Housekeeping

2. Housekeeping • Next Event • Marketing Items • Surveys • Miscellaneous

3. Playing in the Sandbox – Effectively Using RVU’s for Physician Compensation Brian M. McCook, CPA AMD

4. Learning Objectives • Refresher on RVU’s • Benchmark Data Options • Explore opportunities for RVU compensation models • Non-clinical considerations • Wrap-up

5. Intro to RVU’s • Relative Value Unit – a measure of the resources required to provide various services. • Time • Level of skill required • Resources needed • RVU’s are assigned to each encounter, test, procedure or surgery based on CPT codes • Can assign values for non-clinical tasks, if needed.

6. Total RVU’s Components • Physician work – Time, skill, training and intensity (w RVU’s) • Compensation agreements tied to work RVU’s • Practice Expense – Costs of delivering services and maintaining a practice (pe RVU’s) • Malpractice – Professional liability (mp RVU’s)

7. Other Important Terms • Geographic Practice Cost Indices (GPCI) • Conversion Factor (CF) • Monetary value = Total RVU’s x GPCI x CF

8. Example Calculation for CPT Code 99213

9. Benchmark Data Sources • Several national surveys are conducted annually • MGMA • Sullivan, Cotter and Associates • Regional and specialty-specific surveys

10. Using Benchmark Data • Understand how the data was derived, including type and number of respondents • May consider blending multiple sources of data • Be aware of potential inconsistencies that exist in data • RVU data using different fee schedules

11. Work RVU Compensation Models • Can have various models and criteria – as complex and creative as you want to be. • Some sample models: • W RVU Straight Model • W RVU Tiered Model • May have 2 or more tiers • Consider tying into individual P&L’s - Must cover direct expenses and allocated share of overhead to be eligible for bonus. • Be Careful – If too complicated, the physicians will not understand and think they are being cheated!

12. RVU Sample

13. Other Items to Consider • Models are transitioning to account for the shift towards value-based care • Resource Management • Outcomes • Quality • Possible movement from fee for service to global payments • Payments for non-clinical time • Administrative Time • Education/Public Speaking

14. Other Items to Consider • Consider tying compensation to non-financial factors as well • EHR utilization • Corporate citizenship • Patient satisfaction • Best models make sure physicians have some “skin in the game” • Simple can be better!

15. Components of a sustainable model • Expectations that must be established for a long-term sustainable model • Financial viability • Comp model to support this initiative • Allow for reinvestment • Ramp-up for new doctors • Technology • Recruitment • Must be a win-win for system and physicians!

16. Questions

17. What does all this mean? • Develop a compensation plan that balances effort and quality. • Identify the metrics that are important to your practice…and build around them. • Be transparent. • Try to keep as simple as possible. • Make the physician compensation model a recruiting tool for your practice!

18. AMD Health Care Services AMD Health Care Services optimizes staff, resources and revenues for hospitals and physicians by offering solutions and direction to complex practice management issues. We provide an integrated approach to physician practice success from the financial, operational, compliance and strategic perspectives.

19. Playing in the Sandbox – Effectively Using RVU’s for Physician Compensation Brian McCook, CPA bmccook@amdcpa.com 314-655-5564 www.amdhealthcare.com

20. The Patient Centered Medical Home: An Advanced Primary Care Model Model Derrick O’Connell, RN, MBA, Lean Six Sigma Black Belt

21. The First Patient Centered Medical Home • 1967 – American Academy of Pediatrics (AAP) first termed the “Medical Home” as a centralized location for care of children with special needs with the following attributes: • Accessibility • Continuous • Comprehensive • Family-centered (Patient-centered) • Coordinated • Compassionate • Culturally effective

22. The Medical Home Model Evolves • 2004 – The American Academy of Family Practitioners (AAFP) developed a ‘Medical Home” concept • 2006 – The American College of Physicians (ACP) developed an “advanced medical home” concept • 2007 – The AAFP, ACP, AOA (American Osteopathic Association) and the AAP (in conjunction with the NCQA) develop: ‘Joint Principles of the Patient Centered Medical Home’

23. The Joint Principles • Joint Principles of the PCMH: • Personal Physician – Each patient has a personal • physician • Physician Led Team Orientation – A team of health care • professionals provides comprehensive care • Whole Person Orientation – The total bio-psychosocial • sphere of the person is the focus of health management • efforts throughout their complete life cycle • Chronic disease management • Acute care • Age appropriate care • Care is coordinated across the entire continuum – Care • management helps to ensure effective care coordination across • all elements of the complex health system

24. The Joint Principles • Joint Principles of the PCMH: • Quality and safety are hallmarks of the PCMH – • Engages in continuous quality improvement processes • Practices are patient advocates • Use of Evidenced Based Medicine and clinical • decision support tools • Patients actively participate in decision making • Patient experience data • HIT is used to support optimal patient care • Practices go through a voluntary PCMH recognition • process Development of a comprehensive QIP • Enhanced access – Patients are able to access care in • more ways and at more times

25. The Joint Principles • Joint Principles of the PCMH: • Appropriate payment – Payment supports the value- • added team concept of the PCMH **The industry, overall, is moving towards value-based payment methodologies. The PCMH Model of care provides the health care delivery paradigm by which to satisfy the Purchaser Imperative.

26. Infrastructure • Organizational willingness to implement the PCMH • Health Information Technology (HIT) • Quality Improvement Professional(s) • Data analyst

27. Infrastructure • Organizational willingness to implement PCMH a. Strong Physician Champion(s) b. Strong Change Agent c. Strong Governance i. Quality Improvement Committee ii. Board support

28. Infrastructure • Health Information Technology (HIT) a. Electronic Medical Record i. Templates with clinical decision support ii. Evidenced Based Medicine (EBM) Guidelines b. e-Prescribing c. Registry functions d. Lab interfaces e. Future interface with Health Information Exchange (HIE)

29. Infrastructure • Quality Improvement Professional(s) a. Clinical background b. Development of Quality Improvement Plan i. Policy & procedure development c. Data management background d. Liaison with Data Analyst i. Registry development ii. Report development iii. Clinical performance measurement e. Process improvement skills

30. Infrastructure • Data Analyst a. Ability to create queries in collaboration with the Quality Improvement Professional b. Report development c. Registry development

31. Organizational Standards • There are policies and procedures required for the Patient Centered Medical Home • These are your organizational standards • Make them focused and meaningful • You will need to measure your organization’s performance for these standards

32. Population Management • Understand your patient population a. Stratification i. ICD-9 Dx – unique patient count ii. Encounters iii. Charges b. Compare to Center for Disease Control i. National and regional epidemiology • Develop Evidenced Based Medicine Guidelines a. Proven treatment guidelines based upon science i. Reduce disparities ii. Industry standards

33. Population Management • High-risk sub-population(s) a. Barriers to Treatment Plan or medication compliance b. Multiple co-morbidities c. High levels or inappropriate resource use i. Frequent ER or urgent care visits ii. Non-emergent ER utilization iii. Frequent hospitalizations iv. 30-day readmissions d. Behavioral health histories e. Advanced age f. Pediatric at-risk populations

34. Synergy with Meaningful Use • The Patient Centered Medical Home has many synergies with Stage 1 Meaningful Use • Stage 1 Meaningful Use requirements are embedded in the 2011 NCQA PCMH Standards • Stage 1 Meaningful Use workflows and data capture promote the functions of the PCMH • It is advisable to achieve Stage 1 Meaningful Use before, or concomitantly with your PCMH project

35. Standardization • The PCMH model and Meaningful Use • Standardized templates in HIT/EMR • Standardized clinic workflows • Application of EBM Guidelines • Doing the same right thing, at the same right time, all of the time • Mistake-proof workflows for the application of EBM Guidelines • Develop condition-specific protocols

36. Enhanced Access 1. Same day appointments 2. Timely advice a. Telephonically b. Patient portal 3. Access to primary care outside of 8 am – 5 pm, M- F a. Non-ER venue of care b. Expanded office hours c. Urgent Care arrangement 4. 24-hour access to clinical advice a. Telephonic and patient portal **The right care, in the right venue, when the patient/customer wants it

37. Enhanced Communication • Goal is always to collaborate with the patient • Patient-Centeredness • Keep the patient informed about their current status and future plans/goals /responsibilities • Marketing materials to educate patients/families • What is the PCMH • How to access care and information • Roles and responsibilities • Provide access to EBM Guideline condition-specific materials

38. Care Coordination 1. Lab and diagnostic test tracking 2. Coordinate and track consultant and specialist care 3. Following up with patients when they miss important appointments 4. Tracking and coordinating inpatient and ER transitions of care 5. HIT interfaces to electronically exchange key clinical information (may be dependent on HIE deployment)

39. Care Management • Goal is always to educate, coach and mentor patients/families to their highest level of self- management • Improve Treatment Plan and medication compliance • Provide access to specifically trained professionals for chronic disease management education • Notification of gaps in care • Age-appropriate • Chronic condition

40. Performance Measurement & Improvement • Clinical performance • Age appropriate or preventive screenings • Acute and/or chronic care • Utilization • Hospitalizations • 30-day readmissions • ER utilization • Measure patient/customer experience • Annual surveys • CAHPS for the PCMH

41. Performance Measurement & Improvement • Compliance with organizational standards • Track, trend and report all measurements over time • Develop performance goals based upon industry standards/benchmarks or internal incremental improvements • Develop and implement corrective action plans for any performance not meeting goals, standards or customer requirements

42. The Patient Centered Medical Home: An Advanced Primary Care Model Model Derrick O’Connell, RN, MBA, Lean Six Sigma Black Belt

43. PCMH & The Technology SHIFT Eric W. Humes Keystone IT Consulting

44. What is PCMH?(just in case you didn’t know) PCMH = Patient Centered Medical Home As defined by the Agency for Healthcare Research and Quality (AHRQ), a PCMH is a medical home that not simply a place but is also a model of the organization of primary care that delivers the core functions of primary healthcare.

45. 5 Core Functions of PCMH PCMH is built upon the following concepts: Comprehensive Patient-centered Coordinated Accessible Quality/Safety

46. Examples of the 5 Functions Comprehensive care – mental and physical health needs, prevention and wellness, acute and chronic care. Patient-centered – relationship based; recognizes that a patient’s family is part of their care team. Coordinated care – increasing communication across patient ~ family ~ hospital ~ clinics ~ community services. Accessible services – shorter waiting times for urgent needs, enhanced hours, 24x7 phone/internet based support.. Quality / Safety – evidenced-based medicine, clinical decision support tools, reduced errors, measuring/responding to patient satisfaction.

47. Technology’s Role in PCMH Health IT (HIT) can help to achieve each these fundamental goals but primarily relates to: Coordinated care Communication between members of the care team Accessible Services Communication between patient and care team Quality / Safety Clinical data analytics tools, EMR systems, reduced errors with eRx, data trending, dashboarding

48. Technology’s Role in PCMH HIT can support the PCMH model by collecting, storing, and managing personal health information, as well as aggregate data that can be used to improve processes and outcomes. HIT can also support communication, clinical decision-making, and patient self-management.

49. Technology’s Role in PCMH Question: Will significant investment in promoting the adoption of health information technology (IT) and meaningful use of electronic health records (EHRs) through the Health Information Technology for Economic and Clinical Health (HITECH) Act enable primary care practices to become patient-centered medical homes (PCMHs)? Answer: No. While the adoption and meaningful use of EHRs help support some aspects of the PCMH model, HITECH programs and other current Federal legislation are necessary but not sufficient for driving widespread adoption of the medical home model. (Source: AHRQ)

50. The Needed SHIFT HITECH offers some policy options that could ensure EHRs are implemented in a way that supports primary care transformation. These couldinclude the following: Adding explicit functionalities that directly support the PCMH model to the recently released EHR certification standards and criteria. Adding EHR meaningful-use requirements that support the PCMH model for stages 2 and 3 of the EHR Incentive Program.