Lyn Sibley - AcademyHealth

Understanding di the case-mix of
patient-centered medical homes in
Ontario, Canada.
Lyn M Sibley, PhD
Richard H Glazier, MD MPH
Brian Hutchison, MD MSc
29 June 2010
Academy Health, Boston MA
leveraging Leveraging the culture of of performance excellence in health in health systems. systems

Health Care in Ontario
• ~13 million population
• Universal insurance
• Equity is a guiding
principle
• Primary care provided
by family physicians
• 25,268 MDs in 2006
– 11,392 FP/GPs
– 13,876 SPs
leveraging the the culture of performance of excellence excellence in health in health systems systems

Primary Care Models in Ontario
• Physician work in groups
• Enroll patients
t
• After-hours clinic and call requirements
• Retention bonuses/penalties
• Pay-for-performance
– diabetes, mental health, heart failure, smoking
cessation
– preventive care (but only if >650 patients
enrolled)
leveraging the culture of of performance excellence in health in health systems systems

Primary Care Models in Ontario
• Enhanced fee-for-service (FFS)
• FHG began in 2003, capitation element ($2/person/month)
• 100% FFS
• largest model
• Capitation
• Team
• older – HSO, PCN
• newer – FHN in 2002, FHO in 2005
• primarily capitation eg $140/person/year
• age-sex adjustment but not health status
• 10% shadow billing
• FHT in 2005, now 150 teams
• multidisciplinary teams
• doctors required to be on capitation ti or salary
leveraging the culture of of performance excellence in health in health systems systems

Patient Centred Medical Home
College of Family Physicians of Canada
Personal Family Physician
Access to a Patient-Centred Team
Coordination of Care
Timely Access to Patient-Centred Care
Appropriate Funding/Remuneration
Quality Improvement and Evaluation
Electronic Information and Communication
American Academy of Family
Physicians
Personal Physician
Physician Directed Medical Practice
Care is Coordinated and/or Integrated
Enhanced Access
Payment Reform
Quality and Safety
Whole Person Orientation
leveraging the culture of of performance excellence in health in health systems systems

Primary Care Models in Ontario
Patient Centred Medical
Home
Enhanced FFS
(FHG)
Capitation
(FHN, FHO)
Team
(FHT)
Personal Family Physician i
Patient-Centred Team
Coordination of Care
Timely Access
Appropriate Funding
Quality Improvement
Electronic Information
leveraging the culture of of performance excellence in health in health systems systems

PCMH in Ontario
• Large investment by Ministry
• Little is known about the impact on
patients or physicians
• Equity concerns:
– patient t access
– physician reimbursement
leveraging the culture of of performance excellence in health in health systems systems

Objective
• Characterize the morbidity burden of
rosters.
• Examine variations in roster casemix
between three different types of primary
care model types.
leveraging the culture of of performance excellence in health in health systems systems

Study Sample
• Administrative data collected by the
Ontario Ministry i of Health.
•Physicians who belonged to a primary
care patient enrollment group on March
31, 2009.
• Patients enrolled to physician on March
31, 2009.
leveraging the culture of of performance excellence in health in health systems systems

Johns Hopkins ACG Case-Mix
System
• Adjusted Clinical Group
• Identifies groups of patients within
populations that have similar health care
resource needs
• Based on:
– age
–sex
– combination of minor and major diagnoses
• Widely used to adjust capitation payments
leveraging the culture of of performance excellence in health in health systems systems

1. Ontario ACG Morbidity Index:
• Population of Ontario on March 31, 2009
• N ≈ 13 million
• Diagnosis data
– 1 Year (April 08 – March 09)
– physician billing (ICD-9 codes)
– hospital records (ICD-10 codes)
leveraging the culture of of performance excellence in health in health systems systems

1. Ontario ACG Morbidity Index:
• Relative measure of expected resource
use
• Average cost per ACG
– primary care fee codes
– outliers truncated at ±3SD
• Standardize - divide by population
average
leveraging the culture of of performance excellence in health in health systems systems

2. Roster Casemix: SAMI
• Standardized ACG Morbidity Index (SAMI)
• Assigned to each physician’s roster
• Average ACG weight of all patients on the
roster
• Expected primary care use relative to the
population
p
(Hutchison, Reid)
leveraging the culture of of performance excellence in health in health systems systems

Results: Cohort
• Excluded rosters with < 100 patients
• 5,605 physician rosters
• 574 group practices
• 7,048,187 patients
leveraging the culture of of performance excellence in health in health systems systems

Results: SAMI by Group Types
2.5
2.0
SAMI
1.5
Roster
1.0
Mean = 1.22
1.06
0.99
0.5
0.0
Fee-for-Service Capitation Team Capitation
Overall mean SAMI = 1.14
leveraging the culture of of performance excellence in health in health systems systems

Results: SAMI by SES
1,400
1.5
1,200
1.4
# of Ro osters
1,000
800
600
400
1.3
1.2
1.1
1.0
Mean SAMI
200
0.9
0
24.0
% of Low-Income Patients (Quintiles)
0.8
leveraging the culture of of performance excellence in health in health systems systems

Results: SAMI by SES
1,000
15 1.5
900
800
N
Sami
1.4
700
1.3
# of Ro osters
600
500
400
300
200
100
1.2
1.1
1.0
0.9
SAM MI
0
1 2 3 4 5 1 2 3 4 5 1 2 3 4 5
FFS Capitation Team
% of Low-Income Patients (1= Fewest)
0.8
leveraging the culture of of performance excellence in health in health systems systems

Results: SAMI by Rural/Urban
100%
1.50
ters
% of Ros
90%
80%
70%
60%
50%
40%
30%
20%
10%
% SAMI
1.40
1.30
120 1.20
1.10
1.00
0.90
SAMI
0%
Urban
Rural
0.80
leveraging the culture of of performance excellence in health in health systems systems

Results: SAMI by Rural/Urban
100%
90%
80%
70%
% SAMI
1.5
1.4
1.3
% of Ros sters
60%
50%
40%
30%
20%
10%
1.2
1.1
1.0
0.9
SAMI
0%
Urban Rural Urban Rural Urban Rural
FFS Capitation Team
0.8
leveraging the culture of of performance excellence in health in health systems systems

Key Findings
• Family Health Team rosters had a lower
average morbidity burden, fewer rosters
with a high concentration of low income
patients, and more rural practices.
• The FFS rosters had a higher average
morbidity burden, overall and within each
level l of low-income concentration ti and
rural/urban category.
leveraging the culture of of performance excellence in health in health systems systems

Discussion
• Cross-sectional does not permit
conclusions about causation
• Physicians selected model type based on
their existing practice
•Diagnosis coding in:
– capitation models
– teams
– rural
leveraging the culture of of performance excellence in health in health systems systems

Implications for Policy
• Big concern that there are fewer low
income and high h morbidity patents t in
PCMH.
• Inequity in who benefits from patient
centred medical homes in Ontario.
leveraging the culture of of performance excellence in health in health systems systems

Thank you
Lyn M. Sibley, PhD
Department of Health Policy, Management, and Evaluation
University sty of Toronto
o lyn.sibley@utoronto.ca
ph: 416-978-5017
fax: 416-978-7350
leveraging Leveraging the culture of of performance excellence in health in health systems. systems