Attributing Patients to Primary Care Physicians in Teaching Practices

Bruce Soloway, M.D.

Vice Chair Department of Family and Social Medicine NYS HMH Site Visit November 12, 2013

What is a “Medical Home”?

  The site that    provides most of a patient’s primary care serves as a patient’s first point of care for most problems is ultimately responsible for a patient’s chronic and preventive care Principle: Every patient should have one and only one “medical home”

What is a “Primary Care Provider”?

  Within a “medical home”, the provider who is:   the first source of care for each patient ultimately responsible for each patient’s chronic and preventive care Principle: Every patient should have one and only one PCP

What is a “Site Panel”?

   The list of patients for whom each site serves as the medical home The source of demand for appointments and other services for the site The basis for    accountability for patient care and outcomes continuity of care patient satisfaction

What is a “Provider Panel”?

  Within a “medical home”,   the list of patients for whom each provider serves as PCP the source of demand for appointments and other services for each provider The basis for    accountability for patient care and outcomes continuity of care patient satisfaction

Why are provider panels important?

 Within a “medical home”, provider panels  Allow individual feedback to providers aggregate demographics, processes and outcomes for the patients they treat on   Help to define and equitably divide the work of the practice , improving access, efficiency and continuity Allow rational transfer of patients another when a provider enters or leaves a practice from one PCP to

The challenge of teaching practices

   Residents as PCPs  Residents need continuity panels for their training   Continuity, but what level of accountability?

Not recognized by insurers Multiple part-time providers  Frequent cross-coverage Frequent resident turnover  Need for systematic, rational reassignment

Stabilizing teaching practices in Family Medicine   Attending-resident teams    1 Attending (Team Leader) + 3 residents Team Leader supervises and is accountable for residents’ patient care Basis for cross-coverage and provider transitions Consistent clinic sessions each week  Inpatient rotations built around ongoing outpatient responsibilities  Basis for resident continuity and panel-building

How big should a panel be?

  FHC 12,780 unique patients / 9.5 FTE = 1345 patients per FTE x 2.77 visits/yr/pt = 3740 visits per yr per FTE WB 8814 unique patients / 6.1 FTE = 1452 patients per FTE x 2.59 visits/yr/pt = 3724 visits per year per FTE

Ideal panel size by provider

 Assuming 1400 patients per FTE: FTE Panel Size PGY-1 PGY-2 PGY-3 Attendings 0.035

0.15

0.23

0.3

0.4

0.5

0.6

0.7

49 210 322 420 560 700 840 980 Based on ACGME (FM) expected visits/year

Defining terms



EMR PCP

 The provider identified for each patient in the “PCP” field in the EMR  Should be controlled by clinicians based on real primary-care relationships negotiated with patients, but…   Clinical and administrative personnel can change this field Often inaccurate due to provider turnover, unrecorded patient migration, administrative good intentions…

Defining terms

 Visit-based PCP  The active provider seen most often by each patient in the last 18 months   Or, if there is a tie, the active provider seen most recently in the last 18 months Some patients are “orphan patients”  No visit-based PCP, no active EMR PCP  During the past 18 months, have only seen providers who have since left the practice

Panel Reports

  Available on demand for each practice Patient lists for each provider:  Band 1 – Patients for whom the provider is both the EMR PCP and the Visit-Based PCP   Band 2 – Patients for whom the provider is the EMR PCP but not the Visit-Based PCP Band 3 – Patients for whom the provider is the Visit-Based PCP but not the EMR PCP

Who is really the PCP?

 The EMR PCP is regarded as the provider responsible for the care of the patient    Clear, unique assignment across the enterprise Easily queried for generation of reports and registries Requires frequent updating to remain meaningful

Patient reassignment algorithm

  An automated process available to all practices Reassignments are based on:   Roster of active providers in practice  Including FTE, panel status (open vs. closed) Patient-level data   Current EMR PCP  May reflect long-standing relationship (or may not) Recent visit history  Rational reassignment of “orphan” patients

Band 1 Algorithm for PCP Reassignment

E No Change

Provider

= CareCast PCP = Visit-Based PCP

Band 2

Provider

= CareCast PCP Patients with an active Visit-Based PCP also appear in that provider's Band 3 Visits to CareCast PCP in past 18 months?

No Patient has Visit Based PCP?

Yes Yes F No No Change (Patient stays with CareCast PCP) G No CareCast PCP chronically overpaneled?

Yes Visit-Based PCP Chronically Overpaneled?

No Continuity (>1 visit and > half of all visits) with Visit-Based PCP?

Yes No H Yes

Reassign

to Visit Based PCP (4)

Band 3

Provider

= Visit-Based PCP Patients with an active CareCast PCP also appear in that provider's Band 2 With an active CareCast PCP?

No Visit-Based PCP is overpaneled? Yes Continuity (>1 visit and > half of all visits) with Visit-Based PCP?

Yes Handled as part of Band 2 (F,G) No

Reassign

to Visit Based PCP (5) I Yes No

Reassign

to underpaneled providers (by team or at random) (6) April 2010

Orphans Reassign

to underpaneled providers (by team or at random) (7) Patients with no active CareCast PCP or active Visit-Based PCP (All providers who have treated patient in past 18 months have left the practice)

Band 1 Algorithm for PCP Reassignment

E No Change

Provider

= CareCast PCP = Visit-Based PCP

Band 2

Provider

= CareCast PCP Patients with an active Visit-Based PCP also appear in that provider's Band 3 Visits to CareCast PCP in past 18 months?

No Patient has Visit Based PCP?

Yes Yes F No No Change (Patient stays with CareCast PCP) G

Band 1 Band 3

CareCast PCP chronically overpaneled?

No Yes Visit-Based PCP Chronically Overpaneled?

No Continuity (>1 visit and > half of all visits) with Visit-Based PCP?

No H Yes

Reassign

to Visit Based PCP (4)

Algorithm for PCP Reassignment

Yes E No Change

Provider

= Visit-Based PCP Patients with an active CareCast PCP also appear in that provider's Band 2

Provider

= CareCast PCP = Visit-Based PCP With an active CareCast PCP?

Band 2

Yes Visits to months?

Yes F (Patient stays with CareCast PCP) April 2010 G No No Visit-Based PCP is overpaneled?

Provider

Yes Continuity (>1 visit and > half of all visits) with that provider's Band 3 No I

Reassign

to Visit Yes CareCast PCP chronically overpaneled?

Yes No

Reassign

to underpaneled providers (by team or at random) (6) No No No

Reassign

to underpaneled (7) Visit-Based PCP?

Yes No active Visit-Based PCP Based PCP (4)

Band 3

Provider

= Visit-Based PCP Patients with an active CareCast PCP also appear in that provider's Band 2 With an active CareCast PCP?

No Visit-Based PCP is overpaneled? Yes Continuity (>1 visit and > half of all visits) with Visit-Based PCP?

Yes Handled as part of Band 2 (F,G) No

Reassign

to Visit Based PCP (5) I Yes No

Reassign

to underpaneled providers (by team or at random) (6) April 2010

Orphans Reassign

to underpaneled providers (by team or at random) (7) Patients with no active CareCast PCP or active Visit-Based PCP (All providers who have treated patient in past 18 months have left the practice)

Patient reassignment algorithm

   For the past four years, the Department of Family Medicine has updated PCP assignments for its teaching practices on a quarterly basis.

With each update, panel reports are distributed to all providers as Excel files and PDF documents.

Providers have learned to update the EMR PCP themselves when care is transferred and to accept responsibility for the patients on their panel lists.

Outcomes of panel management

Actual/Expected Panel Size WB, October 2013

Cristallo Manners Peralta Becker Villar Thill Young Johnston-briggs Kishore Bumol Oki Lucan Okrent Berlus Dewitt Flores Howell Aguillard Moore Marrero Sato Daguilh Mckee Kumar Polisar Ekanadham Williams Guilliames 0.6

0.7

0.8

0.9

1 1.1

1.2

1.3

1.4

1.5

1.6

Outcomes of panel management

Outcomes of panel management

Outcomes of panel management

Outcomes of Panel Management

 Measuring continuity of care by provider  From the patient’s perspective  During a given interval (e.g. 18 months), at what percent of all visits made by members of a provider’s panel did the patient see the PCP (rather than another provider)?

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Continuity (Patient View) Family Health Center

100 90 80 70 60 50 40 30 20 10 0

Continuity Rate by Provider (Patient View) Family Health Center

Outcomes of Panel Management

 Measuring continuity of care by provider  From the provider’s perspective  During a given interval (e.g. 18 months), what percent of all visits with each provider are with members of that provider’s own panel?

 What percent of all visits with each provider are devoted to cross-coverage of other providers’ patients?

80% 70% 60% 50% 40% 30% 20% 10% 0%

Continuity (Provider View) Family Health Center

100 90 80 70 60 50 40 30 20 10 0

Continuity by Provider (Provider View) Family Health Center

Conclusions

  Patients can be rationally assigned to unique PCPs based on past assignments and retrospective visit histories in the hospital database Patient assignments have many potential applications:      Correction of panel sizes to balance productivity and access Rational transfer of patients to new providers Characterization and balance of panels Accountability for patient care and outcomes Measurement of continuity of care

Questions?