This was presented at FMCC 2015 as part of the "Value of Primary Care" session by Melora Simon, MPH.

1. © 2015 A. Milstein/Stanford Univ
Providing More with Less:
Primary Care Bright Spots
Melora Simon MPH
Stanford Clinical Excellence
Research Center
Family Medicine
Congressional Conference
May 12, 2015

2. The Value of Primary Care
2
Health Reform and Physician-Led Accountable Care
The Paradox of Primary Care Physician Leadership
Even though most adult primary care physicians may
not realize it, they each can be seen as a chief executive
officer (CEO) in charge of approximately $10 million of
annualrevenue.Considerthatatypicalprimarycarephy-
sicianhasapproximately2000patients,eachofwhom
annually accounts for about $5000 for health care
spending.Althoughprimarycaretodayaccountsforonly
5% of that spending, the decisions made in the primary
care setting have important implications for down-
stream medical care, such as subspecialty referrals,
imaging and other medical testing, invasive proce-
dures, and hospitalizations. A group of 100 adult pri-
mary care physicians could potentially influence al-
most $1 billion in health care spending.
Yet for most physicians, practicing today certainly
does not feel like being a CEO. Physicians see opportu-
nities every day to improve quality and lower costs, but
in a recent survey, the vast majority of physicians re-
ported that they should not be expected to play a cen-
tral role in controlling costs.1
They expressed this view
(ACOs) in Medicare, Medicaid, and private insurance
plans could make primary care physicians more like
CEOs,withaccountabilityfortheoverallqualityandcost
results of their patients. In the Medicare Shared
SavingsProgram,primarycareservicesarethebasisfor
assigning patients to the ACO, and 75% of the gover-
nance board seats must be held by ACO physicians. If
ACOsdemonstratesavingsinthetotalcostofcarewhile
maintaining or improving quality and patient experi-
encemeasures,thoseACOswillbeabletoreceiveupto
half of the savings without taking on downside finan-
cial risk.3
In many private insurance plans and multi-
payer collaboratives, primary care physicians receive
some of their payments on a case basis (like a medical
home)andalsoreceiveashareofthesavingsforreduc-
ing overall spending growth.
A key difference between physician-led ACOs
compared with other ACOs, such as those organized
by hospitals, is that physician-led ACOs have clearer
financial benefits from reducing health care costs out-
VIEWPOINT
Farzad Mostashari,
MD, MPH
The Brookings
Institution,
Washington, DC.
Darshak Sanghavi, MD
The Brookings
Institution,
Washington, DC.
Mark McClellan, MD,
PhD
The Brookings
Institution,
Washington, DC.
Author Reading at
jama.com
Opinion
Every
primary
care
physician
can
be
viewed
as
a
CEO
with
$10
million
in
annual
budget
responsibility.
JAMA: May 14, 2014: Primary Care Physicians as CEOS

3. • Attribution and risk adjustment
• Members
a?ributed
to
group
having
maximum
number
of
claims
• Member-­‐level
risk-­‐adjustment
using
3M’s
Clinical
Risk
Group
soIware
(CRG)
• Cost basis
• Allowed
amounts
• Standardized
costs
using
a
fee
schedule
• Composite of > 40 HEDIS, NQF endorsed, or Medicare Star measures
• Balanced across process of care, prevention/wellness, and medication
management domains and specific conditions
• Weighted to reflect a hybrid of clinical and empirical importance
• Clinical
-­‐
medicaOon
management,
prevenOon-­‐wellness,
and
diseases
such
as
diabetes,
asthma,
CVD,
etc.
• Empirical
-­‐
Determines
measures,
weighOng
to
maximize
discriminaOon
between
providers,
idenOfies
measures
to
remove
as
same
in
discriminaOng
providers
Total cost of care
Identifying Bright Spots: Double
Top-Quartile National Ranking
Quality
Approach informed by consultation with diverse panel of
experts in clinical performance assessment.

4. © 2015 A. Milstein/Stanford Univ
Rare But Powerful
<5%
10,000
scorable
sites
In
top
quarOle
on
both
quality
and
cost
• Risk-­‐adjusted
per
capita
total
cost
of
care
>
20%
lower
than
average
• >10%
higher
on
quality
composite

5. © 2015 A. Milstein/Stanford Univ
Bright Spots found in both high
and low cost labor markets
11

6. © 2015 A. Milstein/Stanford Univ
Bright Spot Sites are Diverse
Fee-for-service (FFS)
reimbursement
• Greater Minneapolis,
MN
• Greater Rochester, NY
Capitated
• Greater Orlando, FL
Capitated
• Greater Tampa, FL
Fee-for-service
• Phoenix, AZ
• Memphis, TN
• Greater Dayton, OH
• Greater Cincinatti, OH
Capitated
• Orange County, CA
Independent,
primary care only
Independent,
multispecialty
Part of a
health system
Other • Workplace clinic: San Antonio, TX
• Federally Qualified Health Center: Greater Boston, MA

7. Shared Features of Idol Sites
Deeper
patient
relationships
Wider
scope of
responsibility
Team-based
practice
organization

8. Deeper Patient
Relationships
• Always on
• Conscientiousness and
conservation
ü Adherence
to
guidelines
ü Moderately
adjustable
care
intensity
ü Informal
shared
decision-­‐making,
advanced
care
planning,
&
other
forms
of
choosing
wisely
• Complaints are gold

9. Wider scope of
responsibility
• Responsible in-sourcing
• Staying close
• Closing the loop

10. Team-Based
Practice Organization
• Upshifted staff roles
• “Hived” workstations or rules-based
decision making/standard work
• Balanced compensation
• Investments in people, not space &
equipment

11. Next steps: Validation and Spread
• Builds on Patient Centered Medical Home and
Choosing Wisely (both are necessary, but not
sufficient)
Also need:
• Payment models that support and incentivize
this way of practice
• Transparency for primary care physicians
about their performance on quality and total
cost of care, as well as their available
referral options
11

12. To learn more…
More detail, including profiles of the highlighted
providers at
http://petersonhealthcare.org/most-valuable-
care
If you are interested in learning more or getting
involved in spreading this model of care, email
mostvaluablecare@stanford.edu
12