OVERVIEW OF PCMH
JOHN BENDER, MD, MIRAMONT FAMILY MEDICINE
PATIENT H. RICHARD BRACK & HIS WIFE DEBBIE BRACK
10:00 AM
OVERVIEW OF PCMH- AN XTREME MAKEOVER
From the Patient and Physician Perspective
Presented by John L Bender, M.D., FAAFP
January 9th, 2014
Colorado PCPCC, Denver
Our story begins….
2002 in Fort Collins Colorado….
2002 H.G. Carlson, M.D.
• One of the oldest practices in Fort Collins
• Open 8-5 most days
• Paper Charts
• One Employee
• One Computer (386)
• 1000 patients
In a basement, paneling on the walls
Walls of Paper Charts
Move that Bus!!!
Our story today…
2014 in Colorado….
• 7 locations in 6 separate communities (Urban, Suburban, Rural,
and Frontier)
• Open M-F 8-8, Saturdays 9-1
• 22 providers (11 physicians)
• 75 employees
• Electronic Charts, Patient Portal, NCQA III PCMH recognition
• Over 100 company computers operating in a terminal service
environment and a centralized data center
• 35,000 patients
• Davies Ambulatory Award recognition from HiMSS in 2010
4th fastest growing company in Northern
Colorado
Miramont’s Growth Curve
year
receipts volume
2001
$169,000.00
5,000,000
2002
313,565.00
4,500,000
2003
428,876.00
2004
494,264.00
4,000,000
year
3,500,000
2005
559,110.00
2006
845,298.00
2007
1,449,348.00
3,000,000
2,500,000
2,000,000
2008
1,940,499.00
2009
2,616,000.00
2010
3,505,440.00
2011
4,356,230.00
2012
4,804,885.00
1,500,000
1,000,000
500,000
Miramont's Growth as
measured by receipts
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
receipts volume
$169,000.00
313,565.00
428,876.00
494,264.00
559,110.00
845,298.00
1,449,348.00
1,940,499.00
2,616,000.00
3,505,440.00
4,356,230.00
4,804,885.00
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2010
HIMSS
Ambulatory
Award
2011
Colorado
PCMH of
the Year
34 primary care physicians leave practice
during the same time
specialty
Family Medicine
Family Medicine
Family Medicine
Family Medicine
Family Medicine
Internal Medicine
Internal Medicine
Family Medicine
Internal Medicine
Family Medicine
Family Medicine
Family Medicine
Family Medicine
Internal Medicine
Family Medicine
Family Medicine
Internal Medicine
Family Medicine
Gynecology
OB/Gyn
OB/Gyn
Family Medicine
OB/Gyn
Family Medicine
Family Medicine
Family Medicine
Family Medicine
Internal Medicine
Internal Medicine
Family Medicine
gender
female
male
male
male
male
male
male
male
male
female
female
male
female
male
female
male
male
female
male
female
female
female
female
male
male
male
male
female
male
male
year of
transition
2001
2001
2002
2002
2003
2002
2004
2004
2004
2006
2006
2006
2007
2007
2007
2007
2007
2003
2005
2003
2003
2002
2002
2008
2008
2008
2008
2008
2008
2008
practice zip
code
80524
80524
80524
80536
80524
80524
80524
80524
80524
80524
80524
80550
80526
80524
80550
80537
80537
80526
80524
80528
80528
80524
80524
80528
80521
80521
80524
80524
80524
80549
event
closed/unable to service debt
moved to work for Orthopedists
closed/unable to service debt
sudden death, age 52
sold/less profitable
sold/less profitable
sold/less profitable
sold/less profitable
closed/unable to service debt
closed/unable to service debt
closed/unable to service debt
closed/unable to service debt
sold/less profitable
closed/unable to service debt
closed/?
closed/moved to BTMG
I can not disclose under contract
closed/divorce?
?
?
?
?
unable to service debt
uncertain
offered job in Sports Medicine
sold/less profitable
sold/less profitable
closed by CRMC, non profitable
8 are bankruptcies…
specialty
Family Medicine
Family Medicine
Family Medicine
Family Medicine
Family Medicine
Internal Medicine
Internal Medicine
Family Medicine
Internal Medicine
Family Medicine
Family Medicine
Family Medicine
Family Medicine
Internal Medicine
Family Medicine
Family Medicine
Internal Medicine
Family Medicine
Gynecology
OB/Gyn
OB/Gyn
Family Medicine
OB/Gyn
Family Medicine
Family Medicine
Family Medicine
Family Medicine
Internal Medicine
Internal Medicine
Family Medicine
gender
female
male
male
male
male
male
male
male
male
female
female
male
female
male
female
male
male
female
male
female
female
female
female
male
male
male
male
female
male
male
year of
transition
2001
2001
2002
2002
2003
2002
2004
2004
2004
2006
2006
2006
2007
2007
2007
2007
2007
2003
2005
2003
2003
2002
2002
2008
2008
2008
2008
2008
2008
2008
practice zip
code
80524
80524
80524
80536
80524
80524
80524
80524
80524
80524
80524
80550
80526
80524
80550
80537
80537
80526
80524
80528
80528
80524
80524
80528
80521
80521
80524
80524
80524
80549
event
closed/unable to service debt
moved to work for Orthopedists
closed/unable to service debt
sudden death, age 52
sold/less profitable
sold/less profitable
sold/less profitable
sold/less profitable
closed/unable to service debt
closed/unable to service debt
closed/unable to service debt
closed/unable to service debt
sold/less profitable
closed/unable to service debt
closed/?
closed/moved to BTMG
I can not disclose under contract
closed/divorce?
?
?
?
?
unable to service debt
uncertain
offered job in Sports Medicine
sold/less profitable
sold/less profitable
closed by CRMC, non profitable
Hospital Movement
• IN the past 4 years: The number of EM physicians
double, and ED utilization increases by 50%.
• IN the past 2 years: 250 physicians become
employees of the local hospital owned medical group
(600 total physicians in the county)
Our Product in 2002…
• Test results are slow
• Labor costs high with much non-revenue generating activity /
waste
• No open appointments
• No clinical data management
• Barely any financial data management
• High variability in patient experiences from day to day
• Documentation illegible
• Unable to compete with retail clinics, urgent care, emergency
departments, etc.
Wanting to get out of last century…
“The Restaurant with Bad Food”
Made friends with the banker, accountant,
attorney and local business leaders
• We decided it would take money to make money and the
process starts with investing
• We pledged that we would make Miramont safer, more efficient,
and up to date
• Ensure our own profitability at all times in order that we could be
there for our patients for many years to come
• Eliminate as much as possible non-revenue generating activity
• Find ways to provide needed services in our house, in the free
market health care system that we are given
• Find a better EHR (transition out of a free product we acquired
in 2005)
• Attain NCQA recognition for a Patient Centered Medical Home
$1.4 million in new building in 2005
Every Year We Bring New Products and
Services
•
•
•
•
•
•
•
2002
2003
2004
2005
2006
2007
Female Provider, DEXA scanner
Level 2 Laboratory, IV therapy
Visiting Surgeon, 8-5 hours M-F
New Building, X-ray, bilingual services
Physical Therapy, Psychotherapy, After Hours
INS, Coumadin clinic, Nerve Conduction studies, Saturday hours,
Nurse Educator
2008 Female Physician, Colposcopy, Pain Management Specialist,
Group visits, The Dispensary, Psychologist
Every Year We Bring New
Products and Services
•
•
•
•
•
2009 Patient Centered Medical Home, New Website, patient portal,
online registration, online scheduling requests, online bill
payment, Miramont Value Plan (MVP), Allergy Testing and AIT,
Second location and Third Locations, Laser Aesthetic Medicine
2010 Botox, digital Mammography, Audiology, Pediatrician, CEO level
administrator, email blast marketing to patient base, automated
collections calls
2011DME sales, drive through pharmacy, fluoride dental treatments for
children
2012 4th location in Parker Colorado, self check in kiosks, Phreesia
tablets, Medtronics Insulin pumps, iPro
2013 5th location Loveland, 6th location Fairplay, 7th location Glendale
THE PROCESS OF GAINING
NCQA RECOGNITION or
ACHIEVING MEANINGFUL
USE IS A WORKFLOW
REDESIGN PROCESS IN
ITSELF
Quality Focused – Practice
Tranformation
• Basic Tenants in the PCMH/Specialist
Practice Transformation:
– Physician Leaders who are willing to
lead a team.
– Every person on the team must be empowered
to contribute to process improvement and
workflow redesign
Process as a Root Cause
7 Causes of Waste or MUDA
How to Make a Physician
Owned Lab (POL) Work in
Your Office: Evaluating the
Costs and Benefits
John L Bender, M.D., FAAFP & Amanda J. Cline, RMA
Old Model
•
•
•
•
•
•
Physician orders test
MA fills out requisition
Patient given directions to local lab
Patient drives to lab, has test drawn
Outside lab runs test
Test is reported back to physician next
business day
• MA pulls chart to go with test
• Physician reviews test, signs it off, and tries to
remember what he/she was looking for…
Old Model, continued…
• MA calls and leaves message on answering
machine telling patient that results are in but
unfortunately due to HIPAA cannot leave
results on machine and patient will now have to
call back
• Patient’s spouse hears message, assumes the
worst, and calls back three times with an urgent
message asking for a return call from physician
• MA finally makes contact with patient, new
medication is ordered, another follow-up visit is
scheduled with repeat blood work ordered
• Receptionist refiles chart.
• TOTAL TIME: 20 + minutes
New Model
•
•
•
•
•
•
•
•
Physician orders test
MA draws patient
Test is run in house
Result is reported in room to physician and
patient
Decision is made for new med, result is signed
off
Patient schedules follow up at check-out
Chart is filed
TOTAL TIME: 10 minutes
We finally know how many diabetics we have
A1C documentation improved over time
Managing
population
metrics for
chronic
disease is
realistic with
an EHR
Leveraging New IT
Leveraging New IT
Build the Medical Neighborhood
A Call for Courage
“Sometimes the opposite of
Cautious is not Careless…
Sometimes the opposite of
Cautious is Courage”
- John L Bender, M.D., FAAFP
Overview of PCMH – an
Xtreme Makeover
From the Patient and Physician Perspective
Presented by John L Bender, M.D., FAAFP
January 9th, 2014
Colorado PCPCC, Denver