REPRINTED FROM MEDICAL VOYCE COLORADO EDITION | March 2013

After four years of hard knocks and lessons learned, here’s what practices had to say:

• The patient-centered medical home is the blueprint I’d beenwaiting for — this is the kind of medicine I’ve always wanted to provide but didn’t have the tools or support needed to do it.• It’s a way to improve clinical quality measures and empower bothpatients and staff.• It’s a return to the joy of practicing medicine and a way to remaincompetitive and financially viable.

Here’s what health plans had to say:• The pilot demonstrated real value to the healthcare system,namely, when you give primary care physicians additional resources you get improved care at a lower cost.• Primary care is poised to reclaim a key role in healthcare deliveryand be compensated for their efforts.

Background:The United States spends more on healthcare than any other industrialized nation, consuming almost 18 percent of our gross domestic product (GDP), yet ranking near the bottom in nine of ten categories for quality care. This is not sustainable. To restructure will take a comprehensive approach involving providers, hospitals, health plans, employers and patients working together to achieve Triple Aim goals: improving health outcomes for individuals and populations, reducing per capita costs, and improving experience for patients and their healthcare teams.

So what’s the role of primary care going forward? Traditionally we’ve developed strong relationships with patients, diagnosed and treated problems, and referred when needed. But with the volume- driven, increasingly complex environment, we often revert to “triaging” just to keep our doors open. As new models enhance value-driven care, we’re learning ways to manage patients more pro actively; empower and support them in managing their own health; and coordinate care with medical neighbors, ensuring clear communication to reduce conflicting messages and redundant testing. Through planning, actual or virtual integration of services, and emphasis on preventing problems before they occur, we will

reduce unnecessary costs and improve health. For this to work effectively, someone will need to “quarterback” for patients. Primary care started here and is usually best suited for this job. Returning to these roots will take a shift in thinking, a redesign of our systems and processes, and a restructuring of payment to better align incentives. That’s where the Patient Centered Medical Home

(PCMH) comes in.

The Colorado Multi-Payer PCMH To test this model, the Colorado PCMH pilot was one of the earliest and most complex pilots in the country to launch. Unique was the voluntary agreement among seven health plans, both public and private, to demonstrate that providing more resources to primary care practices willing to provide an advanced model of care would result in better health at a lower cost. Sixteen practices with

approximately 84 providers proved the concept valid. The three-year pilot concluded in April 2012. Quality and patient experience data are resoundingly positive and preliminary cost data for the first two years indicate savings that are very optimistic. HealthTeamWorks, a nonprofit, multi-stakeholder collaborative, convened the pilot and assisted practices in their transformation. The accomplishments of participating stakeholders have paved the way for several initiatives that will benefit Colorado practices, patients and communities for years to come.

C o v e r f e at u r e { Health Care & Practice Redesign }

{ Marjie Harbrecht, MD - Chief Executive Officer }

THROUGH PLANNING, ACTUAL OR VIRTUAL

INTEGRATION OF SERVICES AND AN

EMPHASIS ON PREVENTING PROBLEMS

BEFORE THEY OCCUR, WE WILL REDUCE

UNNECESSARY COSTS AND IMPROVE HEALTH.

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HEALTHTEAMWORKS: HiTTing THE TRipLE AiM

In 2008, 16 small independent practices and seven health plans took a leap of faith when they decided to join the Colorado Multi-Payer Patient-Centered Medical Home (PCMH) pilot.

{ By : MARjiE HARBREcHT, MD AnD cHiEf ExEcuTivE OfficER, HEALTHTEAMWORKS

WWW.HEALTHTEAMWORKS.ORg }

S u m m a r y

Lessons Learned and the Importance of Transformation to Healthcare in the United States1. Payment reform is crucialSix pilot insurers—Aetna, Anthem-WellPoint, Cigna, Humana, CoverColorado and UnitedHealthcare — provided enhanced compensation (Medicaid provided grant opportunities) to 16 family and internal medicine practices that agreed to transform care delivery to achieve pilot goals. Medicaid plans and practices worked collaboratively to develop a consistent payment model, payment schedules, outcome measures, goals, and approaches for data collection and reporting. Although challenging, this was critical in reducing fragmentation and administrative burden on practices and ensuring everyone was on the same page.

The payment structure included traditional fee-for-service (FFS) contracts, a per-member per-month (PMPM) care management fee and bonuses for meeting target goals. In developing PMPM ranges, it was important to balance what practices would need to deliver enhanced care while ensuring that health plans and employers could recoup their investments through savings—otherwise this would not be sustainable for either group. Each plan set its own PMPM amount, averaging $4 to $8, with higher payments for higher National Committee for Quality Assurance (NCQA) recognition levels. Ultimately, 14 clinics achieved NCQA Level 3, the highest level of recognition, and two achieved Level 2.

Pilot leaders knew practices would need sufficient up-front funding to learn new models; build a solid infrastructure by adding technology, hiring or retraining staff for care coordination and care management services; and increase access. As important were incentives to drive outcomes and sustain initial efforts. This would differentiate PCMH from managed care of the 90’s where payments changed but practices were never trained to redesign care and there was no incentive to improve patient outcomes. “It was more about ‘gate keeping’ to prevent referrals rather than a ‘gateway’ to help people improve their health,” said Dave Ehrenberger, MD.

2. Transformation is critical and made easier withcoaching, learning communitiesNCQA PCMH parameters provided a great starting point, but to achieve results practices had to transform care delivery based on Chronic Care Model principles including:

• Expanded access (i.e., through secure e-mail and extended hours);• Team-based care, encouraging staff to perform to the highest levelof licensure• Use of data to drive improvement (collected from electronic healthrecords (EHRs) or registries and submitted to HealthTeamWorks monthly); and• Patient engagement through self-management support andmotivational interviewing.

Clinix Healing Center advises, “For the [PCMH] concept to be sustainable, you must implement systems. Test, test, test before

implementing clinic-wide. Get input from the entire staff, not just the doctors and management.” That said, a key factor for

success was physician leadership. When doctors weren’t engaged, couldn’t agree on consistent processes, or

actively thwarted staff efforts, progress usually stalled or failed.

Change management was essential, but difficult without support, particularly when continuing to see the same number of patients. Through on-site visits, phone

calls and webinars, HealthTeamWorks’ quality improvement coaches were vital in providing cross pollination of ideas among practices and encouraging accountability. According to John Bender, MD, “Every practice and every patient needs a coach. All professional sports teams and athletes have a coach—that’s what differentiates them from amateurs.”

Practices also participated in regular learning collaboratives and webinars to hear from experts, share data and accelerate learning. HealthTeamWorks helped practices optimize available tools, achieve meaningful use of EHRs, and align monetary incentives and NCQA recognition, helped staff improve office efficiency and team effectiveness.

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REPRINTED FROM MEDICAL VOYCE COLORADO EDITION | March 2013

3. Care coordination and care managementPerhaps the most significant and effective change involved embedding care coordination and care management services into daily practice routines. Care coordinators tracked test results and referrals, logged into hospital systems daily to follow-up on patients seen in the ED/hospital and connected patients with “medical neighbors,” including behavioral health and other community resources. Care managers worked with higher-risk patients to overcome barriers and help them set and achieve goals.

Although difficult to obtain, a key lesson learned was the importance of having cost/utilization data from hospitals and health plans to identify:

• high risk/high need patients for caremanagement to improve outcomes and prevent unnecessary ED visits/ hospitalizations;• high quality low-cost referral centers;• whether PCMH efforts were actually bending the cost curve(i.e., increasing access, educating patients about after-hours and urgent care services available at the clinic, and implementing care management/care coordination support).

4. Making patients partners So what about patient responsibility? Rather than just telling patients what to do, PCMH practices took more of a partnership approach. Using “shared decision-making”, they work with patients to develop customized care plans using evidence-based recommendations for preventive and chronic care, and address any acute issues arising. By helping people set their own goals and supporting them in achieving those goals, using techniques such as motivational interviewing, many patients went from “non-compliant” to activated participants in their own health. Providing data (i.e., graphs of blood pressure or HgA1c levels) to show their efforts were making a difference over time was powerful for patients. Patient surveys validated this by changing from initial responses like “I love my doctor” to “I feel like I am finally able to take control of my health; finally.”

5. Data is empowering – measuring is an interventionin itselfWe would never manage a diabetic without understanding where they start and the effect of prescribed treatments. Using the same

approach, data helped practices identify areas of deficiencies and target-specific approaches to improve processes and outcomes. At a program level, HealthTeamWorks provided comparison data among practices so they could measure against peers and learn best practices. According to Dr. Bender, “When we first started measuring, we were below average. By putting the right systems in place, everything started to improve—that became motivational.”

6. Population management – a new skill setAccording to Kelly Lowther, MD, “PCMH changed the way we approached our patients. For example, with diabetics, we now look not only at what care is needed for each individual, we also look at our entire patient group, tracking which patients have or have not received necessary care.”

7. Engaging the medical neighborhoodAfter solidifying their medical homes, pilot practices were ready to reach out to the medical neighborhood: specialists, hospitals, behavioral health professionals, pharmacists and myriad community resources.

HEALTHTEAMWORKS HELPED PRACTICES

OPTIMIZE AVAILABLETOOLS, IMPROVE OFFICE

EFFICIENCY, ACHIEVE MEANINGFUL USE OF

EHRS, ALIGN MONETARY INCENTIVES AND RECIEVE

NCQA RECOGNITION.

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Results AchievedDespite several challenges, the hard work paid off.Improvements were seen across multiple quality measures for diabetes, cardiovascular disease, depression and prevention. Patient satisfaction survey scores remained high and showed positive change in how patients were able to access care and learn needed skills to manage their own health better. Early cost results are also promising.

Anthem-Wellpoint Reported

• 14.5% Reduction in the total cost of care

• 18% decrease in acute IP admissions/1000, compered to 18% increase in control group

• Overall return on investment estimates between 2.5:1 and 4.5:1

Colorado Multi-Payer, Multi-Stakeholder PCMH PilotCA Baseline to Year 2 Assessment

Team Approach

Information System Support

Self-Management Support

Use of Guidelines

Quality Improvement

Population Management

Coordination of Care

Patient-CenteredCare

Mental Health Issues

TA ISS SMS UG QI PM CC PCC MH

70% 72% 77% 81% 75% 74% 70% 73% 71%

78% 81% 79% 85% 80% 82% 74% 80% 76%

Survey Group

Pilot Average - Baseline (n=60)

Pilot Average - Year 2 (n=63)

Pilot Average -Baseline (n=60)

Pilot Average -Year 2 (n=63)

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

TA ISS SMS UG QI PM CC PCC MH

Infrastructure and Process

QualityMeasures

Utilization

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“Working through the referral processes and improving our care coordination was a challenge in the current environment but absolutely essential to improving patient care,” said Scott Hammond, MD, creator of a toolkit to improve communication between primary care and specialists. “Now we have systems in place to ensure that necessary information is obtained by sub-specialists and me to provide the best care and safe transitions. Equally important, was high patient satisfaction with our specialists and referral process.”

What’s Next for Colorado Healthcare and the Pilot PracticesWith increasing evidence that PMCH efforts are demonstrating desired outcomes and based on successes seen in the multi-payer pilot, several plans have expressed enthusiasm for PCMH. As part of this, Colorado was one of seven national sites selected for the Comprehensive Primary Care (CPCi) led by the initiative Center for Medicare and Medicaid Innovation (CMMI). The project involves ten payers willing to pay FFS, a care management fee, and shared savings to 73 selected primary care practices committed to providing advanced patient-centered care. HealthTeamWorks and Rocky Mountain Health Plans will work together to provide in-office coaching and shared learning opportunities.

CPCi will bring advanced primary care to thousands of additional patients and employers and is a great step toward spreading PCMH and enhanced payments across Colorado. But to create a solid, financially-stable primary care base statewide, plans need to extend resources and support to other practices willing to do or currently doing PCMH work; enabling them to serve as strong foundation for an evolved healthcare system.

Through past strategies we’ve become smarter, but this is no longer about just showing up or ‘checking boxes’. It’s about true transformation at all levels. By restoring primary care, building integrated communities of care, and engaging health plans, hospitals, employers and patients to achieve needed outcomes— the Triple Aim is within our grasp.

Congratulations to CPCi PracticesWe are thrilled to learn that 73 Colorado primary-care practices have been chosen for the Comprehensive Primary Care initiative, a multi-payer project that will provide enhanced compensation for high-quality, coordinated, patient-centered care. The CPCi will foster collaboration between public and private healthcare payers to strengthen primary care. In selecting practices to participate in the CPCi, the CMS Innovation Center looked for those with: • Demonstrated commitment to quality improvement;• Use of technology (meaningful use of electronic health records);• Recognition of advanced primary care delivery by accreditationbodies;• Service to patients covered by participating payers;• Experience with practice transformation and improvementactivities; and• Diversity of geography, practice size and ownership structure.

“We are so proud of the work that CPCi-selected practices have done,” said HealthTeamWorks CEO Marjie Harbrecht, MD. “This is a great step toward moving to ‘the way we do business’ and eventually spreading services and enhanced payment to all practices in Colorado interested in making this transformation.”

Thirty of the 73 practices chosen for the CPCi have participated in HealthTeamWorks programs—either the Colorado Multi-Payer PCMH Pilot or PCMH Foundations. Other practices have worked with the Colorado Beacon Consortium, the Colorado Regional Extension Center partners through CORHIO and others. Many of these practices benefited from quality-improvement coaching, technology assistance, help with guideline-concordant care, and additional services and resources for practice transformation.

Building a practice coaching infrastructure makes sense in today’s changing healthcare environment.

PCMH in-office coaching may be on your radar, but have you wondered if it is worth the effort? HealthTeamWorks has been using in-office coaches for over six years, and our experience and literature provide substantial evidence to support the value of in-office practice coaching. A June 2012 policy brief by Grumbach, Bainbridge, and Bodenheimer published by The Commonwealth Fund states:

“… rigorously conducted research has shown that practice coaching is an efficacious intervention to improve delivery of primary care services” (page 5)

“All stakeholders committed to improving primary care will need to devote resources to support a practice coaching infrastructure” (page 7)

The randomized control trial cited in the Journal of General Internal Medicine, September 7, 2012, concludes: “Irrespective of size, practices can make rapid and sustained transition to a PCMH when provided external supports, including practice redesign, care management and payment reform. Without such supports, change is slow and limited in scope.”

HealthTeamWorks programs are designed to help our partners build the internal capacity to do transformation and quality improvement work long after our contract is complete. We pass on our years of experience to partner coaches through an extensive training and mentoring program that helps create local learning groups and empowers an integrated medical neighborhood. Enhanced compensation is coming and practices that are prepared will gain additional compensation for their efforts and improved care. Our experts coaches have helped hundreds of practices navigate the many available options.

If you are interested in learning more about our QI coach training or transformation programs, contact us at info@healthteamworks.org or visit www.healthteamworks.org

“Every practice and patient needs a coach—even Peyton Manning has a coach.”–John Bender, MD, Miramont Family Medicine