the business case for medical home

The Business Case for Medical Home

September 19, 2007 Sustaining Progress in Your State and Community

Steven E. Wegner, JD MDPresident & Medical Director AccessCare

President, NCCCN

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The National Center of Medical Home Initiatives for Children with Special Needs Accessible

Care is provided in community All insurance, including Medicaid, is accepted Family can speak directly to provider

Family-Centered Responsibility and trust exists between patient, family,

and medical home Family is recognized as principal caregiver Clear, unbiased, and complete information and options

are continually shared with family

Source: www.medicalhomeinfo.org

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Continuous Same primary provider is available from infancy through young

adulthood Assistance with transitions is provided Medical home provider participates as much as allowed when care

is provided by another facility

Comprehensive Health care is available 24/7 Preventive, primary, and tertiary care needs are addressed Medical home provider advocates for patient in obtaining

comprehensive care and shares responsibility for care provided

The National Center of Medical Home Initiatives for Children with Special Needs


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Coordinated A plan of care is developed by physician, patient, and

family and is shared with other providers A central record containing all medical information is

maintained at practice

Compassionate Concern for well-being of child and family is expressed Efforts are made to understand and empathize with

feelings and perspectives of family

The National Center of Medical Home Initiatives for Children with Special Needs


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Joint Principles of the Patient-Centered Medical Home

The Patient-Centered Medical Home (PC-MH) is an approach to providing comprehensive primary care for children, youth and adults. The PC-MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate the patient’s family.

American Academy of Family Physicians (AAFP) American Academy of Pediatrics (AAP) American College of Physicians (ACP) American Osteopathic Association (AOA)

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Joint Principles of the Patient-Centered Medical Home

Personal physician

Physician directed medical practice

Whole person orientation

Care is coordinated and/or integrated

Quality and safety

Enhanced access

Payment

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BIPA 2000

The New Beginning

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BIPA 2000 –Medicare, Medicaid, and State Children’s Health Insurance Program Benefits Improvement and Protection Act

To encourage the coordination of health care furnished under Medicare

To encourage investment in care management processes for efficient service delivery

To reward physicians for improving health care processes and outcomes

Source: Cathy Schoen, Sabrina K.H. How, IIlana Weinbaum, John E. Craig, Jr., Karen Davis. The Commonwealth Fund – Commission on a High Performance Health System

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BIPA 2000 –Participating Physician Group Practice (PGP)

Ten diverse, large PGPs (>200 physicians) are participating in the demonstration:

Billings Clinic in Montana Dartmouth-Hitchcock Clinic in New Hampshire Everett Clinic in Washington Forsyth Medical Group in North Carolina Geisinger Health System in Pennsylvania Marshfield Clinic in Wisconsin Middlesex Health System in Connecticut Park Nicollet Health Services in Minnesota St. John’s Health System in Missouri University of Michigan Faculty Group Practice in Michigan


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BIPA 2000 –

RTI (Research Triangle Institute) Evaluation –

Cross-site Themes

1. Improving Care Management and Coordination of Care

Chronic disease management

High-cost/high-risk patient management

Transition management

2. Expanding Palliative Hospice Care


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BIPA 2000 –

RTI (Research Triangle Institute) Evaluation –

Cross-site Themes

3. Modifying Physician Practice Patterns and Behavior

4. Enhancing Information Technology

“Demonstration participants feel that attainment of quality and efficiency goals is a function of the system of care and the efforts of the entire care team, so performance payments should be used to improve systems, not to incentivize individual physicians.”


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What’s a Pound of Prevention Really

Worth?

New York TimesJan 24, 2007

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New York Times (cont.)

With the right preventive care, people can cut their risk of a heart attack by up to 80%, cardiologists estimate.

“We have made major improvements in prevention...but it’s difficult. It takes frequent visits, a close relationship between a physician and a patient and a very committed patient.”1

1 Dr. Gregg W. Stone, Director Cardiovascular Research at Columbia University

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MMA Section 721 Medicare Health Support Pilot

Background: Chronic conditions are a leading cause of illness, disability,

and death among Medicare beneficiaries and account for a disproportionate share of health care expenditures.

For example, about 14%of Medicare beneficiaries have heart failure, but they account for 43% of Medicare spending. About 18 percent of Medicare beneficiaries have diabetes, yet they account for 32% of Medicare spending.

Goals: To help increase adherence to evidence-based care, Reduce unnecessary hospital stays and emergency room

visits, and Help participants avoid costly and debilitating

complications.

MMA Section 721 Medicare Health Support Pilot Organizations and Locations

Organization Location Start Date

LifeMasters Oklahoma August 2005

Health Dialog Services Western Pennsylvania August 2005

American Healthways Washington, D.C. & Maryland August 2005

McKesson Health Solutions Mississippi August 2005

CIGNA Health Support Northwest Georgia September 2005

Aetna Health Management Chicago, Illinois September 2005

Green Ribbon Health Central Florida November 2005

XLHealth Select Counties, Tennessee January 2006

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MMA Section 646Medicare Health Quality Demonstration Program

2006 – 2007

Goal: to improve the quality of care and services delivered to Medicare beneficiaries through system design;

Best practice guideline usage

Continuous quality and patient safety improvement

Shared decision making between providers and patients

The delivery of culturally and ethnically appropriate care

Encourage coordination of Medicare services and reward eligible health care groups for improving health outcomes

Eligible Organizations: Physician Groups or regional coalitions of physicians groups or IDS

Integrated Delivery Systems (IDS) – includes hospitals, clinics, home health agencies, ambulatory surgery centers, skilled nursing facilities, and physicians

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American College of Physicians (ACP) 2006:

The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care

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Primary Care is on the verge of collapse Very few young physicians are going into primary care There will not be enough primary care physicians to take

care of an aging population with growing incidences of chronic diseases

Without primary care, the health care system will become increasingly fragmented, over-specialized, and inefficient-leading to poorer quality care at higher costs

It is anticipated that the demand for general internists will increase from 106,000 in 2000 to nearly 147,000 in 2020 - an increase of 38%

When compared with other developed countries, the United States ranked lowest in its primary care functions and lowest in health care outcomes, yet highest in health care spending

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American College of Physicians (ACP) 2007:

A System in Need of Change

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What is patient-centered care?

Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions

INSTITUTE OF MEDICINE, CROSSING THE QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21ST CENTURY, March 2001

Source: Doherty, Robert. “The Patient Centered Medical Home: A proposal for Redesigning Primary Care.” Combined Conferences At Consumer Health World. <http://www.consumerhealthworld.com/PDFs/may07/2.04.ppt.>.

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A Patient-Centered Health Care System Provides continuous access to a personal primary

physician who cares for the whole patient

Characteristics of care that the evidence shows result in the best possible outcomes

Importance of implementing systems-based approaches

Transparency and information to choose a practice and physician

Accountability and public information

Financing, reimbursement and delivery models

Clinical information systems

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“Qualified” practices would have systems to facilitate patient-centered care

Patient registries

Evidence-based clinical decision support

Secure e-mail

Open scheduling and group visits

Remote monitoring

Leading to . . . a fully functional EHR that incorporates registries, decision support, interoperability, and quality measurement and reporting

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The PCMH is a care facilitator, not a gatekeeper

Personal physician accepts responsibility for patient’s

“whole health” and helps patients get the care they need

from other health professionals

The PCMH facilitates appropriate referrals and sharing

of information among a multidisciplinary team

Patients are not “locked in” and may see a specialist at

any time

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The PCMH must be supported by better reimbursement Traditional FFS pays physicians solely based on

volume of visits/procedures

It does not recognize the value of the time that physicians spend in coordinating care with other health professionals and family caregivers or engaging the patient on self-directed care

Nor does it recognize the expenses associated with acquiring the systems needed

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New payment model for services provided by a PCMH Bundled, severity-adjusted care coordination fee paid

on a monthly basis for the following components: 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 Performance based bonus payments based on

evidence based measures of care

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National Committee for Quality Assurance (NCQA): Physician Practice Connections

Practice Requirements

For Certification

Source: 2006 National Committee for Quality Assurance

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1. Access and Communication The practice provides patient access during and after

regular business hours, and communicates with patients effectively

2. Patient Tracking and Registry Functions The practice has readily accessible, clinically useful

information on patients that enables it to treat patients comprehensively and systematically

3. Care Management The practice maintains continuous relationships with

patients by implementing evidence-based guidelines and applying them to the identified needs of individual patients over time and with the intensity needed by the patients

NCQA – PPC: Standards & Intent

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NCQA – PPC

4. Patient Self-Management Support

The practice collaborates with patients to pursue their goals for optimal achievable health

5. Electronic Prescribing The practice seeks to reduce medical errors and

improve efficiency by eliminating handwritten prescriptions and by using drug safety checks and cost information when prescribing

6. Test Tracking The practice works to improve effectiveness of care,

patient safety and efficiency by using timely information on all tests and results

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NCQA – PPC7. Referral Tracking

The practice seeks to improve effectiveness, timeliness and coordination of care by following through on consultations with other practitioners.

8. Performance Reporting and Improvement The practice seeks to improve effectiveness, efficiency,

timeliness and other aspects of quality by measuring and reporting performance, comparing itself to national benchmarks, giving physicians regular feedback and taking actions to improve

9. Interoperability The practice maximizes use of electronic

communication to improve timeliness, effectiveness, efficiency and coordination of care

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Sec. 204 Medicare Medical Home Demonstration Project (Dec 2006)

The Secretary shall establish a medical home demonstration project to redesign the health care delivery system to provide targeted, accessible, continuous and coordinated, family-centered care to high-need populations and -- Care management fees are paid to personal physicians Incentive payments are paid to physicians participating

in practices that provide a medical home “High-need population” means individuals with multiple

chronic illnesses

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Sec. 204 Medical Home

Duration – three years

Scope –

Urban, rural, and underserved areas

Not to exceed eight states

Encouraging participation of small physician practices

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Sec. 204 Medical Home - Definition

Physician practice that: Is in charge of targeting beneficiaries for

participation in the project Responsible for:

Providing safe and secure technology to promote patient access to personal health information

Developing a health assessment toolProviding training programs for coordination

of care

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Sec. 204 Medical Home - Requirements

Board certified physician who provides first contact and continuous care for individuals under the physician’s care

Staff and resources to manage the comprehensive and coordinated health care of each such individual

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Sec. 204 Medical Home - Services

Provides ongoing support, oversight, and guidance to implement an integrated, coherent, cross-discipline medical care plan

Uses evidence-based medicine and point-of-care clinical decision support tools to guide decision-making

Uses health information technology, including remote monitoring and patient registries

Encourages patients to engage in the management of their own health through education and support systems

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Sec. 204 Medical Home - Payment

Personal Physician Care Management Fee

Secretary shall provide a care management fee to personal physicians.

Using the relative value scale update committee (RUC) process, the Secretary shall develop a care management fee code for such payments and a value for such code.

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Sec. 204 Medical Home – Payment

Medical Home Sharing in Savings

80 % of the reductions in expenditures resulting from participation of individuals that are attributable to the medical home shall be paid to the medical home.

The target will be reductions in the occurrence of health complications, hospitalization rates, medical errors, and adverse drug reactions.

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American Academy of Family Physicians (AAFP)

$8 million practice redesign initiativeStarted in 2006

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American Academy of Family Physicians (AAFP) (cont.)

TransforMED is a new model with these core elements:

Patient-centered care

Electronic medical records

Team approach to care

Open access for patients

Focus on quality and safety

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The Patient Centered Primary Care Collaborative

Major Employers (50 million employees), Consumers and Physicians (330,000) Unite

to Revolutionize the Healthcare System

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The Problem

Employers want to buy high quality healthcare for their employees Employers cannot buy the model of care they want for

their employees

The reimbursement system is inadequate, the IT is insufficient, the accountability and incentives are not in place

This is why we created the PCPCC and want change

So we built a team, got together with the providers, patients and the payers, discussed what

we want to buy, and set out forming a collaborative to design and implement a new

system – one that focuses on primary care and the medical home.

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Patient-Centered Primary Care Collaborative (PCPCC)

Discussion focused on the Patient-Centered Medical Home (PC-MH)

Models: Medical home pilot study in North Carolina and IT Denmark

Commonwealth Fund’s patient-centered care initiative

How to qualify physician practices and strategies for redesigning the healthcare payment system

Paul Grundy MD, FACPM, FACOEM

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The Commonwealth FundCommission on a High Performance Health System

Public Views on Shaping the Future of the U.S. Health System

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Public Views

Many had recent experiences or heard of wasteful, inefficient, or unsafe care

Common belief that expanded use of information technology, care teams, and improved delivery of preventive services could improve the quality of care

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Medical Home Act of 2007Senators Durbin and Burr Methods to Increase:

Cost efficiencies of health care delivery Access to appropriate health care services Patient satisfaction School attendance Quality of health care services provided

Methods to Decrease: Inappropriate emergency room utilization Duplication of health care services

Methods to provide appropriate: Preventive care Referrals to multidisciplinary services

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Medical Home Act of 2007

Project Design 3-year duration, beginning by October 1, 2009 Conducted in 8 states, 4 of which have primary

care case management services Voluntary participation Each enrollee will have a medical home with

access to appropriate medical care, being supervised by their personal physician

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Care Coordination – The demonstration will follow a physician directed care coordination model similar to the highly successful NC Medical Home model.

Uses health information technology (including patient registry systems, clinical decision support tools, remote monitoring, and electronic medical record systems)

Communicates with physician practices and other health care providers

Establishes networks with community practices, hospitals, community health care providers, and local public health departments

Acts as a facilitator in order to ensure that patients receive high-quality care at the appropriate time and place in cost-effective manner

Hires primary care case managers to assist with care coordination


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Payment Payment rate higher than the rate the State would

otherwise pay for services delivered through the personal primary care provider under Medicaid or SCHIP

Payment for performance-based results to recognize achievement of defined quality and efficiency goals

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Evaluation and Report

The Secretary will evaluate the project in order to determine the effectiveness of patients-centered medical homes in terms of : Quality improvement Patient and Provider satisfaction Improvement of health outcomes

Secretary then submits a report to Congress

the business case for medical home

Documents