GPSC Fee Incentives Buy What You Want Presentation to the QMA April 2011

1. GPSC Fee Incentives Buy What You Want Presentation to the QMA April 2011 Presented by Dr. Jean Clarke

2. 4 Priorities $ Value us Pay us Support us Train us

3. Barbara Starfield’s Key Attributes of Primary Care • Access • Co-Ordination • Comprehensiveness • Continuity

4. The Triple Aim

5. Overview • Chronic Disease Management • Complex Care • Conferencing • Palliative Care • Mental Health • Prevention • Maternity

6. GPSC INITIATIVES CHRONIC DISEASE MANAGEMENT

7. Chronic Disease Management Diabetes Mellitus - $125.00 Congestive Heart Failure - $125.00 Hypertension - $50.00 COPD - $125.00 COPD Telephone/E-mail follow up - $15.00 (billable up to 4 times in the 12 months)

8. The CDM fee is a management bonus billable annually on the anniversary of the initial billing date. The CDM fees are for the GP who has accepted responsibility for the ongoing, longitudinal care of the patient. Must have at least 2 visits with patient in 12 months preceding billing of CDM fee. FFS billing for office visits continues. Chronic Disease Management

9. Chronic Disease Management Diabetes, CHF, and COPD CDM fees may be billed for the same patient. Hypertension CDM fee is not billable if also billing for Diabetes and/or CHF (but is billable with COPD.) Use of flow sheets as a tool for tracking care is encouraged but not mandatory provided all required information is included.

10. GPSC INITIATIVES COMPLEX CARE

11. Payment to compensate for the extra time required to provide planned care to complex patients who are living in their home or in assisted living. Payable only to the General Practitioner who accepts responsibility for the longitudinal, coordinated care of the patient. Complex Care

12. Complex Care Eligible patients must have two of the following chronic conditions: Diabetes mellitus Chronic kidney disease Congestive heart failure (CHF) Cerebrovascular disease (CVD) Ischemic heart disease (IHD) Chronic respiratory condition Chronic neurodegenerative diseases (CND) Chronic liver disease (CLD)

13. Annual Complex Care Management fee - $315 Minimum 30-minute complex care planning process: The Complex Care Planning Visit: the development of the care plan is done jointly with the patient. The patient should leave the appointment knowing there is a plan for their care and what that plan is. Billed in addition to office visit fee on the day of the planning appointment. Complex Care

14. FFS billing for subsequent office visits continues. CDM fees and Conferencing fees are payable in addition. Complex Care

15. Complex Care Telephone/E-mail Follow-up Management fee $15 Payable for up to 4 non face to face encounters (telephone, email) in the 18 months following billing of the Complex Care management fee Telephone/Email (2 way) encounters may be provided by the GP or delegated staff. Not for simple appointment reminders or prescription renewals Complex Care

16. GPSC INITIATIVES CONFERENCING FEES

17. Conferencing Fees Community Patient Conferencing fee Facility Patient Conferencing fee Acute Care Discharge Planning Conferencing fee Telephone Consultation with a Specialist or GP with Specialty Training

18. Conferencing Fees Developed to compensate the GP for time spentconferencing with other health care professionals to make acoordinated clinical action plan for the care of patients with more complex needs.

19. Conferencing Fees The Community, Facility and Acute Care Discharge conferencing fees are for the same eligible patient population: Frail elderly (ICD-9 code V15) Palliative care (ICD-9 code V58) Mental illness Patients of any age with multiple medical needs or complex co-morbidity – pregnancy is considered a co-morbidity in complex maternity patients. Payable in units of $40.00 per 15 minutes or greater portion. Maximum 4 units/patient/day; 6 units/patient/year.

20. GP Urgent Telephone Conference with a Specialist Fee Intent is to improve management of the patient with acute needs, and reduce unnecessary ER or hospital admissions/transfers. Billable when the patient’s condition requires urgent (< 2 hours from time of request) consultation with a specialist or GP with specialty training, and the development and implementation of a care plan within the next 24 hours to keep the patient stable in his/her current environment. This fee is not restricted by diagnosis or location of the patient, but by the urgency of the need for care. $40 flat rate fee value. Billable in addition to visit fee.

21. General Practitioners with Specialty Training Telephone Advice Fees “General Practitioner (GP) with Specialty Training” is defined as “A GP who has specialty training and who provides services in that specialty area through a health authority supported or approved program.” “Mirror fees” to the SSC Specialist Telephone Advice fees for FRCP certified Specialists. Service may be provided when physician is located in office or hospital. Telephone advice must be related to the field in which the GP has received specialty training.

22. General Practitioners with Specialty Training Telephone Advice Fees GP with Specialty Training Telephone Advice - Initiated by a Specialist or General Practitioner, urgent (< 2 hours from request for advice) - $60.00. GP with Specialty Training Telephone Patient Management - Initiated by a Specialist or General Practitioner, one week - $40.00. GP with Specialty Training Telephone Patient Management / Follow-up - $20.00; maximum 4/year/patient.

23. GPSC INITIATIVES PALLIATIVE CARE

24. Palliative Care Palliative Care Planning fee - $100 Payable for the development of a Palliative Care Plan for patients who have reached the palliative stage of a life-limiting disease or illness. Requires a face-to-face visit with the patient or the patient’s representative. Medical Diagnoses include: end-stage cardiac, respiratory, renal and liver disease, end-stage dementia, degenerative neuromuscular disease, HIV/AIDS or malignancy. Eligible patients must be resident in the community: at home or in assisted living or supportive housing.

25. Palliative Care Telephone/E-mail Follow-up Management $15.00 This fee is payable for 2-way telephone or email communication with eligible patients or their representative to provide clinical follow-up management billable by the GP who has developed the patient’s Palliative Care Plan Billable up to 5 times.. Palliative Care

26. GPSC INITIATIVES MENTAL HEALTH

27. Community GP Mental Health Mental Health Initiative compensates the Family Physician who accepts responsibility for the longitudinal care of patients who: Have an Axis I diagnosis confirmed by DSM IV criteria With a severity and acuity level causing sufficient interference in activities of daily living that developing a management plan for the rest of the year would be appropriate.

28. GP Mental Health Planning fee - $100.00 Paid for the development of a Mental Health Plan for care during the subsequent calendar year for patients who reside in the community. Requires 30-minute face-to-face visit. Billable once per calendar year per patient. Allows billing for 4 additional annual counselling visits GP Mental Health

29. GP Mental Health Telephone/Email Management fee - $15 This fee is payable for up to 5 telephone/email services (2-way communication) with eligible patients or their representative via telephone or email for the provision of clinical follow-up. Available for up to 18 months after billing Mental Health fee. This fee is not to be billed for simple appointment reminders or referral notification. Community GP Mental Health

30. GPSC INITIATIVES PREVENTION

31. Prevention Fee Personal Health Risk Assessment fee- $50 Billable in addition to an office visit, to undertake a personal health risk assessment visit with “at risk” patients. Targeted patients include those with: Smoking Unhealthy eating Physical inactivity Medical obesity. GP is expected to develop a plan that recommends age- and sex-specific targeted clinical preventative actions of proven benefit. Billable for up to 100 patients per calendar year per physician.

32. GPSC INITIATIVES MATERNITY INITIATIVES

33. GPSC Obstetric Delivery Bonuses Delivery bonuses valued at 50% of delivery fee. Available to GPs who in addition to being paid the delivery fee for the patient are also responsible or share responsibility for providing the patient’s longitudinal primary care. Maximum total of 25 bonuses claimed per calendar year.

34. Maternity Network Payment Quarterly payment to encourage shared care of obstetric patients to reduce burnout. $2100 per quarter. GPs complete a network registration form for the group.

35. Some Key Findings From the Evaluation • Hollander Analytical Services Ltd. • 300 - 895 Fort Street • Victoria, BC V8W 1H7 Tel: (250) 384-2776 Fax: (250) 389-0105 E-Mail: marcus@hollanderanalytical.com

36. A Major New Finding • A major, new finding is that there is a clear inverserelationship between the level of attachment to a primary care practice, and costs, for higher care needs patients. Attachment is defined as the percentage of all GP services in one year provided by the practice which provided the most services.

37. Benefits of Attachment • The more patients go to the same practice, the lower the overall, annual costs to the health care system. • Most of the differential in costs between more attached and less attached patients is in hospital costs: costs are higher for less attached patients • Therefore, activities which foster increased attachment of patients to a particular primary care practice have the potential to reduce health care costs i.e. continuity of care is cost-effective.

38. A Major New Finding (cont’d) • Our findings are based on an analysis of diabetes and congestive heart failure patients. A classification system developed by Johns Hopkins University was used to ensure that people in the analysis had similar levels of care need. • Resource Utilization Band (RUB) 4 represents people with a high need for care. RUB 5 represents people with a very high need for care.

39. Major new findings Annual costs per patient as a function of attachment to practice, for diabetes patients at RUB 4: Fiscal 2007/08

40. Major new findings Annual costs per patient as a function of attachment to practice, for diabetes patients at RUB 5: Fiscal 2007/08

41. Major new findings Annual costs per patient as a function of attachment to practice, for CHF patients at RUB 4: Fiscal 2007/08

42. Major new findings Annual costs per patient as a function of attachment to practice, for CHF patients at RUB 5: Fiscal 2007/08

44. Cost of Care as a Function of Attachment (cont’d) For the four main groups of patients reported in the study, total cost savings per 5% increase in attachment is estimated as:

45. Incentives RISQY

46. Major new findings Annual costs for CDM patients who did, and did not, receive incentive-based care, standardized for difference in age, gender, RUB and attachment levels: Fiscal 2008/09

47. Number of GPs participating in GPSC initiatives

48. Uptake of Incentive Billings Over Time: Fiscal 2003/04 to 2009/10 Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.

49. Percentage of GPs Billing for Chronic Disease Management Incentives Over Time: Fiscal 2003/04 to 2009/10 Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.

50. MSOC Patients Over Time Based on Care Provided to All Patients for Regular GPs Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.