Pay-for-Performance Experience of DMC Primary Care Physicians, P.C.

1. Pay-for-Performance Experience of DMC Primary Care Physicians, P.C. Marilyn Bachelor, R.N., Healthcare Performance Consultant

2. Primary Care Physicians, P.C. (PCPPC) The Group • Incorporated in 1990 as an IPA • Comprised of approximately 150 primary care physicians share holders • From Family Practice, Internal Medicine, and Pediatrics • Located in 5 southeastern Michigan counties • Many have Detroit Medical Center affiliation • Board of Directors meet regularly to review financial, utilization, and other issues to assist with management of the group’s contracts

3. Primary Care Physicians, P.C.Administrative Specialists, LLC • A licensed TPA • All administration is delegated to Administrative Specialists for PCPPC’s managed care contracts: • Contracting • Physician advocate with health plans • Performance (Financial & Quality) analysis and reporting • Managed care education • Computer & technical support • Encounter processing • Commercial & Medicaid contracted health plans: • BCBSM, BCN, Midwest Health Plan, OmniCare Health Plan, and ProCare Plus Health Plan • Participation with each health plan is optional

4. Pay-for PerformanceBCBSM POGS • BCBSM Physician Group Incentive Program (PGIP) was established in 2004 • Focused on chronic disease management and promoting generic drugs • A reward pool was created which BCBSM allocated 100 percent to PGIP-participating physician organizations • Physician Organization Gain Sharing Program, (POGS) began in 2006 • Focused on reducing service category costs • PCPPC participated only in POGS • PCPPC focused on : • Increasing the use of generic drugs • Implementing electronic prescribing • Distributing Evidence Based Care (EBC) quality reports • All members received at least minimal incentive payment for participation • Established committee of the Board for program oversight

5. Pay-for Performance PGIP • PGIP combined both groups in 2007 • 35 physician organizations from across Michigan, including 6,415 primary care physicians and select specialists who are members of BCBSM's TRUST PPO network and provide care for about 1.7 million PPO members • Approximately 64 percent of active primary care TRUST physicians (internal medicine, family practice, pediatrics, and general practice) • Focuses on chronically ill populations • Introduced Patient Centered Medical Home concept

6. PCPPC PGIP Activities Year 1 - 2007 • Administrative Specialists increased capabilities: • Hired in-house IT support • Hired clinical performance consultant • Hired communications consultants • Purchased computers for members’ practices • Increased use of electronic communication tools • Began evaluating electronic registries & EMRs

7. PCPPC PGIP • 20,000+ BC Trust members • 992 diabetics, 4.9% of panel* • 162 asthmatics, 0.8% of panel • 75 CHF, 0.4% of panel • 337 CAD, 1.7% of panel * Opportunity for greatest initial impact

8. PCPPC PGIP Activities Year 2 - 2008 • Increased participation with BCBSM PGIP work groups • Setting initiatives for the year • Selecting disease registry • CDEMS with Data Entry & Reporting Training • WellCentive – limited # licenses • Membership in the Patient Centered Primary Care Collaborative • POGS Committee to PGIP Committee • For goal setting • Tracking progress

9. PCPPC PGIP Activities Year 2 - 2008 • PCPPC Initiatives: • Increasing the use of generic drugs • Increasing electronic prescribing • Decreasing unnecessary high tech radiology utilization • Improving evidence based care (EBC) quality scores – focus on diabetics • Implementing the basic requirements for the patient centered medical home • Test tracking

10. PCPPC PGIP Activities Year 2 - 2008 • Focus for PCMH • Patient -provider agreements for at least 10% of BC patients (> 20% of all patients last qtr) • All-payer electronic patient registry - CDEMS & WellCentive (selected practices) • Install registry and train staff in data entry at each selected practice site • Patient demographics and key clinical measures for diabetes accessible at site of care • Enter a minimum of 20 patients per physician per month • ePrescribing • Selected 7 practices (14 physicians) for PCMH pilot • Added 5 practices (6 physicians) last qtr 08

11. PCPPCPGIP Accomplishments Year 2 - 2008 • Increased generic drug rates • Increased ePrescribing • 10 practices consistent • 1 practice re-implementing • 1 practice to begin 1st qtr 09 • Practices using AIMS high tech radiology precert program • Improving EBC rates • Patient-provider agreements • Developed and provided to the pilot practices • Distributed to all patients • Tracked in CDEMS • Registry implemented • CDEMS loaded with diabetic BC patients for all 12 practices • CDEMS at site of care for 10 practices • Practices responsible for entering 20 diabetics/month - all payer • WellCentive licensed for 5 practices • Identifying additional reporting needs

12. PCPPC - PGIPPlans for Year 3 - 2009 • 2009 initiatives: • Continue 2008 initiatives • Add reduced utilization of ED & inpatient • Add asthma/COPD, CAD, CHF & well child measures to CDEMS • Add more practices to PCMH pilot • Get some of the pilot practices certified by BC as PCMHs • Implement and evaluate WellCentive for 5 sites • Increase IT capabilities • Finalize reporting format • Improve website for communication and 1-site software connectivity

13. PCPPCBarriers to PGIP Success • Resistance to change • Most of the physicians are aged 50+ • Physicians do not incent staff to participate • Reluctance to make major commitment to practice change: • Upgrading staff • Incorporating disease management • Facilitating self management • Cost of health IT (computers, ePrescribing, eHealth education, EMRs, electronic scheduling, electronic registries)