THE CHANGING ROLE OF THE PHYSICIAN IN THE

COORDINATED CARE MODEL

Ron Stock MD MA2014 John Alsever MD Lecture

The Foundation for Medical ExcellenceOctober 11, 2014

Objectives

Describe the healthcare delivery and financial

changes occurring with the Oregon Coordinated

Care Model

Outline the impact that these changes are

having on the professional and personal lives of

the clinician and team members

Discuss the current and anticipated changing

roles within the clinical care team resulting from

healthcare reform

Traditional Budget Balancing

Cut people from care

Cut provider rates

Cut services

www.health.oregon.gov

The Fourth Path

Change how care is delivered to:Reduce wasteImprove healthCreate local accountabilityAlign financial incentivesPay for performance and

outcomesCreate fiscal sustainability

www.health.oregon.gov

Behaviors & Environment70%

Medical Care,10%

Genetics20%

Prevention, 4%

Medical Services96%

$2.6 Trillion

What Drives Health?

Factors InfluencingHealth

National Health Expenditures

Patient Protection & Accountable Care Act (ACA

2010) Individual mandate, health insurance exchange,

and Medicaid expansion

Reduced payments to Medicare Advantage

Created Independent Payment Advisory Board

(IPAB)

Phasing out the Part D “donut hole”

Fraud and abuse

Preventive services: Annual Wellness Exam

Center for Medicare and Medicaid Innovation

(CMMI)

Oregon Chose a New Way

Better Health, Better Care & Lower Costs

Governor’s Vision – Transform the Delivery System

Robust public process

Bi-partisan support

Federal waiver approved - $1.9B investment tied to

quality and reduction in costs

New coordinated care model starting in Medicaid, aiming

to spread to other state purchased coverage, and into

Oregon’s Health Insurance Exchange, private payers

Oregon Healthcare Reform Programs

Coordinated Care Organizations (CCO) Patient-Centered Primary Care Medical Home

State PCPCH (Patient Centered Primary Care Home) PCPCH Institute FQHC Advanced Primary Care Practice Demo Comprehensive Primary Care Initiative

Independence at Home Demonstration Community-based Care Transitions Program Grants: TopMed; Health Commons; Adult Quality

Measures; Statewide Innovations Model grant

Coordinated care organizations

• There are 16 CCOs serving every part of Oregon • Governed by a partnership between health care

providers, consumers, those taking financial risk. • Consumer advisory councils• Mental, physical, and dental care held to one budget• Responsible for health outcomes and receive

incentives for quality• Budgets grow at 3.4% per capita per year

2013-2015 CCO budget is 2 percentage points per capita below national growth trends.

13

Key Levers for Transforming Health Care Delivery

Benefits and services are

integrated and coordinated

One global budget that grows at a fixed rate

Local flexibility

Local accountability for health and

budget

Metrics: standards for

safe and effective care

Meeting the Triple Aim: what we are seeing so far…

CCOs serve over 90 % of Oregon’s Medicaid population

Every CCO is living within their global budget.

The state is meeting its commitment to reduce Medicaid spending trend on a per person basis by 2 percentage points.

Progress may not be linear but data are encouraging.

Results So Far Decreased emergency department visits and

expenditures

Increased primary care visits and expenditures

Increased enrollment in patient-centered primary care homes

Increased adoption of electronic health records

Decreased hospitalization for congestive heart failure, COPD, and adult asthma

Decreased all-cause hospital readmissions

Oregon Patient Centered Primary Care Home

HB 2009 established the PCPCH Program:Create access to patient-centered, high quality care and

reduce costs by supporting practice transformation

CMS Comprehensive Primary Care

Initiative (CPCi) Four year, multi-payer collaboration between

CMS and statewide private payers; 67 practices; 552 clinicians; 48,000 beneficiaries

Redesign of the primary care practice Seven (7) demonstration regions/”markets” (AR,

CO, NY, OH, KY, NJ, OK, OR) New payment model

Monthly per-member-per –month (PMPM) management fee

In years 2-4, potential to share in savings

What Do Physicians Think?

Study Aim: To assess the impact of the Oregon Coordinated Care Organization (CCO) model of care development on the practicing physician and other clinical providers.

Qualitative Study: Interviews and Field Notes March to October 2013

OHSU IRB-approved

Recruitment: 3 CCO’s; 38 email contacts/26 agree/22 completed

Standard Interview Guide (30-45 minutes)

Personal… ‘For me, the idea of a CCO can easily be aligned with our

mission in the medical group, and can easily be aligned with my perspective on medicine my whole life…’

‘…if I’m on committees, taking time away from my family to go to those meetings that are early or after work. So I think that’s probably the main impact in my personal life and to my kids.’

‘I think that having physician autonomy... is one of the things that makes our job more satisfying… having some control over what my job is and how my patients are taken care of.’

‘I feel increasingly, sometimes very badly for young physicians, because they’re going to come out into this world and they have responsibility in so many different directions. And I’m not sure we’re preparing them for that.’

Professional… Those patient relationships are what sustain you in

practice…people that you work with, your colleagues and staff, the good you feel you’re doing for the people that you’re caring for in a situation where you’re the leader of a team, that could potentially suffer…

I think there will be much more interaction, much more exchange of information, much more collaborative work, particularly around best evidence based, best practices, etcetera…

I think we, as physicians, are going to be responsible for a larger population with a broader team that’s helping us take care of that population.

We’re going to be pretty strictly monitored as it relates to are we doing things that people expect us to be doing and are we documenting it appropriately? And so I think that will be challenging.

Professional…

I think that ultimately primary care physicians will probably do better. It's a zero sum game in that there's going to be winners and losers.

What I understand is that there’s a lot of money available in the short run to get these organizations going, and that will go away, and that we will be at risk for the health of the population.

I think there’s been a lot of anxiety…would not be able to afford to stay in business if they weren’t part of something larger.

And contextual…

Primary care vs Specialist

Rural vs Urban

Self-employed vs Health System

employed

Older vs Younger doc

Key Levers for Success and Clinician Impact

“Horses are out of the barn…”

Levers Leadership Financial alignment Community engagement Integration of physical,

behavioral, oral health Accountability and transparency Workforce needs and

development

“The innovation part of it, I think is exciting, bringing a freshness to work. It’s also exciting that feeling…we are on the cutting edge of healthcare reform, and so I think that it’s very invigorating”

-Primary Care Physician, Private Practice