Centers for Medicare and Medicaid Services
Physician Group Practice Demonstration
Project
June 29, 2009
Marilyn A. Follen, RN, MSN
Administrator
Quality Improvement and Care
Management
Marshfield Clinic
Missions
• Mission – “to serve patients through
accessible high quality health care,
research, and education.”
• Long term strategy – built around the six
aims of the Institute of Medicine: Care
should be safe, timely, effective, efficient,
equitable, and patient centric.
Why enter the CMS PGP Project?
• Consistent with the Clinic’s mission
• Marshfield Clinic’s long term strategy built
around the six aims of the Institute of
Medicine.
• Marshfield Clinic was headed in the direction
of value based health care which is consistent
with the CMS PGP demonstration project.
• ALL interventions for the CMS PGP demo are
applied to ALL Marshfield Clinic patients.
Bottom Lines.
1. Improving quality without improving
efficiency results in ($$)
2. Improving efficiency without improving
quality results in $$
3. Our challenge is to improve quality and
efficiency, simultaneously
and fast.
Initial Organizational Response
• Much internal discussion
• Competing priorities
• No up-front funding - need to develop
infrastructure
• Need for rapid change in short period
– Technical
– Adaptive
• PR impact if Marshfield Clinic was not successful
How did we intervene for the PGP
project?
Multiple simultaneous interventions that applied to all
patients
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Best practice models developed for core conditions
Computer based CME opportunities
Physician/Clinical Nurse Specialist regional teams
Care management programs for primary care patients
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Nurseline
Anticoagulation
Heart Failure
Dyslipidemia
Expansion of the EHR
– Point of care applications – preventive service
– Planned visits – intervention list
•
Population based feedback to providers
Operational Experience - Positive
• Participation creates the “burning platform”
for change
• CMS tries to be responsive to data needs
• CMS facilitates meetings/conference calls
among sites to share learnings clinical
strategies to improve performance
Operational Experience - Challenges
• Marshfield Clinic did not own a hospital in
Performance Years 1, 2 & 3
– Ability to influence processes in hospitals
– Discharge planning/transition care
• Time lags between intervention and
availability of data
• Data detail - lag patient specific claims data
Challenges
• Competing definitions of quality from
multiple sources
• Current reimbursement models do not
support
– Intervention for all patients
– Method at odd with fee for service model
• Interventions decrease Marshfield Clinic’s
revenue
• Commercial payors are benefiting without as
much as a “Thank you”
On-going Challenges
• Adaptive vs. technical change
• Patient-centered vs. provider/team centered
• Sparked interest with commercial payors
yet PGP shared-saving methodology is not
generalizable
• Fortunate to earn a performance payment
yet no guarantee payment in future years
CMS PGP demonstration project
Marshfield Clinic results to date
– PY1 – 1 of 2 groups to obtain a performance payment
• 9 of 10 quality measures exceeded (Diabetes)
• Performance payment of $4,828,711 on savings of
$6,035,889 (total savings with 2% threshold > $12M)
– PY2 – 1 of 4 groups to obtain a performance payment
• 27 of 27 quality measures exceeded (Diabetes, CAD, CHF)
• Performance payment of $5,781,573 on savings of
$7,226,966 (total savings with 2% threshold > $13M)
– Largest total savings and performance payments of the
10 sites to date (11/2008)
– PY3 and beyond ???