L. Gregory Pawlson MD, MPH, FACP

1. Patient Centered Medical Home Knowing when we see one L. Gregory Pawlson MD, MPH, FACP

2. Patient-Centered Medical Home:The Concept

3. The Patient-Centered Medical Home DefinedACP, AAFP, AAP, AOA joint statement – April 2007 • Personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, 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 taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care. • Care is coordinated and/or integratedacross all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

4. Brief History of the evolution of the Medical Home • 1980-present • The American Academy of Pediatrics defined the medical home concepts related to caring for children with special needs • 2000-present • AAFP and ACP developed and extended the concept to include care for all patients with chronic illness (ACP-Advanced Medical Home; AAFP-Personal Medical Home) and patient centeredness • 2006-07 • AAFP, AAP, ACP and AOA (with input from NCQA) develop common definition of “patient-centered medical home” (PCMH) and link PCMH to reform of payment for physicians.

5. PCMH-a sharp end (practice) translation • Closely linked to conceptual frameworks for transforming health care from acute and physician-centered to prevention and chronic care and patient-centered • Chronic care model • IOM Crossing the Chasm report (systemness) • Emergence of disease and care management, health promotion-disease prevention to address defects in care

6. Wagner Model for Effective Prevention and Chronic Illness Care

7. Linkage to all levels of health care Old: Acute ModelNew: Prevention-Chronic Patient: passive Clinician: delivers visits and procedures Microenvironment: supports for visits and procedures Organization (group): billing and scheduling Environment: medical necessity benefits and pay for procedures Patient: engaged in own care Clinician: provides ongoing planned care Microenvironment: systems for care management over time Organization: systems support and feedback Environment: value-based benefits and payment

8. Medical home as practice connection for other areas Patient Empowerment Disease-Care Care Management PATIENT-CENTERED MEDICAL HOME Value-based Reimbursement and Benefit Design Evidence-Based Primary Care as Brake on Overuse-Misuse

9. Linkage of PCMH to Reimbursement:One Model Payment per Patient for Qualified Medical Homes (services not normally reimbursed) Pay for Performance Quality, Resource Use and Patient Experience Fee Schedule for Visits/Procedures

10. A lot of potential-some key concerns Issue It won’t solve cost or quality issues It is just a way to try to preserve small practices It will create a barrier between specialty care and patients It is more doctor-centered than patient-centered Considerations Demonstrations are needed to show impact PCMH qualification provides a road map for practices for what leads to quality care; small practices may or may not be able to adapt Focus is on coordination and information exchange; not gate keeping; sub-specialists who take care of patients over time can serve as PCMH’s A major role for NCQA is to focus PCMH on being patient-centered

11. Sounds good-but how do we know one when we see it??

12. Two roads converged • Over the past seven years, NCQA developed, tested and implemented a web based tool to measure how well practices implemented chronic care model • Physician Practice Connection or PPC used in a NCQA recognition program also called the PPC • Over past three years, NCQA has been working on defining and measuring “Patient Centeredness” • ACP, AAFP, AAP and AOA noted convergence of concepts between chronic care model and medical home and need for stronger tie to patient centeredness Result: Convergence of PPC Recognition tool and program and PCMH “Qualification”

13. A bit about the PPC tool and Recognition Program

14. Need for tool to measure systems-CCM • Response to IOM reports • To Err is Human and Crossing the Quality Chasm both provide evidence on critical importance of systems • Change from “blaming” individual clinicians for mistakes and shortfalls to improving systems so clinicians can succeed • Raise awareness of physicians of importance of systems in enhancing quality • Research Translation: Link health services research on systems to clinical practice

15. Steps in Development of PPC • Document evidence base linking specific system to clinical performance • Convene expert panel to review evidence and suggest standards/measures • Conduct analysis of practice defects using six sigma process (with GE in Bridges to Excellence project) • Create standards (aka structural measures) • Test tool for reliability and for validity by showing linkage to clinical process and outcome measures and to patient experience of care • Implement tool in NCQA recognition program-linked to payment for “systemness”

16. Conclusions from Initial testing of PPC tool • Assessment of systems-CCM is feasible though challenging • Finding from testing PPC strong indicate that review of documentation or on-site audit needed to verify some systems • Overall score on PPC correlates with better quality on clinical measures (diabetes etc) but NOT on patient experience of care • Educating physicians and practice staff about systems is high priority • More research on relationship of systems to quality and patient experiences is needed

17. Overall NCQA PPC Recognition Program • Recognition is based on: • Responses in Web-based Survey Tool • Supporting documentation attached to Survey Tool • Each element specifies type of documentation • Reports • Reports from EHR, registry, practice management & billing systems • Documented processes • Policies and procedures, protocols • Records or files • Medical record review – documented in NCQA’s workbook

18. PPC Recognition (current-Sept 2007) • Recognized practice sites – 273 • Physicians practicing at recognized sites – 2,137 • Characteristics of recognized practices • Practice Size • Median number of physicians – 6 • Number of solo practitioner sites - 27 • Practice Specialties • 57% - Primary Care • 19% - Pediatrics • 9% - Cardiology • 2% - OB-GYN • 13% - Multi-specialty

19. Current PPC Initiatives • BCBS NC • CareFirst (BCBS plan-DC metropolitan area) • BTE pilot markets – OH-KY, NY, New England • Silicon Valley – Health Information Technology • MVP Health Plan (New York) • CHPHP (Health Plan, New York) Most successful projects linked to pay for performance

20. BTE Use of Recognition Programs

21. Linking the PPC to the PCMH

22. Content of PPC-PCMH-Wagner CCM Delivery System Design Patient Centered Medical Home ClinicalInformationSystems P P C DecisionSupport Self-ManagementSupport Community Support Wagner CCM What’s Included?(Infrastructure) How Much Used?(Extent) What Functions?(Implementation) Evidenceand Scoring(Verification)

23. Work on tool to identify PCMH’s • AAFP, AAP, ACP AOA reviewed, refined and then endorsed modification of PPC (PCC-PCMH) as desirable tool for “qualifying” medical homes • CMS medical home demonstration project included in TRSCA legislation • NCQA with Mathmatica and Center for Health Systems Strategies awarded contract for assisting in design of MH demo

24. PPC-PCMH Content and Scoring **Must Pass Elements

25. Implementing and Evaluating PCMH-Proposed Model Office Systems Decision Support Information Technology Delivery System Design Patient Support Individual Clinician-Staff Attitudes, behaviors and proficiencies Educational Support Inputs Output Patient Centered Coordinated Care NCQA Qualification as PCMH (PPC-PCMH) Boards Evaluation Programs Tools Patient Experience of Care Measures (CG-CAHPS) Clinical Process & Outcome Measures (underuse, misuse, resource use) (NQF endorsed)

26. Recent Developments • 12/06–CMS medical home demonstration project included in TRSCA legislation • NCQA, in collaboration with Mathematica Policy Research and Center for Health System Change, have received a contract from CMS for assisting CMS in planning PCMH demo • 2007–Increasing interest from health plans, employers and consumers • Creation of Patient-Centered Primary Care Collaborative by ERISA Employers to advocate for PCMH projects • Interest from private payers • PCP shortage • Controlling costs • More than 50 active “leads”- with several close to implementation Major concern: Proliferation of Approaches Confusion of Practices-Blurring of Meaning

27. Moving Forward • Critical need to do meaningful demonstration projects USING COMMON METRICS to evaluate whether: • PCMH can be successfully implemented on large scale • Linking PCMH to revised reimbursement accelerates adoption and use of systems in clinical practice • Implementation of PCMH leads to • higher quality of clinical care • enhanced patient experiences of care • Lower (or at least more rational) resource use/cost • In addition, ACP, AAFP, AAP and AOA want to show that PCMH leads to renewed interested in primary care

28. Questions? Contact: Pawlson@ncqa.org

29. Appendix Slides: Development and content of PPC-PCMH

30. Goals of PPC Measure Development • Develop measures for evaluating systems use and effectiveness in prevention, chronic illness and if possible patient safety • Create measures that are “actionable” at level of physician office practice • Validate measures by relating them to existing disease-specific performance measures and patient perceptions of care

31. Study of Validity: Accuracy of Self-Report • Test accuracy of self-reports of practice systems using on site audit as “gold” standard • Varies by domain, by staff position, and by medical group • The predictive value of a positive report of a practice system is generally high. • Overall agreement with the on-site audit ranges from high (clinical information systems, quality improvement) to low (care management, population management). • Several factors may explain lack of agreement • Variable implementation of systems across sites and conditions • Variations in staff members’ exposure to systems • Lack of familiarity with systems Conclusion: Need Audit or Documentation

32. Studies of Correlation of PPC with Clinical Performance and Patient Experience • Preliminary results from Minnesota (California and Massachusetts in prep) • Overall PPC score, and sub-scores have positive correlation with higher clinical performance on most measures (diabetes, CV, asthma) • Overall PPC score does NOT appear to correlate with patient experiences of care • Presence or absence of EMR per se, correlates ONLY WEAKLY with clinical measures • However, practices with fully functional EMR’s achieve highest scores on PPC

33. Using the PPC in Practice

34. Use of PPC, DPRP and HRSP in BTE • Employers want to improve the quality of care their employees receive, and they want to increase the value of their health care spend: • BTE Programs have actuarially validated savings and BTE recognized physicians deliver higher quality care • Employers want operational simplicity: • BTE is now administered by licensed or certified administrators, mainly health plans • Physicians want to be measured by reliable and valid measures and independent third party organizations: • BTE’s Provider Performance Assessment Organizations and measurement systems are accepted by the physicians • Physicians need to know up front what performance is expected of them and what they will get for achieving it: • BTE’s Operations give physicians a market-wide view

35. PPC Scoring • 9 standards = 100 points • Three levels of recognition, based on total points achieved • Recognized—Level 1 • 25 – 49 points • Recognized—Level 2 • 50 – 74 points • Recognized—Level 3 • 75 – 100 points • Not Recognized(or reported) • 0 – 24 points