1. Analyzing the Successful PCMH: What is Different
16th Annual International Summit on Improving Patient Care in the Office Practice & the Community
March 17, 2015
Dallas, TX
Amber Carlson, MS, CES
Program Manager
HealthTeamWorks®
Dave N. Gans, MSHA, FACMPE
Senior Fellow, Industry Affairs
Medical Group Management Association

2. Learning Objectives ihi.org/Summit
This session will provide you with the knowledge to:
Describe how a PCMH differs from a traditional primary care practice in panel size, level of staff support, and new forms of patient communication
Detail the revenue impact of new payment models on PCMH and non-PCMH primary care practices
Identify the demographic profile, staffing level, provider productivity model, and reimbursement method of PCMHs with the best financial performance
What do you want to accomplish with today's presentation?
ihi.org/Summit

3. What Is a Patient Centered Medical Home?
The Patient-Centered Medical Home is an approach to providing comprehensive primary care for children, youth and adults. The Patient-Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family AAFP, AAP, ACP, AOA
ihi.org/Summit

4. Transforming a Primary Care Practice to a PCMH
The practice’s EHR is used not only for its medical record capabilities but also as a quality tool and to schedule preventive services for individual patients
Patient registries are used to evaluate and improve the health status of patient populations
Hours are expanded to facilitate patient access
Electronic communications with patients is common
Patient education and patient self management of chronic disease is emphasized
The patient and family are engaged to accept personal responsibility for care
Each of these changes incurs a cost for the PCMH practice
Insert story of practices not understanding it is a process vs a destination and how it effects everything they do
ihi.org/Summit

5. The Benefit of Being a PCMH
Aggregated outcomes from the 28 peer-reviewed studies, state government program evaluations, and industry reports:
17 found improvements in cost
24 found improvements in utilization
11 found improvements in quality
10 found improvements in access
8 found improvements in satisfaction
ihi.org/Summit

6. PCMH Transformation ihi.org/Summit
Meeting the accreditation / recognition standard
Additional infrastructure
Enhanced electronic health record and registries
Enhanced telecommunications
Larger clinical facilities to accommodate new functions 
Additional services
Nutrition counseling
Patient education
Care coordination for referrals and hospital discharge
Chronic care management
Mental health counseling
Expanded access
Story of practice doing an assessment and identified they needed a CAC vs a general behavioral health person
Story of practice utilizing Exercise Physiologists to address nutrition and exercise and some other general care management pieces
ihi.org/Summit

7. Cross Sectional Comparison of PCMH and Non-PCMH Primary Care Practices
MGMA Cost Survey – 2014 Report based on 2013 Data
Electronic questionnaire of MGMA members and customers in April 2013
2,518 total responses
215 hospital owned primary care and multispecialty participants (67 PCMH and 160 non-PCMH)
141 independent primary care and multispecialty participants (30 PCMH and 101 non-PCMH)
MGMA Patient-Centered Care: 2012 Status and Prospects Report
Electronic questionnaire of MGMA members and customers in February 2012
1,257 total responses
657 primary care practices (244 PCMH and 393 non-PCMH)

8. FTE Staff per FTE Physician
Story of Cigna looking at 2 MA’s per physician to increase productivity
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

9. FTE Staff per FTE Physician
Story of the value of looking at the type of staff you really need: San Joaquin hiring an admin person to help in the back for reporting and tracking of items to increase efficiency, continuity of care and care coordination
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

10. Productivity per FTE physician
Median Panel Size: ,063 2,400
Median Work RVUs: 5, ,447
Median Square Feet: 2,008 1,827
PCMH
Not a PCMH
Story around design of a practice space – POD vs traditional model (Cigna example)
Source: MGMA Cost Survey: Report Based on 2013 Data
ihi.org/Summit

11. How Staffing Changed as a Result of Becoming a PCMH
*Maybe move the story of San Joaquin here…
Percentage of respondents answering "Mild increase" or "Considerable increase“
Source: MGMA Patient Centered Care Status and Needs Study
ihi.org/Summit

12. New Functions for Patient-Centered Care
*this is going to look different in each practice based on size. Care manager example from large to small system
Source: MGMA Patient Centered Care Status and Needs Study
ihi.org/Summit

13. How Expenses Changed as a Result of Becoming a PCMH
Percentage of respondents answering "Mild increase" or "Considerable increase“
Source: MGMA Patient Centered Care Status and Needs Study
ihi.org/Summit

14. Comparing Revenue and Expenses per FTE Physician
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

15. Comparing Expenses per FTE Physician
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

16. Comparing Revenue and Cost per Patient per Year
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

17. How PCMH Practices Are Paid
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

18. Type of PCMH Payment Impact on Total Medical Revenue
* Insufficient data
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

19. Proposed Medicare Payment for Chronic Care Management Services
2015 Medicare Fee Schedule Final Rule
“As we discussed in the CY 2013 PFS final rule with comment period, we are committed to supporting primary care and we have increasingly recognized care management as one of the critical components of primary care that contributes to better health for individuals and reduced expenditure growth (77 FR 68978).”
“In the CY 2014 PFS final rule with comment period, we finalized a policy to pay separately for care management services furnished to Medicare beneficiaries with two or more chronic conditions beginning in CY 2015 (78 FR 74414).”
Federal Register Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2015, Pages 442 – 496
ihi.org/Summit

20. Creating CPT 99490, Chronic Care Management Services
CPT code (Chronic care management services) at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
Comprehensive care plan established, implemented, revised, or monitored
ihi.org/Summit

21. Payment for CPT 99490 May Provide Additional Revenue for PCMH
Even if a practice is not paid for being a PCMH per se, it can benefit by providing CCM services
CMS has established a payment rate of $40.39 for CCM that can be billed up to once per month per qualified patient
ihi.org/Summit

22. Understanding Profit and Loss in Physician and Hospital Owned Practices
In Physician-Owned Practices
Physician Compensation
Revenue
Costs
Operating Loss or Gain
In Hospital-Owned Practices
Physician Compensation
Revenue
Costs
Subsidy from Parent
Operating Loss or Gain
ihi.org/Summit

23. Defining a “Successful” Physician Owned Medical Group
Greater than 50th Percentile for Total Physician Compensation and Benefit Cost per FTE Physician
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

24. Defining a “Successful” Hospital Owned Practice
Total Net Income Excluding Financial Support per FTE Physician
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

25. Staffing Levels in Successful PCMH Practices
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

26. Total Medical Revenue in Successful PCMH Practices
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

27. Total Operating Cost in Successful PCMH Practices
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

28. Total Physician Compensation and Benefits in Successful PCMH Practices
ihi.org/Summit

29. Total Physician Compensation and Benefits in Successful PCMH Practices
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

30. Net Profit or Loss in Successful PCMH Practices
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

31. Provider Productivity in Successful PCMH Practices
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

32. Cost per Total Relative Value Unit in Successful PCMH Practices
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

33. Payer Mix in Successful PCMH Practices
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

34. PCMH Payment Method in Successful PCMH Practices
Source: MGMA Cost Survey: 2014 Report Based on 2013 Data
ihi.org/Summit

35. Common Themes in Successful Hospital and Physician Owned PCMH
Productivity matters
Operating costs and staffing levels may be greater if the result is increased productivity
Payer mix has a minor financial impact
PCMH reimbursement has a direct impact

36. In the Future, the Successful Practice Needs to Balance Value and Costs
Both financial and non-financial metrics are needed
Payment and quality incentives should be the basis for quantifiable metrics
The practice’s information system will need to aggregate data from multiple sources and time periods
Quality
Patient Experience
Revenue
Production
Expense
Outcomes
ihi.org/Summit

37. In the Future Healthcare Environment You Need the “Right Stuff”
An environment of accountable care and value based payment will reward practices who have:
Lower utilization
Better quality
Better patient satisfaction
Better patient outcomes
Lower cost to the insurer
Which perfectly describes the successful Patient-Centered Medical Home

38. Are There Any Questions?
Amber Carlson, MS, CES
HealthTeamWorks®
Program Manager
David N. Gans, MSHA, FACMPE
Senior Fellow Industry Affairs
Medical Group Management Association®
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