Patient-Centered Medical Home Primary care is not just a doctor and a clipboard anymore. Financial Declaration 10/7/2014.

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1 Patient-Centered Medical Home Primary care is not just a doctor and a clipboard anymore William P. Moran MD MS Professor and Director, General Internal Medicine and Geriatrics Medical University of South Carolina Financial Declaration I have a minor equity interest in Decision Dynamics, Inc. (DDI), Lexington SC, a company which produces care coordination software Revised

2 $8,000 Growth in Total Health Expenditure Per Capita, U.S. and Selected Countries, $7,000 Per Capita Spending - PPP Adjusted $6,000 $5,000 $4,000 $3,000 $2,000 United States Switzerland Canada OECD Average Sweden United Kingdom $1,000 $ Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: /data en (Accessed on 14 February 2011). Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted. Break in series: CAN(1995); SWE(1993, 2001); SWI(1995); UK (1997). Numbers are PPP adjusted. Estimates for Canada and Switzerland in If US health care was a country, it would be the 12 th largest economy in the world CBO and IOM agree: 1/3 of expenditures do not add value to patient care Cumulative Increases in Health Insurance Premiums, Workers Contributions to Premiums, Inflation, and Workers Earnings, Notes: Health insurance premiums and worker contributions are for family premiums based on a family of four. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, (April to April). Revised

3 Quality: Although US costs are highest the quality of care is far from optimal RAND: Americans get evidence-based care only 55% of the time IOM: Up to 98,000 Americans die each year due to avoidable medical errors CDC: 2 million acquire nosocomial infections annually; 90,000 die WHO: US is 37 nd in the world 10/7/ For Medicare by state, more money is associated with care that is lower quality Baicker and Chandra, Health Affairs, 2004 Revised

4 Uninsured The Young Invincibles They re young and healthy, and insurance is expensive. As long as they don t catch the flu, slip on the ice, crash a bike, snowboard into a tree, rupture an appendix, or get hit by a bus, everything will be fine. Right? Aging Population and we have a shrinking primary care workforce Revised

5 Patient Protection and Accountable Care Act of 2010 Insurance reform Coverage expansion Workforce changes Reimbursement from volume-based to valuebased Focus on prevention and quality Patient Protection and Accountable Care Act of 2010 New Delivery System Models Accountable Care Organizations Bundled payments Patient-centered Medical Homes (PCMH) Revised

6 Joint Principles of the Patient- Centered Medical Home AAFP, AAP, ACP, AOA (2006) Personal physician and ongoing relationship Physician directed medical practice Whole person orientation Care coordinated and/or integrated Quality and safety are hallmarks Enhanced access to care Payment appropriately recognizes added value University Internal Medicine at MUSC Faculty practice = 6000 patients 14 faculty most part time Resident practice = 6000 patients 96 residents on 1 month block rotations every 4 months Total visits = 35,000 per year How University Internal Medicine (UIM) became a PCMH: Building Blocks 1. From individual patients to populations Risk stratification 2. From doctors to teams New roles for team members Changes in resident training 3. From clipboards to re-engineering processes (with reliance on EMR) 4. Analytic team for impact and outcome measures 10/7/ Revised

7 Step 1 - The UIM population UNIVERSITY INTERNAL MEDICINE: NCQA CERTIFIED LEVEL 3 PATIENT-CENTERED MEDICAL HOME UIM Patient Demographic Demographics (n=9,933 patients) Age, y (mean ± SD) 58.6 ± , No. (%) 2654 (26.72) 50-64, No. (%) 3285 (33.07) 65-75, No. (%) 2357 (23.73) 75+, No. (%) 1637 (16.48) Male, No. (%) 3669 (36.94) White, No. (%) 4833 (50.88) Married, No. (%) 4596 (46.20) Distribution of National Health Expenditures, by Type of Service (in Billions), 2010 Nursing Care Facilities & Continuing Care Retirement Communities, $143.1 (5.5%) NHE Total Expenditures: $2,593.6 billion Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc. Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at (see Historical; National Health Expenditures by type of service and source of funds, CY ; file nhe2010.zip). Revised

8 UIM patients: 3 years MUSC ED, Hospital, rehospitalization ED HOSP_ALL N of PTs Total # in 3+ years Mean Median Min Max , N of PTs Total # in 3+ years Mean Median Min Max , REHOSP w/in 30 days N of PTs Total # in 3+ years Mean Median Min Max , Prevalence of High Out-of-Pocket Burdens Among the Nonelderly, by Chronic Condition Status, 2001, 2006, and 2008 Percent with Total Burden > 10% of Income Note: Percentages include health insurance premiums. Source: Peter J. Cunningham, Center for Studying Health Systems Change, calculations using 2001, 2006, and 2008 Medical Expenditure Panel Surveys, presented at The National Academies Workshop on Measuring Medical Care Economic Risk, September 8, Frequency of Comorbidities of UIM Patients Revised

9 Concentration of Health Care Spending in the U.S. Population, 2009 Percent of Total Health Care Spending ( $51,951) ( $17,402) ( $9,570) ( $6,343) ( $4,586) ( $851) (<$851) Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized population, including those without any health care spending. Health care spending is total payments from all sources (including direct payments from individuals and families, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers (including dental care), and pharmacies; health insurance premiums are not included. Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), Household Component, Concentration of Health Care Spending in the U.S. Population, 2009 Percent of Total Health Care Spending ( $51,951) ( $17,402) ( $9,570) ( $6,343) ( $4,586) ( $851) (<$851) Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized population, including those without any health care spending. Health care spending is total payments from all sources (including direct payments from individuals and families, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers (including dental care), and pharmacies; health insurance premiums are not included. Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), Household Component, Population Risk Stratification Revised

10 Risk Stratification Cluster A Cluster B Cluster E Cluster C Cluster D Healthy Hypertension Hyperlipidemia & Hypertension Obesity & CV risk Diabetes & CV risk Chronic lung disease, Depression & CV risk Renal Disease, Depression, & CV risk Complex, CV disease & Depressed Revised

11 Step 1: risk stratified high-cost patients, and they have multiple conditions and comorbid depression Step 2 - The UIM Team UNIVERSITY INTERNAL MEDICINE: NCQA CERTIFIED LEVEL 3 PATIENT-CENTERED MEDICAL HOME The UIM Team 4 NP/PAs 8 RNs 10 LPNs/CMA 3 PharmDs 2 Clinical support 8 registration & scheduling Physicians 14 Faculty 96 IM residents Outreach/navigator Revised

12 Why do we need a team? 30 min visit in UIM 10/7/ yo woman with dysuria Issue UTI Preventive care Task Rx Pap dt 10/7/ yo woman with dysuria Hx HBP, Diabetes Issue UTI HBP Diabetes Medications Preventive care Task Rx BP, pulse A1C, lipids, Foot, eye exams Education/self-management Reconcile, Refills Pap mammogram dt, Flu shot 10/7/ Revised

13 Issue 91 yo woman with urinary frequency, Hx HBP, Diabetes, OA, A-fib, dementia UTI HBP Diabetes A fib Arthritis Dementia Medications Preventive care Task Rx BP, pulse A1C, Foot, eye exams Education/home-management Exam, x-rays, Rx Eval, Behavior, caregiver, ADs Reconcile, Refills, labs Complex/High risk regimen Falls, vision dt, Flu shot, Pnvx 10/7/ Issue 91 yo woman with urinary frequency, Hx HBP, Diabetes, OA, A-fib, dementia UTI HBP Diabetes A fib Arthritis Dementia Medications Preventive care Task Rx CMA/LPN BP, pulse A1C, Foot, eye exams Education/home-management Exam, x-rays, Rx Eval, Behavior, caregiver, ADs Reconcile, Refills, labs Complex/High risk regimen Falls, vision dt, Flu shot, Pnvx 10/7/ Issue 91 yo woman with urinary frequency, Hx HBP, Diabetes, OA, A-fib, dementia UTI HBP Diabetes A fib Arthritis Dementia Medications Preventive care Task RN Rx BP, pulse A1C, Foot, eye exams Education/home-management Exam, x-rays, Rx Eval, Behavior, caregiver, ADs Reconcile, Refills, labs Complex/High risk regimen Falls, vision dt, Flu shot, Pnvx 10/7/ Revised

14 Issue 91 yo woman with urinary frequency, Hx HBP, Diabetes, OA, A-fib, dementia UTI HBP Diabetes A fib Arthritis Dementia Medications Preventive care 10/7/2014 Task RN Rx BP, pulse A1C, Foot, eye exams Education/home-management Exam, x-rays, Rx Eval, Behavior, caregiver, ADs Reconcile, Refills, labs Complex/High risk regimen Falls, vision dt, Flu shot, Pnvx Care coordination Transitional Care Management yo woman with urinary frequency, Hx HBP, Diabetes, OA, A-fib, dementia Issue UTI HBP Diabetes A fib Arthritis Dementia Medications Preventive care Task PharmD Rx BP, pulse A1C, Foot, eye exams Education/home-management Exam, x-rays, Rx Eval, Behavior, caregiver, ADs Reconcile, Refills, labs Complex/High risk regimen Falls, vision dt, Flu shot, Pnvx 10/7/ yo woman with urinary frequency, Hx HBP, Diabetes, OA, A-fib, dementia Issue UTI HBP Diabetes A fib Arthritis Dementia Medications Preventive care Task MD Dx, Rx BP, pulse A1C, Foot, eye exams Education/home-management Exam, x-rays, Rx Eval, Behavior, caregiver, ADs Reconcile, Refills, labs Complex/High risk regimen Falls, vision dt, Flu shot, Pnvx 10/7/ Revised

15 PCMH teams: train and practice Step 3 Re-engineering processes UNIVERSITY INTERNAL MEDICINE: NCQA CERTIFIED LEVEL 3 PATIENT-CENTERED MEDICAL HOME Workflow in the real world PATIENT Revised

16 Workflow in the real world PATIENT Workflow in the real world PATIENT PATIENT Revised

17 Then there is paper Therapy orders Home health orders Rehab and nursing home services Written prescriptions (e.g. controlled substances) Medical records, discharge summaries, consultation reports Revised

18 Does he really want to be a General Internist? Revised

19 Team process re-engineering Message management Unit clerk->lpn->rn->md/app Encourage sign-up with MyChart patient portal Standing orders for Immunizations A1C Refills and opioid refill checklist LPN Initiates medication history at each visit and pends refills in EHR before patient visits Team process re-engineering Shifted RNs to care coordination Transitional Care Management goal of 75% of discharges called within 2 days Seen within 7 days by faculty or resident PharmD - medication problems, high risk medications Team meeting identify high risk patients January, 2015 Chronic Care Management (CCM) Revised

20 Access to Care Same day access through Rapid Access Clinic or resident clinic 24/7 practice call coverage by Faculty Sickle cell clinic Acute care/drop-in Ongoing monthly care Hydroxyurea monitoring Outreach: Patients who don t come in. Identify and recall patients overdue with uncontrolled conditions Barriers - Inadequate insurance and copayments - Transportation - Cost and access to medications Some patients do not understand their condition Strategies Outreach to patients not coming to clinic Social worker addressing social barriers RN education Weekly Team Meetings Revised

21 Outcomes: A work in progress UNIVERSITY INTERNAL MEDICINE: NCQA CERTIFIED LEVEL 3 PATIENT-CENTERED MEDICAL HOME Patient Satisfaction CG Consumer Assessment of Healthcare Provider Satisfaction(CAHPS) just begun Faculty Practice 4/6 top box Resident practice not quite as good Process measures: A little competition doesn t hurt in BP and A1C control Resident practice Faculty practice Revised

22 UIM acute care utilization: The largest cost driver of healthcare Revised

23 ACS examples: CHF, COPD, Asthma, CAD, pneumonia etc. Non-ACS: MVA, THR, TKR, trauma, Cancer etc. Revised

24 Cost of PCMH Model and ROI Recent review (Patel et al. Am J Manag Care, 2013) MGMA PC Staffing = 2.68/MD FTE PCMH Staffing = 4.25 FTE per physician Incremental increase 1.57 FTEs ( ) Incremental cost PPPM $4.68 ($3.79-$6.43) For UIM, 10,000 patients = $561,000 Where do we get the money? We need an ROI Revised

25 Return on Investment: UIM clinical staff UIM MD and staffing costs 2009: 8 physician FTE+20 clinical staff = $3.4m/year 2014: 8 physician FTE+ 2 FTE APPs + 24 clinical staff = $3.6m/year Incremental personnel cost = $500,000/year (inflation adjusted to 2014) Cost of PCMH Model and ROI Annual incremental UIM MD/APP+staff cost = $500,000 $41,600/month UIM ED/hospital utilization cost reduction Average over $500,000-$1million/month over last 6 months Hospital/ED utilization-associated cost reduction MORE THAN offset PCMH incremental cost IN THE FIRST MONTH!!!! Others experience with PCMH Geisinger Health System Improved quality and access with significant reduction in utilization Improved job satisfaction and lower burnout symptoms among primary care clinicians Community Care of North Carolina (Medicaid) Dramatic reduction in ED and hospitalizations Revised

26 Accountable Care Organizations (ACOs) Results of 32 Pioneer ACOs built on on PCMH infrastructure Pham et al JAMA (online) 9/17/2014 Payment changes around PCMH that will support PCMH PCMH upfront costs are more than offset by savings in hospital utilization but Reimbursement is lagging badly!!! But. Where are primary care payments going? Fee-for-service probably continue Payments for higher quality of care SC Blue Cross and others Risk-adjusted capitated payments Comprehensive Primary Care Initiative (CMMI) ACOs early shared savings results published by Pioneer ACOs Revised

27 Acknowledgements The people who made this PCMH successful University Internal Medicine staff, faculty and residents Physicians: Drs. Kim Davis & Elisha Brownfield Analysis: Patrick Mauldin Ph.D., Jingwen Zhang MS, Justin Marsden Program Director: Sarah Ball PharmD Questions? Thank you Revised