The Patient-Centered Medical Home Will It Make A Difference?

1. The Patient-Centered Medical HomeWill It Make A Difference? 2009 Population Health ColloquiumDepartment of Health Policy Thomas Jefferson University March 2009 Michael S. Barr, MD, MBA, FACP Vice President, Practice Advocacy & Improvement Division of Governmental Affairs & Public Policy 202-261-4531 mbarr@acponline.org

2. 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

3. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year. President Barack Obama Text from a speech he delivered to a joint session of Congress , February 24, 2009

4. Workforce Economy Payment Policy Education Universal Health Coverage HIT Infrastructure

5. State of the Nation’s Health Care uninsured employed Projections for 2019 45 →54 million 80% • 16 million • 18% ($2.6T) →20% $8,300 underinsured 2017 per capita in 2008 To $13,000 in 2017

6. Comparing ‘97-98 to ‘02-03; 75,000 – 100,000 avoidable deaths Amenable Mortality: 15th to 19th <50% with access to rapid appointment 75% difficulty with after hours care 18% readmission rate within 30 days M’care: High variability The Commonwealth Fund: Why Not the Best; 2008 Nolte & McKee: Measuring the Health of Nations: Updating an Earlier Analysis. Health Affairs, 27:1 (2008)

7. Escalating Costs, Decreasing Coverage Healthcare costs per U.S. auto vs. Germany & Japan Untreated illness & work absence; uninsured $130 billion $1500 vs. $450 vs. $150 70% to 60% 98% vs. 23% Decreasing employer-sponsored coverage (‘70s to ‘06) Growth in premiums vs. inflation (’00 – ’07)

8. Cost v Quality

9. 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.

10. 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

11. “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

12. Team-based care Links to Comm. HIT Self-Mgt Evidence System Design

13. 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 1154-1164 Lipner RS, Bylsma WH, Arnold GK, Fortna GS, Tooker J, Cassel CK: Ann Intern Med. 2006 Jan 3;144(1):29-36

14. Projected shortage of 35 – 45,000 generalists for adults 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

15. Imbalanced System

16. 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

17. “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

18. (Chronic) Care Model Community Health System Health Care Organization Resources and Policies Self-Management Support DeliverySystem Design Decision Support ClinicalInformationSystems Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998: 1:2-4.

19. The Joint Principles of the PCMH Team-based care: NP/PA RN/LPN Medical Assistant Office Staff Care Coordinator Nutritionist/Educator Pharmacist Behavioral Health Case Manager Social Worker Community resources DM companies Others… • 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

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

21. Important Questions • How do you recognize a PCMH? • How is care different? • Will physicians & their teams want to build the medical home? • How do we prepare physicians, students & residents?

22. NCQA: Physician Practice Connections/PCMH • Access & Communication • Patient Tracking & Registry Functions • Care Management • Patient Self-Management Support • Electronic Prescribing • Test Tracking • Referral Tracking • Performance Reporting & Improvement • Advanced Electronic Communication Joint Principles of the Patient-Centered Medical Home

23. PPC-PCMH ≠ PCMH Quality Measures ≠ Physician Consumer Reports ≠ Car

24. The Process • Gap analysis – take the “pre-test.” • Analyze results. • Implement changes necessary • Retake the “pre-test.” • If ready submit application to NCQA. Cost: Readiness assessment = $80 NCQA 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

25. Stepping Up to Excellence Level 3: 75+ Points Level 2: 50-74 Points Level 1: 25-49 Points Increasing Complexity of Services

26. 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 Level 3: 75+ Points Level 2: 50-74 Points Level 1: 25-49 Points

27. 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

28. 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

29. 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

30. 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

31. Specialty Care Connections X • 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)

32. 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

33. Blend of Modified Fee-for-Service and Bundled Per-Patient Payment Perceived as Most Effective for Efficient Health Care System “How effective do you think each of the following payment approaches would be in facilitating a more efficient health care system?” 62 51 23 K. Stremikis, S. Guterman, and K. Davis, Health Care Opinion Leaders' Views on Payment System Reform, The Commonwealth Fund, November 2008

34. Payment Models for the PCMH • Prospective Payment: • -Structure • -Care coordination & • -Non face-to-face care • -Adjusted for complexity of • population & services • Enhanced RBRVS • Fee for Service • Performance • Fee For Service • Enhanced RBRVS • Add-on codes • Performance • Global Payment • Procedures • Performance

35. Medicare Medical Home Demo • Eight states • 800 practices (approximately 50/location) • Eligibility requirements • Practice application and recognition process • Beneficiary agreements • Time line

36. MMHD Care Management Fee • 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

37. Other PCMH Demos http://www.acponline.org/running_practice/pcmh/

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

39. Growing Interest in the 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

40. 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

42. 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