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Pay For Performance: The Benefits of Doing the Right Thing. Hector Flores, M.D. Medical Director Family Care Specialists Medical GroupLos Angeles, CA. Health Care Mega-trends. Cost and Quality of Health Care Health care expenditures: $1.9 Trillion in 2005 Quality chasm in health care

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Pay For Performance: The Benefits of Doing the Right Thing

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Pay for performance the benefits of doing the right thing l.jpg

Pay For Performance:The Benefits of Doing the Right Thing

Hector Flores, M.D.

Medical Director

Family Care Specialists Medical GroupLos Angeles, CA

(c) Family Care Specialists 2006


Health care mega trends l.jpg

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

(c) Family Care Specialists 2006


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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

(c) Family Care Specialists 2006


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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

(c) Family Care Specialists 2006


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The Measurable Disparities:Centers for Disease Control (CDC) 1996

  • Cancer

  • Cardio-Vascular Disease

  • Diabetes

  • HIV/AIDS

  • Immunization Rates

  • Infant Mortality

(c) Family Care Specialists 2006


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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

(c) Family Care Specialists 2006


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Cycle of Life and Social Policy

Conception

MaturityBirth

Adult Childhood

Adolescence

(c) Family Care Specialists 2006


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The Urban Experience:Cycle of Life and Social Policy

Conception

MaturityBirth

Adult Childhood

Adolescence

95%

covered

90%

covered

70%

covered

80%

covered

70%

covered

75%

covered

Source: Kaiser Family Foundation, 2000

(c) Family Care Specialists 2006


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Access

  • Financial/Coverage Issues

  • Geographic

  • Logistical

  • Managed Care

  • Language and Literacy

  • Cultural

  • Legal/Regulatory

  • Immigration

(c) Family Care Specialists 2006


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Culturally Responsive Care*:Good Medicine, Good Business

Behavior

Culture

Environment

Biology

*Adapted:Healthy People 2010

(c) Family Care Specialists 2006


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5 Conditions – 50% of Chronic Care Costs (AHRQ 1994)

  • Asthma

  • Diabetes

  • Heart Disease

  • Hypertension

  • Mood Disorders

(c) Family Care Specialists 2006


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Shortage Area Practice Management:Constructing 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

(c) Family Care Specialists 2006


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The Family Care Specialists Medical Group

Progress Report

(c) Family Care Specialists 2006


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25 Clinicians

72% Latino

20% White

4% Asian/Pacific Islander

4% African-American

Four Offices

120 Employees

95% Women

80% Latino

10% White

5% African-American

5% A/PI

FCS Medical Group

Family Care Specialists MG

Medical Practice

40,000 Patients

70% Managed Care

  • ½ Medicaid

    30% FFS

  • ½ Medicare, PPO

  • ¼ Medicaid

  • ¼ Uninsured

(c) Family Care Specialists 2006


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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

FCS Independent Practice Association

Family Care Specialists IPA

HMO Relationships

  • Risk-Sharing

  • Pay-for-Performance

  • In-Kind Support

(c) Family Care Specialists 2006


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The New Primary Care:Team 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

(c) Family Care Specialists 2006


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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

(c) Family Care Specialists 2006


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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

(c) Family Care Specialists 2006


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FCS MG: Raising the Bar(The California Endowment)

* Top Group in California

**TM –Tele -ophthalmology Retinal Screen Project, 2001

(c) Family Care Specialists 2006


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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

(c) Family Care Specialists 2006


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

(c) Family Care Specialists 2006


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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

(c) Family Care Specialists 2006


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Consumer Assessment Survey(CAS) – CCHRI

*FCS Top Group, CAS 2005

(c) Family Care Specialists 2006


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Yeah, right! Let’s get real!

  • Time

  • Productivity

  • Reimbursement

  • Hassle Factor

  • Patient’s Personal Responsibility

(c) Family Care Specialists 2006


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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

You’re right!

(c) Family Care Specialists 2006


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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)

(c) Family Care Specialists 2006


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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 Nation’s Compelling Interest (2004)

(c) Family Care Specialists 2006


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“To dream is to create the future”-- Victor Hugo

(c) Family Care Specialists 2006


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