PCMH & ReimbursementMichigan State Medical Society

Mary Beth Bolton, M.D.,FACP, CMO & SVPHealth Alliance Plan

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Patient-Centered Medical Home:A Critical Opportunity

Patient-centered medical home presents a critical opportunity

To improve current and future performance in many areas: Quality of care and service Efficiency, effectiveness and cost of health care services Informed choice and access to health care services Patient / member satisfaction with their overall HAP experience

HAP has the experience and tools to capitalize on this opportunity: Primary care physicians with substantial experience with the concepts and

reality of the patient-centered medical home HAP programs and tools, including: physician reports, quality improvement,

“reward for quality” physician incentive program, web tools like Health Risk appraisal and Member Health Manager

HAP has leaders and physician networks with: Demonstrated interest in the medical home Ability to make substantial and rapid progress in its implementation Innovations in practice redesign underway

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Expenditures vs Primary Care Score

Also documented in Patient Centered Medical Home, Maine Center for Public Health, October 15, 2008, by Josh Cutler, MD, Director

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Primary-care score vs health outcomes

0

1000

2000

3000

4000

5000

6000

7000 United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data 5

Average spending on health per capita ($US Purchasing Power Parity)

7681

88 8489 89

99 9788

97

109 106116 115 113

130 134128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150

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Italy

Can

ada

Nor

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Swed

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Finl

and

New

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Den

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1997/98 2002/03

Countries’ age-standardized death rates, list of conditions considered amenable to health care Source: E. Nolte and C. M. McKee, Measuring the Health of Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1):58–71 6

USA worse/19Industrialized nations

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The Value of Primary Care

Evidence suggests that access to high quality primary care results in lower overall health care costs and lower use of higher cost and lower value services, i.e., specialists, ER, inpatient care– Adults with a primary care physician rather than a specialist as their

personal physician had a 33% lower annual adjusted cost of care and 19% lower adjusted mortality

– Increased primary care to population ratios are associated with reduced hospitalization rates for sixteen ambulatory sensitive conditions

– Health care costs are higher in regions with higher ratios of specialists to generalists

Primary care currently operates on a transaction-based model and reimbursement does not recognize the value of (and specifically reimburse for) individualized, comprehensive care management– There is a significant reduction in physicians in primary care specialties

with associated poor access to primary care for patients and escalation of care into higher cost settings

1 Source: Paul Grundy MD, MPH, Director, IBM Healthcare Technology and Strategic Initiatives, “Patient Centered-Primary Care Collaborative,” NCQA Policy Conference, December 7, 2007

Patient Centered Medical Home

The Patient Centered Medical Home is an approach to providing comprehensive primary care for adults and children that emphasizes personal physician, physician directed practice, “whole Person” care orientation, coordinated care, quality and safety, enhanced care access, and full value payment

Recommended new payment model to consider:– Bundled, severity-adjusted care coordination fee paid on a monthly

basis for the following:• The physician and non-physician clinical staff work required to manage

care outside a face-to-face visit• The health information technology and system redesign incurred by the

practice– Combined with per visit FFS payment and– Performance based bonus payments based on evidence based

measures of care

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1 Source: Paul Grundy MD, MPH, Director, IBM Healthcare Technology and Strategic Initiatives, “Patient Centered-Primary Care Collaborative,” NCQA Policy Conference, December 7, 2007

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Patient-Centered Medical Home

Element Explanation Comments

Personal physician Ongoing relationship with a personal physician: first contact, continuous

and comprehensive care

Members are assigned to a PCP at all times

Physician directed medical

practice

Personal physician leads team at practice level that collectively take

responsibility for ongoing care of patients

Team effectiveness is evident in higher / improved performance.

Whole person orientation Providing or arranging all the patient’s health care needs – preventive,

acute, chronic – at all stages of life

PCP accountability for quality and efficient care

Coordinated / integrated

care

Across all providers and settings and the patient’s community. Facilitated

by registries, IT, health info exchange to assure that patients get the

indicated care when and where they need it in a culturally and

linguistically appropriate manner

Documented use of registries and / or HAP MHM.Clinician/group CAHPS

Quality and safety Are hallmarks of the patient-centered medical homeHEDIS quality & safety measures exceed threshold

Enhanced access to care Open scheduling, expanded hours and new options for communications

between patients, personal physician and office staff

Office hours beyond 9-5 M-FNon-traditional hours & weekendsOpen access schedulingE-visits

Payment recognizes

added value to patients

More rational (and higher) payment for primary careFee schedule, pay-for-performance, public recognition

National Consensus Principles – AAAFP, AAP, ACP, AOA (March 2007)

These principles are recognized and supported in NCQA’s updated Physician Practice Connections recognition program and the BCBSM PGIP program

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The Patient-Centered Medical Home

The patient centered medical home concept is supported by a large multi-stakeholder group reflecting a broad range of physician professional associations, major employers, major insurers and others that have formed an organization called the “Patient Centered Primary Care Collaborative”

– Over 80 members including: HAP, General Motors, Delphi, Walgreens, AIAG, IBM, AARP, Blue Cross Blue Shield Assoc, United Healthcare, CIGNA, AETNA, Wellpoint, Medical Network One, most of the primary care focused major physician associations and two major health systems (Geisinger and University of Pittsburgh Medical Center)

The basis for support is evidence that care delivered through primary care physicians increases the value of care, as reflected in improved quality and reduced expense

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PCMH in Michigan

The group determined the joint principles of: Personal physician Physician directed medical practice Whole person orientation Care that is coordinated and/or integrated Quality and safety Enhanced Access Payment

The group then added the following Michigan footnotes: Patient-centered model of care that recognizes the patients as stewards of their own

health Personal physician may be of any specialty, but the practice must meet all requirements Clinical outcomes, safety, resource utilization and clinical and administrative efficiency

are consistent with best practices Transformational change in healthcare financial incentives should occur simultaneously

with, proportionally to, and in alignment with PCMH adoption HAP’s focus initially is to support primary care physicians to develop processes and tools

to support PCMH

The Michigan Primary Care Consortium convened a group of representatives from insurance companies, health plans, and professional associations to develop statewide consensus on the PCMH definition, identification, and metrics

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Components of Patient-Centered Medical Home

Electronic prescribing (eRx)

Clinical information systems: registries, Electronic Health Record (EHR), access to lab, radiology and other test results

Use of registries for chronic care patient identification and tracking of tests and missing chronic care and preventive services

Follow up on abnormal test or subspecialty recommendations I.e. coordination and continuity

Advance planning for visits

Extended access/after hours coverage/same day acute care visits

E-visit or secure e-mail

Chronic care coordination through multidisciplinary teams, home monitoring, family involvement

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Additional Features of Patient-CenteredMedical Home

Patient engagement

Integration of behavioral issues especially depression

Provider transparency cost/quality/patient satisfaction

Group visits for chronic care patients

Medication reconciliation between hospital/office/nursing home