Connecting the Dots: Integrating Services Across Small Practices

Connecting the Dots: Integrating
Services Across Small Practices
May 6, 2009

Nuffield Trust

Steve McDermott, CEO
Hill Physicians Medical Group
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G:CorpSvcAPowerpntSMNational Health System GB 050609.ppt

Steve McDermott
CEO, Hill Physicians Medical Group, Inc.
Chairman, PriMed, Inc.
San Ramon, California

Steve has been Chief Executive Officer of Hill Physicians Medical Group since he
helped organize it in 1984. Steve is also the Chair/CEO of PriMed, the MSO that
manages Hill Physicians. Steve also helped create the Integrated Healthcare
Association (IHA), a unique multi-disciplinary organization of high level health care
executives.
executives As chair of IHA Steve spearheaded the statewide Pay for Performance
IHA,
program for California medical groups that launched the Pay for Performance
movement. Prior to developing Hill Physicians, Steve was CEO of MedAmerica, a
medical management company that organized and managed hospital-based
physicians i 50 h it l i six states. F
h i i in hospitals in i t t From 1973 1976 St
1973-1976, Steve l d th creation of th
led the ti f the
San Francisco Bay Area Emergency Medical System serving as its initial Executive
Director. He obtained a bachelor’s degree in business from Providence College in
1969 and a master's degree in business and health care administration from George
Washington University i 1971
W hi t U i it in 1971.


Paul C. Smith, M.D.

First President of Hill: General Surgeon Fellow of the Royal Academy

Connecting the Dots: Integrating
Services Across Small Practices

1. Background on Hill
2. Leveraging Technology
3.
3 Key I iti ti
K Initiatives
4. Pay for Performance
5. Final Thoughts


1.Background on Hill Physicians
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America’s Largest IPA
2,600 physicians/34 affiliated hospitals
320,000 HMO members
Delegated care via seven HMO plans
100% capitated: commercial, MediCare, Medi-Cal
Serving
S i 9 northern California counties
h C lif i i
(about the size of Wales)
88% of primary care physicians in solo/two person
f i h i i i l /t
practices


Context for Organizing Hill

- emphasize primary care, wellness
- coordinate care and control costs
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- create ‘systemness’ and accountability
- balance the table between payors, hospitals and
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independent physicians and, between primaries
and specialists
Challenge: getting independent professionals to work together at
their own short term expense, giving up their individual
prerogatives in favor of a stronger organization aimed at a greater
good.
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Acid test: Is the result better for their patients and society and
ultimately better for themselves in the long run?


Organizational Structure

Shareholders (participating physicians who qualify); Board of
Directors; formal standing committees
Chief Medical Officer, 8 Medical Directors
― Accountable for geographic regions
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Chiefs of Service
― 32 Specialty
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― 17 Primary Care
PCPs organized into local panels, meet quarterly on clinical and system topics
Specialists organized in regional panels, meet quarterly
Medical Di t h
M di l Directors have annual objectives/performance bonuses
l bj ti / f b

All Medical Directors/Chiefs are practicing physicians


PriMed:
The Engine Under Hill’s Hood
Hill s

MSO
MSO* created in 1981, organized Hill in 1984
1981
Exclusive manager; 455 employees
Cost-based
Cost based budget plus performance bonus (11%)
“Top 100 Places to Work” in SF Bay Area
Ownership: Medical G
O hi M di l Group/Management/Hospitals
/M t/H it l

Focus of Management Expertise,
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System Development and Administrative Support
*Management S i
*M t Services Organization
O i ti


2. Leveraging Technology
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Relay Health - offers Web-based secure messaging
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platform that facilitates online medical services for
patients and doctors
- 2 070 enrolled physicians; 85,000 + online patients
2,070 ll d h i i 85 000 li i
- About 100,000 transactions per month

Hill inSite – online platform to verify patient eligibility,
submit authorizations, check claims status and receive
electronic funds transfers
l i f d f
- Over 1,271 active practices


Other Online Services
eScript (560,107 online prescriptions, 2008)
Referrals to specialists (67,667 in 2008)
(67 667
Secure messages between providers and
patients (340,986 in 2008)
(340 986
Lab results transmitted to patients
Appointment requests made online
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77% claims online; 40% of authorization
requests online*
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*AccessExpress currently being launched will greatly
increase this #.
#


Electronic Health Records

NextGen EHR solution but install and
ongoing support by PriMed
Consolidates all patient records across all
sources of care into a single, accessible
database
Clinical data repository; data mining
“Best practice” protocols
Best practice
Multi-year effort


3. Key Initiatives
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Clinical Support Programs

Predictive Modeling ‘Finding Balance’
Finding Balance
Group Appointments Point of service
Polypharmacy surveys
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Program ‘Practice Support’
Neurobehavioral Leadership Training
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Pain
‘Clinical Snap-shots’


Predictive Modeling
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Program that analyzes patient diagnostic, and lab
& pharmacy data
Identifies patients with highest probability of
developing
d l i complex, chronic conditions
l h i diti
Determined that approximately 28% of patient
base at moderate or higher risk for developing or
exacerbating chronic conditions
Physicians use data to better allocate time to
patients with greatest needs, intervening before
further complications develop.


Group Visits

Primarily used for diabetics; also for asthma,
asthma
migraines and other chronic diseases

Patients improved A1C control, more readily
incorporate recommended exercise and
i d d i d
dietary plans into their lives, fewer ER
visits/hospital admissions
i i /h i l d i i


Polypharmacy Program Pilot

Reviewing 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 patient
safety and quality of care


Neurobehavioral Pain
Management Program
M tP
Psychotherapists teach patients to ‘turn off pain
turn off’
using mind and body focus rather than
pharmacological
Initial results – 30 days after completing program,
participants report:
- 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


Clinical Snapshots
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Physician specific report designed to identify
patients who have “fallen through the cracks”- lost
cracks”
to follow up or non-compliant with treatment plan
Examples:
– diabetics overdue for Alc and lipid tests
– patients with hip fractures who are candidates for
bisphosphonates
Hill contacts members, mails requisitions and
reminders


Helping Physicians Help Themselves
p g y p

Finding Balance in a Medical Life
- Teaches relaxation, cognitive
restructuring,
restructuring and meditation skills
- 181 physicians participated with spouses
- Fourth year; high levels of satisfaction
- Expanded to office staff


Point of Service Online Surveys
y

Kiosks with internet connection are located in
physicians’ office waiting rooms.
Patients log on anonymously and complete
interactive touch screen surveys.
i i h
Initial survey on patient satisfaction
Creates immediate feedback to office staff
Useful for physicians who scored poorly on annual
survey and want to improve
Hill office outreach staff meets with practice manager t
ffi t h t ff t ith ti to
interpret results and suggest improvement projects.


Practice Support

Office manager assistance
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Physician recruitment
Selected subsidies for new MDs
I.T. assistance
Growing menu of services
Promote group practice
- Physician recruitment
- Selected subsidies for new MDs
Practice management?

Physician Leadership Initiative
Program 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 physician
Nomination-based program with class entry once per year
Continuing di l d
C i i medical education credit
i di
Leadership placement based on participation performance
and learning evaluation
90-day; 6-month; and 1 year performance evaluation (self
)
and other)


4. Pay for Performance
Program Goals
Promote results oriented culture
Expand the concept of medical services
Develop teamwork/systemness
D l t k/ t
Move to population management
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Background

Developed in 1997;
D l d i 1997 some specialists added i 2004
i li t dd d in
Rewards efficient and progressive practices
Performance based, population based
Developed/ maintained by medical directors/
p y
management
Paid in addition to fee-for-service payments
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Quarterly distribution
Continuously evolving
C i l l i

Performance Based Profiles - PCPs
Utilization / Controlling Costs professional
pharmacy
facility costs

Clinical Quality (P4P) breast cancer screening
cervical cancer screening
chlamydia screening
diabetes HbA1c
diabetes nephropathy
asthma medication
cholesterol - LDL
childhood immunizations
children with pharn gitis
ith pharnygitis
upper respiratory infection
colorectal cancer screening

Engagement open practice
panel meetings
e-initiatives
Hospitalist Program
exclusivity

Member satisfaction (annual)

Financial Impact
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Range per M D from 0 to $100,000 per Qtr
M.D. $100 000 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


Pay for Performance
$33.8
$32.2
$ Millions
$27.4
$26.0

$17.5

$13.5

$5.2 $4.8 $5.0 $5.1
$7.5 $4.3
$3.8
$3 8 $4.1
$4 1

2002 2003 2004 2005 2006 2007 2008*

Health Plan Bonus Payments to Hill Hill Incentive Payments to its Physicians

Physician Compensation Caveats
There are no “best” techniques; it is an evolving work in
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progress
Doctors need to be looking at good data within accountable
process
Listen to physician feedback with both ears
Continuously adjust measures
Avoid profiles becoming “routine”
Reporting achieves improvement BUT not sustained w/o
R i hi i i d /
pay
Dollars have t b i
D ll h to be impactful, reliable
tf l li bl

5. Final Thoughts
g
Management vs. Professionals: A Natural Conflict
Management: getting people together to accomplish desired
goals; comprises planning, organizing, staffing, leading or
directing, and controlling.
Professions: autonomous with a hi h d
P f i t ith high degree of control exercising
f t l ii
a dominating influence over its entire field, can act monopolist,
rebuffing competition from ancillary trades and occupations, as
well as subordinating and controlling lesser but related trades
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 you
are not making some mistakes, you are not cutting edgeedge.


Management/Physicians: Building Trust
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- clear purpose and goals that resonate
- transparency; full and open communication
- accountability; checks and balances
- aligned incentives
- execute: d what you say you’re going to do
do h ’ i d
and, do it right

.

Last Word

- Leadership: “Strong physician leadership” is helpful but not
enough: nearly all medical organizations (good, bad and
(good
indifferent) have physician ‘leaders’
- Conflict: You cannot avoid conflict, in fact, it is healthy. The
key is b ildi i h k
k i building in checks and balances while clarifying
db l hil l if i
common purpose.
- Risk: You cannot eliminate risk as in doing so y will
g you
eliminate innovation and starve creativity.
- The Illusion of Technique: Health care chases one fad after
another,
another mostly tactics and techniques, substitutes for systemic
techniques
change and/or good management. P4P and the ‘medical home’
are latest examples.


Physician Satisfaction

Measured annually by independent survey group

92%
90% 90%
88%
83%
80%
76%

66%

2000 2001 2002 2003 2004 2005 2006 2007


Connecting the Dots: Integrating Services Across Small Practices

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