Clinician Pay for Performance October 31, 2016
Open Door Family Medical Centers
Founded in the basement of a church in 1972 We’ve grown a bit since then… 5 Primary Care Sites 7 School-based Health Centers Family Medicine Residency program Dental Residency program
Open Door Family Medical Centers By the end of 2015, we had:
Over 100 Medical, Behavioral, and Dental clinicians providing care to… 47,000 patients in… 265,000 visits
Open Door PCP panel sizes Primary care panel size: 1,400/1.0 FTE PCP over 12 months
1,650/1/0 FTE PCP over 18 months 2,100/1.0 FTE PCP over 36 months
Patients by Age and Sex - 2014
(Under age 1)
(65 & Up)
After childhood, we see a considerable difference between the number of men and women that we see. We attribute this trend to the high number of women that we see during child-bearing age.
Insurance Coverage of Our Patients - 2014 4%
CHIP Medicare Private
Pay for Performance in Focus
2001 2006 2007 2009 2011 2013 2014 2016 -
Salary Armageddon NP/PA incentive eClinicalworks implementation Clinical report cards introduced Pay for Performance implemented Human Resources strengthened Tableau database rolled out Relevant database rolled out AZARA PVP rolled out
Paying for clinical quality Clinicians of all stripes want to also be judged by the quality of care they give, not just by how many patients they can see. Clinicians are more concerned about how well they are taking care of patients much more than how fast they are moving from patient to patient.
Volume counts, but it’s not everything Yes, volume-based reimbursement still reigns supreme. BUT…. As healthcare organizations that employ clinicians, shouldn’t their quality of care matter more than it currently is represented?
We are all patients at some point – isn’t a clinician who gives good care what matters most?
Pay For Performance 2010 – plan devised to incorporate clinical quality metrics as a compensation component 2011 – plan rolled-out, first P4P payments HTN bonus trigger set at 60% control rate 2015 – metric goals revised HTN bonus trigger set at 66% control rate
P4P magnifies need to define the PCG Using Hypertension control as an example, we only assign the quality of patient’s care to the PCG if: 1) 2)
Patient is assigned to that PCG Has been diagnosed with Hypertension > 12 months (eliminates concerns about newly diagnosed conditions)
Has seen the PCG at least twice in the past 12 months (eliminates the very common and valid concern about not having sufficient face-time with some patients on one’s panel)
Open Door P4P Primary Care metrics, 1-6 (of 12) Primary Care P4P 2016 Hypertension
2016 P4P HP2020 goal is 66%
A1c < 9
Persistent classes with ICS
Immunizations UTD thru 2 yrs % UTD
HP2020 goal is 80% ODFMC goal is 90%
tracks kids 2-4 years of age Immunizations UTD at 15 years % UTD
HP2020 goal is 50% ODFMC goal is 66%
3 HPV, 1 TDaP, 2 Varicella Paps, in last 3 years % done, > 21 yo
BP < 140/90, adults 18-59 Diabetes
2 Asthma 3
Women age 24-65
Open Door P4P Primary Care metrics, 7-12 (of 12) Primary Care P4P 2016 Mammo, in last 2 years % done, > 50 yo Women age 52-75
Adult Pneumo % done Adults age 65 and older
Adult Tdap in last 10 years % done Age 18 and older
Depression screening/treatment Age 12 and older
Tobacco assessment/cessation Age 13 and older
% done > 50 yo Adults age 51-75
A typical Clinician Report Card A clinician’s report card, showing data: 1) By Goal 2) Open Door overall 3) Clinician’s site (Mount Kisco) 4) Clinician’s data from the most recent 2 quarters He is on track to: Hit P4P metric Miss P4P metric
Pay for Performance breakdown 2016 (2017 breakdown is being revised) Bonus potential is 10% of salary for a clinician who is not in a leadership/managerial position
50% - clinician hits productivity target 25% - clinician site hits productivity 15% - clinician’s clinical quality rating (1-4) 10% - individual goals set with clinician’s site medical director
Determining Clinical Quality Rating We rate clinical quality on a scale of 1-4. Dr. XXX is on track to hit 10 of 12 P4P metrics. Metrics achieved: 10-12 7-9 4-6 0-3
Clinical rating: 4 3 2 1
Summary Clinicians are hard to find, highly-trained, independentminded professionals that you want to nurture, support, and cultivate. Compensation strategies can help or hurt your chances at retention and recruitment.
Incentivize what you want to influence (productivity, quality, panel size, satisfaction, camaraderie/citizenship, etc) Make the system as fair and transparent as possible And if at first you don’t succeed, try and try again!
Who we are • Federally Qualified Health Center • 24,000 patients with 200,000 units of service in 2015 • 8 clinical sites plus 3 mobile vans – including a health care for the homeless site, dedicated dental, urgent care • Joint Commission Accredited
• PCMH Level 3 -2014 Standards • Locations in Hudson Valley include Newburgh, New Windsor, Highland Falls (West Point area), Goshen and newest site co-located in housing project in Binghamton
Our Services • • • • • • • • • • • •
Primary Care: Internal Medicine, Pediatrics, Ob/Gyn Urgent Care Dental Specialties: Cardiology, Podiatry, ID Behavioral Health Services Care Coordination Audiology Optometry Positive Choices (HIV/AIDS Care) Women, Infants, and Children (WIC) Services Enabling Services Center For Recovery (Methadone and Day Rehab)
Clinical Staff 44 clinicians overall • 13 physicians • 11 physician extenders (NP/PA) • 6 Dentists • 6 Dental Hygienists • 2 Psych NP and 4 CSW • 1 Optometrist • 1 Nutritionist
History of Incentive Plan First year of incentive plan 2015; Discussions and Planning began May 2014 Why we started the program: • Reflect pay for performance changes in medicine • Reward high performing providers, incentivize middle of the road providers, align poor performers • Recruitment and retention? • Helps align goals of the providers with the practice • Previous bonuses were not timely or objective enough to change behavior Guiding principles: • Awarding of bonuses is objective & predictable • Compensation is timely and reflective of performance • Supports the goals of organization • Enough “skin in the game” to change behavior • Transparency Getting it off the ground: • CEO buy in • Provider workgroup meets three to four times per year to define objectives and provide feedback • Ongoing meetings with CMO, COO, CFO ( three legged stool meeting) • Communication and feedback from Providers
2015 Incentive Plan Focused on 3 elements: productivity (70%) clinical metrics (20%) and cycle time (10%) Two Phases to allow new providers time to build panel • Phase 1: 5% Bonus Potential for Physicians; 6.5% for Mid-Level Providers of annual base salary; enter phase I after minimum of 6 months to a year of employment • Phase 2: 10% Bonus Potential for Physicians and 11.5% for Mid-Level - with potential of 5% annual withholding; automatic enrollment in Phase 2 after one year. (may elect to enter early) Productivity – based on 3 patients per hour and a 32 hour work week ( the 4200 number) Clinical Performance Measures – UDS/QARR - agreed upon by CMO and Chief of Dept Cycle Time – baseline was 80 minutes – goal of 65 minutes
PRODUCTIVITY STANDARDS Internal Medicine / Pediatrics / Urgent Care and OBGYN (In Office Providers) Provider Completed Appt. Performance Tiers Provider Annual Per Clinical Hour (Percentiles) Productivity (Approximate) >110% 3.3 105% 3.15 100% 3.00 95% 2.85 90% 2.70 85% 2.55 <80% 2.40
Provider Quarterly Productivity 4620 4410 4200 3990 3780 3570 3360
1155 1103 1050 998 945 893 840
** Pediatric providers nursery / newborn hospital encounters are calculated on a 1:1 ratio, inpatient admission on a 3:1 ratio **
Phase I: Total Bonus % of Annual Salary
Phase II: Total Bonus % of Annual Salary
Performance Tiers (Percentiles)
Clinical Outcomes Percent of Annual Salary: Phase I Providers
Percent of Annual Salary: Phase II Providers
Percentage of patients 18 to 85 years of age with diagnosed hypertension (HTN) whose blood pressure (BP) was less than 140/90 at the time of the last reading
Percentage of patients aged 50 to 75 who had appropriate screening for colorectal cancer
Family Practice/Highland Falls
Percentage of patients 18 to 85 years of age with diagnosed hypertension (HTN) whose blood pressure (BP) was less than 140/90 at the time of the last reading ( UDS) Percentage of patients 3-6 years old who completed an annual well child visit (QARR)
OBGYN *( measure of success based on department )*
Percentage of women who delivered during the measurement period that were given Tdap (Tetanus, Diphtheria, Pertussis) during their pregnancy.
Percentage of woman between the ages of 40 – 60 seen in the department who had a mammography in the previous 2 years.
Percentage of female patients that have three HPV vaccines by age thirteen (QARR)
Percentage of patients 3-6 years old who completed an annual well child visit (QARR)
Cycle Time Performance Standards Percent of Achievement 105% 100% 95% 90%
Percent of Achievement 105% 100% 95% 90%
2014 Cycle Time Standard (Minutes) 61.75 65 68.25 71.5
2015 Cycle Time Standard (Minutes) 57 60 63 66
Percent of Annual Salary: Phase I Providers .50% .38% .25% .13% Percent of Annual Salary: Phase I Providers .50% .38% .25% .13%
Percent of Annual Salary: Phase II Providers 1.00% 0.75% 0.50% 0.25%
Percent of Annual Salary: Phase II Providers 1.00% .75% .50% .25%
Administrative / Qualifying Metrics: In order to qualify for a bonus all the following standards must be met. If the criteria are not met the provider cannot benefit from quality or productivity bonus, but are still at risk for salary holdback if they do not meet 90% productivity.
On the 4th Friday of every month a report will be generated. All providers must have signed off on any office visit that is more than 48 hours old.
Participation in one community event, health screening, health fair or lecture for medical students – approval by CMO
Peer Review: 5 Peer Review forms will be distributed quarterly. Peer Reviews need to be completed and submitted within 2 weeks of distribution.
Provider must write 2 blogs for the health center on a topic of their choice – first one due by 6/1/16 and 2nd one due no later than 12/31/16.
What we learned from 2015? • Previous issues with coverage resolved itself – departments covered themselves • Overall increase in productivity. Some providers respond, some not so much. • Not all clinical sites and departments should be held to same standard. Difficult to reconcile this and still appear to be objective and fair. • Providers made more money • Have not figured out a way to include Ob’s who deliver in hospital in plan • Cycle Time Improved
2016 Plan Updates • Increased weighting of clinical outcomes from 20% to 35% to reflect the shift to Value Based Compensation. Included plan to get to a 50% bonus based on clinical outcomes by 2018 • Urgent Care performance tier moved up
• No more differentiation between mid – levels and physicians • This was first year providers required to have downside risk (5% holdback for productivity performance < 85%) • 3 providers had money held back; 1 recently left organization and cited dissatisfaction with downside risk in exit interview
• Eliminated Bonus for 90%; Shifted more bonus to high performers ( >100%). Plan included to only bonus for >100% by 2018. • Clinical Performance measures based on departmental performance
Value Based Incentives Bronx Lebanon Primary Care Isaac Dapkins MD Outgoing CMO Bronx Lebanon Integrated Services Systems Inc.
• • • • •
Background of BLISS Impetus for Change Measure Alignment Challenges Dashboarding
Background of Bronx Lebanon Integrated Services Systems Inc. YEAR
MLK Jr Health Center opened its doors the first urban and largest community health center funded by the Office of Economic Opportunity.
Bronx-Lebanon Hospital Center (BLHC) was directly funded by a grant from the Bureau of Community Health Services.
Bronx Ambulatory Care Network (BACN), a freestanding, not-for-profit corporation, was funded by PHS under the Section 330 Grant Program. BACN contracted with BLHC and Montefiore Hospital Medical Center, as sub-recipients, to provide comprehensive primary care to the residents of the South Bronx. Bronx-Lebanon Integrated Services System Inc. (BLISS) was formed as one of two successor entities to the Bronx Ambulatory Care Network (BACN), and funded as a direct recipient of section-330 funding.
Current status of Bronx-Lebanon Integrated Services Systems Inc. • Two subrecipients: MLK Jr HC and Bronx Lebanon Hospital Centers – 22 clinical programs at 9 different sites. – All 9 sites are PCMH Level 3 (2011 Standards, 2014 application pending)
• Allscripts Sunrise Clinical Manager since 2008 • 579 acute care beds • Over 1 million ambulatory care visits, 120,000 FQHC patients • 330 long-term care beds • Part owner of Healthfirst • Lead of Bronx Health Access PPS
* Managed Medicaid
PCMH Level 3
Proposed VBP incentive
1 Year Incentive Review Period
Programs impacting decision to go to value based 5
Impetus for Change • Healthfirst FullRisk Contract • Medicare Access and CHIP Reauthorization Act of 2015 • Multiple P4P Programs (DSRIP, UDS, HQIP)
• Decision to reduce Volume Based incentive for physicians
• Revenue flows based on Number of months patients assigned to a PCP • Better quality increases the PMPM value of each client • Better documentation increases the PMPM value of each client http://miv42.informatics.stonybrook.edu/
PCMH • Establishes a core understanding of population level healthcare • Requires provider engagement on a population level
• Does not take into account cost of care
Healthfirst Quality Incentive Program (HQIP/Medicaid)
DSRIP – DSRIP Guaranteed Funds were funneled through Equity Performance Program • Revenue flows via Pay for Performance metrics through contracts with Managed Medicaid Companies
– DSRIP Performance Payments are shifting from Process and Reporting to Performance measures (Domains 2&3) • MY3 (July 1, 2016-June 30, 2017) is the highest value year for bonus payments related to performance
DSRIP EPP Measures EPP Measures**
Children´s Access to Primary Care – 12 to 24 months
Children´s Access to Primary Care – 25 months to 6 years
Children´s Access to Primary Care – 7 to 11 years
Children´s Access to Primary Care – 12 to 19 years
Prenatal and Postpartum Care – Postpartum Visits
Prenatal and Postpartum Care – Timeliness of Prenatal Care
Well Care Visits in the first 15 months (5 or more Visits)
Childhood Immunization Status (Combination 3 – 4313314)
Frequency of Ongoing Prenatal Care (81% or more)
Follow-up care for Children Prescribed ADHD Medications – Continuation Phase Chlamydia Screening (16 – 24 Years)
Follow-up care for Children Prescribed ADHD Medications – Initiation Phase Lead Screening in Children
Med. Assist. w/ Smoking & Tobacco Use Cessation – Discussed Cessation Medication
Med. Assist. w/ Smoking & Tobacco Use Cessation – Discussed Cessation Strategies
Comprehensive Diabetes Care
Controlling high blood pressure
Diabetes screening for persons with schizophrenia or Bipolar Disease who are using Antipsychotic Medication
Comprehensive Diabetes screening – All Three Tests
Adherence to anti-psychotic medications for individuals with schizophrenia
Diabetes monitoring for persons with schizophrenia
Behavioral Health – follow up after hospitalization for mental illness (30 day)
Initiation and Engagement in Alcohol and Other Drug Dependence Treatment (IET) within 14 days of substance abuse episode
Follow-up on Alcohol and Other Drug Dependence Treatment (IET) within 44 days of initial engagement
Behavioral Health – follow up after hospitalization for mental illness (7 day)
Challenges • • • •
Behavioral Economics Empanelment Measuring Patient Satisfaction Tools for effectuating change in population health
Ann Intern Med. 2016;164(2):114-119.
Empanelment • Patients seen in the past 15 months + • Patients on Managed Medicaid Panel + • Patients are asked to agree on Primary Provider (“Preferred PCP”) as part of the PCMH.
Telephone Survey Questions • When visiting your primary care physician or specialist, how long do you usually spend in the waiting room before you see the doctor? • Overall, how would you rate the quality of care you received from this doctor? • How would you rate this doctor on giving you a clear explanation of tests and treatment options?
Tools for effectuating change • How can we increase our panel? • How can we get patients to come in to be seen if they need a measure? • How can we see what our progress has been?
Bronx Lebanon Incentive Plan • Total incentive could result in an increase of reimbursement of approximately 30% • Data aggregated for quality across multiple HEDIS measures using RHIO data • Patient satisfaction data collected on a daily basis through telephone surveys (Cipher Health) • Visit volume will be a component that is phased out over time • Panel size based on empanelment
Final Incentive Breakdown Values
Panel Size Providers incentivized to have more 1800 patients in care: • Patients seen in the past 15 months + • Patients on Managed Medicaid Panel + • Patients are asked to agree on Primary Provider (“Preferred PCP”)
Quality Component • Standard measures that are based on the UDS, EPP and HQIP. • Each measure has a threshold above which incentive $ begin to be available and a benchmark when the maximum dollar amount is achieved. • We only pay to the benchmark – so doing better than benchmark does not benefit provider
Patient Satisfaction • Provider specific patient satisfaction responses on a modified CAHPS survey • Baseline threshold of >20% positive topline answers
• Target >55% topline answers
Visit Volume • Incentive is a per/visit dollar value for each visit.
Documentation Improvement • Providers receive real time alerts at time of visit • Provider achieves incentive based on their response to documentation improvement alerts
Provider Action List
* Managed Medicaid
PCMH Level 3
Proposed VBP incentive
1 Year Incentive Review Period
Programs impacting decision to go to value based 27
Questions Isaac Dapkins MD CMO Lutheran Family Health Center