Ten Steps to an Efficient Effective Profitable Family

Ten Steps to an Efficient, Effective, Profitable Family Medicine Office (aka PCMH) Anton J. Kuzel, MD, MHPE Harris-Mayo Distinguished Professor and Chair VCU Department of Family Medicine

The new ideal: The Patient Centered Medical Home

The current reality • Too many PCPs feel overworked, underpaid • About 1% of practices are at level 3 PCMH status • No idea of how to get to an idealized model without special financing

Hamster wheels • http: //www. youtube. com/watch? v=UFHCfw. F 87_o

There is hope, and a way • We need to get off the hamster wheels • A significant minority of practices are doing remarkably well – Physician, staff, patient satisfaction – Ambulatory quality measures – Physician income • We need to learn from these practices!

Step 1: Documentation and coding o Stop leaving money on the table • 20 -30% of FM established patient codes are level 4 • 60+% of FM established patient codes could/should be level 4 • Using Medicare payment rates, this would generate about $50, 000 per year per physician in extra income (more if average payment exceeds Medicare rates) • Little/no extra work/time from physician • Why not? Don’t know how, or afraid of audit • Coding from the bottom up; memorize 99214 • This is low hanging fruit!

Coding from the bottom up: 99214 • Decision Making (presenting problem) • 1 Chronic illness with exacerbation • ≥ 2 Chronic stable illnesses • New problem of uncertain diagnosis • Acute illness with systemic symptoms • Acute complicated injury • PLUS – Hx: 4 element HPIs, 2 ROS, 1 PFSHx OR – PE: Detailed (affected area and related organ system) • Must read: Coding from the Bottom Up, FPM

Step 2: Add staff, with a purpose • Physicians are the ones generating income • Physicians should not be doing things that don’t require their expertise • Nurses, other staff should take non-physician work AWAY from the physicians • All people working to the top of their license • Systematic attention to prevention, CDM • Adds capacity, increases quality, creates opportunity for increased income • Must read: Working Smarter, Not Harder; FPM November 2006

Preliminary Questions • How many calls or faxes/day for prescription renewal? • How do you handle results reporting to pt? • Can pts be seen same day? • Who returns phone calls? • Who completes the paper work? .

Physicians as Clerical Staff Work within the skill-set of others is now displaced to physician: – Transcription – Documentation – Proofreading – Paper work – Data gathering – Data entry – Order entry – Medication reconciliation – Processing prescriptions

Patient Centered Medical Home A systems approach • Planned Care Appt • Order sets • Pt. Questionnaire • Empowered Nursing • Prescription Mgm’t • Visit Summary

Planned Care Appointment • Pre-appt lab • • Planned Care Appt Order sets Pt. Questionnaire Empowered Nursing Prescription Mgm’t Visit Summary Annual Exam Rapid Access • – Majority lab few days before appt Quality – 1000 tests/week – Missing or overlooked inform • Patient Centered – Collaborative decision making improves outcomes • Efficiency – Decreases stand-alone chart review by MD • 2 -4 hrs of f/u work per session (Kaiser, others) – “Just in time” info processing • Once • In context • At time of decision making

Planned Care Appointment • • • 67 yo diabetic Planned Care Appt – A 1 c 6. 2 Order sets – LDL 160 Pt. Questionnaire • RTC 4 mo w/lab Empowered Nursing Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors

Planned Care Appointment • • • Close the loop during appt Planned Care Appt – Pt’s work is done Order sets • No wait Pt. Questionnaire • No worry • Reserved time; can plan Empowered Nursing – MD’s work is done Prescription Mgm’t • No hangover re-work Visit Summary • Saved an hour/day Annual Exam Rapid Access Intentional Behaviors

Post-Appointment Order Sets • • Planned Care Appt Order sets Pt. Questionnaire Empowered Nursing Prescription Mgm’t Visit Summary Annual Exam Rapid Access • Arrange planned care appts; minimum checks • Tool to integrate – – Acute Chronic Prevention Pt ed, procedures, referrals

Post-Appointment Order Sets • • Planned Care Appt Order sets Pt. Questionnaire Empowered Nursing Prescription Mgm’t Visit Summary Annual Exam Rapid Access • Quality – Order sets – Reduces errors of ommission • Efficiency – Saves time – Dx codes: default & alternative – Decrease stand alone chart reviews by staff • Paper or electronic

Pre-appointment Questionnaire • • • Identifies the patients agenda Planned Care Appt • MD plan visit before Order sets entering Pt. Questionnaire • Update PFSH Empowered Nursing • Complete ROS Prescription Mgm’t • Behavior issues (exercise, alcohol, smoking) Visit Summary • Future Annual Exam – Kiosk in waiting area Rapid Access – Web portal from home Fam Prac Mgt 2008; 15: 35 -40 www. aafp. org/fpm/20080300/35 have. html

Pre-appointment Questionnaire • • • Planned Care Appt • Order sets Pt. Questionnaire • Empowered Nursing Prescription Mgm’t • Visit Summary Annual Exam Rapid Access 59 yo f/u of sleep disturbance Social History – “Are you or others concerned about your drinking” “I was too embarrassed to put this on my form” A systems way of conveying that the subject is fair game

Empowered Nursing • • • Nursing staff are full partners in Planned Care Appt care of our patients Order sets • Staff work to full level of ability Pt. Questionnaire • Minimize MD time on work within Empowered Nursing skill set of others Prescription Mgm’t Visit Summary Annual Exam Rapid Access

Building the Case for Strong Team Infrastructure • 2 more 99214 patients per day covers MA cost Assumptions: MA works 48 weeks/year; payer mix generates $40/RVU; non-facility 99213 = 1. 71, 99214 = 2. 58 t. RVUs; MA salary and benefits = $50, 000/yr

Hypothetical Modeling • • • Doctor-does-it-all – 0. 5 MA – 20 patients/day Doctor-does-the-doctoring – 1. 5 MA – 24 patients/day The Business Case – 4 more 99214 pt/d = $90, 000/yr – net benefit of $40, 000/year Assumptions: MA works 48 weeks/year; payer mix generates $40/RVU; nonfacility 99213 = 1. 71, 99214 = 2. 58 t. RVUs; MA salary and benefits = $50, 000/yr

The Business Case for Support: Medical Associates Clinic • Nurses – 1. 75 nurses vs 1. 25 – 56% more production • Exam rooms – 3 rooms vs 2 – 34% more production

Prescription Management • • • Survey: majority calls for Planned Care Appt scripts Order sets – Consumes staff time Pt. Questionnaire – Care out of context Empowered Nursing • Systems change: All scripts Prescription Mgm’t (non-narcotic) 15 mo at annual exam Visit Summary Annual Exam • ↓ phone calls by 50% Rapid Access • Safety – Authorized by personal MD – In context of other meds – In context of other illnesses

Prescription Management • “Rational Prescribing” • Planned Care Appt • Before change • Order sets • • • – Pt calls in 8 x a year as Pt. Questionnaire meds randomly come due Empowered Nursing Prescription Mgm’t • After change Visit Summary – Pt may not need to call in Annual Exam at all Rapid Access

Step 3: Rapid access scheduling • • Requires information system to know panel sizes Balance supply and demand Choose easier ways of working down the backlog Improves continuity, which supports coding to higher levels of care • Do today’s work today • Patients love it

Step 4: Increase patients seen per day • • • Typical FP sees 20 -25 per day Adding 5 per day: $85, 000 per year Adding 10 per day: $170, 000 per year We need more PC capacity! Can be done without adding work hours! (Assumes we continue with a fee for service financing model) • (Could be a good bridge model until we have more PCPs and a more rational financial model for health care)

You’ve created an efficient office! You will use less energy to get work done.

Step 5: Extend hours • Only reasonable if part of a group practice, though could imagine doing this among multiple solo practices for evening, weekend urgent care • Patients love it • Likely to reduce overall costs of care (less ED care, “doc in a box” care – no continuity, more tests) • Should not result in physicians working more hours per week, just different hours than is now typical

It will take some flexibility…

Step 6: Buy and implement EMR • Wait until you have established a highly functional, paper-based team • Can be expensive, will almost certainly create a temporary drag on productivity • Creates opportunities for important next steps • Necessary for many “bonus” payment programs

Step 7: Start doing population QI work • Up to now, doing it right, one patient at a time • Depending on how well that is going, registry may be more of a way to catch “errors” – i. e. , patients who haven’t been in for their annual visit for prevention, CDM • Can lead to enhanced reimbursement • Find and work with your local/state experts

Step 8: Patient portal • Integrated with EMR • Allows for secure, two-way communication • Can allow for patient entry of history, scheduling of appointments, obtaining lab results, even e-visits (if compensated for same)

Step 9: E-link with other providers • Can happen if in same network and with same platform • May involve Health Information Exchange (HIE) • Reduces your work (tests, consults automatically populate EMR) • Improves care coordination • Reduces cost (uneccesary testing) • Improves patient safety

Step 10: Help costliest patients • Kaiser data: 1% of patients account for 36% of costs • Kaiser data: 10% of patients account for two-thirds of costs • May require more staff than your office has, and regional collaboration • Community Care of North Carolina is proven model – saving NC hundreds of millions of dollars annually • Geisinger seeing 250% ROI • A MUST DO for controlling inflation of health care costs

Key enablers • Overcoming obstacles to documentation, coding • Office culture: getting relationships right • Getting political support to reduce risk of pushback from payers (PC spend could go from 5% to 6 -7%; this might be less of a worry, given recent CMS recommendations) • Creating and sustaining “communities of practice” – helping one another solve shared problems

Can this really work? • First, no outside financing needed • Second, directly addresses frustrations felt by many PCPs • Third, does not require specialized training (e. g. , Lean, Six Sigma) – depends on “R&D” (IHI) • Fourth, many practices have redesigned to PCMH without special coaching or outside resources • Fifth, many people I have talked to in private

Proof of concept project • Riverside Medical Group (Tidewater region of Virginia) • 6 -7 primary care offices • Healthy culture; near capacity • Emotional appeal: more fun, better income, (better quality) • Use peers in state as trainers – Coding for reimbursement – Creating and sustaining team care – Moving to advanced access scheduling

It’s time to start having fun again at the office!

Your staff may surprise you with a practical joke!

Go out there and have some purposeful fun! I know you can do it!