GPSC Fee Incentives

Buy What You Want

Presentation to the QMA

April 2011

Presented by Dr. Jean Clarke

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4 Priorities

Barbara Starfield’s Key Attributes of Primary Care

Access

Co-Ordination

Comprehensiveness

Continuity

The Triple Aim

Population health

outcomes

Patient and provider

experience

TRIPLE AIM

Per capita cost

Overview

Chronic Disease Management

Complex Care

Conferencing

Palliative Care

Mental Health

Prevention

Maternity

GPSC INITIATIVES

CHRONIC DISEASE

MANAGEMENT

Chronic Disease Management

Diabetes Mellitus - $125.00

Congestive Heart Failure - $125.00

Hypertension - $50.00

COPD - $125.00

COPD Telephone/E-mail follow up - $15.00 (billable up to 4 times in the 12 months)

The CDM fee is a management bonus billable annually on the anniversary of the initial billing date.

The CDM fees are for the GP who has accepted responsibility for the ongoing, longitudinal care of the patient.

Must have at least 2 visits with patient in 12 months preceding billing of CDM fee.

FFS billing for office visits continues.

Chronic Disease Management

Chronic Disease Management

Diabetes, CHF, and COPD CDM fees may be billed for the same patient.

Hypertension CDM fee is not billable if also billing for Diabetes and/or CHF (but is billable with COPD.)

Use of flow sheets as a tool for tracking care is encouraged but not mandatory provided all required information is included.

GPSC INITIATIVES

COMPLEX CARE

Payment to compensate for the extra time required to provide planned care to complex patients who are living in their home or in assisted living.

Payable only to the General Practitioner who accepts responsibility for the longitudinal, coordinated care of the patient.

Complex Care

Complex Care

Eligible patients must have two of the following chronic conditions:

Diabetes mellitus Chronic kidney disease Congestive heart failure (CHF) Cerebrovascular disease (CVD) Ischemic heart disease (IHD) Chronic respiratory condition Chronic neurodegenerative diseases (CND) Chronic liver disease (CLD)

Annual Complex Care Management fee - $315

Minimum 30-minute complex care planning process:

The Complex Care Planning Visit: the development of the care plan is done jointly with the patient. The patient should leave the appointment knowing there is a plan for their care and what that plan is.

Billed in addition to office visit fee on the day of the planning appointment.

Complex Care

FFS billing for subsequent office visits continues.

CDM fees and Conferencing fees are payable in addition.

Complex Care

Complex Care Telephone/E-mail Follow-up Management fee $15

Payable for up to 4 non face to face encounters (telephone, email) in the 18 months following billing of the Complex Care management fee

Telephone/Email (2 way) encounters may be provided by the GP or delegated staff. Not for simple appointment reminders or prescription renewals

Complex Care

GPSC INITIATIVES

CONFERENCING FEES

Conferencing Fees

Community Patient Conferencing fee

Facility Patient Conferencing fee

Acute Care Discharge Planning Conferencing fee

Telephone Consultation with a Specialist or GP with Specialty Training

Conferencing Fees

Developed to compensate the GP for time spent conferencing with other health care professionals to make a coordinated clinical action plan for the care of patients with

more complex needs.

Conferencing Fees

The Community, Facility and Acute Care Discharge conferencing fees are for the same eligible patient population: Frail elderly (ICD-9 code V15) Palliative care (ICD-9 code V58) Mental illness Patients of any age with multiple medical needs or complex

co-morbidity – pregnancy is considered a co-morbidity in complex maternity patients.

Payable in units of $40.00 per 15 minutes or greater portion. Maximum 4 units/patient/day; 6 units/patient/year.

GP Urgent Telephone Conference with a Specialist Fee

Intent is to improve management of the patient with acute needs, and reduce unnecessary ER or hospital admissions/transfers.

Billable when the patient’s condition requires urgent (< 2 hours from time of request) consultation with a specialist or GP with specialty training, and the development and implementation of a care plan within the next 24 hours to keep the patient stable in his/her current environment.

This fee is not restricted by diagnosis or location of the patient, but by the urgency of the need for care.

$40 flat rate fee value. Billable in addition to visit fee.

General Practitioners with Specialty Training Telephone Advice Fees

“General Practitioner (GP) with Specialty Training” is defined as “A GP who has specialty training and who provides services in that specialty area through a health authority supported or approved program.”

“Mirror fees” to the SSC Specialist Telephone Advice fees for FRCP certified Specialists.

Service may be provided when physician is located in office or hospital.

Telephone advice must be related to the field in which the GP has received specialty training.

General Practitioners with Specialty Training Telephone Advice Fees

GP with Specialty Training Telephone Advice - Initiated by a Specialist or General Practitioner, urgent (< 2 hours from request for advice) - $60.00.

GP with Specialty Training Telephone Patient Management - Initiated by a Specialist or General Practitioner, one week - $40.00.

GP with Specialty Training Telephone Patient Management / Follow-up - $20.00; maximum 4/year/patient.

GPSC INITIATIVES

PALLIATIVE CARE

Palliative Care

Palliative Care Planning fee - $100

Payable for the development of a Palliative Care Plan for patients who have reached the palliative stage of a life-limiting disease or illness.

Requires a face-to-face visit with the patient or the patient’s representative.

Medical Diagnoses include: end-stage cardiac, respiratory, renal and liver disease, end-stage dementia, degenerative neuromuscular disease, HIV/AIDS or malignancy.

Eligible patients must be resident in the community: at home or in assisted living or supportive housing.

Palliative Care Telephone/E-mail Follow-up Management $15.00

This fee is payable for 2-way telephone or email communication with eligible patients or their representative to provide clinical follow-up management

billable by the GP who has developed the patient’s Palliative Care Plan

Billable up to 5 times..

Palliative Care

GPSC INITIATIVES

MENTAL HEALTH

Community GP Mental Health

Mental Health Initiative compensates the Family Physician who accepts responsibility for the longitudinal care of patients who:

Have an Axis I diagnosis confirmed by DSM IV criteria

With a severity and acuity level causing sufficient interference in activities of daily living that developing a management plan for the rest of the year would be appropriate.

GP Mental Health Planning fee - $100.00

Paid for the development of a Mental Health Plan for care during the subsequent calendar year for patients who reside in the community.

Requires 30-minute face-to-face visit.

Billable once per calendar year per patient.

Allows billing for 4 additional annual counselling visits

GP Mental Health

GP Mental Health Telephone/Email Management fee - $15

This fee is payable for up to 5 telephone/email services (2-way communication) with eligible patients or their representative via telephone or email for the provision of clinical follow-up.

Available for up to 18 months after billing Mental Health fee.

This fee is not to be billed for simple appointment reminders or referral notification.

Community GP Mental Health

GPSC INITIATIVES

PREVENTION

Prevention Fee

Personal Health Risk Assessment fee - $50

Billable in addition to an office visit, to undertake a personal health risk assessment visit with “at risk” patients.

Targeted patients include those with: Smoking Unhealthy eating Physical inactivity Medical obesity.

GP is expected to develop a plan that recommends age- and sex-specific targeted clinical preventative actions of proven benefit.

Billable for up to 100 patients per calendar year per physician.

GPSC INITIATIVES

MATERNITY INITIATIVES

GPSC Obstetric Delivery Bonuses

Delivery bonuses valued at 50% of delivery fee.

Available to GPs who in addition to being paid the delivery fee for the patient are also responsible or share responsibility for providing the patient’s longitudinal primary care.

Maximum total of 25 bonuses claimed per calendar year.

Maternity Network Payment

Quarterly payment to encourage shared care of obstetric patients to reduce burnout.

$2100 per quarter.

GPs complete a network registration form for the group.

Some Key Findings From the Evaluation

Hollander Analytical Services Ltd. 300 - 895 Fort Street Victoria, BC V8W 1H7

Tel: (250) 384-2776Fax: (250) 389-0105E-Mail: marcus@hollanderanalytical.com

A Major New Finding

A major, new finding is that there is a clear inverse relationship between the level of attachment to a primary care practice, and costs, for higher care needs patients.

Attachment is defined as the percentage of all GP services in one year provided by the practice which provided the most services.

Benefits of Attachment

The more patients go to the same practice, the lower the overall, annual costs to the health care system.

Most of the differential in costs between more attached and less attached patients is in hospital costs: costs are higher for less attached patients

Therefore, activities which foster increased attachment of patients to a particular primary care practice have the potential to reduce health care costs i.e. continuity of care is cost-effective.

A Major New Finding (cont’d)

Our findings are based on an analysis of diabetes and congestive heart failure patients.

A classification system developed by Johns Hopkins University was used to ensure that people in the analysis had similar levels of care need.

Resource Utilization Band (RUB) 4 represents people with a high need for care. RUB 5 represents people with a very high need for care.

39

Major new findings

Annual costs per patient as a function of attachment to practice, for diabetes patients at RUB 4: Fiscal 2007/08

40

Major new findings

Annual costs per patient as a function of attachment to practice, for diabetes patients at RUB 5: Fiscal 2007/08

41

Major new findings

Annual costs per patient as a function of attachment to practice, for CHF patients at RUB 4: Fiscal 2007/08

42

Major new findings

Annual costs per patient as a function of attachment to practice, for CHF patients at RUB 5: Fiscal 2007/08

Cost per Patient as a Function of Attachment to Practice, for Diabetes RUB 4: Fiscal 2008/09

0

2,000

4,000

6,000

8,000

10,000

12,000

Attachment to Practice

Co

st p

er P

atie

nt

Total Cost 11,349 8,778 7,767 6,620 5,239

Hospital 6,966 4,793 3,852 2,865 1,648

MSP 2,943 2,470 2,369 2,241 2,039

Pharmacare 1,440 1,515 1,546 1,513 1,552

0-39% 40% - 59% 60% - 79% 80% - 89% 90% or More

Cost per Patient as a Function of Attachment to Practice, for Diabetes RUB 5: Fiscal 2008/09

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Attachment to Practice

Co

st p

er P

atie

nt

Total Cost 32,361 25,787 20,947 16,438 12,091

Hospital 24,056 18,630 14,543 10,440 6,788

MSP 6,036 4,857 4,201 3,781 3,360

Pharmacare 2,269 2,299 2,203 2,217 1,942

0-39% 40% - 59% 60% - 79% 80% - 89% 90% or More

Cost per Patient as a Function of Attachment to Practice, for Congestive Heart Failure RUB 4: Fiscal 2008/09

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

Attachment to Practice

Co

st p

er P

atie

nt

Total Cost 16,209 12,478 10,645 8,895 6,293

Hospital 11,167 7,823 6,157 4,712 2,484

MSP 3,514 2,848 2,697 2,529 2,217

Pharmacare 1,529 1,806 1,792 1,654 1,592

0-39% 40% - 59% 60% - 79% 80% - 89% 90% or More

Cost per Patient as a Function of Attachment to Practice, for Congestive Heart Failure RUB 5: Fiscal 2008/09

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

Attachment to Practice

Co

st p

er P

atie

nt

Total Cost 39,835 30,356 24,921 20,352 14,213

Hospital 30,865 22,869 18,225 14,073 8,738

MSP 7,070 5,314 4,532 4,143 3,583

Pharmacare 1,900 2,172 2,164 2,137 1,893

0-39% 40% - 59% 60% - 79% 80% - 89% 90% or More

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Cost of Care as a Function of Attachment (cont’d)

For the four main groups of patients reported in the study, total cost savings per 5% increase in attachment is estimated as:

Disease RUB

$ Decrease per 5% increase in

attachment (per person)

Sample Size (N)

Total decrease if each person in sample

increased attachment by 5%

Diabetes 4 $408.00 40,483 $16,517,064.00

5 $1,340.50 22,557 $30,226,380.00

CHF 4 $620.00 18,697 $11,592,140.00

5 $1617.00 16,299 $26,355,483.00

TOTAL $84,691,067.00

Incentives

5% in attachment =

$85M in high-RUB costs

RISQY

Major new findings

Annual costs for CDM patients who did, and did not, receive incentive-based care, standardized for difference in age, gender, RUB and attachment levels: Fiscal 2008/09

Cost categories

Diabetes incentive

CHF incentive

Hypertension incentive

No $$ With $$ No $$ With $$ No $$ With $$

GP, specialist, and diagnostic facilities

1599 1728 2479 2657 1264 1247

Hospital 2339 1999 5706 5019 1486 1272

Pharmacy 1036 1192 1580 1588 526 487

Annual total (average)

4974 4919 9765 9264 3275 3006

Number of GPs participating in GPSC initiatives

48

Uptake of Incentive Billings Over Time: Fiscal 2003/04 to 2009/10

Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.

Year 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10

# of GPs Full Service 3,218 3,204 3,235 3,263 3,291 3,311 3,371 Other 1,306 1,375 1,434 1,497 1,521 1,594 1,657 Total 4,524 4,579 4,669 4,760 4,812 4,905 5,028

% Using Incentives Full Service 45.6 63.3 80.1 87.5 92.2 92.9 92.6 Other 4.1 8.1 13.6 21.6 27.4 27.0 27.5 Total 33.6 46.7 59.7 66.8 71.7 71.5 71.1

% Using More than 10 Incentives

Full Service 33.2 44.6 65.6 78.6 87.3 87.8 88.2 Other 0.8 1.5 4.0 7.9 13.5 11.5 10.6 Total 23.8 31.7 46.7 56.4 64.0 63.0 62.6

49

Percentage of GPs Billing for Chronic Disease Management Incentives Over Time: Fiscal 2003/04 to

2009/10

Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.

 % Using Incentives

Chronic Disease Diabetes Heart Disease Hypertension

Group Year  

Full Service 2003/04 45.6 45.3 25.1 0.0

2004/05 58.8 58.6 29.0 0.0

2005/06 76.2 76.0 38.0 0.0

2006/07 83.8 82.0 47.4 65.3

2007/08 87.5 85.9 57.9 78.8

2008/09 87.9 86.5 57.9 80.3

2009/10 87.9 86.1 59.4 81.7Other 2003/04 4.1 4.1 0.7 0.0

2004/05 5.8 5.6 1.3 0.0

2005/06 10.0 9.6 2.6 0.0

2006/07 12.9 10.1 2.4 7.0

2007/08 14.9 11.9 3.7 11.0

2008/09 13.3 9.7 3.3 9.7

2009/10 11.1 7.5 2.2 7.9

50

MSOC Patients Over Time Based on Care Provided to All Patients for Regular GPs

Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.

Average MSOC Patients per GP

Majority Source of Care ALL Patients Majority Source of Care SELECTED Patients

2005 2006 2007 2008 2009 200506 200607 200708 200809 200910

All 540.9 558.4 567.7 572.0 573.2 95.0 102.3 114.0 122.3 126.6

Quartile

1 409.0 411.7 413.1 412.6 412.0 57.7 60.3 60.5 66.2 68.4

2 437.9 454.6 463.7 470.2 469.4 67.9 73.1 78.1 85.5 88.0

3 558.4 583.3 592.4 597.6 601.3 100.7 108.3 120.0 129.4 133.2

4 757.5 783.1 800.5 806.3 809.0 153.5 167.1 197.2 207.8 216.3

Quality

Diabetes patients receiving 2+ HbA1c tests per year

RISQY

Quality

Mean total acute and rehab days per patient by physician

RISQY

53

Health Indicators for Diabetes Patients 2002/03 Death Rates For Patients Alive March 31, 2006

Excluding Patients 85 and Over as of March 31, 2002

Incentive before April, 2006

All No Yes

Number of

Patients Deaths % who

Died

Number of

Patients Deaths % who

Died

Number of

Patients Deaths % who

Died

All 83,347 9,070 10.88 24,992 3,188 12.76 58,355 5,882 10.08

Years With Diabetes to Mar 31, 2003

0-1 19,681 1,528 7.76 7,557 665 8.80 12,124 863 7.12

2-5 28,100 2,626 9.35 8,718 1,021 11.71 19,382 1,605 8.28

6-9 21,636 2,507 11.59 5,695 831 14.59 15,941 1,676 10.51

10 or More 13,930 2,409 17.29 3,022 671 22.20 10,908 1,738 15.93

Attachment to Practice Group

1. 00% - 59% 5,660 997 17.61 2,309 452 19.58 3,351 545 16.26

2. 60% - 79% 27,384 3,819 13.95 8,812 1,336 15.16 18,572 2,483 13.37

3. 80% - 89% 23,817 2,476 10.40 6,447 788 12.22 17,370 1,688 9.72

4. 90% or More 26,486 1,778 6.71 7,424 612 8.24 19,062 1,166 6.12

Source: British Columbia Ministry of Health Services, Primary Care Data Repository, Fiscal 2009/10.

Professional satisfaction Payer satisfaction

The Bottom Line

80% of GPs surveyed in 2010 $$$ cost avoidance