1. The Michigan Primary Care Consortium MPCC Member Orientation. March 5, 2010

2. The Primary Care Crisis

3. 3 National MD Experience

4. 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. 200020012002200320042005 0 200 400 600 800 Primary Care Non-Primary Care Primary Care367.5318.5281.5289.5261.5276 Non-Primary Care499.5493.5530.5593.5629.5703 4 Michigan DO Experience

5. Ideal: 50% Primary Care Physicians (Pew Commission Report on Health Care Workforce) Michigan: 35% Primary Care Physicians, of which 43% plan to retire or stop practicing within ten years (MDCH Survey of Physicians 2008) 5 Michigan’s Primary Care Status

6. $150,000 - $200,000 Debt Three Years GME @ $40-45,000/Year Take 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) 6 Medical School Perspective

7. YearInflationMedicaidMedicareBCBSM 20053.39-2% (-4% for 6 months) 1.5%2% 20042.6801.5%2% 20032.2701.4%2% 20021.5911%*-4.8%2% 20012.8305.0%2% 20003.3805.5%1.5% 19992.1902.3%1.6% (2% for 8 months) 19981.5502.3%.8% 19972.340.6%2.4% 19962.930.8%2% Totals25.1%9%16.1%18.3% *Medicaid HMOs received an 11% increase for physician services. The amount that flowed to physicians is unknown. 7 How does Michigan’s reimbursement compare to inflation?

8. FIN Per Capita Health Care Expenditures Primary Care Score 8 Primary Care Score vs. Health Care Expenditures, 1997

9. More Primary Care Physicians / 100,000 Lower Cost Higher Quality (2003 Medicare Data on “General Practitioners”) 9 Primary Care is the Foundation of the Health Care System

10. Community safety Education Family & social support Employment Built environment Environmental quality Income Unsafe sex Alcohol use Diet & exercise Tobacco use Access to care Quality of care Physical environment (10%) Social & economic factors (40%) Health behaviors (30%) Clinical care (20%) Health Factors Programs and Policies Health Outcomes Mortality (length of life): 50% Morbidity (quality of life): 50% County Health Rankings model © 2010 UWPHI

11. The Michigan Primary Care Consortium: A Brief History

12. 12 World Health Org: 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 the 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.)

13. 13 Changing Needs 1900 – 1950 Infectious disease 1950 – 2000Acute, episodic care 2000 – 2050 Chronic care Gerald Anderson, PhD – Johns Hopkins University How do we create new systems to meet today's healthcare needs?

14. Health Care Spending Fact: 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. 14

15. 15 Broken Health Care System 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 all Aging population greater demands on health care system

16. 16 Primary Care System in Crisis Fragmented, uncoordinated patient care Inconsistent delivery of evidence-based care, especially preventive and chronic care Misaligned reimbursement system 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?

17. The Michigan Primary Care Consortium BACKGROUND In 2005-06, 134 Michigan professionals developed strategic recommendations to resolve key primary care system barriers Five barriers to effective primary care: Under-use of community resources Under-use of patient registries, other HIT Under-use of evidence-based guidelines Inappropriate reimbursement system Practices not designed to deliver effective chronic care 17

18. 18 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

19. 19 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

20. 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 huge challenges like inadequate reimbursement for primary care services and looming workforce shortages Building consensus on the actions needed 20

21. 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 regarding self-care 21

22. MI Primary Care Consortium MPCC: Current Status 22

23. 23 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 (7) as of March 2010 MPCC Membership: >100

24. 24

25. 25 MPCC Committees Steering/Board of Directors and Executive – 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

26. Michigan Primary Care Consortium 26 Since 2008, MPCC activities have focused on Redesign of primary care practices to be patient-centered and efficient, and Patient-Centered Medical Homes Utilization of health information technology to improve safety and quality of care Processes to ensure that evidence-based preventive and chronic disease care are the norm Overhauling the way that primary care is reimbursed Making good use of community health resources Helping consumers become actively engaged members of their health care team Rebuilding the primary care workforce

27. 27 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 become activated and achieve their health goals

28. 28 Michigan Primary Care Consortium Improving Performance in Practice” (IPIP) Program

29. 29 “Improving Performance in Practice” Program The American Board of Medical Specialties created IPIP to support new physician recertification requirements 7 states were provided with program materials and support; Michigan was 3 rd state selected A grant, funded by Robert Wood Johnson Foundation provided 2 years of seed money to states, with states adding additional funds

30. 30 Michigan IPIP: A Unique Partnership with Industry Michigan enrolled 35 practices in a year-long learning collaborative. Practices are charged with implementing the change package and working toward PCMH Each practice is coached by one or more volunteer quality improvement engineers from industry who had received an orientation to healthcare The final Outcomes Congress will be March 24-25, 2010

31. 31 Key IPIP Interventions 1. Use a Patient Registry 2. Initiate Team Care 3. Implement Planned Visits 4. Provide Self-Management Support 5. Work toward Creation of a PCMH

32. 32 Michigan Primary Care Consortium MPCC Non-Profit Status Unanimous approval by MPCC Leadership IRS Form 1023 process: awaiting final internal approval Submission Planned before end of March 2010 Why non-profit status?

33. 33 Michigan Primary Care Consortium MPCC Funding Efforts No more fiscal support from the State of Michigan for infrastructure No fiscal support for implementation of priorities other than in-kind Long term sustainability?

34. 34 Michigan Primary Care Consortium Priorities Michigan Primary Care Consortium

35. 35 2009 White Paper Series Primary Care is in Crisis Part 1: Primary Care is in Crisis Part 2: Transform Primary Care Practice and Payment Part 3: Activate Consumers of Primary Care Part 4: Rebuild the Primary Care Workforce

36. 36 White Paper Recommendations  The white papers contained over 51 recommendations. Of these, 12 were identified as most important.  30 objectives for achieving the important recommendations were identified  Action Groups were formed to create implementation plans for the objectives

37. 37 MPCC Action Groups Created Implementation Plans for 30 Objectives Objectives and plans were further ranked and categorized: 9 were Top Priority Plans to be achieved by end of 2010 11 were Logical “Next Steps” to be implemented when top priority plans are implemented 10 were deemed beyond MPCC’s current capacity to implement, but could be implemented if a member organization agreed to sponsor and staff them

38. MPCC Action Planning Groups 1.Practice Transformation Leads: Ernie Yoder, MD, St John Health System and Larry Abramson, DO, POH 2.Consumer Engagement and Empowerment Lead: Stacey Hettiger, MSMS 3.Rebuilding the Primary Care Workforce Lead: TBD 38

39. Top Priority Objectives FOCUS AREA 1: PRIMARY CARE PRACTICE TRANSFORMATION Promote Health Information Technology (HIT) Create PCMH Toolkit Spread PCMH throughout Michigan Prepare Providers to Teach Self-Management Assessing Need/Demand for Community Resources Determine the Cost of Creating a PCMH 39

40. Practice Transformation Activities A HIT Handbook will help practices prepare for, purchase and implement EHR systems A PCMH Toolkit is available that includes web- accessible resources to assist practices meet BCBSM’s PGIP and NCQA’s PCMH requirements PCMH Spread Group will be surveying physician organizations to: Determine their capacity to support their practices working toward PCMH recognition Identify whether / how MPCC might assist 40

41. Practice Transformation Activities (cont.) Self-management support resources for practices are being assembled. The workgroup is identifying strategies to make these accessible to practices Consideration of what community resources are needed in communities to address medical and social determinants of health, and how to identify, use and align different resource databases, including 2-1-1 41

42. Top Priority Objectives FOCUS AREA 2: CONSUMER ENGAGEMENT AND ACTIVATION Teach Self-Management to Consumers Teach Health Literacy in the Michigan Model for Comprehensive School Health Education 42

43. Top Priority Objectives FOCUS AREA 3: REBUILD PRIMARY CARE WORKFORCE Create a Workforce State Plan Convene a Strategic Partnership Conference with HRSA 43

44. Top Priority Objective FOCUS AREA 4: PAYMENT REFORM Accomplishments - All-Payer Agreements on: 1. Michigan definition of PCMH 2. Components of PCMH to incent in 2010 using common metrics: a) Expanded Access b) Use of Registry c) Use of E-Prescribing 3. Discussion on measures for 2011 is underway 44

45. In summary: MPCC is helping the primary care community to: Redesign primary care practices to be patient-centered and efficient Improve safety and quality of care by using health information technology Make evidence-based care the norm Overhaul the way that primary care is reimbursed Help consumers become active engaged members of their health care team Ensure there are sufficient primary care providers

46. 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. 46

47. 47 Michigan Primary Care Consortium For more information about the MPCC: www.MIPCC.org PCCstaff@MIPCC.org (517) 241-7353