Using pay for performance to strengthen medical homes while protecting patient centered care

1. Using pay for performance to strengthen medical homes while protecting patient centered care Department of Family Medicine and Community Health University of Minnesota Medical Center Family Medicine Residency Program / Smiley’s Clinic

2. Presenters David Satin – Faculty / Bioethics Fellow Macaran Baird – Department Head Jennifer Welsh – Residency Program Director Sara Johnson – G3 Outgoing Chief Resident Sara Hartfeldt – G2 Incoming Chief Resident

3. Following this seminar, participants will be able to: • Explain how current Pay-for-Performance (P4P) quality initiatives provide opportunities to strengthen primary care medical homes. • Describe the tension between P4P and patient centered care. • Cite practical steps towards harnessing P4P to strengthen medical homes while protecting patient centered care.

4. Opening Presentations • Welcome, introductions, and exegesis of “What is P4P?” (Dr. Satin - 10 minutes) • “Current state of affairs at intersection of P4P and medical homes” (Dr. Baird– 5 minutes) • “Resident perspective of P4P’s impact on primary care medical homes and patient centered care (Drs. Johnson & Hartfeldt – 15 minutes) • “P4P’s potential negative impact on patient centered care and positive impact on medical homes” (Drs. Satin & Welsh – 10 minutes)

5. Audience Participation / Panel • Participants divides into small groups generating lists of practical steps towards either: (10 minutes) a) maximizing P4P’s potential positive impact on medical homes, or b) mitigating P4P’s potential negative impact on patient centered care • Small groups will then report back to the large group, one practical step towards their assigned goal. Large group response/discussion will then focus on enhancements and barriers to achieving these steps. (20 minutes)

6. Closing Presentations • “Operational components of the practical steps raised in the group discussion” (Dr. Welsh – 7.5 minutes) • Open Q and A with panel’s closing remarks. (Participants and panel – 10 minutes) • Participants fill out STFM session feedback cards. (2.5 minutes)

7. What is P4P?

8. Pay-for-Performance (P4P) Definition “The use of incentives to encourage and reinforce the delivery of evidence-based practices and health care system transformation that promote better outcomes as efficiently as possible.” Outcomes-Based Compensation: Pay-For-Performance Design Principles 4th Annual Disease Management Outcomes Summit Johns Hopkins / American Healthways, Nov. 2004

9. What is P4P? Third party payer or health system awards periodic bonus to clinicians and/or practices that reach particular quality goals. Quality goals are typically consistent with the National Committee for Quality Assurance’s Health Plan Employer Data and Information Set (HEDIS) quality markers. Foubister, Vida. “Issue of the Month: Pay-for-Performance in Medicaid” The Commonwealth Fund. Accessed 8/29/05 http://www.cmwf.org/publications_show.htm?doc_id=274106

10. Quality goals may be in areas of: Structure: e.g.Having an electronic medical record Process: e.g. Adherence to professional guidelines such as checking a hemoglobin A1c every 3 months in patients with DM2 Outcomes: e.g. Hemoglobin A1C <7.0 in patients with DM2 Outcomes-Based Compensation: Pay-For-Performance Design Principles, 4th Annual Disease Management Outcomes Summit, Johns Hopkins / American Healthways, Nov. 2004

11. Who sets the goals? P4P programs vary by third party payer or health system. Some require a 90% childhood vaccination rate, others 80%. Some goals vary annually based on last year’s top clinics’ results. Some require personal improvement over last year’s results. Some restrict their P4P criteria to patients with their insurance. Personal investigation of Minnesota’s major insurers including Medica, HealthPartners, Blue Cross Blue Shield, UCare; interviews, internet search on insurance websites, and internal UMN DFMCH documents, 9/2005.

12. The Money Some P4P program “bonuses” truly represent new funds while others represent a 3% “withhold” across the board from the current fee-for-service schedule. P4P reimbursements range from 3%-20% of a physician’s fee-for-service reimbursements. Personal investigation of Minnesota’s major insurers including Medica, HealthPartners, Blue Cross Blue Shield, UCare; interviews, internet search on insurance websites, and internal UMN DFMCH documents, 9/2005.

13. The P4P Rationale Physicians change practice patterns in response to substantial changes in methods of reimbursement. Average length of hospital stay halved since DRG payments began in 1980s. Achieving HEDIS quality measures and adhering to professional guidelines result, on average, in better patient outcomes. Outcomes-Based Compensation: Pay-For-Performance Design Principles, 4th Annual Disease Management Outcomes Summit, Johns Hopkins / American Healthways, Nov. 2004 Werner RM, Bradlow ET. Relationship between Medicare’s hospital compare performance measures and mortality rates. JAMA. 296(22):2694-2702, 2006 Dec 13.

15. P4P, MH, PCC: What do these acronyms mean to you? How about your residents? Purpose: To determine resident and faculty understanding of P4P and its impact on the Medical Home and Patient-Centered Care. How: A 13-question survey

16. Presenting Residents Sara Hartfeldt MD -Second year resident Sara Johnson MD -Third year and chief resident

17. The Survey 13 questions with fill-in definitions for P4P, Medical Home and Patient-Centered Care

18. What is Pay-for Performance?Resident Responses A basic resident answer: “(a) clinic reward system for medical goals being met.”

19. What is Pay-for-Performance?Resident Responses A sophisticated answer: “Insurance companies have decided on goals for patients based on …middle-aged patients with one chronic illness and then applied them to all patients, including the elderly and those with multiple chronic illnesses, and pay doctors less if they are not met.”

20. How well do you know what the P4P guidelines are at our clinic?

21. How much have these guidelines improved your medical knowledge?

22. How much have these guidelines improved efficiency in clinic?

23. How do you think these guidelines have affected your patients’ outcomes?

24. What is a Medical Home?Resident Responses

25. What is a Medical Home?Resident Responses A basic answer: “A primary care clinic” A wrong answer: “Medical care at the patient’s home with PCP and health system coming to them instead of patient coming to the clinic.”

26. What is a Medical Home?Resident Responses A sophisticated answer: “When the health care provider and family have a holistic approach to health care resulting in improved outcomes with compliance to treatment and patient satisfaction.”

27. How do you think P4P helps or hurts our clinic’s function as a Medical Home?

28. What is Patient Centered Care?Resident Responses

29. What is Patient Centered Care?Resident Responses A basic response: “Respecting patients’ ideas and values about their medical care.”

30. What is Patient Centered Care?Resident Responses A sophisticated answer: “Physicians working with patients - together improving health care in a way ‘tailored’ to the patient, in an individualized way.”

31. How do you think Pay-for-Performance helps or hurts patient centered care?

32. How important do you think it is to learn about topics like P4P, MH, or Patient Centered Care?

33. Questions?

34. Key points • P4P has broken through as a “concept” and most residents have some idea what it means, and generally think there is some benefit for them and their patients.

35. Key points • Residents have much less knowledge about what MH and PCC mean as terms of art in our field.

36. Key points • In general, residents think that learning about these concepts is less important than faculty do.

38. YOUR JOB: • Generate ideas to capitalize on P4P’s potential positive impact on medical homes. • Generate ideas to mitigate P4P’s potential negative impact on patient centered care.

39. P4P’s potential negative impact on patient centered care

40. Patient Centered Care Definition: Care which… • explores the patients' main reason for the visit, concerns, and need for information; • seeks an integrated understanding of the patients' world—that is, their whole person, emotional needs, and life issues; • finds common ground on what the problem is and mutually agrees on management; • enhances prevention and health promotion; • enhances the continuing relationship between the patient and the doctor Stewart, Moira. Towards a global definition of patient centred care, BMJ. 2001 February 24; 322(7284): 444–445

41. Ways P4P May Negatively Impact Patient Centered Care P4P may: • Increase non patient-care related work • Increase barriers to accessing care • Strain physician-patient relationship

42. P4P may increase non patient-care related work • Accurate data collection is burdensome. • Battles over appropriate and fair measures is time/energy consuming. • Participation in P4P programs can require substantial administrative/financial investment. Harper, P. Assistant Professor, Dept. of Family Med and Community Health, UMN. Personal interview, 9/19/2005. Metsemakers, J. Professor of General Practice, Department Chair, U of Maastricht. Personal interview 9/7/2005.

43. 2. P4P may increase barriers to accessing care • Sicker patients may get worse care. • P4P may increase health care disparities. • Smaller, rural, poorer clinics may not survive. Weiss G, What would you do? New issues in medical ethics. Medical Economics, Aug 2006, p56-61 Shen Y. Selection incentives in a performance-based contracting system. Health Serv. Res. 2003;38:535-52 Zaslavsky, A.M., J.N. Hochheimer, et al. “Impact of sociodemographic case mix on the HEDIS measures of health plan quality.” Med Care 38(10): 981-92, 2000. Satin, DJ. Paying Physicians and Protecting the Poor. Minnesota Medicine, Apr. 2006, p42-44

44. 3. P4P may strain physician-patient relationship • Will physicians get angry with patients who decline recommended treatments? • Will physicians be able to facilitate non-coerced, informed decision making? • P4P discourages individualized care and clinical judgment. • Slippery slope of self regulation (underuse vs overuse measures). Satin, DJ. The Impact of Pay-for-Performance Beyond Quality Markers – A Call for Bioethics Research. Bioethics Examiner, University of Minnesota Center for Bioethics, Fall 2006. Boyd CM. Darer J. Boult C. Fried LP. Boult L. Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 294(6):716-24, 8/10/2005.

45. YOUR JOB: Generate ideas to mitigate P4P’s potential negative impact on patient centered care.

47. P4P’s potential positive impact on primary care medical homes

48. Medical Home Definitions The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care. Policy Monograph, ACP, 1-22-06. http://www.hhs.gov/healthit/ahic/materials/meeting03/cc/ACP_Initiative.pdf Patient-centered, physician-guided, cost-efficient, longitudinal care that encompasses and values both the art and science of medicine.

49. TransforMed: transforming clinical practices. Available at transforMed.com. Accessed 4-16-08.

50. How do P4P initiatives help create a medical home? • To capture P4P dollars, you must improve quality of care markers. • Improving quality of care markers requires implementing components of the medical home. • Patient-centered care • Care coordination • Teams • Quality and safety • EMR, registries