The Michigan Primary Care Consortium Epi Division Day Carol Callaghan November 10, 2010

W.H.O. on Acute vs. Chronic Care “Health care systems [throughout the world] evolved around the concept of infectious disease, and they perform best when addressing patients’ episodic and urgent concerns. However, the acute care paradigm is no longer adequate for the changing health problems in today’s world. Both high- and low-income countries spend billions of dollars on unnecessary hospital admissions, expensive technologies, and collection of useless clinical information. As long as the acute care model dominates health care systems, health care expenditures will continue to escalate, but improvements in the population’s health status will not.” World Health Organization. Innovative care for chronic conditions: building blocks for action: global report. (Geneva: WHO; 2002.)

Health Care Spending In 2007, the U.S. spent $2.2 trillion — or more than 16% of its Gross Domestic Product — on health care. We spend more than any other country, yet our health system continually underperforms and lags behind less advanced countries. 3

Copyright ©2008 by Project HOPE, all rights reserved. Ellen Nolte and C. Martin McKee, Measuring The Health Of Nations: Updating An Earlier Analysis, Health Affairs, Vol 27, Issue 1, 58-71

Copyright ©2008 by Project HOPE, all rights reserved. Ellen Nolte and C. Martin McKee, Measuring The Health Of Nations: Updating An Earlier Analysis, Health Affairs, Vol 27, Issue 1, 58-71

6 Broken US Health Care System  Ever-rising costs of health care  Rising rates of uninsured, underinsured  Flat or worsening health status indicators  Significant health disparities  Unimpressive quality indicators  Rising dissatisfaction by nearly everyone  Aging population means greater demands on health care system

7 Primary Care System in Crisis Fragmented, uncoordinated patient care Inconsistent delivery of evidence-based care, especially preventive and chronic care Misaligned reimbursement system (volume, not value) Increasing expectations by payers and purchasers impacting providers’ quality of life Shrinking primary care workforce (i.e., physicians, NP’s, PA’s, others) Will primary care survive?

8 Primary Care MUST be the Foundation of the U.S. Health Care System More Primary Care Physicians per 100,000 population Lower Cost + Higher Quality

9 National MD Experience

Number of Residents 2000 to 2005 * Combined Primary Care/Specialty Residents, e.g. FM/ER, are Counted as a.5 FTE, all FM & IM Emphasis and Track Interns are Included in these Numbers as well as MDs who participate in SCS programs. Traditional interns are not included Primary Care Non-Primary Care Primary Care Non-Primary Care Michigan DO Experience

$150,000 - $200,000 Debt Three Years $40-45,000/Year What would be YOUR choice? Starting Salaries: Family Practice$120,000 - $150,000 Internal Medicine$120,000 - $175,000 Pediatrics$110,000 - $125,000 Orthopedic Surgery $250,000 - $400,000 Cardiology$250,000 - $400,000 Medical Opportunities in Michigan, 2006 Data 11 Medical School Perspective

Ideal: 50% Primary Care Physicians (Pew Commission Report on Health Care Workforce) Of 29,000 Michigan MD/DO’s providing patient care  35% are in primary care specialties  43% of all current physicians plan to retire or stop practicing in the next 1 – 10 years  Less than 5% of new grads in nation apply for primary care residencies 12 Michigan’s Primary Care Physicians

The Michigan Primary Care Consortium BACKGROUND In , 130+ Michigan professionals developed strategic recommendations to address the crisis in primary care. Five barriers to effective primary care identified: Misaligned reimbursement system Underuse of patient registries, other HIT Underuse of evidence-based guidelines Underuse of community resources to assist patients Practices poorly designed to deliver effective chronic care

14 The Mission of the MPCC  The MPCC is a collaborative partnership of organizations concerned about the survival of primary care  The MPCC was created to improve preventive and chronic care  The MPCC is committed to aligning existing QI initiatives, addressing gaps, and engaging in problem-solving

Michigan Primary Care Consortium The MPCC spent its early years: Convening organizations concerned about the rising incidence of preventable health conditions, spiraling health care costs, and the survival of primary care Gathering information on the huge challenges of inadequate reimbursement for primary care services and the looming workforce shortages Building consensus on the actions needed 15

Strategies to Solve Michigan’s Primary Care Crisis (2008) Transform practices to Patient-Centered Medical Homes (PCMH) Increase reimbursement for Primary Care Professionals in PCMH practices Rebuild the supply of MDs/DO’s, NP’s, and PA’s working in Primary Care Activate consumers for self-care

17 Professional & Trade Associations (15) Insurers and Payers (11) Health Systems and Centers (7) Physician Organizations (26) Businesses (10) Regional QI Initiatives (4) Public Health Organizations (5) Academia (14) Consumer Organizations (4) Others (8) as of Oct 2010 MPCC Membership: 100+

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19 MPCC Committees  Board of Directors and Executive Committee – Chair, Janet Olszewski, MDCH  Priorities – Chair, Kim Sibilsky, MPCA  Communications – Chair, Rebecca Blake, MSMS  Governance – Chair, Dennis Paradis, IHCS-MSU  Funding – Chair, Lody Zwarensteyn, AFH  Strategic Planning – Chair, Larry Wagenknecht, MPA

Michigan Primary Care Consortium 20 Since 2008, MPCC activities have focused on Promoting redesign of primary care practices to become Patient-Centered Medical Homes Promoting adoption of health information technology to improve safety, quality and efficiency of care Promoting strategies to ensure that evidence-based preventive and chronic disease care are the norm Linking payment reform to PCMH Planning how to increase access to community health resources Helping consumers become engaged members of their health care team Building consensus on how to rebuild the workforce

21 Patient-Centered Medical Home PCMH is an approach to providing comprehensive, team-based primary care for children, youth, adults and seniors based on the Chronic Care Model PCMH is a health care setting that facilitates partnerships between patients and their personal physicians and health teams and, when appropriate, the patient’s family or caregivers A PCMH makes effective use of community resources and supports to assist patients and families to achieve their health goals

22 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model Outcomes

Features of the Patient-Centered Medical Home Foundation: Chronic Care Model Other Features: Personal physician/primary care provider Multi-disciplinary team care Whole-person orientation Comprehensive care Care is proactive and coordinated Quality and safety are hallmarks Self-management is taught and supported Enhanced access to care Reimbursement policies recognize added value

24 “Improving Performance in Practice” Program The American Board of Medical Specialties created National IPIP to support new physician recertification requirements, with funding from Robert Wood Johnson Foundation 7 states were provided with program materials and 2 years of seed money; MPCC’s successful application made Michigan the third state selected

25 Michigan IPIP: A Unique Partnership with Industry MPCC enrolled 35 primary care practices in a year-long learning collaborative MPCC and AIAG trained 100+ QI engineers from the auto industry on primary care practice operations and priorities Practices were charged with implementing a Change Package and working toward PCMH-designation Each practice was coached by one or more volunteer QI engineers to improve practice efficiency and reduce wasted time and money through standardization and “change” techniques

26 IPIP Change Package/ Key Interventions 1. Use a Patient Registry 2. Initiate Team Care 3. Implement Planned Visits 4. Provide Self-Management Support 5. Work toward PCMH-designation

27 Key Learnings from IPIP 1. Culture change in a medical practice is DIFFICULT 2. Leadership by a Physician Champion in the practice is crucial to success 3. Practices CAN incorporate the Chronic Care Model into their operations 4. Industrial engineers can help medical practices improve quality and efficiency

28 Funding for the Michigan Primary Care Consortium From , MDCH state funds supported MPCC staffing and other infrastructure needs In 2010 and beyond, no further state funding is available What alternatives exist? Long term sustainability?

29 Michigan Primary Care Consortium MPCC became a non-profit corporation in Michigan early in 2010 Application to IRS was approved for a 501(c)3 charitable tax status, retroactive to January 2010 Serious fund-raising efforts are underway

30 Michigan Primary Care Consortium Priorities

White Paper Series Primary Care is in Crisis Part 1: Primary Care is in Crisis Part 2: Transform Primary Care Practices and Reform the Payment System Part 3: Activate Consumers Part 4: Rebuild the Primary Care Workforce

32 White Paper Recommendations  White Papers contained over 51 recommendations. Of these, 12 were identified as most important  30 objectives for achieving the most important recommendations were identified  Further prioritization identified 9 objectives for achievement in 2010  Action Groups created implementation plans for the priority objectives

MPCC Action Groups 1.Practice Transformation Leads: Ernie Yoder, MD, PhD, St John Health System and Larry Abramson, DO, Pontiac Osteopathic Hospital 2.Payment Reform Lead: Mary Beth Bolton, MD, Health Alliance Plan 3.Consumer Engagement and Empowerment Lead: Stacey Hettiger, MSMS 4. Rebuilding the Primary Care Workforce Lead: Kevin Piggott, MD, MPH, Marquette General Hospital /Marquette Co. Health Department 33

Top Priority Objectives PRIMARY CARE PRACTICE TRANSFORMATION Promote Health Information Technology (HIT) including all-patient registries, EMR/EHR, e-Rx Create PCMH Toolkit Prepare providers to teach Self-Management to their patients Assess options for providing relevant Community Resources 34

Top Priority Objectives PAYMENT REFORM All-Payer Agreements on: 1. Michigan definition of PCMH 2. Components of PCMH to incent in 2010 (and beyond) using common metrics: a) Expanded Hours b) Use of All-Patient, All-Payer Registry c) Use of E-Prescribing 35

Top Priority Objectives CONSUMER ENGAGEMENT AND ACTIVATION Teach Health Self-Management to Consumers Teach Health Literacy in the Michigan Model for Comprehensive School Health Education (on hold) 36

Top Priority Objectives REBUILD PRIMARY CARE WORKFORCE Create a Workforce State Plan (Dec 2010) Convene Stakeholders (Feb 2011) Engage HRSA 37

Important New Developments  Opportunities in Health Care Reform Law (PPACA): o PCMH and Accountable Care Organization (ACO) demonstrations o Elimination of co-pays and deductibles for high-value preventive services o Enhanced Medicare and Medicaid reimbursement for primary care providers  State policies will support OR will impede health reform  CMS Multi-payer Medical Home Demonstration

MPCC Accomplishments to Date  Published White Paper series on the Crisis in Primary Care  Detailed Action Plans for implementation of 2010 priorities  Consensus among Michigan-based payers on PCMH definition, components to be incentivized, common metrics  Major consultation project – IPIP – assisted 35 practices transform to PCMH and demonstrated value of quality engineers from industry  Expansion of membership from 35 to 112 organizations  Transition to non-profit corporation with charitable tax status  Creation of application that MDCH submitted to CMS for a Multi-Payer Medical Home Demonstration: o 500 primary care practices to participate o All Michigan-based payers to participate o 1.8 million Michigan residents to be served o $130 million to Michigan from Medicare

The Michigan Primary Care Consortium Message Comprehensive, coordinated, whole-person care that is adequately reimbursed should be available in every primary care setting in Michigan 40

41 Michigan Primary Care Consortium For more information about the MPCC: (517)