- participant will understand/be able to discuss the important trend of PCMH in health care

- participant will understand/be able explore the rationale and supporting evidence for PCMH

- participant will understand/be able understand the impact on patients, providers and payers

Disclosure: – I am a full time Emplyee of IBM I WILL NOT discuss any pharmaceuticals, medical procedures, or devices I have gratefully had my expenses covered to do some of my talks about PCMH by Merck, and Pfizer.

Course Objectives

Who was the Shooter’s Doctor?

Away from Episodes of Care - FFS

Population management !!

Accountability !!

Animated Short: The Amazing Health Care Arms Race

http://www.publicradio.org/columns/marketplace/business-news-briefs/2011/09/oh-the-jobs-youll-create.html

$10,743

$28,530

+166%

Why Innovate Affordability

Costs continue their upward climb…

…with employers still picking up much of the tab…

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

a- Employer Cost - Employee Payroll Contributions - Employee Out of Pocket Expenses

2001 2009 2019

$4,918

+118%

The Elephant in the room

Slide From Dr Martin Sepulveda

If we truly want to understand costs and where they can be reduced without compromising outcomes, we need to aggregate costs around the patient. (need a place to do that – that is PCMH)

The way care is currently organized leads to redundant administrative costs, unnecessary and expensive delays in diagnosis and treatment, and unproductive time for physicians.

A system integrator a place where data is aggregated, understood and held accountable at the level of the individual patient -- THAT IS PCMH. In fact, cost reduction will often be associated with better outcomes.

The Big Idea: How to Solve the Cost Crisis in Health Careby Robert S. Kaplan and Michael E. Porter  Sept 2011 Harvard review

Health care is a business issue, not a benefits issue

Slide From Dr Martin Sepulveda

OUR IBM Patient needs A long-term comprehensive relationship with a Personal Physician empowered

with the right tools and linked to their care team.

The Joint Principles: Patient Centered Medical Home Personal physician - each patient has an ongoing relationship with a personal

physician trained to provide first contact, and 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 arranging care with other qualified professionals

Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges

Quality and safety are hallmarks of the medical home- Evidence-based medicine and clinical decision-support tools guide decision-making; Physicians in the practice accept accountability voluntary engagement in performance measurement and improvementEnhanced access to care is available - systems such as open scheduling, expanded hours, and new communication paths between patients, their personal physician, and practice staff are used

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home- providers and employers work together to achieve payment reform

9

ACO and the Principles of the PCMH

Whether building a community-wide ACO or a solo primary care practice, adherence to guiding PRINCIPLES provides the foundation. Through the PCMH Joint Principles, we (the buyers and providers) have agreed to change our covenant with one another. The Joint Principles of the PCMH have been agreed on by those who deliver comprehensive care (the primary care providers) and their specialist colleagues. For Accountable Care to achieve its goals, successful organizations will NEED a foundation in these principles.

As a buyer, I want to be assured that the foundation - the principles - are in place: a personal relationship with a healer, improved access, care that is coordinated, integrated, and comprehensive.

PCMH is the patients view from the bottom up The kind of care they want: relationship, accessible, coordinated

From the System view it is ACO

Or, like the Euro tunnel you can start on one side building PCMHAnd the other side ACO, but somewhere you have to meet in the middle, where care is delivered- centered on the needsof the Patient.

2010 2011

Adults (18-64)

ER visits -6.6% -9.9%Primary care sensitive ER Visits -7.0% -11.4%Ambulatory care sensitive Hospitalizations (per 1,000) -11.1% -22.0%

BCBS MA 6% decrees cost (NEJM) BCBS MI 2670 physician (BIG study)

36.3% Drop in hospital days32.2% Drop in ER use -9.6% Total cost (Mayo Zero cost increase) 10.5% Inpatient specialty care costs are down18.9% Ancillary costs down 15.0% Outpatient specialty down

Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US, K. Grumbach & P. Grundy, November 16th 2010

Smarter Healthcare

HEALTH INDUSTRY -- WSJWellPoint's New Hire.What Is Watson?

IBM - Mayo Clinic Establish Medical Imaging Research Center

The Cause? Mostly due to unregulated fee-for-service payments and an over reliance on rescue/specialty care. This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the nation's poor performance are not to blame - it is the failure of the deliver system!!”

- Unaccountable Care Organizations* Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010

Dubuque, Iowa

USA 2011NC 2011

Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!

Unaccountable care, lack of organization, DO NOT GO THERE ALONE !!

Be wise when you pay for care, KNOW WHAT YOU BUY!!

Least Expensive Most Expensive Ogden, UT $2,623 Dubuque, IA $2,719 McAllen TX $2,950

Anderson, IN $7,231

Punta Gorda, FL $7,168

Racine, WI $6,528

Providence $6,367

Naples, FL $6,312

Ocean City, NJ $6,128

Cost of Commercial lives

Community Impact on the Triple Aim

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Date

Impr

ovem

ent

DM LDL <100

DM Self Management Goal

CAD LDL < 100

DM LDL <100Commercial

DM LDL <100 Uninsured

Hospital Readmissions

Patient Satisfaction

Ambulatory Care SensitiveConditions Admissions

Linear (Ambulatory CareSensitive ConditionsAdmissions)

Battle Creek, MI

New study -- health care costs are swallowing up almost all income gains that Americans have made over the past decade. Studies like this show us again and again, why it is so necessary that we look for ways to control costs while still providing quality care.

“growth in healthcare spending sharply reduced the disposable income of Americans while increasing the federal deficit,".

In RI $545 out of employee pockets every month vs .

Dr. Arthur Kellerman, Director of RAND Health Sept 2011

“ We don't have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, micro systems, each performing in ways that too often create sub-optimal performance, both for the overall health care infrastructure and for individual patients." George Halvorson, from “Healthcare Reform Now

Coordination -- we do NOT know how to play as a team

“We do kidney transplants and dialysis more often than anyone, but we need to, because patients are not given the kind of coordinated primary care that would prevent chronic complications of renal and heart disease from becoming acute.”

George Halvorson (CEO Kaiser) from “Healthcare Reform Now”

PopulationHealth

System Integrator

PatientExperience

The System Integrator

Creates a partnership across the medical

neighborhood Drives PCMH primary

care redesignOffers a utility for

population health and financial management

Per Capita Cost

Productivity

The Quadruple AimReadiness, Experience of Care, Population Health,

Cost

So simple!So much!

If you scan the world for value based healthcare, you will find a common element: a relationship-based team with a project manager! A comprehensivist that can command and control in an accountable system.

Superb Access to Care

Patient Engagement in Care

Clinical Information Systems

Care Coordination

Team Care

Patient Feedback

Publicly Available Information

Defining the Care Centered on Patient

OPM $39 Billion Book with Accountable CarePatient at the Center

24-7 clinician phone response Provide open scheduling. Provide care management and

coordination by specially-trained team members.

Use an EHR with decision support.

Use CPOE for all orders, test tracking, and follow-up.

Medication reconciliation for every visit.

Prescription drug decision support.

Implement e-prescribing.

Pre-visit planning and after-visit follow-up for care management.

Offer patient self-management support.

Provide a visit summary to the patient following each visit.

Maintain a summary-of-care record for patient transitions.

Email consultations. Telephone consultations. The development of care

plans. Performance outcome measures.

Payment reform requires more than one method, you have dials, adjust

them!!!fee for health”

“fee for outcome”

“fee for process” “fee for belonging

“fee for service”

“fee for satisfaction”

11% CMS Shift in payment away from FFS to other dials.

CMS Bundling!! CMS Advanced Primary Care

Wellpoint PCMH, BCBS Hawaii no new FFS $$

CMS Plus most other buyers

HIT Infrastructure: EHRs and Connectivity

Primary Care Capacity: Patient Centered Medical Home

Operational Care Coordination: Embedded RN Coordinator and Health Plan Care Coordination $

Value/ Outcome Measurement: Reporting of Quality, Utilization and Patient Satisfaction Measures

Value-Based Purchasing: Reimbursement Tied to Performance on Value (quality, appropriate utilization and patient satisfaction)

Achieve Supportive Base for ACOs and Bundled Payments with Outcome Measurement and Health Plan Involvement

Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement

Public Health Prevention

Specialists

PCMH in Action Vermont “Blueprint” model

Community Care TeamNurse Coordinator

Social WorkersDieticians

Community Health WorkersCare Coordinators

Public Health Prevention HEALTH WELLNESS

Hospitals

PCMH

PCMH

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

A Coordinated Health System

1 2 3 4 5$300,000,000

$320,000,000

$340,000,000

$360,000,000

$380,000,000

$400,000,000

$420,000,000

IMPACT OF MEDICAL HOME SAVINGS ACROSS TOTAL POPULATION

YEARS

INC

REM

ENTA

L C

OST

PE

R Y

EAR

Vermont Financial Impact

Avoidable emergency room visits continue downward trend, seven percent better than market. Following evidence-based medicine continues to improve, six percentage points better than market. Medical cost trend is more than seven percentage points better than market.

$9 PMPM cost savings. Diabetes is better controlled, will improve long-term health and lower medical costs.

And Today in NC PCMH practices

The NC Plan

You Developed a better healthcare system for RI starting with Public Private payers Private payers Joined

Strong Primary care is foundational to a high performing healthcare system

Additional resources needed to help primary care manage populations

Learned timely data is essential to success Learned must build better local healthcare

systems (public-private partnership) Physician leadership is critical Improve the quality of the care provided and

cost will come down A risk model is not essential to success- shared

accountability is!

Patientis the center

of theMedical Home

Population Health

Patient-Centered

Care

Refocused Medical TrainingPatient &

Physician Feedback

Advanced IT Systems

Access to Care

Team-Based Healthcare

Delivery

Decision Support Tools

Model adapted from theNNMC Medical Home

Enhancing Health and the Patient Experience

Medical Home Model

Care that is Accountable

PATIENT CENTERED MEDICAL HOME: VHA Patient Aligned Care Team

Replaces episodic care based on illness and patient complaints with coordinated care and a

long term healing relationship

THE PRIMARY CARE TEAM

Reinventing Medicaid findings are Outstanding Oklahoma's patient-centered medical home initiative

has reduced Medicaid costs $29 per patient per year from 2008 to 2010. Moreover, use of evidence-based primary care, including screening for breast and cervical cancer, increased.

The Colorado initiative expanded access to care. Before the initiative, only 20 percent of pediatricians in the state accepted Medicaid; as of 2010, 96 percent and did and at a lower cost to the state.

Vermont, inpatient care use and related per-person per-month costs decreased 21 percent and 22 percent, respectively, from July 2008 to October 2010. ER use and related per-person per-month costs decreased 31 percent and 36 percent, respectively. 

Patient Centered Medical Home in Washington in State Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average.

Citation -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34.

The Bottom Line in Medicaid PCMH starting to show an impact in access to care, quality, and cost control.

Patients love to see meaningful information about themselves and it take IT tools to

If you give patients educational materials with their name on it and with their data analyzed in it, they will read it, pour over it and discuss it with you.

If you tear off a generic sheet and give it to them, it often goes in the waste basket. If you give patients an analysis of their health risk AND if you include a “what if” scenario, i.e., what will their health risk be if they make a change; you can prove to them,

“if you the healer make a change, it will make a difference to your patient.”

PCMH is non-political – the right POV for delivery transformation

“We never abandoned advocating newModels of care. We’ve long pushed folksto realize that Delivery reform is the key.”The patient-centered medical home iscore.

“We included the attached chapter on PCMH in our book. and have a new publication on ACOs coming out in January.”

Physician Practice Size

(# of patients) Level 1+ Level 2+ Level 3+< 10,000 $4.68 $5.34 $6.01

10,000 - 20,000 $3.90 $4.45 $5.01> 20,000 $3.51 $4.01 $4.51

PMPM Payment: Commercial Population

Level of PCMH Recognition

43

Tier Major Condition Groups Minutes of Work PMPM PMPM Payment

0 None N/ A N/ A 1 3-Jan 15 $10.14 2 6-Apr 30 $20.27 3 9-Jul 60 $40.54 4 10+ 90 $60.81

44

Payment Model Component PMPM PaymentCare management payments Up to $2.50 PMPMPay-for-performance payments Up to $2.50 PMPM

Payment Model Component PMPM PaymentPractice transformation cost payments (year 1 only)

$1.67 PMPM

Performance bonus (beginning in year 2) Up to $2.38 PMPM (value based on performance)Risk-adjustment Up to $1.67 PMPM (only for practices with above average

patient panel risk profiles; amount varies by practice)

Payment Model Component PMPM PaymentPractice support payments $1.50 PMPM

$0.60 PMPM (ages 0-17)$1.50 PMPM (ages 18-64)$5.00 PMPM (ages 65-74)$7.00 PMPM (ages 75+)

Shared savings Value based on performance

Care management payments

Trends, Reactions, Assumptions in the U.S. Provider consolidation is accelerating Medical Homes are in demand ACO based thinking is evolving and re-

defining partnerships Competitors as well as payers/providers

are merging New places and types of care are on the

increase Quality is required for both processes and

care Consumer health will be the mantra,

engagement is key The “End Game” is not clear but the

industry is engaged