the patient-centered medical home impact on cost and quality: an annual review of evidence

CHCI Weitzman symposium May 2014J. Nwando Olayiwola, MD, MPH, FAAFP

Associate Director, Center for Excellence in Primary CareAssistant Professor, Department of Family & Community Medicine

University of California, San Francisco

The Patient-Centered Medical Home’s Impact on Cost and Quality: A Review of the

Evidence from 2012-2013

AuthorsMarci Nielsen, PhD, MPH

Chief Executive Officer, PCPCC

J. Nwando Olayiwola, MD, MPH, FAAFPAssociate Director, Center for Excellence in Primary Care; Assistant Professor, Department of Family and Community Medicine, University of California, San Francisco

Paul Grundy, MD, MPHPresident, PCPCC; Global Director, Healthcare Transformation, IBM

Kevin Grumbach, MDProfessor and Chair, Department of Family and Community Medicine; University of California, San Francisco

Lisa Dulsky Watkins, MDFormer Associate Director, Vermont Blueprint for Health

ReviewersMelinda Abrams, MS

Vice President, Health Care Delivery System Reform; The Commonwealth Fund Asaf Bitton, MD, MPH

Instructor, Division of General Medicine, Brigham and Women's Hospital; Instructor, Department of Health Care Policy, Harvard Medical School

Mark GibsonDirector, Center for Evidence-Based Policy; Oregon Health & Science University

Bruce Landon, MD, MBA, MSc

Professor of Health Care Policy, Harvard Medical School; Professor of Medicine, Division of General Medicine and Primary Care; Beth Israel Deaconess Medical Center

Len Nichols, PhDDirector, Center for Health Policy Research and Ethics; George Mason University

Kavita Patel, MD Managing Director for Clinical Transformation and Delivery; Engelberg Center for Health Care Reform; Fellow, Economic Studies The Brookings Institution

Mary Takach, MPH, RNSenior Program Director; National Academy for State Health Policy

Take Home PointsPCMH evaluations over the past year reported

significant improvements across a broad range of clinical and financial outcomes

The PCMH is playing an increasingly critical role in delivery system reform, including ACOs and the medical neighborhood

Significant payment reforms continue to incorporate the PCMH

The Landscape: PCMH Momentum

NCQA Recognized PCMH By State – 12/31/10

Source: Analysis by the National Committee for Quality Assurance, Dec. 2010.

NCQA-Recognized Practices Across the United States

ME

VT

RI

NJ

MD

MA

DE

NY

WA

OR

AZ

NV

WI

NM

NE

MN

KS

FL

CO

IA

NC

MI

PAOH

VAMO

HI

OK

GA

SC

TN

MT

KY

WV

AR

LA

AL

INIL

SD

ND

TX

ID

WY

UT

AK

CA

CT

NH

MS

61–200 sites

21–60 sites

0 sites

1–20 sites

201+ sites

Source: Analysis by the National Committee for Quality Assurance, Oct. 2012.

4,937 sites & 23,396 clinicians as of 10/31/2012

PCMH Recognized Physicians and Sites: Growth Over Time

National Imperative: Triple Aim

Source : Berwick, Donald M., Thomas W. Nolan, and John Whittington. "The triple aim: care, health, and cost." Health Affairs 27.3 (2008): 759-769.

Methods• Examined medical home/PCMH studies published

between August 2012 and December 2013– Peer-reviewed scholarly articles– Industry reports

• Explored relationship between “medical home/PCMH” model of care and Triple Aim outcomes – Predictor variable: “Medical home” or “PCMH” – Outcome variables: Cost & utilization; care experience

(access & patient satisfaction); health outcomes (population health & preventive services)

• Resulted in 13 peer reviewed (academic) studies, and 7 industry reports

13 Peer-Reviewed (Academic) Studies• Alaska Southcentral Foundation• Colorado Multi-Payer PCMH Pilot• BlueCross BlueShield Michigan• Military Health System• Veterans Health Administration • New Hampshire Citizens Health Initiative• Horizon BlueCross BlueShield• EmblemHealth – New York• WellPoint - New York• UPMC Health Plan• Rhode Island Chronic Care Sustainability Initiative• University of Utah• Group Health Cooperative

• BlueCross BlueShield Alabama• Connecticut Health Enhancement Program• Horizon Blue Cross Blue Shield• BlueCross BlueShield Michigan• CareFirst BlueCross BlueShield• Oregon Coordinated Care Organizations• Highmark PCMH Pilot

7 Industry generated Reports

Key Point #1:PCMH evaluations report improvements across a broad range of clinical and financial outcomes

PCMH Peer Reviewed Peer Reviewed Outcomes

PCMH Industry Generated Industry Generated Outcomes

Key Point #2:PCMHs play a critical role in delivery system reform, including ACOs and the medical neighborhood

Public Health

Employers

Schools

Faith-Based Organizations

Community Centers Home

Health Hospital

Pharmacy Diagnostics

Specialty & Subspecialty

Patient-Centered Medical Home

Community Organizations

Connected via Health IT

$

$

PCMH: Foundation to ACOs & the Medical Neighborhood

Emerging Trends

ACO Climate and Opportunities

ACO Growth Over Time

Source: Muhlestein D. Accountable Care Growth in 2014: A Look Ahead. Health Affairs Blog. January 2014

ACOs by Sponsoring Entity

Source: Muhlestein D. Accountable Care Growth in 2014: A Look Ahead. Health Affairs Blog. January 2014

Estimated ACO Lives 2014

Source: Muhlestein D. Accountable Care Growth in 2014: A Look Ahead. Health Affairs Blog. January 2014

Key Point #3:Significant payment reforms continue to incorporate the PCMH

Payment Reform Drivers – Making the Case

Policy Influences

Sustainable Growth Rate (SGR)

• “Volume to Value”• Federal legislation = long term

adoption• Encourages more providers to

accept risk-based payments (5% Medicare increase)

• Repeal calls for PCMH as supportive framework

• Will lead to broader acceptance of PCMH and ACOs

State Medicaid Activity and Expansions

• “Volume to Value”• State based = short term

adoption• Oregon and Utah pioneers in

state Medicaid ACO• Providers bear some risk while

meeting quality benchmarks• State based reimbursements for

PCMH recognition important driver

Payment Reforms

Source: S. Guterman, M. Zezza, C. Schoen, Paying for Value: Replacing Medicare's Sustainable Growth Rate Formula with Incentives to Improve Care, The Commonwealth Fund, March 2013.

Private Sector Reforms• Commercial health plans moving from traditional

fee-for-service models• Transition from PCMH “demonstrations” to standard

business operations– Incentives for primary care– PCMH incentives– Care coordination reimbursements– PMPM add ons

Overview of Medicaid Medical Home Activity 42 State Medicaid/CHIP Programs Planning/Implementing PCMH

27 Making Medical Home Payments

Source: National Academy for State Health Policy State Scan, October 2012, http://www.nashp.org/med-home-map.

WA

OR

TX

CO

NC

LA

PA

NY

IA

VA

NE

OK

RI

AL

MD

MT

ID

KS

MNMA

ME

AZ

VT

MOCA

WY

NM

IL

WIMI

WV

SC

GA

FL

HI

UTNV

ND

SD

AR

INOH

KY

TN

MS

AK

Significant activity for Medicaid/CHIP PCMH advancement (15 states)

No PCMH Medicaid activity (8 states)

States making payments for PCMH (27 states)

NJ

DE

NH

CT

Overview of Medicaid Medical Home Activity47 State Medicaid/CHIP Programs Planning/Implementing PCMH

30 Making Medical Home Payments, 22 Involved in Multi-payer Pilots

WA

OR

TX

CO

NC

LA

PA

NY

IA

VA

NE

OK

RI

AL

MD

MT

ID

KS

MN NHMA

ME

AZ

VT

MOCA

WY

NM

IL

WIMI

WV

SC

GA

FL

HI

UTNV

ND

SD

AR

INOH

KY

TN

MS

AK

Significant activity for Medicaid/CHIP PCMH advancement (26 states + DC)

Medicaid multi-payer activity/involvement (22 states)

States making payments for PCMH (30 states)

NJ

DE

Source: National Academy for State Health Policy State Scan, May 2014, http://www.nashp.org/med-home-map.

CT

DC

WA

OR

TX

CO

NC

LA

PA

NY

IA

VA

NE

OK

AL

MD

MT

ID

KS

MN

ME

AZ

VT

MOCA

WY

NM

IL

WIMI

WV

SCGA

FLHI

UTNV

ND

SD

AR

INOH

KY

TN

MS

AK

National Momentum: Spread of Medical HomesAt Least One Payer in 49 States Testing PCMH

Multi-payer payment (22 states)

Identified pilot activity (49 states)

No identified pilot activity (1 state)

Source: Patient Centered Primary Care Collaborative and National Academy for State Health Policy, updated May 2014

DE

NH

RIMACT

NJ

The Year in Review: Case Study Snapshots

Veterans Health Administration Patient Aligned Care Team

• Optimize workflow and coordinate care through the use of an interprofessional “teamlet” model

• Enact advanced scheduling, such as same-day appointments

• Add phone consults and group appointments

National program5 million patients

ResultsPCMH Strategies

• 8% fewer urgent care visits

• 4% fewer inpatient admissions

• Decrease in face-to-face visits• Increase in phone encounters,

personal health record use, and electronic messaging to providers

Source: Rosland, A.M., Nelson, K., Sun, H., Dolan, E.D., Maynard, C., Bryson, C., Stark, R., Schectman, D., (2013). The Patient-Centered Medical Home in the Veterans Health Administration. American Journal of Managed Care. 1-4.

BlueCross BlueShield of Michigan Physician Group Incentive Program

Michigan3 million patients

ResultsPCMH Strategies• 13.5% fewer pediatric

ED visits• 10% fewer adult ED

visits

• 17% fewer inpatient admissions

• 6% fewer hospital readmissions

• Savings of $26.37 PMPM• $155 million in cost

savingsSource: Blue Cross Blue Shield of Michigan. Patient-Centered Medical Home Fact Sheet. July 2013. Retrieved from http://www.valuepartnerships.com/wp-content/uploads/2013/07/2013-PCMH-Fact-Sheet.pdf.

• Develop patient registries to track and monitor patients’ care

• Offer 24-hour patient access to a clinical decision-maker through

• extended office hours• telephone access• a linkage to urgent care

• Provide online patient resources that allow for electronic communication and greater patient access to medical information

UPMC Health Plan Medical Home Pilot

Pennsylvania 23,390 patients

ResultsPCMH Strategies

• 2.6% reduction in total costs• 160% ROI

• 2.8% fewer inpatient admission

• 6.6% increase in patients with controlled HbA1c

• 18.3% fewer hospital readmissions

• 23.2% increase in eye exams• 9.7% increase in LDL

screenings

• Practice-based nurses provide care management

• Create telehealth options for care managers to connect to patients when in-office visits are not possible or necessary

• Offer incentives to payers to enter into PCMH contracts

Source: Rosenberg, C.N., Peele, P., Keyser, D., McAnallen, S., & Holder, D. (2012) Results from a patient-centered medical home pilot at UPMC Health Plan hold lessons for broader adoption of the model. Health Affairs. 31(11).

CareFirst BlueCross BlueShield Maryland

Maryland1 million patients

ResultsPCMH Strategies

• $98 million in total cost savings

• 4.7% lower costs for physicians that received an incentive award

• 3.7% higher quality scores for panels that received incentives

• Quality scores for PCMH panels rose by 9.3% from 2011 to 2012

Source: CareFirst Blue Cross Blue Shield. Patient-centered medical home program trims expected health care costs by $98 million in second year. Press Release, June 2013. Retrieved from https://member.carefirst.com/wps/portal/!ut/p/c4/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hLbzN_Q09LYwN

• Use local care coordination teams to track high-risk members

• Create an infrastructure for nursing support, easily-accessible online tools and data, and targeted health programs

• Offer increased reimbursements to physicians based on performance in the program

Oregon Health Authority Coordinated Care Organizations (CCOs)

Statewide Medicaid program600,000 patients

ResultsPCMH Strategies

• 9% reduction in ED visits• 14-29% fewer ED visits for

chronic disease patients

• 12% fewer hospital readmissions

• 18% reduction in ED visit spending

• Reduced per capital health spending growth by >1%Source: Oregon Health Authority. (2013). Oregon’s Health System

Transformation: Quarterly Progress Report. Retrieved from http://www.oregon.gov/oha/Metrics/Documents/report-november-2013.pdf.

• Establish a primary care infrastructure that includes 450 PCMH practices and clinics

• Increase the use of outpatient care to promote prevention

• Increase well-care visits to adolescents to reduce unnecessary ED visits

• Provide follow-up care to patients within 7 days of being discharged

The Challenge of Studying the PCMH: The Right Metrics?

• Right metrics?– Gap in clinician satisfaction measures – tied to

workforce needs– Need for better/more patient satisfaction measures

of self-reported health status/well-being– Measures need to account for patient diversity,

socioeconomics and social determinants of health – Need for standard core measures – including

behavioral health and oral health integration– Stronger case for connection to health equity

• Right methods?– Study designs appropriate for investigating

complexity of health system reforms– Recognition that the model/philosophy is evolving– Evaluation often in the midst of multimodal

change processes

Source: Grumbach, Kevin. "The Patient-Centered Medical Home Is Not a Pill: Implications for Evaluating Primary Care Reforms." JAMA internal medicine 173.20 (2013): 1913-1914.

The Challenge of Studying the PCMH: The Right Methods?

Take Home PointsPCMH evaluations over the past year reported

significant improvements across a broad range of clinical and financial outcomes

The PCMH is playing an increasingly critical role in delivery system reform, including ACOs and the medical neighborhood

Significant payment reforms continue to incorporate the PCMH

Thank You!

Contact:J. Nwando Olayiwola, MD, MPH, FAAFPAssociate Director, Center for Excellence in Primary CareUniversity of California, San FranciscoOlayiwolaJ@fcm.ucsf.edu Twitter: @DrNwando(415) 206-2970 (O)