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

2. 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.)

3. 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 3

4. 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.

5. 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.

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 6 6

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? 7 7

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 8 8

9. National MD Experience

10. Michigan DO Experience
Number of Residents 2000 to 2005
800
600
Primary Care
400
Non-Primary Care
200
2000
2001
2002
2003
2004
2005
Primary Care
367.5
318.5
281.5
289.5
261.5
276
Non-Primary Care
499.5
493.5
530.5
593.5
629.5
703
*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.

11. Medical School Perspective
$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 11

12. Michigan’s Primary Care Physicians
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 12

13. 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 14 14

15. 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

16. 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. MPCC Membership: 100+ 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

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

20. Michigan Primary Care Consortium
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 21 21

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

23. 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 24 24

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
Use a Patient Registry
Initiate Team Care
Implement Planned Visits
Provide Self-Management Support
Work toward PCMH-designation 26 26

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

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

31. 2009 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
Papers defined problems, Identified potential solutions, Recommended actions for MPCC to take
Papers laid the foundation for collaborative efforts to resolve the primary care crisis.

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

33. MPCC Action Groups
Practice Transformation Leads: Ernie Yoder, MD, PhD, St John Health System and Larry Abramson, DO, Pontiac Osteopathic Hospital
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

34. 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 34

35. 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

36. 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)

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

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

39. 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:
500 primary care practices to participate
All Michigan-based payers to participate
1.8 million Michigan residents to be served
$130 million to Michigan from Medicare

40. 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

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