Valued
based reimbursement for health insurance prioritizes the overall efficiency of patient
care when compared to the fee-for-service model. Since the introduction of
health maintenance organizations (HMO) following the Health Maintenance
Organization Act of 1973, fee-for-service reimbursement was the standard for health
insurance companies. The fee-for-service model of reimbursement pays for the
number and type of service provided to a patient. Unfortunately, this payment
model incentivizes medical professionals to over provide healthcare services. In
addition, by focusing payments towards acute care services, the fee-for-service
model has lead to a neglect of preventative health services. In response, a new
model of value based care focuses on patient metrics instead of quantity of
services provided.
Queens Medical Professionals
Association (QMPA) intends to confront the fee-for-service model still present
in the primary care practices of Queens to improve preventative healthcare
measures and streamline primary care practices. According the US Government
census, the borough of Queens in New York City has a population of 2,333,054
residents. Within this group reside some 5,049 physicians. Of the total number
of physicians, 1,897 are primary care providers.[1] This
leaves a ratio of 1,176:1 for inhabitants per primary care provider or about 85
physicians per 100,000 residents. The New York overall average is 94 physicians
per 100,000 residents (AAMC, 2015).[2]
Queens has lower physician to population ratio than New York State overall.
This ratio indicates the strain placed on primary care physicians attempting to
maintain the health of their respective neighborhoods. Doctors within the
neighborhood of Flushing and Elmhurst have reached patient loads of over 2,000
per primary care provider.[3] Doctors
are not required to accept large patients loads, however, they do so in order
to maintain their revenue stream as insurers have paid less for “nonessential”
services. Predictably, the large patient loads result in shorter face-to-face
interactions with the doctor ranging from a maximum of one hour to a minimum of
15 minutes. A doctor with an average of 30 patients daily would require at
least 15 hours to provide quality health care, difficult to achieve even in the
best of conditions.[4]
Heavy time burdens as well as lack of incentives discourage physicians from
coordinating patient care with other healthcare professionals. The end result
is an endless array of paperwork back and forth with other health institutions,
over issues patient issues that may have been already covered a month ago.
QMPA’s efforts will be directed
towards the neighborhood of Elmhurst. Elmhurst presents a perfect preliminary
testing ground for a transition to value-based healthcare. Like most of America,
its population suffers from rising chronic health issues such as a 25% obesity
rate and a 14% diabetes rate. 66% of the population is foreign born and 53% of
neighborhood has limited English proficiency (NYC DOHMH, 2015). The cultures
from this neighborhood vary widely and will significantly affect patient
relations with medical professionals. Overcoming these challenges will
demonstrate that the program is scalable to the rest of Queens.
QMPA intends to roll out its value-based
CARE program, Core Assessment Review Evaluation. At the
center of the program are ten core assessments of quality healthcare:
1. Cholesterol
management (medication, report, long term plan)
2. Cancer
management (treatment, report, long term plan)
3. Hypertension
(treatment medication, report via BP monitoring 130/80 baseline, long term
plan)
4. Diabetes
(medication, report via HbA1c results 7 baseline, long term plan)
5. Obesity
(report BMI scale, long term plan)
6. Mental
health (report PH2+PH9 assessments, psych services, long term plan)
7. Gastro-intestinal
health (report on bowel movements, treatment plans)
8. Smoking
(treatment for addiction, long term plan)
9. Drinking
(report for liver function, treatment for addiction, long term plan)
10. Healthcare
cooperation (P2P referrals, online portals, shared patient access)
These ten objectives are to be promoted
at 30 primary care practices.
The first step of the program will
be an analysis of the individual practices. While the general structure of a
primary care office remains unchanged, each practice has its own work
organization and workflow. A specific study must be undertaken to determine the
weaknesses and the strengths of each practice. After a preliminary review of
practice workflow, the assigned project manager will provide possible
suggestions to the office manager or physician, depending on who is responsible
for overall practice management. At the same time, the project manager will
extract patient data from the practice’s EHR to determine out of the entire patient
population, which patients require follow up services or treatment for the core
measures listed above. Separate lists of patients will be generated for each
core assessment.[5]
Once the list for each core assessment is complete, the project officer will
compile a report with the data. The report will describe the practices’ overall
patient first stage treatment percentage and follow up treatment percentage on
each of the core assessments. A review of the report will allow us to
determine, which of the ten sectors the physician is lacking in. Project
managers can identify areas needing improvement and can focus their efforts on
cooperating with practices to increase patient data transparency.
*Core assessment number 10 will use
a different formula for the report.
The expected score of a first time
pass without any changes in policy will be a lenient cut off of 50%. The
expectation is that the score will rise overtime as some improvements have been
made.
In the second part of the program
the report will be used to focus on improvements. However, there is a major preliminary step
that must be completed prior to suggesting improvements and or changes to the
practice’s policies. The results of the report must be discussed with
physicians, allied health staff, and administrative workers to determine if
there is an error with EHR data compilation. Sometimes healthcare practices
forget an extra click or neglect to use structured data resulting in skewed
results when using the registry. A spot check must be performed on at least 50%
of the patients the do not meet the core assessment standards. Only after this
preliminary check is completed can suggestions of changes can be done.
Suggestions for improvements have
three tiers (bottom to top):
At the bottom of the suggestion
tiers is EHR methodology changes. QMPA provides EHR training for reporting and
data management as well as consultation regarding system integration of new
payment models. Often physicians and associated medical staff are not familiar
with the updates and expanded capabilities of their EHR software. All too often
the base requirements of the program such as appointment scheduling and SOAP
note writing are utilized. Project managers up to date on the latest EHR
software will be able to point out how new chains of commands can streamline a
billing process or how template usage can be adapted for patients.
At the middle tier are medical
suggestions to allied health or physicians. Perhaps the physician has been
using one test as a core part of his assessment when there would be other more
effective tests. Or perhaps allied health staff was unaware of recent research
findings on a specific procedure. Recent research findings can be integrated
into practices’ for a more efficient method of introducing treatment change.
At the top tier of suggestions are policy-based
changes that will dramatically affect the practice’s workflow and patient
interactions. Hiring auxiliary staff to handle insurance and other medical
paperwork in conjunction with using other health practitioners is a few of such
examples. The dramatic change to the structure of the practice will require
group huddles and concentrated dedication to the new model system developed.
For the third part of the program,
an evaluation will be performed on the changes made to practice. Using percent
difference, we can determine whether or not the changes had any noticeable
effect on healthcare efficiency.
The program is to be carried out at
these 30 locations for a period of two years. Training sessions will be
provided weekly and assessments will be performed quarterly. Evaluations will
be based off patient participation percentages in the CARE program. Incremental
improvements of at least 2-5% compliance are expected at first, with greater
percentages following the setup of a coordinated system.
[1]
Accounting for physicians of general internal medicine, family medicine,
general practice, and pediatrics using data from 2013.
[2]
Association of American Medical Colleges focuses only on primary care
physicians and does not include specialists in this report.
[3]
Recommended patient loads for quality care are 800 patients or less (Schimpff,
2014)
[4]
Assuming patients present at least one symptom and do not suffer from
comorbidity.
[5]
The exception being core assessment number 10, which tests for effective
communication of patient data rather than focusing on patient health.
