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.

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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

callaghanc@michigan.gov (517) 335-8368