A Publication of the Connecticut Academy of Family Physicians
CONNECTICUT FAMILY PHYSICIAN
Vol. 11 • Issue 3• July 2011
Journey to a Level 3 Patient-Centered Medical Home by: David R. Howlett, MD
Although financial compensation for this has been slow to catch on in Connecticut, the bottom line is that patients are given the best of care.
Editor’s Note: David Howlett, M.D., moderated a Panel Discussion during the recent Patient-Centered Medical Home Conference. Participating in the panel were: Christine Johnson, PhD., PMP, Practice Enhancement Facilitator at TransforMED; Kenneth Lalime, Executive Director of the Connecticut State Medical SocietyIPA; Kenneth Sacks, M.D., FACP, Medical Director of the CSMSIPA and Michele Kelvey-Albert, Manager of Outpatient Consulting Services at Qualidigm. Dr. Howlett will be presenting a lecture at the CAFP 2011 Symposium on his practice’s Journey to a Level 3 Patient-Centered Medical Home.
New CAFP Members Welcome: Sharon J. Anderson, M.D. New Haven Gary S. Boxer, M.D. Fairfield Josephine S. Genese, D.O. Waterbury Pankaj A. Ksheersager, M.D. Manchester William H. Kober, M.D. Mystic
East Granby Family Practice (EGFP), www.familydoctors.org/ egfp, is a six physician, three APRN suburban family medicine practice group located north of Hartford in East Granby, CT caring for over 15,000 patients. We decided to apply for recognition as a Patient Centered Medical Home (PCMH) in November 2010, partly because many of the requirements are similar to those needed for “Meaningful Use,” and partly to gain the NCQA recognition for the care we deliver in hopes that, in the future, not only will the patients benefit from such care, but also that our practice might be reimbursed
for the additional cost of technology and man-power associated with such comprehensive care.
deliver in disease management and how well we deliver preventive care. We have re-designed workflow and have established processes to involve all staff to work to their full level of train-
The web site of the NCQA, www.NCQA.org, describes the organization and the Patient(Continued on page 2) Centered Medical Home concept. The National Committee for Quality Assurance is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the health care system, helping to elevate the issue Dr. David Howlett (see article) chats with of health care quality to the top one of the attendees at the conference. of the national agenda. East Granby Family Practice has for many years ascribed to many of the tenets of a Patient Centered Medical Home, even before the formal NCQA PCMH recognition program was formulated. As Family Medicine Board certified physicians, the goals of East Granby Family Practice have always been to provide cost effective patient centered care. We have always had extended hours (evenings and weekends) and open access scheduling - especially since we have many pediatric patients who often need same day appointments. Since EGFP’s purchase of McKesson’s Practice Partner EHR in 2004, we have been able to analyze the care we
Ken Lalime, (L) and Dr. Ken Sacks, (R) took time at the conclusion of the Panel Session to review ideas with Dr. Tom Fignar (C)
Jessica Johnson, MSIII, discussed the impact of the PCMH on students with Christine Johnson, PhD, TransforMED
Of Note… Of Note… Jenn Mastrocola of the Jenn Mastrocola of the UConnUConn School School of Medicine, of was theMedicine, winner ofwas twothe CAFP awardswinner at the UConn Senior of two CAFP Awardsawards luncheon: theUConn Dr. at the David and Arthur Schuman Senior Awards Award luncheon: of Excellence theand Dr. the outstanding graduate going David and Arthur into family practice. She Schuman Award of also received an award from Excellence and the the University for outstanding graduating at thegoing top ofinto her graduate class. (see letters to the family practice. She editor)also received an Dr. Craig Czarsty of award from the Oakville, a past president of University for the CAFP, was named bytop graduating at the the AAFP to Chair of her class.the (seeRules Committee at to thethe 2011 letters editor) Congress of Delegates Dr. Craig Czarsty of meeting in Orlando, Florida Oakville, a past in September. president of the Attending CAFP, the was AAFP named 2011 by the AAFP towere Chair Leadership Forum Drs. Robert the Rules Carr, Committee Southbury; at the 2011 Domenic Congress Casablanca, Shelton; of Delegates meeting Johvonne Claybourne, in Orlando, Florida West Hartford; in September. Kathleen Mueller, Attending the AAFP 2011 Windsor; Barbara Leadership Forum Phillips, Manchester; Drs. New Neenawere Pursnani, Britain; Stacy Taylor, Robert Carr, Winsted; and Kathleen Southbury; Viereg, Cheshire as well Dominic as Mark Schuman, PhyllisCasablanca, Darby and Mary Yokose of the CAFP staff.
Dr. Thomas Agresta has Johvonne been appointed Professor and Dr. Diana Heiman Claybourne, an Associate Professor in West Hartford; the Department of Family Kathleen Medicine at the University of Connecticut School Of Mueller, Medicine.
Level 3 Patient-Centered Medical Home (continued) ing to deliver patient centered care. Through our participation in three study projects of the Practice Partner Research Network (PPRNet), www.PPRNet.org, since 2005, and by working with Qualidigm, the Quality Improvement Organization (QIO) for Connecticut, www.Qualidigm.org, for over 5 years on multiple quality improvement initiatives, we have learned how to deliver better evidence-based care and to efficiently record the care and preventive services given. Provider meetings are held to discuss results and to formulate procedures to improve care delivery. This has allowed us to greatly surpass national benchmarks of care and be awarded the PPRNet “Best Practices Award” for performance in the top 25% of all participating practice each year since 2008. East Granby Family Practice worked directly with Qualidigm, through its PCMH project, to analyze the practice, write or revise office procedures, establish protocols, and to compile and submit data. The St. Francis Care Physician’s Organization, www.saintfrancishealthcarepart ners.org reviewed and submitted data to satisfy a number of the PCMH reporting requirements and reported diabetic care measures of eligible EGFP physicians which resulted in each physician achieving the NCQA Recognition for Delivery of Quality Diabetic Care.
The journey to recognition as a Patient-Centered Medical Home is a process that may take a number of months for practices that have already practiced many of the requirements of the NCQA’s Patient-Centered Medical Home. For practices that have not adopted such principles, this process may take a number of years. It is important that each practice start the process now to prepare for accountable, transparent, comprehensive and coordinated delivery systems that may well be mandated in the near future and to prevent financial penalties that may be imposed upon those who do not. Although financial
David R. Howlett, MD is a partner and full time practicing physician of East Granby Family Practice, LLC. He has been the practice’s project manager for the implementation of EMR, quality management and certification as a Level 3 – Patient Centered Medical Home. He is on the Board of Directors and a Past President of the Connecticut Academy of Family Physicians. He was recently appointed to the Board of Directors of Qualidigm.
BU Study - Hospital Readmissions Are Cut When Family Physicians Are Added Researchers from Boston University School of Medicine and Boston Medical Center have found that by adding one family physician per 1,000, or 100 per 100,000, could reduce hospital readmission costs by $579 million per year, or 83 percent of the Patient Protection and Affordable Care Act (ACA) target. These findings currently appear on the website of the “Robert Graham Center,” a primary care think tank. Growth of family physicians has fallen over the last decade due to payment disparities and other strong incentives for subspecialization, and lack of accountability of teaching hospitals for producing the physi-
Amanda V. de La Paz of Barbara the Yale University School of Medicine won the 2011 Phillips, CAFP Award of Excellence Manchester; presented to a graduating Neena senior going into family practice. Pursnani, New
compensation for this has been slow to catch on in Connecticut, the bottom line is that patients are given the best of care.
CONNECTICUT FAMILY PHYSICIAN is published by the Connecticut Academy of Family Physicians and is made possible in part through unrestricted grants from: Connecticut Medical Insurance Company Core Content Review of Family Medicine
cians the country needs. The Patient Protection and Affordable Care Act (ACA) seeks to improve healthcare quality and reduce costs. One provision targets a decrease in hospital readmissions to save $710 million annually. It is believed that timely management of fragile patients in primary care after discharge may reduce readmission.
Middlesex Family Medicine Residency Program Honored The Middlesex Family Medicine Residency Program was one of 16 Residency Programs to receive the 2011 AAFP Foundation Pfizer Immunization Award for increased immunization rates in their communities through creative solutions.
From AAFP ACOs Top List of Concerns at Family Medicine Conference The government’s proposed regulations for accountable care organizations, or ACOs, were a top concern among attendees at the 2011 Family Medicine Congressional Conference on May 9. Many attendees were worried about how the model would affect family medicine and their practices, but AAFP President Roland Goertz, M.D., M.B.A. of Waco, Texas, was quick to remind them that they have an important role to play in health care reform. “The Patient Protection and Affordable Care Act emphasizes prevention and wellness, which puts primary care and family medicine in a position to drive systematic and sustained changes in how care is delivered and paid for,” noted Goertz during the conference, which was jointly sponsored by the AAFP and the Council on Academic Family Medicine. Even as Congress is riven by partisan strife regarding the Affordable Care Act, “we have a message that can cut through (the bickering) because we can offer, at least in the health care arena, something (Congress) can do,” Goertz told the nearly 200 family physicians, medical students and state chapter officials attending the conference. He urged meeting participants to “think about the core message that represents family medicine and how we take care of patients. That is the message that cuts through it all.” The “whole notion of primary care (and) the place of family physicians in our delivery system has swung front and center,” said former Rep. Earl Pomery, D-N.D. “Your profile has never been higher.”
Still, CMS’ proposed Medicare ACO rule was a concern for many attendees. FP Paul Lazar, M.D., of Flint, Mich., described the proposed regulation as “very complicated.” In the final analysis, ACOs could shortchange physicians and their patients, said Lazar during a session on ACOs presented by Jonathan Blum, deputy administrator of CMS and director of the Center for Medicare Management. ACOs are a key part of the Affordable Care Act, said Blum, but he stressed that participation in the organizations by physicians and other providers is voluntary. However, one of the overriding goals of the Medicare ACO program is to encourage lots of different organizations to participate, Blum said. “Our notion here is not to think one size fits all, but to encourage all kinds of organizational models to come into the program,” he explained. This includes large and small physician practices, integrated delivery systems, and hospitals that employ physicians.
AAFP President-elect Glen Stream, M.D., of Spokane, Wash., asked Blum to clarify a statement he made about antitrust provisions intended to protect private insurers from the aggregation of physician practices. “I am curious why health insurance plans -- which enjoy protected status as large conglomerates in many parts of the country – why do we try to protect them when physicians don’t have adequate rights to aggregate for purposes of negotiating with those private insurers?” asked Stream, sparking audience applause. According to Blum, if it is not structured carefully, the Medicare ACO program could lead to broader hospital consolidation and dominance. The antitrust laws represent a “balancing act” – an attempt to create strong incentives for the creation of ACOs and, thus, better care coordination while blocking attempts by hospitals to use ACOs as means for achieving market dominance, said Blum.
Identify alternative policies so that primary care physicians are able to participate in multiple Medicare ACOs; Not confine its payment method to the current, traditional Medicare fee-forservice payments to ACO par-
CAFP Foundation Contributors As of June 27, 2011 Anne Brewer, M.D. Neil Brooks, M.D. Amber Cheema, M.D. Joseph Connelly, M.D. Rocco Cornacchio, M.D. Craig Czarsty, M.D. Joseph Danyliw, M.D. Phyllis Darby Tuula Fabrizio, M.D.
AAFP Submits ACO Recommendations To improve the final Medicare ACO regulation, the AAFP submitted to Dr. Donald Berwick, Administrator of the Center of Medicare and Medicaid services, the following detailed recommendations related to this rule. Key recommendations include urging that CMS;
“...whole notion of primary care (and) the place of family physicians in our delivery system has swung front and center,” said former Rep. Earl Pomery, DN.D. “Your profile has never been higher.”
Kevin Flanagan, M.D. Malcolm Gourlie, M.D.
ticipants, but instead employ a variety of payment approaches, such as blended fee -for-service payments, prospective payments, episode/ case rate payments, and partial capitation payments;
Drastically reconsider its proposed Medicare ACO policies and instead offer greater flexibility so that small to medium -sized primary care practices will be more eligible to participate;
Neena Pursnani, M.D.
Michael Kalinowski, M.D. Jacqueline Lustig, D.O. Andrea Needleman, M.D. James Ouellette, M.D. John Paardenkooper, M.D. Richard Salmon, M.D. Art Schuman Mark Schuman Howard Selinger, M.D. Mary Swaykus, M.D. Stacy Taylor, M.D. Kathleen Viereg, M.D.
(Continued on page 4)
Roy Zagieboylo, M.D.
AAFP seeks changes from the RUC
So, we’re looking at what does the nation need in terms of a workforce? They need primary care.
The American Academy of Family Physicians has long argued for more equity in payments for primary care services, but this month it became more outspoken. The national organization representing more than 100,000 family doctors sent a letter to the American Medical Association/Specialty Society Relative Value Scale Update Committee, most commonly known as RUC, demanding the committee make specific changes to its structure, processes and procedures. Specifically, the AAFP is asking for: more seats for family medicine, general internal medicine and general pediatric medicine
Connecticut Family Physician is published by the Connecticut Academy of Family Physicians (CAFP). Views and opinions published in the Connecticut Family Physician are not necessarily endorsed by the CAFP.
the addition of three new seats for external representatives such as consumers, employers and health plans a permanent seat for geriatric medicine
CONNECTICUT FAMILY PHYSICIAN
Connecticut Academy of Family Physicians PO Box 30 Bloomfield, CT 06002 Phone: 860-243-3977 Or 800-600-CAFP Fax: 860-286-0787 Email: Mark Schuman Mschuman@ssmgt.com Phyllis Darby Pdarby@ssmgt.com Arthur Schuman Aschuman@ssmgt.com
Editor Michelle Apiado, M.D.
Vol. 11 • Issue 3 • July 2011
the elimination of existing rotating subspecialty seats as the current representatives “term out” greater voting transparency on the RUC votes “The drumbeat of changes in payment for primary care has been fairly longstanding,” said Lori Heim, M.D., AAFP board chair. “When you end up with a payment structure that creates a payment for specialists that so far outstrips the value of primary care then I think that we have not got a system that truly values what the communities need.” The RUC, formed by the AMA in 1991, is a group of 29 members (and 29 alternates) that advises the Centers for Medicare and Medicaid Services on the relative value of physician services, which determines how much physicians get paid. The RUC has been criticized for many years as favoring specialists.
“The problem is that the payment structure right now has created a huge differential between procedures versus cognitive care,” said Heim. “It’s that differential between them that’s created the impetus for medical students to go into subspecialties. So, we’re looking at what does the nation need in terms of a workforce? They need primary care. What does the literature and research say you need to do to create the balance? You need to decrease that differential because that’s what drives students. We need to look at how we pay primary care versus subspecialists, proceduralists, etc. How should cognitive services be valued differently?” The AAFP has requested that the RUC respond to its recommendations by March 1, 2012. The RUC chair, Barbara Levy, M.D. said, “The RUC has received and will review the changes suggested by AAFP.”
ACO Recommendations (continued)
Letter to the Editor Dear Mr. Schuman, Please accept my sincere apology for this delayed note. As I continued to unpack boxes this weekend (in Madison, WI) I came upon a package you sent me. I thoroughly enjoyed reading your grandfather’s writings. I was touched by his words and reflections on various times throughout one’s medical career. Thank you so very much for sharing them with me. I am honored and humbled by the awards (Dr. David and Arthur Schuman Award of Excellence and the 2011 Outstanding Graduate from UConn) I have received. I hope all is well in Connecticut and with the CAFP. I will miss the group and hope to keep in touch. Please let me know if there is anything I can ever do to help. Sincerely, Jenn Mastrocola Dear Mark, Congratulations to the Connecticut Academy of Family Physicians for your membership achievements. AAFP is proud to recognize the Chapter for the: First Place (Medium Chapters) Highest Percent Increase – Active Membership 100% Resident Membership Award The enclosed certificates recognize your Chapter’s drive and commitment to excellence. Your membership recruitment and retention efforts have paid off as we advance towards the 100,000 member mark! Again we commend you for your exceptional achievements! Please accept my personal gratitude for all you do to support our members and the AAFP. Sincerely, Elaine Jastram Conrad, CAE AAFP Division Director, Membership
Consider proposing additional tracks that are tailored for smaller medical practices less familiar with assuming financial risk; Specify that Medicare ACO governance structure must utilize primary care physicians in the top leadership positions to ensure that Medicare ACOs are primary care driven; and Outline quality reporting requirements for the full threeyear program, significantly reduce the number of required quality measures, and only require reporting on quality measures that improve population health outcomes and efficiency.
Published on Jul 6, 2011