Case Study Of A Primary Care Accountable Care Organization (Text Version)

On September 28, 2010, David West made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (1.5 MB).

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Case Study Of A Primary Care Accountable Care Organization

David R. West, PhD
Robert Phillips, MD, MSPH

AHRQ Task Order: SNOCAP-USA (University of Colorado) HHSA290200710008

Dr. David Lanier: Task Order Officer
September 28, 2010

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Disclosure

I have no financial relationships to disclose.

And

I will not discuss off label use and/or investigational use in my presentation.

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Project Team

• From the Robert Graham Center
  • Robert Phillips, MD, MSPH: Task Order Leader
  • Svetlana Bronnikov, MS
  • Stephen Petterson, PhD
  • Bridget Teevan, MS, MPH
• From the University of Colorado
  • Maribel Cifuentes, RN

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What Can We Learn From a "Mature" PCMH?

• Aim 1: Determine: How A PCMH developed their model.
• Aim 2: Determine if the PCMH improved processes of care and outcomes.
• Aim 3: Determine the incremental in-practice expenses (reduced to a pm/pm) required to operate the patient-centered medical home.

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Mixed Methods Approach

Qualitative Analysis

• 58 Key Informant Interviews (Executives, Clinicians, Administrative and Finance staff, Patients)

Quantitative Analysis

• Collection/analysis of reported process and outcome indicators
• Analysis of WellMed vs. matched CMS data (Parts A and B): Controls for Ischemic Heart Disease (IHD), Chronic Obstructive Pulmonary Disease (COPD), and Type 2 Diabetes Mellitus (DM)

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WellMed As A Case Study (in progress)

• Have been providing primary care services for 20 years in their community.
• Accepts full risk capitation for most services (primary care, specialist care, physician, inpatient hospital, outpatient hospital, etc.).
• Documented use of a patient-centered continuous quality improvement approach including social services, prevention, and active disease management protocols.
• Availability of electronic health data for analysis

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Willing to let us under the hood!

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WellMed Accountable Care Organization

Screenshot of an organization chart.

• PCMH (6 of them)
• Hospital
• Specialist
• Social Services
• Transportation

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A screen shot of the www.wellmed.net Web site is shown.

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At A Glance

Chairman and CEO: George M. Rapier III, M.D.

Wellmed clinics (Primary care): 24 in Texas; 4 in Florida Treasure Coast Region

In-take transition centers (Healthcare assessment): 2 in Texas (San Antonio and Corpus Christi)

Medicare Advantage Plan markets (Health plan options for Medicare beneficiaries): Texas—Austin, Corpus Christ, El Paso Harlingen; Arkansas—Little Rock; New Mexico—Las Cruces; Florida—Fort Lauderdale

Affiliated Physicians' Offices (Medical management services for patients on select MA plans): More than 100 in Texas and Florida

Targeted patients: Medicare-eligible senior citizens

Employees: 1200+ (more than half support clinic operations)

Patients and insured members: 83,000+

2008 Revenues: $560.6 million

2008 Assets: $223 million

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Practice setting

• Lots of space
  • In primary care trend is downsizing footprint
  • Big community space for exercise classes, computer classes, nutrition/cooking classes
• Podiatry, Rheumatology, Dermatology rotate through
• Free orthopedic shoes fitted onsite

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Teams With Defined Roles

• Med Assistants do most data entry
• Health Coaches
  • Call patients next day to reinforce care plan
  • Meet with patients (clinic, home, phone) to do behavior change, mental health, care plan
• Disease Mgmt program for COPD, DM, CHF, CAD—manage most fragile, high cost patients intensely

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Teams Continued...

• Inpatient
  • Their own case managers and hospitalists (their culture, their plan)
  • Interventions for specific conditions—national award for model Knee Replacement protocol
• Nursing home teams led by NPs for nursing homes (4 core)

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Teams Continued...

• Very low turnover compared to market
• Grow their own—able MAs trained and mentored into higher roles
• Starting an MA school
  • Cut usual cost in half (more diversity)
  • Train to their model
• Two week orientation for new physicians + pairing with best clinicians for shadowing and mentoring

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EMR

• Home-grown system now a decade old and still evolving
• Docs typically write brief notes, heavy on care plan and MAs type them up, enter other data

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Control of Dollars & Data

• Data for all patients, all settings, all care
• Very innovative population data array
  • Used to monitor quality
  • Identify, develop, evaluate interventions
  • Identify outliers; not keeping appointments, not filling prescriptions, increased utilization
• Team bonuses based on quality improvement

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Investment/Connection to the Community

• Free Flue Shots I: The San Antonio Metropolitan Health District received $250,000 to offer free flu vaccines across the Bexar county population in 2007 and an additional $100,000 in 2008. This allowed an additional 42,000 flu shots to be delivered in the community.
• Free Flue Shots II: The flu shot campaign expanded in 2008 into Atascosa, Comal, Guadalupe and Kendall counties, as well as Bexar (Greater San Antonio), targeting Medicare-eligible residents only. WellMed clinics along Florida's Treasure Coast offer free flu shot clinics to Medicare-eligible residents in Indian River, St. Lucie and Martin County during flu season. All influenza vaccinations are a gift from WCF and are NOT charged back to Medicare.
• Senior Outreach: In 2008, WellMed partnered with the City of San Antonio's Department of Community Initiatives to offer free flu shot clinics at more than 30 events around San Antonio, mostly at senior nutrition centers. In 2009, the Foundation funded a campaign promoting free flu shots for homebound seniors and to build awareness about various social services available through WellMed and the City of San Antonio, such as free transportation to medical appointments, prescription assistance, etc.

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PCMH Timeline

1990—Established with particular emphasis on Medicare population

1990—Strengthen and support primary care role in health care (e.g., support comprehensive care approach including hospital and nursing home care, work on team based chronic disease care

1993—Begin benefits review process to add benefits that remove patient barriers to essential care—this eventually includes transportation help, paid health maintenance visits, expanded medication coverage for essential medications, expanded eye care, expanded dental benefits, expanded hearing aid benefits

1996—Same day appointments available in medical offices

1997—Regularly track patient satisfaction

1999—Starts disease management division

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PCMH Timeline (continued)

2001—Installs EHR including electronic prescribing

2002—Add clinical decision support system along with improved registry functions

2003—Transform disease management to health coach concept- patient centered and available to all patients

2006—Web access to patient level data for treating specialists

2006—Portable "EHR" system given to patients to improve data transfer to other care providers

2008—Transitions "Health Coach" function from a centralized approach to primary care office based approach and begin transition to expanded team based chronic care model

2008—Web access for medical data for patients

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Trends in rates of health screening & meeting chronic disease targets

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Tests and References	Denominator	Numerator
Global: All eligible WellMed patients 65 years or older
Mammography test (Pham et al. 2005; Freeman et al. 2002; Asch et al. 2000)	Female patients excluding those with cancer diagnoses or mastectomy	From ICD9 code: 87.36, 87.37, V76.11, V76.12 very year
Colon cancer screening tests: (1) Colonoscopy, (2) Flex sigmoidoscopy, (3) Fecal occult blood test (NCQA 2008, Pham et al. 2005; Freeman et al. 2002)	Exclude those with prior cancer diagnoses	From lab data: any of the 3 tests that were administered
Hemoglobin A1c test & monitoring (Skeie et al. 2001, NCQA 2008, Pham et al. 2005)	With DM, ICD9: 250.00 thru 250.91	Every year. For control: HA1c ≤ 7
Cholesterol LDL test (NCQA 2008)	All with DM or IHD diagnoses	Every year LDL<100 mg/dL
Blood pressure test (NCQA 2008)	All with HBP diagnosis	Every year <140/90
ER visits per patient (Shenkman, 2003)	All WellMed eligible patients	Place of service=ER
Hospitalization rate (Jencks et al. 2009)	All WellMed eligible patients	Patients hospitalized as derived from hospital data
Re-hospitalization rate (Jencks et al. 2009)	Exclude those deceased at last discharge	Within 30 days of last discharge
Mortality (Buescher, 1998)	All WellMed eligible patients	Determined from hospital and identifier data

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Test Type	2000	2001	2002	2003	2004	2005	2006	2007	2008
Mammography test rates (%)	19	28	29	26	28	33	34	37	40
Colon cancer screening test rates (%)	11	14	21	32	42	43	48	49	50
Hemoglobin A1c testing rates (%) for patients with Diabetes	55	53	70	73	75	77	78	75	71
LDL Cholesterol screening rates (%)	47	35	47	50	59	63	69	68	70
LDL Cholesterol screening rates (%) for patients with Diabetes	53	51	65	70	73	79	82	79	78
LDL Cholesterol screening rates (%) for patients with ischemic heart disease	53	45	58	64	71	77	79	76	76
Blood pressure screening rates (%)		38	50	74	83	80	80	76
Blood pressure screening (%) for patients with High Blood Pressure		46	58	85	92	91	91	88
DM patients with A1c ≤7	81	84	87	90	92	93	93	93	93
DM patients with LDL ≤100	51	56	57	63	67	74	77	78	95
IHD patients with LDL ≤100	48	56	60	63	66	72	75	75	93
HBP patients with BP <140/90		67	72	80	86	90	92	90

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Trends in health outcomes

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	2000	2001	2002	2003	2004	2005	2006	2007	2008
ER visit rates (%)	15.9	14.9	14.2	14.5	15.2	16.6	17.6	17.4	17.8
Hospitalization rates (%)	13.9	12.9	12.0	11.8	11.9	12.7	13.9	13.7	14.4
Patients who were discharged from hospital alive	1,892	2,125	1,913	1,834	1,928	2,152	2,333	2,370	2,578
Re-hospitalization rates (30 days) (%)	13.8	12.6	14.1	12.4	14.2	14.4	12.7	13.6	13.4
Crude Death rates, all causes (per 1000)	18.8	11.7	14.4	19.8	23.3	25.7	27.3	27.0	22.0
65-74	7.2	4.8	7.2	7.2	8.5	9.6	9.1	8.5	10.4
75-84	20.9	14.9	15.5	25.0	27.7	31.4	33.0	27.5	20.3
85+	66.2	32.5	40.8	51.0	65.7	67.0	70.1	83.2	62.4
Female	18.1	9.9	13.7	18.9	22.1	23.8	24.9	25.5	20.2
Male	19.7	14.0	15.2	20.9	24.6	27.8	30.2	28.9	24.0
Adjusted Death rates, all causes (per 1000)
65-74	7.7	4.8	5.8	7.9	9.1	9.9	10.1	9.7	7.8
75+	30.0	18.7	22.3	30.0	35.2	39.0	41.0	40.7	33.2
Texas Age-adjusted mortality rate, 65-74		24.2	24.0	23.2	22.2	21.8	20.9	20.8
Texas Age-adjusted mortality rate, 75+		84.0	83.1	80.3	77.7	78.6	76.9	77.3

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Qualitative Analysis

Research Questions:

• How did WellMed develop their level 3 PCMH model—the facilitators, barriers, key components, history and leadership?
• How did the implementation of the WellMed model impact patient and provider satisfaction?

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Qualitative Analysis Themes

Patients identify five factors of the WellMed model as important to their satisfaction:

• Personal relationship with a physician over time.
• Access, ease of making appointments.
• Being greeted cordially, technical competency, compassion, taking time to listen and explain information.
• Affordability. of medications, discounted prices, reasonable co-pays.
• Getting referrals, having people remember basic care (e.g. flu shots).

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Qualitative Analysis Themes

Staff identify four factors of the WellMed organization that are important to their satisfaction:

• Belief in what the company stands for and the sharing of values.
• Good compensation and bonuses.
• Leadership that listens and values employees.
• Opportunities for advancement.

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Qualitative Analysis Themes

• The guiding principles from which the WellMed model was constructed and the way in which the model has evolved stem from and promote the 4 pillars of primary care:
  • Easy access to first contact care.
  • Comprehensive care—accountability for addressing large majority of personal healthcare needs. Includes the convenience of having majority of services under one roof.
  • Coordination of care.
  • Personal relationships over time.
• WellMed has acted on these primary care principles by using ACO methods.

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Qualitative Analysis Themes

• 5 Key factors used to guide and implement the marriage of PCMH and ACO elements of the WellMed model:
  • Use of economics as a driver for quality.
  • Collaborating and co-evolving with others that understand and buy-in to the model.
  • Customer service is key to everything we do.
  • Identify every day problems and implement common sense solutions—evolve solution as needed. "is there a way we can do this better and more efficiently".
  • We're big on prevention.

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Next Steps

• Completing Qualitative Study
• Completing matched cohort study (costs/outcomes of similar Medicare beneficiaries)
• Completing financial/Business Model Review