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
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.
Paul C. Smith, M.D.
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First President of Hill: General Surgeon Fellow of the Royal Academy
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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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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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?
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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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
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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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 #.
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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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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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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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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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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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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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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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?
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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)
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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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
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)
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
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
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.
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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.
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
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