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Case Study Of A Primary Care Accountable Care Organization (Text Version)

Slide presentation from the AHRQ 2010 conference.

On September 28, 2010, David West made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (1.5 MB).

Slide 1

Case Study Of A Primary Care Accountable Care Organization  
Case Study Of A Primary Care Accountable Care Organization

David R. West, PhD
Robert Phillips, MD, MSPH

AHRQ Task Order: SNOCAP-USA (University of Colorado) HHSA290200710008

Dr. David Lanier: Task Order Officer
September 28, 2010

Slide 2



I have no financial relationships to disclose.


I will not discuss off label use and/or investigational use in my presentation.

Slide 3

Project Team

Project Team

  • From the Robert Graham Center
    • Robert Phillips, MD, MSPH: Task Order Leader
    • Svetlana Bronnikov, MS
    • Stephen Petterson, PhD
    • Bridget Teevan, MS, MPH
  • From the University of Colorado
    • Maribel Cifuentes, RN

Slide 4

What Can We Learn From a 'Mature' PCMH?

What Can We Learn From a "Mature" PCMH?

  • Aim 1: Determine: How A PCMH developed their model.
  • Aim 2: Determine if the PCMH improved processes of care and outcomes.
  • Aim 3: Determine the incremental in-practice expenses (reduced to a pm/pm) required to operate the patient-centered medical home.

Slide 5

Mixed Methods Approach

Mixed Methods Approach

Qualitative Analysis

  • 58 Key Informant Interviews (Executives, Clinicians, Administrative and Finance staff, Patients)

Quantitative Analysis

  • Collection/analysis of reported process and outcome indicators
  • Analysis of WellMed vs. matched CMS data (Parts A and B): Controls for Ischemic Heart Disease (IHD), Chronic Obstructive Pulmonary Disease (COPD), and Type 2 Diabetes Mellitus (DM)

Slide 6

WellMed As A Case Study (in progress)

WellMed As A Case Study (in progress)

  • Have been providing primary care services for 20 years in their community.
  • Accepts full risk capitation for most services (primary care, specialist care, physician, inpatient hospital, outpatient hospital, etc.).
  • Documented use of a patient-centered continuous quality improvement approach including social services, prevention, and active disease management protocols.
  • Availability of electronic health data for analysis

Slide 7

Willing to let us under the hood!

Willing to let us under the hood!

Slide 8

WellMed Accountable Care Organization

WellMed Accountable Care Organization

Screenshot of an organization chart.

  • PCMH (6 of them)
  • Hospital
  • Specialist
  • Social Services
  • Transportation

Slide 9

Screen Shot:

A screen shot of the Web site is shown.

Slide 10

At A Glance

At A Glance

Chairman and CEO: George M. Rapier III, M.D.

Wellmed clinics (Primary care): 24 in Texas; 4 in Florida Treasure Coast Region

In-take transition centers (Healthcare assessment): 2 in Texas (San Antonio and Corpus Christi)

Medicare Advantage Plan markets (Health plan options for Medicare beneficiaries): Texas—Austin, Corpus Christ, El Paso Harlingen; Arkansas—Little Rock; New Mexico—Las Cruces; Florida—Fort Lauderdale

Affiliated Physicians' Offices (Medical management services for patients on select MA plans): More than 100 in Texas and Florida

Targeted patients: Medicare-eligible senior citizens

Employees: 1200+ (more than half support clinic operations)

Patients and insured members: 83,000+

2008 Revenues: $560.6 million

2008 Assets: $223 million

Slide 11

Practice setting

Practice setting

  • Lots of space
    • In primary care trend is downsizing footprint
    • Big community space for exercise classes, computer classes, nutrition/cooking classes
  • Podiatry, Rheumatology, Dermatology rotate through
  • Free orthopedic shoes fitted onsite

Slide 12

Teams With Defined Roles

Teams With Defined Roles

  • Med Assistants do most data entry
  • Health Coaches
    • Call patients next day to reinforce care plan
    • Meet with patients (clinic, home, phone) to do behavior change, mental health, care plan
  • Disease Mgmt program for COPD, DM, CHF, CAD—manage most fragile, high cost patients intensely

Slide 13

Teams Continued . . .

Teams Continued...

  • Inpatient
    • Their own case managers and hospitalists (their culture, their plan)
    • Interventions for specific conditions—national award for model Knee Replacement protocol
  • Nursing home teams led by NPs for nursing homes (4 core)

Slide 14

Teams Continued . . .

Teams Continued...

  • Very low turnover compared to market
  • Grow their own—able MAs trained and mentored into higher roles
  • Starting an MA school
    • Cut usual cost in half (more diversity)
    • Train to their model
  • Two week orientation for new physicians + pairing with best clinicians for shadowing and mentoring

Slide 15



  • Home-grown system now a decade old and still evolving
  • Docs typically write brief notes, heavy on care plan and MAs type them up, enter other data

Slide 16

Control of Dollars and Data

Control of Dollars & Data

  • Data for all patients, all settings, all care
  • Very innovative population data array
    • Used to monitor quality
    • Identify, develop, evaluate interventions
    • Identify outliers; not keeping appointments, not filling prescriptions, increased utilization
  • Team bonuses based on quality improvement

Slide 17

 Investment/Connection to the Community

Investment/Connection to the Community

  • Free Flue Shots I: The San Antonio Metropolitan Health District received $250,000 to offer free flu vaccines across the Bexar county population in 2007 and an additional $100,000 in 2008. This allowed an additional 42,000 flu shots to be delivered in the community.
  • Free Flue Shots II: The flu shot campaign expanded in 2008 into Atascosa, Comal, Guadalupe and Kendall counties, as well as Bexar (Greater San Antonio), targeting Medicare-eligible residents only. WellMed clinics along Florida's Treasure Coast offer free flu shot clinics to Medicare-eligible residents in Indian River, St. Lucie and Martin County during flu season. All influenza vaccinations are a gift from WCF and are NOT charged back to Medicare.
  • Senior Outreach: In 2008, WellMed partnered with the City of San Antonio's Department of Community Initiatives to offer free flu shot clinics at more than 30 events around San Antonio, mostly at senior nutrition centers. In 2009, the Foundation funded a campaign promoting free flu shots for homebound seniors and to build awareness about various social services available through WellMed and the City of San Antonio, such as free transportation to medical appointments, prescription assistance, etc.

Slide 18

PCMH Timeline

PCMH Timeline

1990—Established with particular emphasis on Medicare population

1990—Strengthen and support primary care role in health care (e.g., support comprehensive care approach including hospital and nursing home care, work on team based chronic disease care

1993—Begin benefits review process to add benefits that remove patient barriers to essential care—this eventually includes transportation help, paid health maintenance visits, expanded medication coverage for essential medications, expanded eye care, expanded dental benefits, expanded hearing aid benefits

1996—Same day appointments available in medical offices

1997—Regularly track patient satisfaction

1999—Starts disease management division

Slide 19

PCMH Timeline (continued)

PCMH Timeline (continued)

2001—Installs EHR including electronic prescribing

2002—Add clinical decision support system along with improved registry functions

2003—Transform disease management to health coach concept- patient centered and available to all patients

2006—Web access to patient level data for treating specialists

2006—Portable "EHR" system given to patients to improve data transfer to other care providers

2008—Transitions "Health Coach" function from a centralized approach to primary care office based approach and begin transition to expanded team based chronic care model

2008—Web access for medical data for patients

Slide 20

Trends in rates of health screening and meeting chronic disease targets

Trends in rates of health screening & meeting chronic disease targets

Slide 21


Tests and References Denominator Numerator
Global: All eligible WellMed patients 65 years or older
Mammography test (Pham et al. 2005; Freeman et al. 2002; Asch et al. 2000) Female patients excluding those with cancer diagnoses or mastectomy From ICD9 code: 87.36, 87.37, V76.11, V76.12 very year
Colon cancer screening tests: (1) Colonoscopy, (2) Flex sigmoidoscopy, (3) Fecal occult blood test (NCQA 2008, Pham et al. 2005; Freeman et al. 2002) Exclude those with prior cancer diagnoses From lab data: any of the 3 tests that were administered
Hemoglobin A1c test & monitoring (Skeie et al. 2001, NCQA 2008, Pham et al. 2005) With DM, ICD9: 250.00 thru 250.91 Every year. For control: HA1c ≤ 7
Cholesterol LDL test (NCQA 2008) All with DM or IHD diagnoses Every year LDL<100 mg/dL
Blood pressure test (NCQA 2008) All with HBP diagnosis Every year <140/90
ER visits per patient (Shenkman, 2003) All WellMed eligible patients Place of service=ER
Hospitalization rate (Jencks et al. 2009) All WellMed eligible patients Patients hospitalized as derived from hospital data
Re-hospitalization rate (Jencks et al. 2009) Exclude those deceased at last discharge Within 30 days of last discharge
Mortality (Buescher, 1998) All WellMed eligible patients Determined from hospital and identifier data

Slide 22


Test Type 2000 2001 2002 2003 2004 2005 2006 2007 2008
Mammography test rates (%) 19 28 29 26 28 33 34 37 40
Colon cancer screening test rates (%) 11 14 21 32 42 43 48 49 50
Hemoglobin A1c testing rates (%) for patients with Diabetes 55 53 70 73 75 77 78 75 71
LDL Cholesterol screening rates (%) 47 35 47 50 59 63 69 68 70
LDL Cholesterol screening rates (%) for patients with Diabetes 53 51 65 70 73 79 82 79 78
LDL Cholesterol screening rates (%) for patients with ischemic heart disease 53 45 58 64 71 77 79 76 76
Blood pressure screening rates (%)   38 50 74 83 80 80 76  
Blood pressure screening (%) for patients with High Blood Pressure   46 58 85 92 91 91 88  
DM patients with A1c ≤7 81 84 87 90 92 93 93 93 93
DM patients with LDL ≤100 51 56 57 63 67 74 77 78 95
IHD patients with LDL ≤100 48 56 60 63 66 72 75 75 93
HBP patients with BP <140/90   67 72 80 86 90 92 90  

Slide 23

Trends in health outcomes

Trends in health outcomes

Slide 24

Yearly breakout

  2000 2001 2002 2003 2004 2005 2006 2007 2008
ER visit rates (%) 15.9 14.9 14.2 14.5 15.2 16.6 17.6 17.4 17.8
Hospitalization rates (%) 13.9 12.9 12.0 11.8 11.9 12.7 13.9 13.7 14.4
Patients who were discharged from hospital alive 1,892 2,125 1,913 1,834 1,928 2,152 2,333 2,370 2,578
Re-hospitalization rates (30 days) (%) 13.8 12.6 14.1 12.4 14.2 14.4 12.7 13.6 13.4
Crude Death rates, all causes (per 1000) 18.8 11.7 14.4 19.8 23.3 25.7 27.3 27.0 22.0
   65-74 7.2 4.8 7.2 7.2 8.5 9.6 9.1 8.5 10.4
   75-84 20.9 14.9 15.5 25.0 27.7 31.4 33.0 27.5 20.3
   85+ 66.2 32.5 40.8 51.0 65.7 67.0 70.1 83.2 62.4
Female 18.1 9.9 13.7 18.9 22.1 23.8 24.9 25.5 20.2
Male 19.7 14.0 15.2 20.9 24.6 27.8 30.2 28.9 24.0
Adjusted Death rates, all causes (per 1000)                  
   65-74 7.7 4.8 5.8 7.9 9.1 9.9 10.1 9.7 7.8
   75+ 30.0 18.7 22.3 30.0 35.2 39.0 41.0 40.7 33.2
Texas Age-adjusted mortality rate, 65-74   24.2 24.0 23.2 22.2 21.8 20.9 20.8  
Texas Age-adjusted mortality rate, 75+   84.0 83.1 80.3 77.7 78.6 76.9 77.3  

Slide 25

Qualitative Analysis

Qualitative Analysis

Research Questions:

  • How did WellMed develop their level 3 PCMH model—the facilitators, barriers, key components, history and leadership?
  • How did the implementation of the WellMed model impact patient and provider satisfaction?

Slide 26

Qualitative Analysis Themes

Qualitative Analysis Themes

Patients identify five factors of the WellMed model as important to their satisfaction:

  • Personal relationship with a physician over time.
  • Access, ease of making appointments.
  • Being greeted cordially, technical competency, compassion, taking time to listen and explain information.
  • Affordability. of medications, discounted prices, reasonable co-pays.
  • Getting referrals, having people remember basic care (e.g. flu shots).

Slide 27

Qualitative Analysis Themes

Qualitative Analysis Themes

Staff identify four factors of the WellMed organization that are important to their satisfaction:

  • Belief in what the company stands for and the sharing of values.
  • Good compensation and bonuses.
  • Leadership that listens and values employees.
  • Opportunities for advancement.

Slide 28

Qualitative Analysis Themes

Qualitative Analysis Themes

  • The guiding principles from which the WellMed model was constructed and the way in which the model has evolved stem from and promote the 4 pillars of primary care:
    • Easy access to first contact care.
    • Comprehensive care—accountability for addressing large majority of personal healthcare needs. Includes the convenience of having majority of services under one roof.
    • Coordination of care.
    • Personal relationships over time.
  • WellMed has acted on these primary care principles by using ACO methods.

Slide 29

Qualitative Analysis Themes

Qualitative Analysis Themes

  • 5 Key factors used to guide and implement the marriage of PCMH and ACO elements of the WellMed model:
    • Use of economics as a driver for quality.
    • Collaborating and co-evolving with others that understand and buy-in to the model.
    • Customer service is key to everything we do.
    • Identify every day problems and implement common sense solutions—evolve solution as needed. "is there a way we can do this better and more efficiently".
    • We're big on prevention.

Slide 30


Next Steps

  • Completing Qualitative Study
  • Completing matched cohort study (costs/outcomes of similar Medicare beneficiaries)
  • Completing financial/Business Model Review
Current as of December 2010
Internet Citation: Case Study Of A Primary Care Accountable Care Organization (Text Version). December 2010. Agency for Healthcare Research and Quality, Rockville, MD.


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