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Thursday, May 24, 2018

Statement of Need - QMPA CARE project


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.

Changing payment models is expected to cause a considerable amount of confusion for older primary care physicians with developed systems. Greater effort in terms of consultation and training will be provided to these practices. Another issue bound to turn up is the lack of patient healthcare progress. Unless there is significant social, economic incentive and or willpower, many patients will struggle to break old habits and routines. For these issues, referrals to specialists, counselors and or patient management companies are recommended. The third problem is that Electronic Health Records (EHR) are not standardize and the different software will make coordinating efforts difficult. Our trainers will take a survey of EHRs being used by the 50 primary care providers. After compiling a list of EHRs, our trainers will contact the EHR companies for software demonstrations.


[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.

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