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The Michigan Primary Care Consortium
Epi Division Day
Carol CallaghanNovember 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
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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
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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?
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Primary Care MUST be the Foundation of the U.S. Health
Care System
More Primary Care Physicians per100,000 population
Lower Cost+
Higher Quality
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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.
2000 2001 2002 2003 2004 20050
200
400
600
800
Primary Care
Non-Primary Care
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
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Michigan DO Experience
• $150,000 - $200,000 Debt
• Three Years GME @ $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
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Michigan’s Primary Care Physicians
The Michigan Primary Care Consortium
BACKGROUND
In 2005-06, 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
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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
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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
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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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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
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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
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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
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Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformation
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
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“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
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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
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IPIP Change Package/Key Interventions
1. Use a Patient Registry2. Initiate Team Care3. Implement Planned Visits4. Provide Self-Management Support5. Work toward PCMH-designation
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Key Learnings from IPIP1. Culture change in a medical practice
is DIFFICULT2. Leadership by a Physician Champion
in the practice is crucial to success3. Practices CAN incorporate the
Chronic Care Model into their operations
4. Industrial engineers can help medical practices improve quality and efficiency
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Funding for the Michigan Primary Care Consortium
From 2005-2009, 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?
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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
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Michigan Primary Care Consortium
Priorities
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2009 White Paper SeriesPrimary Care is in Crisis
Part 1: Primary Care is in CrisisPart 2: Transform Primary Care
Practices and Reform the Payment SystemPart 3: Activate ConsumersPart 4: Rebuild the Primary Care
Workforce
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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 ReformLead: 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
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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 PCMH2. 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
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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)
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Top Priority Objectives
REBUILD PRIMARY CARE WORKFORCE
Create a Workforce State Plan (Dec 2010)
Convene Stakeholders (Feb 2011) Engage HRSA
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Important New Developments
Opportunities in Health Care Reform Law (PPACA):o PCMH and Accountable Care Organization (ACO) demonstrationso Elimination of co-pays and deductibles for high-value preventive serviceso 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 participateo All Michigan-based payers to participateo 1.8 million Michigan residents to be servedo $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
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Michigan Primary Care Consortium
For more information about the MPCC: www.MIPCC.org
[email protected] (517) 335-8368