The Patient-Centered Medical HomeWill It Make A Difference?

2009 Population Health ColloquiumDepartment of Health PolicyThomas Jefferson University

March 2009Michael S. Barr, MD, MBA, FACP

Vice President, Practice Advocacy & ImprovementDivision of Governmental Affairs & Public Policy

202-261-4531mbarr@acponline.org

Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and protection.

President Harry Truman Text from a speech he delivered to a joint session of Congress in 1945

So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year.

President Barack ObamaText from a speech he delivered to a joint session of Congress , February 24, 2009

Workforce

Education

HIT Infrastructure

Universal Health

Coverage

Economy

PaymentPolicy

State of the Nation’s Health Care

45 →54 million80%16 million18% ($2.6T) →20% $8,300

uninsuredemployed

underinsured

per capita in 2008

Projections for 2019

To $13,000 in 2017

2017

Amenable Mortality: 15th to 19th

<50% with access to rapid appointment75% difficulty with after hours care

18% readmission rate within 30 days

The Commonwealth Fund: Why Not the Best; 2008Nolte & McKee: Measuring the Health of Nations: Updating an Earlier Analysis. Health Affairs, 27:1 (2008)

M’care: High

variability

Comparing ‘97-98 to ‘02-03;

75,000 – 100,000 avoidable deaths

Escalating Costs, Decreasing Coverage

$130 billion$1500 vs. $450 vs. $150

70% to 60%98% vs. 23%

Untreated illness & work absence;

uninsured

Healthcare costs per U.S.

auto vs. Germany &

Japan

Decreasing employer-sponsored

coverage (‘70s to ‘06) Growth in

premiums vs. inflation (’00 – ’07)

Cost v Quality

Primary Care Score vs. Health Care Expenditures 1997

Source: The Commonwealth Fund, Data from B. Starfield, “Why More Primary Care: Better Outcomes, Lower Costs, Greater Equity,” Presentation to the Primary Care Roundtable: Strengthening Adult Primary Care: Models and Policy Options, October 3, 2006.

The Case for Health Care Reform

• Poor access to care, especially for the uninsured

• Escalating costs & volume of services• No link between cost and quality• Excessive administrative costs• Dysfunctional payment system• United States is lagging internationally • Impending “collapse” of primary care

“How can we fail to provide health insurance for 16% of our population, deliver uneven quality to the 84% of Americans who are insured, and yet pay 50% more per person than countries like France, Israel, and Britain, which cover all of their citizens?”

Ezekiel J. Emanuel, MD, PhDHealthcare, Guaranteed: A Simple, Secure Solution for America, 2008

Evidence

HIT

Team-based care

Links to

Comm.

Self-Mgt

System Design

PCMH

A Dying Breed

• JAMA 2008: 2% of 1177 4th year medical students (at 11 medical schools) planned careers in general internal medicine

• A 2004 survey of board certified internists found that after ten years of practice, 21% of general internists were no longer working in GIM compared to a 5% decrement for subspecialists

Hauer, KE et al. JAMA. September 10, 2008; Vol 300, No. 10 p 1154-1164Lipner RS, Bylsma WH, Arnold GK, Fortna GS, Tooker J, Cassel CK: Ann Intern Med. 2006 Jan 3;144(1):29-36

Jack M. Colwill, James M. Cultice, and Robin L. Kruse, Will Generalist Physician Supply Meet Demands Of An Increasing And Aging Population?, Health Affairs, Vol 27, Issue 3, w232-241w

Projected shortage of 35 – 45,000

generalists for adults

Imbalanced System

Increasing demand

Decreasing supply

What is the Patient-Centered Medical Home?

• …a vision of health care as it should be• …a framework for organizing systems of

care at both the micro (practice) and macro (society) level

• …a model to test, improve, and validate• …part of the health care reform agenda

“PCMH” is Our Term…

• …to describe a pathway to excellent health care• …to re-claim a role as advocates for our patients

(with our patients & their families)• …to encourage team-based care• …to create educational opportunities• …to attract medical students and residents to

primary care

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformationSystems

Self-Management Support

Health System

Resources and Policies

Community Health Care Organization

(Chronic) Care Model

Improved Outcomeshttp://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998: 1:2-4.

The Joint Principles of the PCMH• Personal physician • Physician directed medical practice• Whole person orientation • Care is coordinated

and/or integrated• Quality and safety• Enhanced access to care • Payment to support the PCMH

Team-based care: NP/PARN/LPNMedical AssistantOffice StaffCare CoordinatorNutritionist/EducatorPharmacistBehavioral HealthCase ManagerSocial WorkerCommunity resourcesDM companiesOthers…

Building the Medical Home• Collaboration• Recognition• Demonstration• Advocacy• Expansion• Education• Education• Education

Important Questions

1. How do you recognize a PCMH?2. How is care different?3. Will physicians & their teams want to build

the medical home?4. How do we prepare physicians, students &

residents?

NCQA: Physician Practice Connections/PCMH

1. Access & Communication

2. Patient Tracking & Registry Functions

3. Care Management4. Patient Self-

Management Support5. Electronic Prescribing

6. Test Tracking7. Referral Tracking8. Performance

Reporting & Improvement

9. Advanced Electronic Communication

Joint Principles of the Patient-Centered Medical Home

PPC-PCMH ≠ PCMHQuality Measures ≠ Physician

Consumer Reports ≠ Car

The Process

1. Gap analysis – take the “pre-test.”2. Analyze results.3. Implement changes necessary4. Retake the “pre-test.”5. If ready submit application to NCQA.Cost: Readiness assessment = $80NCQA application fee: varies by size of practice

from $450 for 1 physician to $2,700 for 6+http://www.ncqa.org/tabid/631/Default.aspx

Stepping Up to Excellence

Level 1: 25-49 Points

Level 2: 50-74 Points

Level 3: 75+ Points

Increasing Complexity of Services

Level 1: 25-49 Points

Level 2: 50-74 Points

Level 3: 75+ Points

• Demonstrates timely access and communication processes

• Organizes charts (paper or electronic) to facilitate team-based care and tracking age-appropriate and condition-specific interventions

• Identifies key clinical conditions among population served & follows evidence-based guidelines

• Encourages and provides support for patient/family self-management

• Addresses health literacy issues

• Tracks tests & referrals to assure completion

• Collects and reports on quality & satisfaction data to practice

Key Points for Level 1 PCMH

• Does not require electronic health record• Will require registry & tracking functions• Emphasis is on providing better care through:

– Access to care– Organization of office structure & processes– Enhancing patient self-management; addressing health

literacy issues– Introduction of evidence-based guidelines, measurement

& quality improvement

Level 2 → Level 3

• Advanced access options for patients • Electronic health record• More, and more complex care coordination

and patient support• Robust population management• Advanced reporting and quality improvement

initiatives• Additional technology solutions

More Features of a PCMH Practice

• Uses each team member to highest capability• Supports cultural competency training • Understands health literacy• Establishes connections to the community• Provides extensive self-management support• Engages a Patient/Family Advisory Group

More Features of a PCMH Practice• Provides individualized written care plans and

monitors adherence to the plan• Assesses barriers to adherence and initiates

plans to overcome them• Collaborates with other physicians, external

entities & institutions to insure timely access to information

• Manages transitions of care seamlessly

Specialty Care Connections• PCMH is NOT a gatekeeper system• Jointly develop/identify referral guidelines • Emphasis on transitions in care & continuity

– Referral agreements– Care transitions programs

• Some subspecialists may want to qualify as PCMH• ACP in discussions with several groups regarding the

PCMH model and primary care/specialty care interface (sharing care)

X

Practice Implications

• Challenges of transformation• Initial capital and restructuring costs• Ongoing support & maintenance• Reporting on quality, cost and satisfaction • Implementation of HIT coincident with PCMH

Blend of Modified Fee-for-Service and Bundled Per-Patient Payment Perceived as Most Effective for Efficient Health Care System

K. Stremikis, S. Guterman, and K. Davis, Health Care Opinion Leaders' Views on Payment System Reform, The Commonwealth Fund, November 2008

“How effective do you think each of the following payment approaches would bein facilitating a more efficient health care system?”

Series1 5

19

25

18

32

37

Very effective Effective

A blend of the modified fee-for-service and bundled per-patient payment systems

Bundled per-patient payment(a single payment for all services

provided to the patient during the year),with bonus payments for high quality

A modified fee-for-service system,with bonus payments for high quality

and efficiency

62

51

23

Payment Models for the PCMH

•Fee For Service•Enhanced RBRVS•Add-on codes•Performance

•Prospective Payment:-Structure-Care coordination &-Non face-to-face care-Adjusted for complexity ofpopulation & services•Enhanced RBRVS•Fee for Service•Performance

•Global Payment•Procedures•Performance

Medicare Medical Home Demo

• Eight states• 800 practices (approximately 50/location)• Eligibility requirements• Practice application and recognition process• Beneficiary agreements• Time line

MMHD Care Management Fee

Per Member per Month Payments

HCC Score <1.6 HCC Score >1.6 Blended Rate

Tier 1 $27.12 $80.25 $40.40

Tier 2 $35.48 $100.35 $51.70

HCC score indicates disease burden

Estimate that 25% of beneficiaries with HCC <1.6 and Medicare costs at least 60% higher than average

First 2% of savings not shared

80% of savings above 2% (minus fees) shared with practices

Other PCMH Demos

http://www.acponline.org/running_practice/pcmh/

http://www.acponline.org/running_practice/pcmh/

• Patient-Centered Primary Care Collaborative– 300+ organizations; represent 50+ million people– www.pcpcc.net

• Articles in NEJM, JAMA, Health Affairs, Annals of Internal Medicine

• Trade & Lay Press• Legislation• Commercial payer demos• Public payer demos

Growing Interest in the PCMH

A Commitment to Excellence• Patient-centered communication• Shared decision making• Timely access to care • Electronic health records• Use of comparative effectiveness research &

evidence-based guidelines• Measure, improve, measure• Transparency & accountability• Safety

Now, there are some who question the scale of our ambitions, who suggest that our system cannot tolerate too many big plans. Their memories are short, for they have forgotten what this country has already done, what free men and women can achieve when imagination is joined to common purpose and necessity to courage.

What the cynics fail to understand is that the ground has shifted beneath them, that the stale political arguments that have consumed us for so long, no longer apply.

-President Barack Obama, January 20, 2009