patient-centered medical home an educational and practice challenge new mexico medical society july...
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Patient-Centered Medical HomeAn Educational and Practice Challenge
New Mexico Medical SocietyJuly 17, 2009
2Physician Practice Connections--Patient-Centered Medical Home
Overview of Presentation
• Driving forces behind Patient Centered Medical Home
• Origins of Medical Home• Need for qualification and evaluation of
PCMH• Development of PPC-PCMH • Beyond measurement: the challenge to
Education and Practice– What is needed for the medical home to
succeed?– The challenge to educational groups at all
levels
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Why do we need a “new” system (some would say we don’t have one now)
• Costs have (for 50 years), and continue to, rise faster than GDP – Uninsured, underinsured and related issues– Can’t improve access without controlling
costs– Major variation in costs WITHOUT
relationship to quality (national/international)
• Major gaps in quality– Hospital deaths and readmissions– In ambulatory care-about 50/50 chance of
getting needed services
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Primary Care Has Changed….Negatively
• Increasing need for PCPs– Population age 85 and over will increase 50% from
2000 to 2010– Aging population means an increase in care for
complex and chronic medical conditions• Decreasing number of PCPs
– Projected shortage of 200,000 PCPs by 2020– Plunging interest in primary care
• Entering internal medicine residents down to 10 % in 2008 from 54% in 1998.
• Family Medicine: not filling residencies and high proportion filled by non US medical graduates
– Primary care physicians are overworked and dissatisfied
– Compensation is bottom of pay scale for physicians
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Median Compensation for Selected Medical Specialties
Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005
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Yet Primary Care Leads to Better Quality and Lower Costs
• Higher ratio of PCPs to specialists is associated with improved health outcomes and lower costs (Starfield-both international and within US data) – Adding 1 family practitioner per 10,000
people associated with 70 fewer deaths per 100,000 (9% reduction in mortality) and lower costs (fewer ambulatory sensitive admissions)
– Specialists practicing outside their specialty area leads to an increase in mortality and cost (Fisher)
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Impact of Primary Care Decline• Patients are dissatisfied and so are
doctors– Patients can’t get timely access to acute care
• Inability of patients to get timely appointment was 23% in 1997 and rose to 33% in 2005
– Physicians hampered in provision of comprehensive chronic care• Lack time and state-of-the-art systems and
processes (the hamster on a treadmill effect) • Pay for procedures- no compensation for nearly
25% of work that occurs between visits, for quality or efficiency
• Gaming rather than value (procedure hobbies that reimburse well versus counseling)
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Key Steps to a true “Health Care System”
• Primary Care Patient Centered Medical
Home as key building block• Implementation and use of health
information technology and care systems at all levels of health care
• Integration of care (real or virtual)• Reimbursement linked to desired
process and outcomes of care (pay for what you want)
• Measurement and feedback to determine if you are getting where you want to be
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The Current Model of Care:Connection by Billing
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The Current Model of Care:Connection by Billing
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Future Model of Care: Step II Patient Centered “Medical
Neighborhood”
Patient-CenteredMedical Home
Sub-specialty “Medical Home Neighbor”
Sub-Specialty Procedural Practice
Insurer
Hospital
Data Center
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Patient Centered Medical Home
A blending of concepts and critical building block for health system
change
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The Medical Home “Defined”ACP, AAFP, AAP, AOA
• Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
• Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
• Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.
• Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
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The Patient Centered Medical Home is a journey not a destination
“In transforming one's practice there is no "there there". There is no moment when the work is completely done.
Those who think that the ultimate goal is achieving NCQA recognition will be disappointed. The goal is continuous transformation. Those practices who have a strong internal culture, a capacity to change, a sense of excitement and a perpetual ability to critically examine their own practices are best suited for this new environment.”
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Primary Care
• Multiple formulations from 1960’s on• Core concepts of
– First contact – Coordinated– Comprehensive– Continuous
• Strong empiric base linking primary care to higher quality and lower cost (within US and international)
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Wagner Model for Effective Prevention and Chronic Illness
Care
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Wagner Model Chronic (Planned) Care Model
• Formulated in 1980’s but with prior roots in primary care and elsewhere
• Based on varying amounts of empiric evidence (qualitative to RCT’s)
• Since developed, multiple studies evaluating model and components of the model (www.improvingchronicillness.org)
• Successful application to both chronic and preventive care (thus “planned care”)
• Empiric basis bolstered by Shortell work on systems and quality
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Patient Centeredness
• Studies and formulations funded and led by Picker
• Defined in “Crossing the Quality Chasm by IOM “the system of care should revolve around the patient, respect patient preferences and put the patient in control”
• Recent work funded by Commonwealth –including work by NCQA and others in refining the definition and creating measures (ACES, CG-CAHPS, supplement to CG CAHPS)
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DecisionSupport
Self-MtgSupport
Comprehensive
First Contact
Perfect Confluence?
What’s Included?(Infrastructure)
How Much Used?(Extent)
What Functions?(Implementation)
Evidence
Wagner CCM Community Linkages
InformationSystems
Delivery system design
Coordinated
Continuous
Medical Home
Primary Care
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Theoretical Frameworks Informing Development of PPC_PCMH
Based on best available empiric evidence in each area and on testing of reliability and validity of elements in field tests using on site audit as “gold”
standard
Chronic Care Model
Patient Centered Care
Cultural Competence
Medical Home
Clinical information Systems
Decision SupportPatient Self-
ManagementDelivery System
RedesignCommunity LinkagesHealth Systems
Respect Patient ValuesAccessible Family-Centered Continuous Coordinated Community LinkagesCompassionate Culturally Appropriate Emotional Support Information and
Education Physical ComfortQuality Improvement
Culturally competent interactions
Language services
Reducing disparities
Personal physicianPhysician directed
teamWhole person
orientationCare is coordinated
and integratedQuality and safetyEnhanced access
PRIMARY CAREFirst contact-comprehensive-continuous-coordinated
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A Critical Missing Ingredient: REIMBURSEMENT THAT SUPPORTS
GOOD CARE
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Fee For Service Reimbursement: The Road to Ruin for Primary Care
• Rewards and encourages volume and new procedures-not primary care
• Is largely influenced and controlled by CPT-4 coding panels and the Resource Utilization Committee (ie: sub-specialists)
• Makes first contact, continuous, coordinated and comprehensive care an economic hardship for most practices
• Treadmill-have to see 20 patients a day to pay for staff-and 10 more for clinicians to make a reasonable living
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Conclusion: Too Little
Wrong Incentives
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Linkage of PCMH to Reimbursement:
Balanced (and increased) Payment
Fee Schedule for Visits/Procedures
Payment per Patient for Qualified Medical Homes(services not normally reimbursed)
Pay for PerformanceQuality, Resource Use and Patient Experience
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Goals for PCMH Implementation
• Improved quality for preventive services and care of persons with chronic illness
• Moderation-or at least, more rational use of resources (lower ambulatory sensitive hospitalization, reordered labs etc)
• Improved patient centeredness as expressed in patient experience of care surveys
• Enhanced reimbursement for primary care • Improved clinician and staff satisfaction
with primary care practice
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How do we “know” a PCMH when we see one?
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Need for a Standardized Tool for QUALIFICATION as PCMH
• If payers are going to provide extra reimbursement to PCMHs, they need an valid and reliable, actionable tool
• When reimbursement at stake, major problems with – Use of practice (clinician) surveys without
documentation or on site verification– Use of clinical performance measures or
patient experience of care (sample size, cost, risk adjustment)
• Critical for practices to have standardization since practices may participate in projects for multiple payers
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PPC-PCMH Development
• Existing PPC 2006 (based on PCM) modified with input from AAFP, AAP, ACP and AOA – Align standards with Joint Principles
of PCMH created by four groups– Incorporate critical attributes of
PCMH not in CCM – Define foundational elements (“must
pass” requirements)Endorsed by NQF
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Research Findings: Validity of Self-Report
• Practices can report on systems, however…
– Overall agreement with an on-site audit ranges from high (clinical information systems, quality improvement) to low (care management, population management)
• Several factors may explain lack of agreement– Variable implementation of systems across sites and
conditions– Variations in staff members’ exposure to systems– Lack of familiarity with systems
Conclusion: Need Audit or Documentation
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Correlation of Systems, Clinical Performance
• Published and in process research on PPC– Presence or absence of EMR per se, correlates ONLY
WEAKLY with clinical measures• However, practices with fully functional EMR’s achieve highest
scores on PPC
– Overall PPC score, and some sub-scores have positive correlation with higher clinical performance on measures tested (diabetes, CV, depression)
– Overall PPC score and some sub-scores have positive coorelation with lower inpatient days for ambulatory sensitive conditions
– Overall PPC score does NOT appear to correlate with overall patient experiences of care but with selected sub-components (ACES- questions with variance attributable to practice level)
More research needed on all aspects –especially on relationship to cost and utilization: ER visits; tests;
specialty care; drug interactions etc
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PPC-PCMH Content and ScoringStandard 1: Access and CommunicationA. Has written standards for patient access and
patient communication**B. Uses data to show it meets its standards for
patient access and communication**
Pts
45
9
Standard 2: Patient Tracking and Registry Functions A. Uses data system for basic patient information
(mostly non-clinical data) B. Has clinical data system with clinical data in
searchable data fields C. Uses the clinical data system D. Uses paper or electronic-based charting
tools to organize clinical information**E. Uses data to identify important diagnoses
and conditions in practice**F. Generates lists of patients and reminds patients
and clinicians of services needed (population management)
Pts
2
33
64
3
21
Standard 3: Care ManagementA. Adopts and implements evidence-based
guidelines for three conditions **B. Generates reminders about preventive services
for clinicians C. Uses non-physician staff to manage patient care D. Conducts care management, including care plans,
assessing progress, addressing barriers E. Coordinates care//follow-up for patients who
receive care in inpatient and outpatient facilities
Pts
3
4
35
5
20
Standard 4: Patient Self-Management Support A. Assesses language preference and other
communication barriersB. Actively supports patient self-management**
Pts
24
6
Standard 5: Electronic Prescribing A. Uses electronic system to write prescriptions B. Has electronic prescription writer with safety
checksC. Has electronic prescription writer with cost
checks
Pts33
2
8
Standard 6: Test Tracking A. Tracks tests and identifies abnormal
results systematically** B. Uses electronic systems to order and retrieve
tests and flag duplicate tests
Pts7
6
13
Standard 7: Referral Tracking A. Tracks referrals using paper-based or
electronic system**
PT4
4
Standard 8: Performance Reporting and Improvement
A. Measures clinical and/or service performance by physician or across the practice**
B. Survey of patients’ care experience C. Reports performance across the practice
or by physician **D. Sets goals and takes action to improve
performance E. Produces reports using standardized
measures F. Transmits reports with standardized measures
electronically to external entities
Pts
3
33
3
21
15
Standard 9: Advanced Electronic Communications A. Availability of Interactive Website B. Electronic Patient Identification C. Electronic Care Management Support
Pts121
4
**Must Pass Elements
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PCMH Must Pass Elements1. PPC1A: Written standards for patient access and patient
communication
2. PPC1B: Use of data to show meeting standards
3. PPC2D: Use of paper or electronic-based charting tools to organize clinical information
4. PPC2E: Use of data to identify important diagnoses and conditions in practice
5. PPC3A: Adoption and implementation of evidence-based guidelines for three conditions
6. PPC4B: Active support of patient self-management
7. PPC6A: Tracking system to test and identify abnormal results
8. PPC7A: Tracking referrals with paper-based or electronic system
9. PPC8A: Measurement of clinical and/or service performance
10. PPC8C: Performance reporting by physician or across the practice
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How PPC-PCMH Recognition Works
Physician/practice• Self-assess, collect data using Web-based software
• Submit documentation to NCQA when ready
• May be asked to submit more data if needed
NCQA • Evaluates and scores all applications
• Checks licensure of physician
• Audits a sample of applications
• Posts Recognized physicians on web
• Distributes list of Recognized physicians monthly to health plans and others
• Physicians sent media kit, press releases, letter & certificate
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Myths• Small practices can’t qualify (>20% of
qualified practices are solo physician sites/practices)
• Passing (25 points) is too hard (practices do not have to submit tool until they score above passing)
• Passing (25 points) is too easy (estimate fewer than 15% of practices could pass without making changes)
• You have to have an EMR to pass (can get nearly 50 points without)
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Office SystemsDecision Support
Information Technology Delivery System Design
Patient Support
Implementing and Evaluating PCMHImplementing and Evaluating PCMH
Inputs
Evaluation
Programs
Tools
PatientExperience
of CareMeasures
(CG-CAHPS)
Clinical Process And
Outcome Measures(Recognition programs
& Group/plan data)
Office Systems
Assessment (PPC-PCMH)
Patient CenteredOngoing Care
IndividualClinician-Staff
Attitudes, behaviorsand proficiencies
Educational Support
Output
MOC(Boards)
Practice Evaluation Programs NCQAQualification
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What Will be Needed for PCMH to Succeed?
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Education, Education, Education
• Education is NOT lectures or traditional CME
• Education must be at all levels –student, resident, and practice-and all types of practitioners and support staff
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Education- Practitioners
• Knowledge, Skills, Attitudes-as individuals– Collaborative “team” practice (clinical
staff, support staff and other physicians)
– Population health-as a link between personal and public health
– Quality measurement and improvement basics
– Patient self (or better “collaborative) health and care management support
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Some Promising Models (of many)• New York City
– Department of Health providing EHR to 2,000 MDs serving Medicaid population; implementation and QI support
– Goal to reach PPC-PCMH Level II within 2 years• Mid-Hudson Valley
– 150 practices participating in THINC consortium with common EHR, interoperability and implementation support
– Goal to reach PPC-PCMH Level II within 2 years• North Carolina Medicaid
– Nurse care managers shared by practices-reported >50 million in savings/year
• Geisinger (reported in Health Affairs)– Introduced in Geisinger Health System– Reduced ambulatory care sensitive hospital admissions
• CMS Demonstration– Large Scale (>200 practices in each of eight regions)– Practices could potentially earn nearly $100,000/MD/year– Will use nurse case manager model similar to North Carolina
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Is the PCMH enough?
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Future Model of Care:Patient Centered Medical Home as
Foundational
Sub-specialty “Medical Home Neighbor”
Sub-Specialty Procedural Practice
Insurer
Hospital
Patient-CenteredMedical Home
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The Future Model of Care: Step IIIPatient Centered Integrated Delivery
System
Sub-specialty “Medical Home Neighbors” Referrals and Procedures
Insurer
Patient Centered Hospital
Patient Centered Medical Home
Data Center
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Summary: Issues to Consider
• PCMH is not THE answer to our cost and quality problems, but a vital building block
• Challenge to provide sufficient help to practices to become PCMH’s to enable them to achieve and demonstrate the cost savings and quality improvement we need
• Challenge to build on the PCMH to create virtual accountable entities (for primary, specialty care and hospital care)