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Prescription for PennsylvaniaThe Pennsylvania Multi-Payer
Statewide Medical Home Model
Robert Gabbay MD, PhDDirector, Penn State Institute for Diabetes and ObesityProfessor of MedicinePenn State College of Medicine
Today
• Development of the PA initiative• Key aspects• Early outcomes• Unique features• Questions to ponder
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Origin and Purpose of the Governors’ Chronic Care
Commission
• Established May 2007 by Executive Order with Commissioners appointed in their individual capacity.
• Purpose: to design the informational, technological and reimbursement infrastructure needed to implement and support widespread dissemination and implementation of the Chronic Care Model throughout Pennsylvania.
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The Chronic Care Model
Most widely accepted evidence- based model for
Improving Chronic Care
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The Chronic Care Model
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Delivery SystemDesign
DecisionSupport
Clinical Info
Systems
Self- Management
Support
Health SystemResources and Policies
Community Health Care Organization
Improved Outcomes
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Why Diabetes?
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It’s Where theMoney is!
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Avoidable Hospitalization Costs for Pennsylvanians with Chronic Disease
00.10.20.30.40.50.60.70.80.9
Heart
Dise
ase
Lung
Dise
ase
Diabete
s
Asthm
a
Chronic Disease
Cos
t in
$ B
illio
ns
2005
2006
Why Diabetes?
• High Morbidity and Mortality• High Cost for preventable complications• Consensus evidence based goals• An epidemic is ahead
– Diabetes will double in next 20 years
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The PA Chronic Care Commission
Strategic Plan• The Commission presented its Strategic Plan to the
Governor and the Speaker of the House on February 13, 2008
• The Plan provides a business case and framework for implementing the Chronic Care Model across the Commonwealth
• Implementation is incremental • Diabetes (with co-morbidities) and lesser extent asthma
primary focus of the initial rollout with spread to other chronic illnesses
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The Intervention
1. Learning collaboratives2. Practice coaches3. Registry Reporting 4. Patient Centered Medical Home
implementation5. Reimbursement/infrastructure payments
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Implementation of the Chronic Care Model in PA
• Incremental rollout• Southeastern PA was the first regional rollout
May 2008• Rollouts in South Central PA followed by
Western, NW and NE PA and throughout the State
• Rollouts persist for at least three years• To date- 780 providers across the state
involved with population of 1 million patients
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Partner Organizations• Governors Office for Health Care Reform• Governor’s Chronic Care Commission• Payers
– Independence Blue Cross, Highmark, Capital Blue Cross, Aetna, Keystone Mercy, Health Partners, Geisinger, Cigna, others (17 Total)
• Professional Organizations/Societies– Improving Performance in Practice (IPIP)– ABIM– ACP– PAFP
One of the Largest Multi- Payer PCMH Initiative in US
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Goals
• Change processes of care• Improve clinical outcomes (diabetes is the
target disease but untimely spread to other diseases)
• Cost containment
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Overall Framework
1. Learning collaboratives2. Registry reporting 3. Practice coaches4. Patient Centered Medical Home5. Reimbursement/incentives changes
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1. The Breakthrough Series Learning Collaborative
• 2 days each 3 months for One-year then every 6 months for next 2 years
• Sharing across teams facilitated by conference calls between sessions, listservs, websites for materials
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PDSACycle
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2. Registry Reporting
• Use your own otherwise State provides one free (RMD)
• Monthly reporting of outcomes along with narrative reports
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3. IPIP Practice Coaches
IPIP : Improving Performance in Practice – piloted in Colorado and North Carolina –
RWJ supported• Help practices problem solve during PDSA
cycles• Implement Registry
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4.PPC-PCMH Content and ScoringStandard 1: Access and CommunicationA. Has written standards for patient access and patient
communication**B. Uses data to show it meets its standards for patient
access and communication**
Pt s
45
9Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information
(mostly non-clinical data) B. Has clinical data system with clinical data in
searchable data fields C. Uses the clinical data system D. Uses paper or electronic-based charting tools to organize
clinical information**E. Uses data to identify important diagnoses and conditions
in practice**F. Generates lists of patients and reminds patients and
clinicians of services needed (population management)
Pt s
2
33
64
321
Standard 3: Care ManagementA. Adopts and implements evidence-based guidelines for
three conditions **B. Generates reminders about preventive services for
clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans,
assessing progress, addressing barriers E. Coordinates care//follow-up for patients who receive
care in inpatient and outpatient facilities
Pt s
3
4
35
520
Standard 4: Patient Self-Management Support A. Assesses language preference and other
communication barriersB. Actively supports patient self-management**
Pt s
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6
Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety
checksC. Has electronic prescription writer with cost
checks
Pts33
28
Standard 6: Test Tracking A. Tracks tests and identifies abnormal results
systematically** B. Uses electronic systems to order and retrieve
tests and flag duplicate tests
Pts7
613
Standard 7: Referral Tracking A. Tracks referrals using paper-based or electronic
system**
PT4
4Standard 8: Performance Reporting and Improvement A. Measures clinical and/or service performance by
physician or across the practice**B. Survey of patients’ care experience C. Reports performance across the practice or by
physician **D. Sets goals and takes action to improve
performance E. Produces reports using standardized measures F. Transmits reports with standardized measures
electronically to external entities
Pts
3
33
3
2115
Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support
Pts1214**Must Pass Elements
Focus on Chronic Care Model
But reimbursement based on PCMH certification
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5.Reimbursement• 17 leading insurers initially involved and
expanding• GOHCR ‘convener’ for negotiations• Goal is to support implementation of the
CCM
Reimbursement• Reimburse for time away from practice at
learning collaboratives• Benchmark payments based on NCQA
PCMH Certification (requires care management)
• Per FTE prorated by Carrier contribution of Practice’s total revenue
• In NEPA- savings shared with practices• Can be ~$30-50 K /FTE/ yr
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Strengths of the PA Approach
• Government Convener• Multi-Payer (17)• Teaching practices to change• Chronic Care Model Focus• Lots of small practices• All Practices Reporting Monthly• Scope
– 780 Providers and 1 Million Patients25
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Implementation of the Chronic Care Model in PA
A Look at the Numbers
Region Number of Practices
Total Providers FTE'S
Total Reported Patients
Average FTE's/Practice
Average Patients/FT
E
Year 1 Payments
Total Estimated
Payments By Insurers
SEPA 32 236 150.5 209,354 5 1,391 $1,965,982 $13,599,231
SCPA 25 78 65.5 136,317 3 2,081 TBD $4,711,210
SWPA 23 86 64.0 154,435 3 2,413 TBD $6,219,842
NEPA 37 103 89.0 216,049 2 2,428 TBD $6,159,615
Total 117 503 369 716,155 3 1,941 $1,965,982 $30,689,898
NWPA 16 37 37 73,964 2 2,026 $192,000
NCPA 14 81 81 75,049 6 927 $168,000
SEPA 2 23 159 159 228,078 7 1,434 $276,000
Total 53 277 277 377,091 5 1,364 $636,000
Grand Total 170 780 646 1,093,246 4 1,694 $2,601,982 $30,689,898
Charecteristics of reimbursed practices
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SEPA SCPA SWPA NEPANumber Participating Practices 25 25 22 30 Number Participating Providers 143 134 87 154Percent Urban Practices 52% 0% 50% 0%Percent At-risk Populations•African American•Hispanic
12%37%
2%2%
13%1%
3%3%
Percent of Practice Type•FQHC•Resident•Family Medicine•Internal Medicine
32% 16% 28%24%
0% 0%
80% 20%
9%0%
86% 5%
0%7%
86% 7%
Percent Practices with Providers•1 to 3•4 to 10•Greater than 10
20%76%
4%
24% 68% 8%
50% 45% 5%
67%26%7%
Government-Payer-Provider Partnership
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Outcomes Measures
• Clinical• Patient centered• Utilization• Costs
Preliminary Results: Southeastern PA
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• 25 practices working on Diabetes• 143 providers and 10,000 patients• Improvement in complication screening,
evidence based medication use, and clinical outcomes
• NCQA certification
Evidence Based Treatment
0
10
20
30
40
50
60
70
Aspirin Statin* ACE/ARB* SM Goal
Baseline Mean
Value at One Year
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Early Cost Data From One Major Insurer in SE
• First year of SEPA practices saw:• 26% decrease in hospital admissions • 30% decrease in emergency room visits• 16% decrease in overall costs
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Questions
• How is Success Determined and Who Defines Success?
• What parts of the intervention are most important
• Spreading to all Chronic illness Care
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It Takes a Team…..• Governor’s Office of Health Care Reform –
Ann Torregrossa, Phil Magistro, Brian Ebersole, Gregory Howe and of course the Governor
• Ed Wagner, Michael Bailit, Connie Sixta, the brave practices, and many, many more
• PA Association of Family Practice/Improving Performance in Practice (IPIP)- Pat Bricker
