SETMA -- Primary Care -- Home Health -- Nursing Faciity -- Acute Care Services

Dear Optimetra:

On the same day that we received a request for a meeting with Molina Healthcare’s Treanise Owen and with Dr Larry O’Brien, Medical Director for Molina Healthcare (Marketplace, Star, Star+Plus, CHIP with Molina), we received a request for a meeting from Optimetra (www.optimetra.com) asking for SETMA to participate in an onsite survey seeking “patterns of opportunities for health plan to further support providers who participate in their STAR+Plus network.”   Optimetra’s note inquired about Southeast Texas Medical Associates, LLP’s (SETMA, LLP, www.jameslhollymd.com) services in four areas.  Brief details of SETMA are added in parentheses to each:

• Primary care services – (Internal Medicine, Family Medicine, Pediatrics, Nurse Practitioners and supporting specialists within SETMA, 43 providers)
• Home health care services – (Close collaboration with home health)
• Nursing facility services – (over 1,200 SETMA patients in 28 long-term care facilities)
• Acute care services – (extensive services in three major hospital systems)

SETMA has six clinical locations covering a five county area, all clinics are interconnected with electronic records, communications and services.  SETMA has an extensive hospital, in-patient care program in three regional hospitals, all hospitals are connected with SETMA’s EMR.  All nursing homes are connected with SETMA’s EMR.  We have used EMR since 1998 and have won numerous national awards.  All of our management tools are displayed at www.jameslhollymd.com, as are nine years of public reporting by provider name of provider performance on over 300 quality metrics.

All six locations are accredited as Patient-Centered Medical Homes (PC-MH, 2010-2019) by National Committee for Quality Assurance (NCQA), the Accreditation Association for Ambulatory Heath Care (AAAHC), URAC and by the Joint Commission.

SETMA accreditation by The Joint Commission includes:

• Ambulatory Care
• Reference Laboratory
• Patient-Centered Medical Home

SETMA is also a participant in the Robert Wood Johnson Foundation’s Learning from Exemplar Ambulatory Practices’ Study (LEAP).  Out of 400 nominated practices, 30 where chosen for participation in this study.  SETMA is one of those. The following comments from these two organizations are a helpful introduction to SETMA. 

The Joint Commission Accreditation for Ambulatory Care and PC-MH Conclusion about SETMA

Both the surveyors and one of the executives at The Joint Commission commented about the philosophical foundation of SETMA’s work.  Wednesday afternoon (March 5, 2014) I called my executive contact at The Joint Commission. He said, “I was just talking to one of my colleagues and showing him SETMA’s notebook which was prepared in response to The Joint Commission’s Standards and Requirements Chapter Seven on leadership.”  The executive said:  “Look at this; everything they do is founded upon a philosophical foundation.  They know ‘what they are doing,’ but more importantly, they know why they are doing it.’”  SETMA is not the result of random efforts but of innovations and advances which are consistent with a structured set of ideals, principles and goals.  It is helpful that The Joint Commission recognized this and commented upon it.  It is one of the strengths of SETMA and it is one of the principle guides to SETMA’s developmental history, i.e., what caused SETMA to become what it is.

Robert Wood Johnson Foundation LEAP Study conducted by the MacColl Institute

The fifth area of uniqueness of SETMA identified by the RWJF team was a surprise to them; it was SETMA’s IT Department.  The RWJF team felt that SETMA has approached healthcare transformation differently than anyone they have seen.  They related that uniqueness to the decision we made in 1999 to morph from the pursuit of “electronic patient records” to the pursuit of “electronic patient management.”  They were surprised to see how centrally and essentially electronics are positioned into SETMA and how all other things are driven by the power of electronics.  They marveled at the wedding of the technology of IT with clinical excellence and knowledge.  The communication and integration of the healthcare team through the power of IT is novel, they concluded.

Brief History of SETMA – including MIPS, MACRA and their similarities with SETMA’s pre-existing model of care

Between 2000-2005, SETMA (1995-2017) developed a Healthcare Model of Care (see:  SETMA’s Model of Care Patient-Centered Medical Home: The Future of Healthcare Innovation and Change) defined by four standards of care.  When CMS and HHS announced the Medicare Access and CHIPs Reauthorization Act (MACRA) in 2015, the Merit-Based Incentive Payment System (MIPS) was defined.  On October 8, 2016, after extensive study of MACRA and MIPS, SETMA realized that our four standards which are deeply imbedded in our design and deployment exactly parallel the four categories of MIPS (see:  Four Categories Defined by MIPS Correlate with SETMA’s Four Strategies for Transforming SETMA and Healthcare).  The following compares the CMS value-based model of care and SETMA’s model which has been in place for over 16 years.

SETMA’s Strategies for Healthcare Transformation - MIPS Categories of Scoring System

1. The methodology of healthcare must be electronic patient management - MIPS Advancing Care Information (an extension of Meaningful Use with a certified EMR) 
2. The content and standards of healthcare delivery must be evidenced-based medicine - MIPS Quality (This is the extension of PQRI which in 2011 became PQRS and which in 2019 will become MIPS -- evidence-based medicine has the best potential for legitimately effecting cost savings in healthcare while maintaining quality of care)
3. The structure and organization of healthcare delivery must be patient-centered medical home - MIPS Clinical Practice Improvement activities (This MIPS category is met fully by Level 3 NCQA PC-MH Recognition).
4. The payment methodology of healthcare delivery must be that of capitation with additional reimbursement for proved quality performance and cost savings - MIPS Cost (measured by risk adjusted expectations of cost of care and the actual cost of care per fee-for-service Medicare and Medicaid beneficiary)

The following material will expand your understanding of SETMA:.  

1. SETMA’s Development: Automation and Model of Care Which Prepared For Medicare Access and CHIPS Reauthorization Act (MACRA) and the Merit-Based Incentive Payment System (MIPS) -- QIN-QIO Sharing Call -- this material was presented on October 18, 2016 to a national audience for the CMS QIOs – a shorter version of this presentation has been prepared for our meeting on the 10th. 
2. SETMA.com | Accreditations | SETMA's Accreditation, NCQA, AAAHC, TMF Health Quality Institute, URAC and Joint Commission -- SETMA's Accreditation, NCQA, AAAHC, TMF Health Quality Institute, URAC and Joint Commission -- As we will discuss on the 10th, 25% of the score for the Merit-Based incentive Payment System (MIPS) of the Medicare Access and CHIPS Reauthorization Act of 2015 (MACRA) is fulfilled by a practice being accredited as a Patient-Centered Medical Home.  SETMA is accredited by all four agencies and has been from 2010-2019.
3. SETMA.com | Letters | Complete Summary and Annotated List of All 24 Articles Discussing SETMA’s Work in Thinking About and Preparing for MACRA and MIPS -- Complete Summary and Annotated List of All 24 Articles Discussing SETMA’s Work in Thinking About and Preparing for MACRA and MIPS -- Between August and October, 2016, SETMA has studied MACRA and MIPS and prepared tools and methods for meeting the new standard of payment model.  This link is an annotated list of the twenty-four articles which SETMA has produced in that effort.  SETMA providers have been “practicing” on patients from October-December, 2016 so that in 2017, we will be ready for maximum efficiency and effectiveness in meeting cost and quality metrics.  The following link is to the tutorial for SETMA providers fulfilling the MIPS quality metrics which is the successor to PQRI (2006, voluntary) and PQRI (2011, mandatory):  SETMA’s Merit-Based Incentive Payment System (MIPS) Quality Metric Tool Tutorial.
4. SETMA.com | The SETMA Way | SETMA’s Model of Care Patient-Centered Medical Home -- SETMA’s Model of Care Patient-Centered Medical Home: The Future of Healthcare Innovation and Change -- This is a description of SETMA’s Model of Care which was developed between 1996-1999.  Interestingly, SETMA four standards of care developed in 2000-2005 anticipated exactly the four categories of MIPS.
5. SETMA.com | Medical Home | Display and Explanation of SETMA's Patient-Centered Medical Home Tools -- Display and Explanation of SETMA's Patient-Centered Medical Home Tools -- this material describes and illustrates SETMA’s PC-MH deployment.
6. Overview and the Philosophical Underpinnings to SETMA’s Website (www.jameslhollymd.com) which is SETMA’s “Offer” to the Center for Medicare and Medicaid Services’ (CMS) Transforming Clinic Practice Initiative (TCPI) -- Transforming Your Practice -- This describes SETMA’s offer to CMS’ TCPI program which is intended t effectively change 140,000 primary care healthcare providers.

Hopefully, this begins to introduce to SETMA.  For the past twenty years, SETMA has published a weekly healthcare article, all of which appear on our website at Your Life Your Health.  The following is a recent summary of our first nine years as a PC-MH:  http://jameslhollymd.com/Your-Life-Your-Health/pdfs/pc-mh-setmas-first-nine-years-continuity-creativity-consistency.pdf. 

We look forward to visiting with you.

James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com

Adjunct Professor
Family & Community Medicine
University of Texas Health San Antonio
The Joe R. and Teresa Lozano Long School of Medicine 

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center