access to care where are we all going to get care? bruce a. bishop senior counsel/director of...
TRANSCRIPT
Access to Care Where Are We All
Going to Get Care?
Bruce A. BishopSenior Counsel/Director of
Compliance Northwest Permanente, P.C.,
Physicians and Surgeons
Today’s ReadingsToday’s Readings
“Aim High: Building a Healthy Oregon” http://www.oregon.gov/OHPPR/HFB/docs/Final_Reporthttp://www.oregon.gov/OHPPR/HFB/docs/Final_Report
_12_2008.pdf_12_2008.pdf “2009 Physician Workforce Survey”
http://www.oregon.gov/DHS/healthplan/data_pubs/rehttp://www.oregon.gov/DHS/healthplan/data_pubs/reports/pws-2009.pdfports/pws-2009.pdf
““The Redesign of Primary Care With Implications for Training”
http://www.oregon.gov/OHPPR/HPB/Workforce/Docs/Dhttp://www.oregon.gov/OHPPR/HPB/Workforce/Docs/DHHS_Primary_Care_Dentistry.pdf?ga=tHHS_Primary_Care_Dentistry.pdf?ga=t
“Oregon Professional Panel for Analysis of Medical Professional Liability Insurance”
http://www.oregon.gov/OHPPR/HPB/MedicalLiability/http://www.oregon.gov/OHPPR/HPB/MedicalLiability/Docs/PinnacleReport_Combined.pdfDocs/PinnacleReport_Combined.pdf
Building Block Six:Building Block Six: Train A New Health Care Train A New Health Care
WorkforceWorkforce
GOAL: Ensure that Oregon’s health GOAL: Ensure that Oregon’s health care workforce is sufficient in numbers care workforce is sufficient in numbers and training to meet the demands and training to meet the demands that will be created by proposed that will be created by proposed coverage expansions, system coverage expansions, system transformations and an increasingly transformations and an increasingly diverse Oregon population.diverse Oregon population.
2009 Physician Workforce 2009 Physician Workforce Survey:Survey: What Do We Know What Do We Know About Oregon Physicians?About Oregon Physicians?
KEY FINDINGSKEY FINDINGS Concern over Medicare reimbursement rates Concern over Medicare reimbursement rates
topped a list of 23 issues that physicians face.topped a list of 23 issues that physicians face. 79 percent rated it “very important”79 percent rated it “very important”
Concern over the cost of doing business was Concern over the cost of doing business was the second highest priority.the second highest priority.
77 percent rated it “very important”77 percent rated it “very important” Concern over health care reform was the third Concern over health care reform was the third
high priority.high priority. 70 percent rated it “very important”70 percent rated it “very important”
Source: www.oregon.gov/DHS/healthplan
2009 Physician Workforce 2009 Physician Workforce Survey:Survey: What Do We Know What Do We Know About Oregon Physicians?About Oregon Physicians?
KEY FINDINGS (Continued)KEY FINDINGS (Continued) 48 percent of Oregon physicians think 48 percent of Oregon physicians think
that fee-for-service payment systems that fee-for-service payment systems are effective at encouraging high quality are effective at encouraging high quality and effective care. (52 percent do not.)and effective care. (52 percent do not.)
Revisions to Medicare and Medicaid fee Revisions to Medicare and Medicaid fee schedules topped the list of six schedules topped the list of six hypothetical approaches for realigning hypothetical approaches for realigning provider payment to improve health provider payment to improve health care delivery in Oregoncare delivery in Oregon
Source: www.oregon.gov/DHS/healthplan
2009 Physician Workforce 2009 Physician Workforce Survey:Survey: What Do We Know What Do We Know About Oregon Physicians?About Oregon Physicians?
KEY FINDINGS (Continued)KEY FINDINGS (Continued) 22 percent of Oregon physicians plan to 22 percent of Oregon physicians plan to
retire in the next five years. (78 percent do retire in the next five years. (78 percent do not.)not.)
Physician acceptance of patients with Physician acceptance of patients with commercial insurance, Medicare or commercial insurance, Medicare or Medicaid is down compared with 2004. The Medicaid is down compared with 2004. The reason cited most frequently was reason cited most frequently was reimbursement rates. (Few physician reimbursement rates. (Few physician practices can succeed without one or more practices can succeed without one or more of these revenue streams.)of these revenue streams.)
Source: www.oregon.gov/DHS/healthplan
0
5
10
15
20
25
30
35
Under40
40-49 50-59 60-69 70 &Over
Source: 2009 Oregon Physician Workforce Survey
Oregon physician age distribution, 2009
0
10
20
30
40
50
60
Metro NW OR Eastern Central
Source: 2009 Oregon Physician Workforce Survey
Oregon physician age by region, 2009
Source: 2009 Oregon Physician Workforce Survey
Oregon physicians’ primary practice setting 2009
Private Clinic/Office
Other
Emergency Care
Inpatient
Hospitalist
University clinic Community Clinic
Urgent Care
Source: 2009 Oregon Physician Workforce Survey
Oregon physicians’ specialties, 2009
Family/General
Ob/GynGen IM
Pediatrics
Medical Sub
Gen Surg
Ped SubSurg Sub
Psych
Hospital
Other
Neurosurg
Source: 2009 Oregon Physician Workforce Survey
Oregon physicians’ employment status, 2009
Full Owner
Part Owner
Contractor
Employee
Other/Volunteer
05
101520253035404550
AllAges
40-49 60-69
Source: 2009 Oregon Physician Workforce Survey
Oregon physician retirement plans, 2009
0
5
10
15
20
25
30
PortlandMetro
Southern Eastern
Source: 2009 Oregon Physician Workforce Survey
Oregon physician retirement plans by region, 2009
0
5
10
15
20
25
30
<8 8 to16
17-24
25-32
33-40
41-48
49-60
>60
Source: 2009 Oregon Physician Workforce Survey
Hours spent in direct patient carein a typical week, all specialties 2009
05
1015
2025
303540
45
None 1-2patients
3-5patients
6-10patients
Source: 2009 Oregon Physician Workforce Survey
Taking call
05
101520253035404550
None 40+ 31-40
21-30
11 to20
1 to10
Source: 2009 Oregon Physician Workforce Survey
Charity care
0 20 40 60 80
Payment
Payor Mix
Admin Req
Liab Ins
““Very Important” factors in Very Important” factors in decision to limit Medicare, decision to limit Medicare,
20092009
Source: 2009 Oregon Physician Workforce Survey
0 20 40 60 80
Payment
Payor Mix
Admin Req
Liab Ins
““Very Important” factors in Very Important” factors in decision to limit decision to limit MedicaidMedicaid, ,
20092009
Source: 2009 Oregon Physician Workforce Survey
0 20 40 60 80 100
Medical Home
Rx costs
Patient Safety
HC Reform
M'care reimb
Importance of Health Policy Importance of Health Policy Issues (Selected), 2009Issues (Selected), 2009
Source: 2009 Oregon Physician Workforce Survey
0
5
10
15
20
25
30
35
40
Patientrelationships
Income Clinicalpractice
Source: 2009 Oregon Physician Workforce Survey
What Matters To Physicians?(What is your greatest source of professional satisfaction?)
Back to the main question: Back to the main question: Where are we all going to get Where are we all going to get
care?care?Case Study
Group Health Cooperative of Puget Sound, a large, consumer-owned integrated delivery system in the Northwest, is rolling out a major transformation of its primary care practices. In 2007, Group Health piloted a Patient-Centered Medical Home redesign at one of its Seattle clinic sites.
The redesign included substantial workforce investments to reduce primary care physician panels from an average of 2,327 patients to 1,800; expand in-person visits from 20 to 30 minutes and use more planned telephone and email virtual visits; and allocate daily “desktop medicine” time for staff to perform outreach, coordination, and other activities. The redesign emphasized team-based chronic and preventive care and 24/7 access using modalities including electronic health record (EHR) patient portals.
A 12-month controlled evaluation of the pilot clinic redesign found the following: Better quality: The pilot clinic had an absolute increase of 4% more of its patients
achieving target levels on Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, significantly different from the control clinic trend; pilot clinic patients also reported significantly greater improvement on measures of patient experiences, such as care coordination and patient activation.
Better work environment: There was less staff burnout, with only 10% of pilot clinic staff reporting high emotional exhaustion at 12 months compared to 30% of staff at control clinics, despite being similar at baseline. Group Health has seen a major improvement in recruitment and retention of primary care physicians.
Reduction in ER and inpatient hospital costs: Patients had 29% fewer ER visits and 11% fewer ambulatory sensitive care admissions.
Better value proposition: An additional investment in primary care of $16 per patient per year was associated with offsetting cost reductions, with the net result being no overall increase in total costs for pilot clinic patients (the total net cost trend was a savings of $17 per patient per year, which was not statistically significant). Unpublished data from the 24-month evaluation reportedly show a statistically significant decline in total costs.
Conclusion: As a result of the success of the pilot clinic redesign, Group Health is currently implementing the Patient-Centered Medical Home model at all 26 of its primary care clinics serving 380,000 patients (Grumbach, Bodenheimer, & Grundy, 2009).
