Pay For Performance: The Benefits of Doing the Right Thing

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Pay For PerformanceThe Benefits of Doing the
Right Thing

• Hector Flores, M.D.
• Medical Director
• Family Care Specialists Medical GroupLos Angeles,
  CA

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Health Care Mega-trends

• Cost and Quality of Health Care
• Health care expenditures 1.9 Trillion in 2005
• Quality chasm in health care
• Population Diversity
• Health status disparities
• Language and literacy barriers
• Workforce Diversity
• Medical Education and IT
• The Bridge to Quality
• Workforce competencies

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Health Care Costs and Quality

• 1.9 Trillion in Y2005
• Illness-oriented, Specialty-driven, High
  Tech-dependent system of care
• 45 Million Americans Uninsured
• 40 Million Underinsured
• Patient Dissatisfaction
• Health Status Disparities

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The National Report Card, 2000

• Nearly 100,000 deaths occur in U.S. hospitals
  each year as a result of medical errors
• Americans with chronic disease receive
  evidence-based interventions only about 50 of
  the time
• 180,000 unexpected deaths each year are (at least
  partially) attributable to the actions of
  physicians

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The Measurable DisparitiesCenters for Disease
Control (CDC) 1996

• Cancer
• Cardio-Vascular Disease
• Diabetes
• HIV/AIDS
• Immunization Rates
• Infant Mortality

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The California Medical Practice Environment

• Population Totals 33.5 Million
• 27 Million with Insurance or Sponsored Program
  (e.g., Medicare, Medicaid, Healthy Families)
• 90 of covered patients are enrolled in managed
  care (e.g., HMO, POS, PPO)
• 7 Health Plans control 80 of covered patients
• 6.5 Million are uninsured

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Cycle of Life and Social Policy

• Conception
• Maturity Birth
• Adult Childhood
• Adolescence

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The Urban ExperienceCycle of Life and Social
Policy

• Conception
• Maturity Birth
• Adult Childhood
• Adolescence

90 covered
95 covered
80 covered
70 covered
70 covered
75 covered
Source Kaiser Family Foundation, 2000
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Access

• Financial/Coverage Issues
• Geographic
• Logistical
• Managed Care
• Language and Literacy
• Cultural
• Legal/Regulatory
• Immigration

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Culturally Responsive CareGood Medicine, Good
Business
Behavior
Culture
Environment
Biology
AdaptedHealthy People 2010
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5 Conditions 50 of Chronic Care Costs (AHRQ
1994)

• Asthma
• Diabetes
• Heart Disease
• Hypertension
• Mood Disorders

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Shortage Area Practice ManagementConstructing
the Right Vehicle(s)

• Understand the Big Picture
• Develop a Mission and Vision
• Follow the Money Where is the 1.9 Trillion?
• Team delivery of care
• Measure Performance and physician profiles
• Provide (and align) the right incentives

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The Family Care Specialists Medical Group

• Progress Report

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FCS Medical Group
Family Care Specialists MG

• Four Offices
• 120 Employees
• 95 Women
• 80 Latino
• 10 White
• 5 African-American
• 5 A/PI

• Medical Practice
• 40,000 Patients
• 70 Managed Care
• ½ Medicaid
• 30 FFS
• ½ Medicare, PPO
• ¼ Medicaid
• ¼ Uninsured

• 25 Clinicians
• 72 Latino
• 20 White
• 4 Asian/Pacific Islander
• 4 African-American

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FCS Independent Practice Association
Family Care Specialists IPA

• HMO Contracts
• 7 major HMOs
• 30,000 patients
• Medicare, Medicaid, SCHIP and SSPs

• Network
• 230 specialists
• 90 Board-Certified
• Ortho, ENT, Eye, Allergy, Endocrine, Rheum,
  Plastic Surgery, Derm in short supply

• HMO Relationships
• Risk-Sharing
• Pay-for-Performance
• In-Kind Support

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The New Primary CareTeam Medicine

• Team delivery of care clinicians, psychologists,
  health educators, and case managers
• Family-Centered Care
• Reach patients where they live, work, play, go to
  school, practice their faith, etc.
• Comprehensive High Touch-to-High Tech Service
• Achieve a therapeutic alliance among equals

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Team Strategies Continued

• Engage remote interpretation services provider
  (e.g., Pacific Interpreters, Inc.)
• Redefine the Primary Care Team to include
  Promotores de Salud (Community Health Workers)
  and other patient advocates
• Make the business case for Culturally
  Responsive care and Promotores

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Challenges in Implementing P4P Quality
Initiatives, 2001- 2005

• Encounter data (E/M code CPT ICDM-9 code) is
  coupled with
• Laboratory Claims (Pap smears, STD, LDL
  Cholesterol, A1c)
• Radiology Claims (Mammograms)
• Pharmacy Claims (Asthma Rx, Beta Blocker)
• CPT is used to track IZZ, Retinal screen

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FCS MG Raising the Bar(The California Endowment)
Top Group in California TM Tele
-ophthalmology Retinal Screen Project, 2001
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CB DMMP Raising the Bar(The California
Endowment)

• Patient Clinical Outcomes
• Lowered the average HbA1c by 10 (8.7 ? 7.8)
• Lowered the average HbA1c by 17 in group
  appointment cohort (9.0 ? 7.5)
• Increased Documented DM Health Education from 43
  to 93 and 2X patient knowledge
• Adverse effect on Body Mass Index (BMI) / Weight
  due to sulfonylureas

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Raising the Bar Diabetes ABC Outcomes(Percent
of Pop. Achieving Targets)
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Patient Experience

• Patient empowerment through
• 1) Self
• 2) external locus of control, and
• 3) By the Clinician and the new health
  system
• Clinician availability and accessibility
• 1) Open Access and Telephonic 24/7
• 2) Group Appointments
• 3) Health Education
• 4) The new extenders

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Consumer Assessment Survey(CAS) CCHRI
FCS Top Group, CAS 2005
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Yeah, right! Lets get real!

• Time
• Productivity
• Reimbursement
• Hassle Factor
• Patients Personal Responsibility

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Youre right!

• Time
• Productivity
• Reimbursement
• Hassle Factor
• Personal Responsibility

• Open Access, Group Appointments, Integrated
  Practice
• P4P, HCCs, coding
• P4P, HCCs, contract terms
• Stratify Care and use Dx Registries EMR
• Empower patients

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Institute of Medicine (iom.edu)

• Ensure patient safety To Err is Human (IOM 1999)
• Promote best practices The Quality Chasm (IOM
  2001)
• Reduce or eliminate disparities Unequal
  Treatment (IOM 2002)

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Institute of Medicine (iom.edu)

• Health Professions Education The Bridge to
  Quality (2003)
• Health Literacy A Prescription to End Confusion
  (2004)
• Workforce Diversity In the Nations Compelling
  Interest (2004)

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To dream is to create the future-- Victor Hugo