1 Swedish Community Health A Medical Home Pilot With an Innovative Payment Model Carol Cordy, MD, Clinical Site Director Mark Johnson, MD, Residency Site Director Miranda Lu, MD, Faculty

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3 Clinic History Opened March 31, 2009 Basic PCMH concepts from day one Residency training site Hospital supported Mixed payment model

4 Current Staff Clinical: Six family medicine residents Three clinical faculty One family medicine nurse practitioner Two nurses Non-Clinical: Patient services representative Clinic coordinator Part-time clinic manager ~2.0 FTE provider staff with 4.5 FTE paid support staff

5 Other Staff One consulting psychiatrist Two clinical psychologists One diabetes educator Two on-call social workers New – data analyst Residency and hospital employees

6 Medical Home Components Longer visits Same or next day appointments Patient centered care Evidence based care 24 hour physician telephone access Data collection EHR (EPIC)

7 Services Provided Full spectrum family medicine Preventive care Immunizations Minor procedures 15 point of care labs Psychological care

8 Services Not Included Other labs Radiology Pathology Specialty care Casting

9 Residency Site Needs Patient-centered Medical Home model Variety of ages Diversity of medical conditions Broad range of socioeconomic status

10 Alternative Payment Models in Patient-Centered Medical Homes Concierge Practice A – high monthly fee for personalized care – insured patients only ($208/mo) – no FFS Concierge Practice B – monthly fee for personalized care – catastrophic insurance encouraged ($50 - $120/mo depending on age) – no FFS

11 Alternative Payment Models in Patient-Centered Medical Homes Low overhead practices – providers with front desk and billing department – all FFS Monthly Self-Pay for limited coverage for uninsured – majority of practice FFS Our Model – mixed payment model – FFS plus monthly fees – self-pay and insured with goal of 100% monthly fees (PMPM)

12 Problems with Fee for Service Rewards over-utilization of services Fails to recognize differences in provider quality and/or performance Encourages use of high-reimbursement services Fails to compensate for care coordination Bases payment on what the market will bear rather than health care value Fails to use provider incentives

13 100% PMPM Mixed Payment Model Patient health is our bottom line FeatureBenefits No co-payPatientClinic No FFS billingPatientClinicInsurance plan No collectionsPatientClinic Pay per performancePatientClinicInsurance plan Shared cost savingsClinicInsurance plan Accountability to patient and insurer PatientInsurance plan

14 More Benefits for Patients and Insurance Companies Primary Care (cure for health care crisis) Reduced ED visits Reduced hospitalizations Reduced referrals to specialists Reduction in unnecessary labs and imaging Healthier patients

15 Our Mixed Payment Model Private Insurance - PMPM Molina/Medicaid - PMPM Self-Pay - PMPM Medicare - FFS Medicaid - FFS Financial assistance

16 Private Insurance Contracted with Premera – Blue Cross – not for profit insurance company in Washington and Alaska Paid on per member per month basis plus pay for performance Covers all serviced provided within the clinic ’ s walls ED, hospitalization, specialists, labs, imaging covered by Premera

17 Private Insurance Contracted with Molina – a Medicaid for- profit insurance company Paid on per member per month basis plus pay for performance Covers all services provided within the clinic ’ s walls ED, hospitalization, specialists, labs, imaging, medications covered by Molina

18 Self-Pay Patients with no insurance (or with insurance who want to enroll) pay $45 a month for all services covered within the walls of the clinic – clinic is contracted with the hospital for discounts on some lab and imaging services Patients encouraged to sign up for a catastrophic insurance plan to cover ED visits and hospitalizations

19 Self-Pay - continued Patient are given names of local pharmacies where they can purchase generic medications for $4 a month and $10 for three months Patients need to pay for sub-specialty care Patients need to pay for labs and imaging studies not done in the clinic

20 Medicare Hoping to contract with Medicare Advantage Plan – uncertain with health care reform bill At present Medicare patients are billed on a fee for service basis

21 Financial Assistance Patients with income under 200% of poverty or who are self-pay and cannot afford labs or imaging can apply for financial assistance through the hospital Patients may also qualify for other government programs that cover contraception, mammograms, paps and colon cancer screening

22 How Have We Done? Private Insurance – Contract signed with Molina for Medicaid patients - August 2009 and Premera – November 2009 Contracted with First Choice – hospital employees – January 2010 Self-Pay – word of mouth and media Medicaid – Some still FFS Medicare – All FFS Financial Assistance

23 Percentage to Goal 75% of our patients are paying or their insurance is paying on a PMPM basis 25% of our patients are still being billed on a FFS basis so billing still necessary

24 Rewards of PMPM Model for physicians Simplified billing Smaller back office staff Flexibility to deliver the care the patient needs Offering primary care to the uninsured for a nominal monthly fee A clinic-wide goal of patient care -- not productivity Patient’s health is our bottom line

25 Advantages for Patients Family physician-led care Patient Centered Medical Home Longer Visits/ Increased access Comprehensive Care Continuity of Care Team Care A clinic that adapts to meet their needs

26 Challenges Negotiating more contracts with private insurers Changing state laws for PMPM payment models Competition vs cooperation with private insurers Collecting monthly fees when credit and debit cards don ’ t work (dis-enrolling patients) Collecting data for insurers - difficult with present EHR Falling back into “old habits”

27 Challenges Goal of 100% PMPM payment may be unrealistic because of need to include Medicare and Medicaid patients Unknown impact of health care reform on clinic payment model Replicating this model in other sites Integrating residency education into this model Pricing obstetrical care

28 QUESTIONS

29 THANK YOU