Management Support
• Work toward Creation of a PCMH

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IPIP Practice Sites, 2008-09
N22
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Improving Performance in Practice

• For more information about IPIP
• http//ipip.aiag.org
• Rose Steiner rsteiner_at_aiag.org 
• State Director [phone]

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RECOMMENDATIONS for Action by MPCC and all
Stakeholders

• Help create informed, activated patients and
  families by supporting proactive teams in every
  primary care practice and in all community health
  settings
• Promote IPIP Program to primary care practices as
  a transformation opportunity
• Identify community resources that can help small
  practices create a PCMH for their patients
• Create PCMHs in all primary care settings in
  public sector
• Provide leadership in communities to spread PCMH
  via Wagners community model
• Encourage PCMH practices to advocate for
  community supports healthy public policy,
  community environments that encourage healthy
  lifestyles, community actions directed at social
  determinants of health

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VISION FOR A HEALTHY MICHIGAN
Michigan Primary Care Consortium A
Patient-Centered Medical Home for All
  Removal of System Barriers to enable
Use of Community Resources Payment Reform
that supports PCMH Use of Evidence-based
Clinical Guidelines Redesigned Practices for
Efficient, Effective Use of Patient
Registries other Info Technology Preventive
and Chronic Care
Michigan Steps Up! Move More, Eat Better,
Dont Smoke 20-year Statewide Social Change
Movement State Community Coalitions for
Environment Policy Change Toward
Wellness Roles for Business, Schools, Health
Care, Faith Based Community Organizations PH
Fellowship Program for Workforce
Replacement Minority Health Resource
Consultation Center Informing, Empowering
Citizens Modeling Public Health Improvement
for Citizens
Michigan First Proposal to CMS Access
to Insurance for All Private Market
Products Medicaid 1115 Waiver
Subsidized Cost for those lt200
poverty Unsubsidized Resource for those
gt200 Poverty Coverage for Prevention, Primary
Care, Pharmacy, Mental Health, Limited
Hospital Services Encouraging Personal
Responsibility Monitoring Safety, Quality
Informing Citizens Modeling Prevention
Benefits for all Health Insurers
Healthy, Empowered Citizens   Healthy
Communities   Healthy Michigan Economy
State Local Public Health Programs Public
Health For Michigan, For You Immunizations
Smoke-Free Policies WIC Stroke
Prev/Management Health Promotion Blood
Pressure Control School Health Heart Disease
Prevention Obesity Prevention Cancer
Screening Asthma Control Diabetes Prev
Control Osteoporosis Prev. Kidney Disease
Prev. Fall Prevention Health Disparity
Reduction Injury Prevention End of
Life/Palliative Care Suicide Prevention Etc.
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Michigan Primary Care Consortium

• For more information about the MPCC
• www.MIPCC.org
• PCCstaff_at_MIPCC.org
• [phone]