Amy Gibson, MS, RN Chief Operating Officer, PCPCC

1. Payment Reform and the Medical Home Amy Gibson, MS, RN Chief Operating Officer, PCPCC

2. Transformation requires…

3. Primary care of the future . . . Data Warehousing & Mining Patient and Provider Portals Family Supports Specialty Care Pharmacy Home Health • Patient/Family • Medical Home • Team-based • Coordinated • Comprehensive • Accessible Long Term Care Acute Care Community Health Schools Palliative Care Health Plans Data Registries & Decision Support EHR Connectivity & Interoperability

4. A Change in Paradigm

5. PCMH and Accountable Care: Two Sides of the Same Coin Accountable Care PCMH Hospitals PCMH Shared Services Care Coordination Care Managers PCMH Specialists PCMH Public Health PCMH Health IT Infrastructure

7. Private Sector Payment Reform • Only 11 percent of payments create incentives for providers to meet quality standards, improve quality, or reduce waste. • 57% are “at -risk” arrangements -- bundled payment, capitation (as well as partial-capitation or condition-specific capitation), and shared-risk payment arrangements. • 35% of non-FFS payments include quality is a factor

8. Transparency: Health Plans 98% of plans offer/support a cost calculator 77% of hospital choice tools have integrated cost calculators 77% of physician choice tools have integrated cost calculators 86% of plans report benefit design details (copays, cost sharing, and coverage exceptions) Only 2% of total enrollment use these tools Source: National Scorecard on Payment Reform, 2013

9. What does the data tell us about the PCMH?

10. New PCPCC Publication • Provides nationwide results from 34 recent peer reviewed and industry reports • health care costs • acute care services • quality of care • Provides additional information on 23 case studies outlining specific features of a PCMH

13. Overview of Commercial Health Plan Medical Home Activity AK WA ME MT ND VT NH MN OR NY MA WI CT ID SD RI MI WY NJ PA IA NE OH DE NV IL IN MD WV UT VA CO MO KS CA KY NC TN OK SC AR AZ NM GA AL MS LA TX HI FL Multipayer pilot discussions/activity (30 states) Identified pilot activity (49 states) No identified pilot activity (1 state) Source: Patient Centered Primary Care Collaborative, updated Jan 2012.

14. Examples of Industry Investment

15. Medicaid multipayer activity/involvement (18 states) States making payments for PCMH (27 states) Significant activity for Medicaid/CHIP PCMH advancement (15 states) Overview of Medicaid Medical Home Activity 42 State Medicaid/CHIP Programs Planning/Implementing PCMH27 Making Medical Home Payments, 18 Involved in Multipayer Pilots AK WA ME ND VT MT NH MN OR NY MA WI CT ID RI SD MI WY NJ PA IA OH NE DE IN NV IL MD WV UT VA CO MO KS CA KY NC TN OK SC AR AZ NM GA AL MS HI LA TX FL Source: National Academy for State Health Policy State Scan, October 2012, http://www.nashp.org/med-home-map.

16. Overview of CMS Innovation Center PCMH Initiatives

17. Role of The Collaborative (PCPCC) • Lead from the front • Challenge the status quo • Drive the marketplace • Disseminate timely information • Provide networking & educational opportunities

18. Why the Medical Home Works: A Framework Patient-Centered Feature Definition Sample Strategies Potential Impacts Patients are more likely to seek the right care, in the right place, and at the right time • Dedicated staff help patients navigate system and create care plans • Focus on strong, trusting relationships with physicians & care team, open communication about decisions and health status, compassionate/culturally sensitive care Supports patients and families to manage & organize their care and participate as fully informed partners in health system transformation at the practice, community, &policy levels Comprehensive A team of care providers is wholly accountable for patient’s physical and mental health care needs – includes prevention and wellness, acute care, chronic care Patients are less likely to seek care from the emergency room or hospital, and delay or leave conditions untreated • Care team focuses on ‘whole person’ and population health • Primary care could co-locate with behavioral, oral, vision, OB/GYN, pharmacy, etc • Special attention paid to chronic disease and complex patients Coordinated Ensures care is organized across all elements of broader health care system, including specialty care, hospitals, home health care, community services & supports, & public health Providers are less likely to order duplicate tests, labs, or procedures • Care is documented and communicated effectively across providers and institutions, including patients, primary care, specialists, hospitals, home health, etc. • Communication and connectedness is enhanced by health information technology Better management of chronic diseases and other illness improves health outcomes Accessible Delivers consumer-friendly services with shorter wait-times, extended hours, 24/7 electronic or telephone access, and strong communication through health IT innovations • Implement efficient appointment systems to offer same-day or 24/7 access to care team • Use of e-communications and telemedicine to provide alternatives for face-to-face visits and allow for after hours care Focus on wellness and prevention reduces incidence / severity of chronic disease and illness Committed to quality and safety Demonstrates commitment to quality improvement through use of health IT and other tools to ensure patients and families make informed decisions • EHRs, clinical decision support, medication management to improve treatment & diagnosis. • Establish quality improvement goals; use data to monitor & report about patient populations and outcomes Lower use of ER & avoidable hospital, tests procedures & appropriate use of medicine = $ savings

19. Contact: Amy Gibson, MS, RN Chief Operating Officer agibson@pcpcc.net www.pcpcc.net