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Creating scalable primary

care innovation

Craig P. Tanio MD MBA

Chief Medical Officer, ChenMed

Chairman, Maryland Health Care Commission

Assistant Professor of Medicine, Johns Hopkins School of Medicine

@drtanio

September 2014

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Snapshot of Chen Med

Who we are: Privately held, primary care-led physician group

Our focus: Low to moderate income adults > 55 with multiple chronic

conditions in urban areas. Typical patient searches for a PCP every 18

months, often considered “frequent flyers” by other health systems.

Care model: 400-450 patients per PCP; on-site Rx, focus on culture,

patient relationships, decision making, customized information technology,

intensive care coordination

Scale: Designed to scale quickly; Growth from 5 centers in Miami market in

2010E to 36 centers in 8 markets at 2013E . 40+k risk lives in 2014.

Payment: Global risk adjusted capitation from Medicare Advantage plans

ranging $7k - $30k per patient per year

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Miami Outcomes in CY 2011 prior to scaling

Chen NMC National Difference

Consumer Net

Promoter Score92 40-50 >100%

Medication Possession

Ratio82 42 73%

Hospital Days per 1000 1058 1712 (38%)

Percent of Ambulatory

Encounters on Site 86% N/A

Patient Visits at Center

Per Year13.3 N/A

PCP Visits with Same

Physician92% 40-60% > 50%

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Our strategy to scale

Innovation Platform

Selective integration within geographic

markets

Value based workflows supported by proprietary information

technology

Accountable clinical culture to create an optimal enduring healing relationships

Specializing primary care: focus on patient segment, reimbursement, payor collaboration

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Key dimensions of focus

▪ Transportation, case management, interdisciplinary team

▪ Control generalist decision making (e.g., primary care, hospitalist,

SNFist) across transitions

▪ Common care plan

▪ Focus on minimizing preventable hospitalizations, poor outcomes

▪ Disparate data integrated into a system for physician to review

▪ Discussion in physician conferences 3 x a week

Real time

attentiveness

▪ Ambulatory ICU layout

▪ Primary care, diagnostics, acupuncture, targeted specialty services

▪ No private offices for physicians

Overcoming

barriers to care

One stop shop

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Patient

population

▪ Over age 55

▪ 5 or more chronic conditions

▪ Drives > 70% of Medicare costs

▪ Underserved low to moderate income, urban segment

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Physician culture is critical to get care right

“from the inside out”2

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Getting the right physician behavior and mindset

requires a comprehensive approach

Role-modeling

Behavior and

mindset shiftsDeveloping talent

and skillsReinforcing with formal

mechanisms

Fostering understanding

and convictions• Physician call

behavior

• Weekend worrier

program

• Medical Director as

master clinician

• Physician meetings 3x

wk

• Interdisciplinary team

meetings

• 4 M leadership

• Physician education

– ChenMed U

• Clinical leadership

programs

• Panel management

tools

• Behavioral interviewing

tools

• Compensation

• 2 day review process

with professional dev

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Overview discussed in The Health Care

Blog

May 18, 2014

http://bit.ly/1j3BMLj

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Need to get workflows right at a deep level

Cheaper to build than to modify vendor technology

The technology “last mile” is getting the right share of mind with physician

Create exam room tools with Agile based methodology and front line physician input

• Patient Life Cards

with scanning

functions

• Greeting and eligibility

displays

• Air Traffic Controller

• Patient education

• Electronic Medical

Records

• Diagnostic accuracy

algorithms

• Physician and MA

decision support

• Payor integration to

tap into analytics

• On-site pharmacy

• Referrals and

diagnostic tracking

• Patient education

and portal

• Integration to

hospital, SNF, case

management

systems

• iPhone call system

• Physician toolkit to

review panel

outcomes with

coaching

• Case management

and IDT toolkit for

highest risk patients

• Risk stratification

with qualitative and

quantitative tools

• Data integration from

multiple sources

Patient flowDecision

support

Care Continuum

and Transitions

Panel

management

Value based workflows are fundamentally different than

volume based ones3

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Providing a suite of tools to optimize decision making

in the exam room

Real-time internal HEDIS Metrics• My Work• MAQReal-time patient flow

metrics (i.e. wait times)• ATC

Inpatient care and coordination• HITs Application• Dash2Go

Medical Costs

• Care Timeline

High Risk home and social support limitations

Pharmacy & Medication Adherence• CMEDs

Coordinate comprehensive specialty clinical data• My Facesheet

Patient Experience & Growth• Apt maker

ChenMed PCP

Standard PCP (Additional responsibilities)

vs.Coordinate comprehensive specialty clinical data

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Manage across

transitions

▪ Build in continuity where possible; hospitalist follows patients to first

follow-up visit

▪ PCP and NP joint SNF decision-making

▪ Initial home assessment

▪ Interdisciplinary weekly team meetings by center

Design around

access

▪ One stop shop – most patients within 7 miles ; transportation

▪ On-site physician drug dispensing

▪ Wellness focused activities on-site

▪ Not looking to be a complete multi-specialty group

Build up care

team

▪ Nurse case manager, social worker, transitions team

▪ Developing medical assistants as coaches

▪ Creating expertise in risk assessment and reduction

▪ Develop relationships with trusted specialists over time

Selective integration with the healthcare geographic

market4

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Staged rollout

Pipeline of innovation for the annual plan

We believe that ongoing innovation can eliminate 30-

50% of unnecessary waste in the US

Establish foundation for

secondary prevention

• Physician culture ,

performance assessment,

feedback compensation

• Medicare Advantage and

care coordination skills

• Center design, patient flow

and service

• On-site Rx

• Begin physician capabilities

on risk

• “Boots on the ground” for

transitions of care (hospital,

SNF, home)

Drive complex condition

management

• Physician panel management

capabilities

• Behavioral medicine integration into

model

• Interdisciplinary teams for high risk

patients

• Align payor and provider care

management capabilities

• Hospice and advance care planning

• Point of care decision support

• Complement qualitative and

quantitative risk assessment

• Increase engagement with

preferred specialists

Tackle primary prevention

• “Food as medicine”, sleep,

exercise, health literacy

• Engage entire center around

behavior change – group

visits, employee health,

coaches, patient connectivity

• Remote monitoring

• Use of behavioral economics

• Integration with community

and social services around

health opportunities

• Substitution of office visits as

appropriate

Where we

are today

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Focused and concentrated change can have substantial impact

quickly

Creating the right physician culture, accountability and ownership

for population health results matters

Developing enduring, high quality patient-doctor relationships has a

cumulative effect

Takeaways

Segmenting primary care can unlock significant productivity

improvements for care of patients with multiple chronic conditions

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How can we create a aspirational culture that elevates professional

excellence and engagement?

2 questions for the NHS

How can we create more effective, high quality relationships

between the patient with multiple chronic conditions and the GP?