The Patient Centered Medical Home Will It Make A Difference?

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1 The Patient Centered Medical Home Will It Make A Difference? 2009 Population Health Colloquium Department of Health Policy Thomas Jefferson University March 2009 Michael S. Barr, MD, MBA, FACP Vice President, Practice Advocacy & Improvement Division of Governmental Affairs & Public Policy mbarr@acponline.org

2 Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and protection. President Harry Truman Text from a speech he delivered to a joint session of Congress in 1945

3 So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year. President Barack Obama Text from a speech he delivered to a joint session of Congress, February 24, 2009

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5 State of the Nation s Health Care uninsured million employed 80% Projection s for million underinsured 18% ($2.6T) 20% 2017 $8,300 per capita in 2008 To $13,000 in 2017

6 Comparing to 02 03; 75, ,000 avoidable deaths Amenable Mortality: 15 th to 19 th <50% with access to rapid appointment 75% difficulty with after hours care 18% readmission rate within 30 days M care: High variability The Commonwealth Fund: Why Not the Best; 2008 Nolte & McKee: Measuring the Health of Nations: Updating an Earlier Analysis. Health Affairs, 27:1 (2008)

7 Escalating Costs, Decreasing Coverage Healthcare costs per U.S. auto vs. Germany & Japan $130 billion $1500 vs. $450 vs. $150 70% to 60% 98% vs. 23% Decreasing employersponsored coverage ( 70s to 06) Growth in premiums vs. inflation ( 00 07) Untreated illness & work absence; uninsured

8 Cost v Quality

9 Primary Care Score vs. Health Care Expenditures 1997 Source: The Commonwealth Fund, Data from B. Starfield, Why More Primary Care: Better Outcomes, Lower Costs, Greater Equity, Presentation to the Primary Care Roundtable: Strengthening Adult Primary Care: Models and Policy Options, October 3, 2006.

10 The Case for Health Care Reform Poor access to care, especially for the uninsured Escalating costs & volume of services No link between cost and quality Excessive administrative costs Dysfunctional payment system United States is lagging internationally Impending collapse of primary care

11 How can we fail to provide health insurance for 16% of our population, deliver uneven quality to the 84% of Americans who are insured, and yet pay 50% more per person than countries like France, Israel, and Britain, which cover all of their citizens? Ezekiel J. Emanuel, MD, PhD Healthcare, Guaranteed: A Simple, Secure Solution for America, 2008

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13 A Dying Breed JAMA 2008: 2% of th year medical students (at 11 medical schools) planned careers in general internal medicine A 2004 survey of board certified internists found that after ten years of practice, 21% of general internists were no longer working in GIM compared to a 5% decrement for subspecialists Hauer, KE et al. JAMA. September 10, 2008; Vol 300, No. 10 p Lipner RS, Bylsma WH, Arnold GK, Fortna GS, Tooker J, Cassel CK: Ann Intern Med Jan 3;144(1):29 36

14 Projected shortage of 35 45,000 generalists for adults Jack M. Colwill, James M. Cultice, and Robin L. Kruse, Will Generalist Physician Supply Meet Demands Of An Increasing And Aging Population?, Health Affairs, Vol 27, Issue 3, w w

15 Imbalanced System

16 What is the Patient Centered Medical Home? a vision of health care as it should be a framework for organizing systems of care at both the micro (practice) and macro (society) level a model to test, improve, and validate part of the health care reform agenda

17 PCMH is Our Term to describe a pathway to excellent health care to re claim a role as advocates for our patients (with our patients & their families) to encourage team based care to create educational opportunities to attract medical students and residents to primary care

18 Community Health System Resources and Policies Self- Management Support Health Care Organization Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Prepared, Proactive Practice Team Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998: 1:2-4.

19 The Joint Principles of the PCMH Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated Quality and safety Enhanced access to care Payment to support the PCMH Team based care: NP/PA RN/LPN Medical Assistant Office Staff Care Coordinator Nutritionist/Educator Pharmacist Behavioral Health Case Manager Social Worker Community resources DM companies Others

20 Building the Medical Home Collaboration Recognition Demonstration Advocacy Expansion Education Education Education

21 Important Questions 1. How do you recognize a PCMH? 2. How is care different? 3. Will physicians & their teams want to build the medical home? 4. How do we prepare physicians, students & residents?

22 1. Access & Communication 2. Patient Tracking & Registry Functions 3. Care Management 4. Patient Self Management Support 5. Electronic Prescribing 6. Test Tracking 7. Referral Tracking 8. Performance Reporting & Improvement 9. Advanced Electronic Communication Joint Principles of the Patient Centered Medical Home

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24 The Process 1. Gap analysis take the pre test. 2. Analyze results. 3. Implement changes necessary 4. Retake the pre test. 5. If ready submit application to NCQA. Cost: Readiness assessment = $80 NCQA application fee: varies by size of practice from $450 for 1 physician to $2,700 for 6+

25 Stepping Up to Excellence Level 3: 75+ Points Level 2: Points Level 1: Points Increasing Complexity of Services

26 Demonstrates timely access and communication processes Organizes charts (paper or electronic) to facilitate team based care and tracking age appropriate and condition specific Level 2: Points interventions Identifies key clinical conditions Level among 1: Points population served & follows evidence based guidelines Level 3: 75+ Points Encourages and provides support for patient/family self management Addresses health literacy issues Tracks tests & referrals to assure completion Collects and reports on quality & satisfaction data to practice

27 Key Points for Level 1 PCMH Does not require electronic health record Will require registry & tracking functions Emphasis is on providing better care through: Access to care Organization of office structure & processes Enhancing patient self management; addressing health literacy issues Introduction of evidence based guidelines, measurement & quality improvement

28 Level 2 Level 3 Advanced access options for patients Electronic health record More, and more complex care coordination and patient support Robust population management Advanced reporting and quality improvement initiatives Additional technology solutions

29 More Features of a PCMH Practice Uses each team member to highest capability Supports cultural competency training Understands health literacy Establishes connections to the community Provides extensive self management support Engages a Patient/Family Advisory Group

30 More Features of a PCMH Practice Provides individualized written care plans and monitors adherence to the plan Assesses barriers to adherence and initiates plans to overcome them Collaborates with other physicians, external entities & institutions to insure timely access to information Manages transitions of care seamlessly

31 Specialty Care Connections PCMH is NOT a gatekeeper system Jointly develop/identify referral guidelines Emphasis on transitions in care & continuity Referral agreements Care transitions programs Some subspecialists may want to qualify as PCMH ACP in discussions with several groups regarding the PCMH model and primary care/specialty care interface (sharing care)

32 Practice Implications Challenges of transformation Initial capital and restructuring costs Ongoing support & maintenance Reporting on quality, cost and satisfaction Implementation of HIT coincident with PCMH

33 Blend of Modified Fee for Service and Bundled Per Patient Payment Perceived as Most Effective for Efficient Health Care System How effective do you think each of the following payment approaches would be in facilitating a more efficient health care system? A blend of the modified fee-for-service and bundled per-patient payment systems 62 Bundled per-patient payment (a single payment for all services provided to the patient during the year), with bonus payments for high quality 51 A modified fee-for-service system, with bonus payments for high quality and efficiency 23 K. Stremikis, S. Guterman, and K. Davis, Health Care Opinion Leaders' Views on Payment System Reform, The Commonwealth Fund, November 2008

34 Payment Models for the PCMH Fee For Service Enhanced RBRVS Add-on codes Performance Prospective Payment: -Structure -Care coordination & -Non face-to-face care -Adjusted for complexity of population & services Enhanced RBRVS Fee for Service Performance Global Payment Procedures Performance

35 Medicare Medical Home Demo Eight states 800 practices (approximately 50/location) Eligibility requirements Practice application and recognition process Beneficiary agreements Time line

36 MMHD Care Management Fee Per Member per Month Payments HCC Score <1.6 HCC Score >1.6 Blended Rate Tier 1 $27.12 $80.25 $40.40 Tier 2 $35.48 $ $51.70 HCC score indicates disease burden Estimate that 25% of beneficiaries with HCC <1.6 and Medicare costs at least 60% higher than average First 2% of savings not shared 80% of savings above 2% (minus fees) shared with practices

37 Other PCMH Demos

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39 Growing Interest in the PCMH Patient Centered Primary Care Collaborative 300+ organizations; represent 50+ million people Articles in NEJM, JAMA, Health Affairs, Annals of Internal Medicine Trade & Lay Press Legislation Commercial payer demos Public payer demos

40 A Commitment to Excellence Patient centered communication Shared decision making Timely access to care Electronic health records Use of comparative effectiveness research & evidence based guidelines Measure, improve, measure Transparency & accountability Safety

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42 Now, there are some who question the scale of our ambitions, who suggest that our system cannot tolerate too many big plans. Their memories are short, for they have forgotten what this country has already done, what free men and women can achieve when imagination is joined to common purpose and necessity to courage. What the cynics fail to understand is that the ground has shifted beneath them, that the stale political arguments that have consumed us for so long, no longer apply. President Barack Obama, January 20, 2009