steve mcdermott: connecting the dots

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Connecting the Dots: Integrating Services Across Small Practices May 6, 2009 Nuffield Trust Steve McDermott, CEO Hill Physicians Medical Group G:\CorpSvc\APowerpnt\SM\National Health System GB 050609.ppt

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Page 1: Steve McDermott: Connecting the dots

Connecting the Dots: Integrating Services Across Small Practices

May 6, 2009

Nuffield Trust

Steve McDermott, CEO

Hill Physicians Medical Group

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y p

Page 2: Steve McDermott: Connecting the dots

Steve McDermottCEO, Hill Physicians Medical Group, Inc.Chairman, PriMed, Inc. San Ramon, California

Steve has been Chief Executive Officer of Hill Physicians Medical Group since heSteve has been Chief Executive Officer of Hill Physicians Medical Group since hehelped organize it in 1984. Steve is also the Chair/CEO of PriMed, the MSO thatmanages Hill Physicians. Steve also helped create the Integrated HealthcareAssociation (IHA), a unique multi-disciplinary organization of high level health careexecutives As chair of IHA Steve spearheaded the statewide Pay for Performanceexecutives. As chair of IHA, Steve spearheaded the statewide Pay for Performanceprogram for California medical groups that launched the Pay for Performancemovement. Prior to developing Hill Physicians, Steve was CEO of MedAmerica, amedical management company that organized and managed hospital-basedh i i i 50 h it l i i t t F 1973 1976 St l d th ti f thphysicians in 50 hospitals in six states. From 1973-1976, Steve led the creation of the

San Francisco Bay Area Emergency Medical System serving as its initial ExecutiveDirector. He obtained a bachelor’s degree in business from Providence College in1969 and a master's degree in business and health care administration from GeorgeW hi t U i it i 1971

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Washington University in 1971.

Page 3: Steve McDermott: Connecting the dots

Paul C. Smith, M.D.

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First President of Hill: General Surgeon Fellow of the Royal Academy

Page 4: Steve McDermott: Connecting the dots

Connecting the Dots: Integrating Services Across Small Practices

1. Background on Hill1. Background on Hill2. Leveraging Technology3 K I iti ti3. Key Initiatives4. Pay for Performance5. Final Thoughts

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Page 5: Steve McDermott: Connecting the dots

1.Background on Hill Physiciansg y

America’s Largest IPA2,600 physicians/34 affiliated hospitals 320,000 HMO membersDelegated care via seven HMO plans100% capitated: commercial, MediCare, Medi-CalS i 9 h C lif i iServing 9 northern California counties(about the size of Wales)88% f i h i i i l /t88% of primary care physicians in solo/two person practices

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Page 6: Steve McDermott: Connecting the dots

Context for Organizing Hill

- emphasize primary care, wellnessdi d l- coordinate care and control costs

- create ‘systemness’ and accountability- balance the table between payors, hospitals andp y , p

independent physicians and, between primariesand specialists

Challenge: getting independent professionals to work together attheir own short term expense, giving up their individualprerogatives in favor of a stronger organization aimed at a greater

dgood.

Acid test: Is the result better for their patients and society andultimately better for themselves in the long run?

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ultimately better for themselves in the long run?

Page 7: Steve McDermott: Connecting the dots

Organizational Structure

Shareholders (participating physicians who qualify); Board of Directors; formal standing committeesDirectors; formal standing committees

Chief Medical Officer, 8 Medical Directors―Accountable for geographic regionsg g p g

Chiefs of Service― 32 Specialtyp y― 17 Primary Care

PCPs organized into local panels, meet quarterly on clinical and system topicsSpecialists organized in regional panels, meet quarterlyM di l Di t h l bj ti / f bMedical Directors have annual objectives/performance bonuses

All Medical Directors/Chiefs are practicing physicians

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Page 8: Steve McDermott: Connecting the dots

PriMed: The Engine Under Hill’s HoodThe Engine Under Hill s Hood

MSO* created in 1981 organized Hill in 1984MSO created in 1981, organized Hill in 1984Exclusive manager; 455 employeesCost based budget plus performance bonus (11%)Cost-based budget plus performance bonus (11%)“Top 100 Places to Work” in SF Bay AreaO hi M di l G /M t/H it lOwnership: Medical Group/Management/Hospitals

Focus of Management Expertise, g pSystem Development and Administrative Support*M t S i O i ti

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*Management Services Organization

Page 9: Steve McDermott: Connecting the dots

2. Leveraging Technologyg g gy

Relay Health - offers Web-based secure messaging y g gplatform that facilitates online medical services for patients and doctors

2 070 ll d h i i 85 000 li i- 2,070 enrolled physicians; 85,000 + online patients- About 100,000 transactions per month

Hill inSite – online platform to verify patient eligibility, submit authorizations, check claims status and receive l i f d felectronic funds transfers- Over 1,271 active practices

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Page 10: Steve McDermott: Connecting the dots

Other Online Services

eScript (560,107 online prescriptions, 2008)Referrals to specialists (67 667 in 2008)Referrals to specialists (67,667 in 2008)Secure messages between providers and patients (340 986 in 2008)patients (340,986 in 2008)Lab results transmitted to patients

i d liAppointment requests made online77% claims online; 40% of authorization

li *requests online**AccessExpress currently being launched will greatly increase this #

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increase this #.

Page 11: Steve McDermott: Connecting the dots

Electronic Health Records

NextGen EHR solution but install andNextGen EHR solution but install and ongoing support by PriMedConsolidates all patient records across allConsolidates all patient records across all sources of care into a single, accessible databaseClinical data repository; data mining“Best practice” protocolsBest practice protocols

Multi-year effort

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Page 12: Steve McDermott: Connecting the dots

3. Key Initiativesy

Clinical Support ProgramsClinical

Predictive Modeling

Support Programs

‘Finding Balance’Predictive ModelingGroup AppointmentsPolypharmacy

Finding BalancePoint of service surveysPolypharmacy

ProgramNeurobehavioral

y‘Practice Support’Leadership Training

Pain ‘Clinical Snap-shots’

p g

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Page 13: Steve McDermott: Connecting the dots

Predictive Modelingg

Program that analyzes patient diagnostic, and lab & pharmacy dataIdentifies patients with highest probability of d l i l h i ditideveloping complex, chronic conditionsDetermined that approximately 28% of patient base at moderate or higher risk for developing orbase at moderate or higher risk for developing or exacerbating chronic conditionsPhysicians use data to better allocate time to patients with greatest needs, intervening before further complications develop.

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Page 14: Steve McDermott: Connecting the dots

Group VisitsGroup Visits

Primarily used for diabetics; also for asthmaPrimarily used for diabetics; also for asthma, migraines and other chronic diseases

Patients improved A1C control, more readily i d d i dincorporate recommended exercise and dietary plans into their lives, fewer ER

i i /h i l d i ivisits/hospital admissions

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Page 15: Steve McDermott: Connecting the dots

Polypharmacy Program Pilot

Reviewing patients who regularly take 10 orReviewing patients who regularly take 10 or more prescription medications

Identifying adverse reactions to combinations of drugs, work with physician offices to reduce patients risks

Goal: control drug costs and improve patientGoal: control drug costs and improve patient safety and quality of care

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Page 16: Steve McDermott: Connecting the dots

Neurobehavioral PainM t PManagement Program

Psychotherapists teach patients to ‘turn off’ painPsychotherapists teach patients to turn off pain using mind and body focus rather than pharmacologicalInitial results – 30 days after completing program, participants report:

71% suggest total pain reduction; 93%- 71% suggest total pain reduction; 93%report at least some pain reduction;

- 82% report total stress reduction; 97% respond with at least some stress reduction

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Page 17: Steve McDermott: Connecting the dots

Clinical Snapshotsp

Physician specific report designed to identify patients who have “fallen through the cracks” lostpatients who have “fallen through the cracks”- lost to follow up or non-compliant with treatment plan Examples:Examples: – diabetics overdue for Alc and lipid tests– patients with hip fractures who are candidates forpatients with hip fractures who are candidates for

bisphosphonates

Hill contacts members, mails requisitions and reminders

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Page 18: Steve McDermott: Connecting the dots

Helping Physicians Help Themselvesp g y p

Finding Balance in a Medical LifeFinding Balance in a Medical Life- Teaches relaxation, cognitive

restructuring and meditation skillsrestructuring, and meditation skills- 181 physicians participated with spouses

Fourth year; high levels of satisfaction- Fourth year; high levels of satisfaction- Expanded to office staff

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Point of Service Online Surveysy

Kiosks with internet connection are located in physicians’ office waiting rooms.Patients log on anonymously and complete i i hinteractive touch screen surveys.Initial survey on patient satisfaction

Creates immediate feedback to office staffCreates immediate feedback to office staffUseful for physicians who scored poorly on annual

survey and want to improveHill ffi t h t ff t ith ti tHill office outreach staff meets with practice manager to

interpret results and suggest improvement projects.

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Practice Support

Office manager assistancegPhysician recruitmentSelected subsidies for new MDsSelected subsidies for new MDsI.T. assistanceGrowing menu of servicesGrowing menu of servicesPromote group practice

- Physician recruitment- Selected subsidies for new MDs

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Practice management?

Page 21: Steve McDermott: Connecting the dots

Physician Leadership InitiativeProgram content and structure based on four levels of physician leadership that tie roles, tasks, and traits to performance

Two-year program with an average of 32 instruction hours per physicianper physician

Nomination-based program with class entry once per year

C i i di l d i diContinuing medical education credit

Leadership placement based on participation performance and learning evaluationand learning evaluation

90-day; 6-month; and 1 year performance evaluation (self and other)

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)

Page 22: Steve McDermott: Connecting the dots

4. Pay for Performance4. Pay for Performance

Program Goals

Promote results oriented culture

Expand the concept of medical services

D l t k/ tDevelop teamwork/systemness

Move to population managementp p g

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Page 23: Steve McDermott: Connecting the dots

Background

D l d i 1997 i li t dd d i 2004Developed in 1997; some specialists added in 2004

Rewards efficient and progressive practices

Performance based, population based

Developed/ maintained by medical directors/ p ymanagement

Paid in addition to fee-for-service paymentsp y

Quarterly distribution

C i l l i

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Continuously evolving

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Performance Based Profiles - PCPsUtilization / Controlling Costs professional

pharmacyfacility costs

Clinical Quality (P4P) breast cancer screeningcervical cancer screeningchlamydia screeningdiabetes HbA1cdiabetes nephropathyasthma medicationcholesterol - LDLchildhood immunizationschildren ith pharn gitischildren with pharnygitisupper respiratory infectioncolorectal cancer screening

Engagement open practiceEngagement open practicepanel meetingse-initiativesHospitalist Programexclusivity

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Member satisfaction (annual)

Page 25: Steve McDermott: Connecting the dots

Financial Impactp

Range per M D from 0 to $100 000 per QtrRange per M.D. from 0 to $100,000 per Qtr.

Average per M.D.: $25,000 per Qtr.

84% of participating physicians earn bonus

Those not earning bonus: 87% of RBRVS vs. those earning bonus: 112% average

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Pay for Performance

$32.2$33.8

$ Millions$26.0

$27.4

$ Millions

$17.5

$3 8 $7.5 $5.2

$13.5

$4.8 $5.0 $5.1 $4.3 $4 1$3.8 $4.1

2002 2003 2004 2005 2006 2007 2008*

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Health Plan Bonus Payments to Hill Hill Incentive Payments to its Physicians

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Physician Compensation CaveatsThere are no “best” techniques; it is an evolving work in progressp g

Doctors need to be looking at good data within accountable process

Listen to physician feedback with both ears

Continuously adjust measuresContinuously adjust measures

Avoid profiles becoming “routine”

R i hi i BUT i d /Reporting achieves improvement BUT not sustained w/o pay

D ll h t b i tf l li bl

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Dollars have to be impactful, reliable

Page 28: Steve McDermott: Connecting the dots

5. Final ThoughtsgManagement vs. Professionals: A Natural ConflictManagement: getting people together to accomplish desiredManagement: getting people together to accomplish desiredgoals; comprises planning, organizing, staffing, leading ordirecting, and controlling.P f i t ith hi h d f t l i iProfessions: autonomous with a high degree of control exercisinga dominating influence over its entire field, can act monopolist,rebuffing competition from ancillary trades and occupations, aswell as subordinating and controlling lesser but related tradeswell as subordinating and controlling lesser but related trades.

Doctors trained to avoid risk, make no mistakes,causes them to be risk adverse if not perfectionists.But taking risk is fundamental to business; if youare not making some mistakes, you are not cutting edge

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are not making some mistakes, you are not cutting edge.

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Management/Physicians: Building Trustg y g

- clear purpose and goals that resonateclear purpose and goals that resonate- transparency; full and open communication

accountability; checks and balances- accountability; checks and balances- aligned incentives

d h ’ i d- execute: do what you say you’re going to do and, do it right

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.

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Last Word

- Leadership: “Strong physician leadership” is helpful but not enough: nearly all medical organizations (good bad andenough: nearly all medical organizations (good, bad and indifferent) have physician ‘leaders’

- Conflict: You cannot avoid conflict, in fact, it is healthy. The k i b ildi i h k d b l hil l if ikey is building in checks and balances while clarifying common purpose.

- Risk: You cannot eliminate risk as in doing so you will g yeliminate innovation and starve creativity.

- The Illusion of Technique: Health care chases one fad after another mostly tactics and techniques substitutes for systemicanother, mostly tactics and techniques, substitutes for systemic change and/or good management. P4P and the ‘medical home’ are latest examples.

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Physician SatisfactionPhysician Satisfaction

Measured annually by independent survey group

92%

76%80%

83%88% 90% 92% 90%

66%

76%

2000 2001 2002 2003 2004 2005 2006 2007

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2000 2001 2002 2003 2004 2005 2006 2007