The Michigan Primary Care Consortium and its Initiatives

March 2009

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 2

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 3

• • • • • •

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 4

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 6

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 7

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 Membership: Diverse 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 10

MPCC Membership: Diverse 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 11

MPCC Membership: Diverse 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 12

MPCC Membership: Diverse 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 13

MPCC Membership: Diverse 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 Membership: Diverse 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 15

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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 17

“White Paper” Work Groups

• • • • Primary Care in Crisis – and Dennis Paradis, MOA Lead: Kevin Piggott, MD Consumer Engagement – MSMS Lead: Stacey Hettiger, Rebuilding Primary Care Workforce – Wehrwein, MSN, PhD-MSU and Robert Burack, MD WSU Teresa Practice Transformation and Payment Reform – Lead: Joseph Fortuna, MD-AIAG 18

2009-2010 MPCC Action Groups

1.

2.

3.

4.

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 19

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 20

Michigan Primary Care Consortium

Priorities for 2009-2010

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Michigan Primary Care Consortium’s Priority Projects for 2009/2010

1.

2.

3.

4.

5.

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 MPCC’s “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 23

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 patient’s 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 27

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. 28

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 32

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 33

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 MPCC’s 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 34

•

PRIMARY CARE TRANSFORMATION

Practice 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 35

PRIMARY CARE TRANSFORMATION

Health Information Technology

• The MPCC should promote the effective use of patient/population registries and other useful health information technology in primary care practices. 36

MPCC Recommendations to its Action Group

4.

Payment Reform – focus on: – Payment Policies for PCMH – Practice Infrastructure Support 37

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 REFORM

Practice 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 39

PAYMENT REFORM

Practice 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 40

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 today’s 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 population’s health status will not.”

World Health Organization. Innovative care for chronic conditions: building blocks for action: global report. (Geneva: WHO; 2002.) 41

Chronic Care Model Community Resources and Policies Self Management Support Health System Health Care Organization Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team

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 patient’s 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 44

• • • • • • •

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 45

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, NP’s and PA’s into primary care Slowing the rise in health care spending 46

2007 Joint Principles for PCMH

Jointly approved by: • American Academy of Family Physicians • American Academy of Pediatrics • American College of Physicians • American Osteopathic Association • • • • • • • 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 47

PCMH Definition in Michigan

• Same as Joint Principles with footnotes to further define: • • • • Patient-Centered Personal Physician Quality and Safety Payment 48

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. 49

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 patient’s 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 practitioner’s 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. 52

Payment – MI Footnote

• Transformational change in healthcare financial incentives should occur simultaneously with, proportionally to, and in alignment with Patient-Centered Medical Home adoption. 53

NCQA Practice Connections – Patient Centered Medical Home Certification 54

BCBSM’s 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 55

MICHIGAN PCMH METRICS Tiers 1-3 Data and Value Source

Patients Providers Payers Purchasers Health System Community Access Comprehen siveness Coordinated Continuous Patient / Family Centeredness Continuous Improvement Integration Linkage 56

“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 1. Guidelines 2. IT software and support 3. Care management 4. Consumer education Health Systems in a Community Widespread Practice Change

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 3 rd state selected Funded by RWJF, grant provides 2 years of seed money to states, with states adding additional funds 59

“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 60

Key IPIP Interventions

1.

2.

3.

4.

5.

Use a Patient Registry Initiate Team Care Implement Planned Visits Provide Self-Management Support Work toward Creation of a PCMH 61

IPIP Practice Sites, 2008-09 N=22

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Improving Performance in Practice

For more information about IPIP: http://ipip.aiag.org

Rose Steiner [email protected]

State Director (248) 213-4656 63

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 Wagner’s 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 64

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 * Use of Evidence-based Clinical Guidelines * Use of Patient Registries & other Info Technology * Payment Reform that supports PCMH * Redesigned Practices for Efficient, Effective Preventive and Chronic Care

Michigan Steps Up!

“Move More, Eat Better, Don’t Smoke”

Healthy, Empowered Citizens Healthy Communities * 20-year Statewide Social Change Movement * State & Community Coalitions for Environment & Policy Change Toward Wellness Healthy Michigan Economy State & Local Public Health Programs * Roles for Business, Schools, Health Care, Faith Based & Community Organizations * PH Fellowship Program for Workforce Replacement * Immunizations * WIC

“Public Health: For Michigan, For You”

* Smoke-Free Policies * Stroke Prev/Management * Minority Health Resource & Consultation Center * Health Promotion * School Health * Blood Pressure Control * Heart Disease Prevention * Informing, Empowering Citizens * Obesity Prevention * Cancer Screening * Asthma Control * Diabetes Prev & Control * Modeling Public Health Improvement for Citizens * Osteoporosis Prev. * Kidney Disease Prev. * Fall Prevention * Health Disparity Reduction

“Michigan First” Proposal to CMS “Access to Insurance for All”

* Private Market Products * Medicaid 1115 Waiver * Subsidized Cost for those <200% poverty * Unsubsidized Resource for those >200% 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 * Injury Prevention * Suicide Prevention * End of Life/Palliative Care * Etc.

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Michigan Primary Care Consortium

For more information about the MPCC: www.MIPCC.org

[email protected]

(517) 241-7353 66