22nd National Conference: How Will it Work? PPACA and the Community-based Teaching Hospital (Part 2, Cobb)

We gratefully acknowledge the sponsorship of the Marian University College of Osteopathic Medicine (Indianapolis, Indiana) for funding the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:

 

Stephen W. Cobb, MD, Medical Director, Exempla Physician Network, Denver

Stephen W. Cobb, MD; Exempla Healthcare, Denver

Good morning.  I’m Steve Cobb from Denver. It’s good to be here. Three years ago I gave up running the family medicine residency at Saint Joseph Hospital in Denver. Now I run our group practice, which has doubled in size in two years. I wonder if that’s happening in your markets too. Hospitals are buying up practices. I met a colleague who’s on the same career path as me. It’s the 90s all over again! It’s a different world!

I will present a different perspective on the potential impact of PPACA. Saint Joseph Hospital takes care of the underserved in Denver, now that the University of Colorado no longer serves them. There’s no one left in Denver but St Joseph Hospital to care for that population. Only last year, the hospital got Disproportionate Share Hospital [DSH] money for the first time.

Denver is very different than Hector’s situation in Los Angeles  [see 22nd National Conference: How Will it Work? PPACA and the Community-based Teaching Hospital (Part 1, Flores)]. Saint Joseph Hospital is very much a partner with the Kaiser system in providing care, 80% of the admissions at our hospital are Kaiser patients.

Competition between Denver’s hospital systems

I will describe the three hospital cartels in the Denver market. I use the word “market”, even though I think that’s a bad word in this group. I don’t want to see any stones thrown at me up here, but I think that it might be instructive to hear this.

Mt story will tell how PPACA has provided pressure for cartels to collaborate with one another. The resulting collaboration is affecting the Saint Joseph family medicine residency.

The company I work for is Exempla. We have three hospitals in Denver. If I don’t show you geography none of this is going to make any sense, so I have to use pictures for my story.

Locations of Exempla’s Three Denver Hospitals

Our three hospitals employ physicians whose practices support the mission of the hospital. That’s why those practices exist.

We have three major cartels in our market. The first, HealthOne is the Hospital Corporation of America [HCA] by another name. There is a a community partnership with HCA that makes them feel better about being a “for profit” entity, but it’s still just part of HCA. The corporation hosts two family medicine residencies in Denver.

The second cartel, Centura, is a marriage between the Adventist and the Catholic hospitals. They have six Denver hospitals and six “mountain” hospitals as well, with one family medicine residency in Denver and one in Colorado Springs.

The third, Exempla, is the weaker player in town, but I believe being the underdog is a good thing. We are Catholic sponsored [the Sisters of Charity of Leavenworth Health System]. We have a family medicine residency in Denver and our parent company owns one in Grand Junction.

Just to show you are we are the weaker member, below is a map of the geographical reach of the Centura network:

Eastern Colorado's Centura hospital network

These hospital systems do not like each other. They do not like to collaborate. They do not trust each other. They don’t like to share data.

Medicaid Funding of Cooperative Efforts between Family Medicine Residency Programs

However, the family medicine residencies collaborate with each other, even though we fight over the medical students we recruit to Colorado.

So why do the family medicine residencies collaborate in Colorado? We collaborate because we have leveraged Medicaid money that funds a state commission that was established in 1977 so that we could build a primary care workforce in Colorado.

From this nucleus there is a history of nine family medicine residency directors working with commissioners appointed by the Governor to ensure Colorado has primary care physicians throughout the state. That has proved to be very important. We’ll discuss the commission more fully later.

At our hospital we have four 104 residents in four physician specialties. In the family medicine residency clinic we have 18,000 visits a year, of which 44% are self pay (in our hospital and that means no pay, since patient don’t pay for their care). The Sisters of Charity pay. They very intentionally operate a charity system that funds a lot of health care – at least the primary care.

What we think will happen after PPACA is fully implemented, is that our “self pay” percentage will go down by half and will be converted into Medicaid at some point in time. We think it’s important to be prepared for that.

Collaborative Efforts to Implement Patient-Centered Medical Home Principles

All nine family medicine residencies in Colorado applied for and received a grant from the Colorado Health Foundation, an HCA subsidiary.  HCA, a competitor, is giving us and its other competitors money to implement patient-centered medical home principles in the nine Colorado family medicine residencies. The residency programs are all at various stages in their development and face various struggles.

The goal is to get everyone’s residency program recognized by NCQA [National Committee for Quality Assurance] as a patient-centered medical home, and eligible for the contracts associated with tha designation. The residency in Fort Collins does very well financially and they probably will get some nice commercial contracts out of being a patient centered medical home recognized. At Saint Joe’s we probably won’t get any such contracts.

Medicaid-funded accountable care organizations

Our state Medicaid agency is creating accountable care collaborative organizations. I’ll describe how we’re going to participate in those. We will be developing new competencies for residents, like we do for students. We have to think about what kind of doctor that we will need to produce to be successful in the patient-centered medical home model.

What will this mean for a residency program that historically has produced docs that when they finish can go to work in a Kaiser system and be successful, but also can go out into rural America and be successful? Is that going to change? I think it will.

The Colorado Patient-centered Medical Home Initiative

Colorado’s patient-centered medical home initiative, although funded by the Colorado Health Foundation, will be administered by the University of Colorado and the Colorado Association of Family Medicine Residencies.

Here is what will happen at Saint Joe’s. Now our residents will all complete two quality improvement projects a year based on their patient practice populations. They will have to demonstrate health improvement in their practice population. This they will be required to do in addition to their ICU rotations and their continuity OB clinics.

We are tracking referrals and doing followup, which in the past was not done in this practice. There is intentional, continuous quality improvement in place. Never before were those words uttered in this program. We will have completed implementing EPIQ [Evidence-based Practice for Improving Quality]  in a few weeks. Our patients, who are 44% self pay/no pay patients, are really going to access their charts electronically.  You can imagine that it is a big deal for this population. It’s important that someone is there during the entire period of change, and we’ll be there throughout this process.

The Challenges of Care Management

Those of us who run residency programs all know that team-based care is one of the most difficult administrative challenges. We’re all part-time doctors in that practice, and there is a lot of discontinuity, no matter what our values and principles are. For these reasons, we’ve implemented nurse practitioner-run teams of care and we all work with them. That’s been very successful.

What’s not going well? 1) Care management! Nobody knows how to do it in our program. We don’t know how to fund it.  It’s very difficult to do for the population that we serve, even if you have money. 2) Population management! It is also very, very difficult to manage patients in this situation by registry for a lot of reasons. 3) Self-care! The facilitation of self-care is not going well. These are all resources that we don’t have. No matter how much we ask for the resources, the hospital doesn’t have it either.

We’re on the difficult journey that we hope leads to an effectively operating patient-centered medical home. The other eight residencies have similar struggles.

Medicaid Accountable Care Collaborative Program

The enactment of PPACA has, I believe, increased interest in a separate initiative, the Medicaid Accountable Care Collaborative Program.  There are three elements to this collaborative program: 1) Primary care docs providing patient-centered medical homes, 2) regional care collaborative care organizations which will be important,  and  3) comparative statewide data. A data analytics coordinator position has been established, to enable providers have be able to compare how they are performing with others.

Colorado is still divided into seven regions. In Denver County, where Saint Joe’s is, the Saint Joseph Hospital family medicine residency will be participating in a patient-centered medical home. You get a $4 member per month management fee, but all you have to do in this contract is say yes, I’m committed to patient-centered medical home principles and I commit to work with the regional care collaborative organization. That, at the present time is all you have to commit to. Nobody’s measuring anything. On top of your management fee, you get fee-for-service reimbursement.

What’s interesting though is that in region six (Denver) a contract to create a collaborative care organization was awarded to what’s called the Colorado Community Health Association – a collaboration between the IPA to which all of our primary care doctors in Exempla belong as do those of Centura, a competitive hospital system. Through this collaboration we jointly will address the care of the Medicaid population.

Hector alluded to the cartels in Los Angeles, where there are also emerging Accountable Care Organizations [ACOs] that are comprised of IPAs and competitor hospital systems and residency programs. These cartels are going to try to work together to try to do something that might be helpful for the Medicaid population. Why are the IPAs and hospitals doing that? I think, because they want practice experience, so that when commercial products come along they will have some competency to do this work. Maybe the motivation isn’t pure, but the side effect is that the Medicaid population may get better care.

Developing Residency Faculty Competencies for Quality Assurance 

What probably is more important in the current situation than focusing on resident competencies is the need for better faculty competencies. Our residents have competency, even now, in some of these quality improvement tools. Our faculty doesn’t really know how to manage care. It’s not something that they’ve done.

For this reason, I hired two of my former residents to work in our system. Six months after I hired them, one described three PDSA [Plan-Do-Study-Act] healthcare improvement cycles she has already done in her clinic, where she’s working to make various things better. Up until about five years ago, I didn’t know what a PDSA was. I am really proud of her.

Learning how to be NCQA recognized and what all that means; participating in mandatory Medicare quality initiatives like PQRS [Physician Quality Reporting System] –  are competencies that are new for our residency.  Beyond that, there is a whole new science for patient safety that we’re now teaching in the residency.

This is a very granular picture of the big changes that are occuring in one residency because of PPACA.

A Potential Unintended Consequence of PPACA in Denver

If we ever are going to get the resources to do population management at Saint Joe’s, it’s going to come from collaborating with the Kaiser system. Saint Joseph Hospital doesn’t have the money, but Kaiser does. Kaiser ends up with about half of our graduates every year. They’re very invested in those doctors being competent in population management. So Kaiser is interested in taking over the residency program all together.

Kaiser’s interest in our residency, heightened because of the changes PPACA will bring to health care delvery, may very well affect our rural medicine mission. I’m very proud to tell you that two years ago the family medicine residency program established an OB fellowship and our first graduate completed 120 C-sections. That matters to me. I spent my first five years in practice in rural Oklahoma taking care of Native Americans. My passion is rural medicine.

If Kaiser were to run our program, this is what I think would happen. Kaiser doesn’t really care if family medicine doctors deliver babies, or if they’re competent to work in ICUs, or whether they can do their own C-sections. The program that I built based on my personality and my belief of what a family doc should be won’t continue.

I think we’ll probably end up with an exposure rather than a mastery experience in obstetrics. I think the obstetrical fellowship will go away. Maybe that’s the right thing to do with the program, but these might be the unintended consequences of the impact of PPACA on our little community hospital residency.

I will conclude my story with this picture of Saint Joe’s.

Saint Joseph Hospital Denver with Kaiser Hospital in Background

We have two towers. (There’s a story behind that.)  In the background, right behind Saint Joe’s, is the Kaiser building. That’s how connected we are to them down in Denver.

These are my comments.