Population Health and the Patient-Centered Medical Home

1. Population Health and the Patient-Centered Medical Home Tricia Barrett, Vice President, Product Design and Support

2. NCQA: What we do, and why To improve the quality of health care OUR MISSION OUR METHOD • Measurement • Transparency • Accountability • We can’t improve what we don’t measure • We show how we measure so measurement will be accepted • Once we measure, we can expect and track progress

4. GoalHigh value health care • 20%OF PEOPLE Measurement, transparency & accountability move health care toward greater value generate • 80% OF COSTS Healthy/low risk Value • At risk High risk • Early symptoms • Active disease Health Care Spending

5. Population Health Management Adapted from Population Health Alliance’s Model

6. Aligning Accountability for PHM

7. A comprehensive PHM Strategy includes PCMH Person-centered care should be supported at all levels Delivery System Community Including PCMHs and other providers engaging in direct patient care Connect patients to available resources to resolve social determinants of health issues Payers Including public and private payers or health plans that support the delivery system and community

8. Health Plan Accreditation: PHM Standards Focus on: Delivery System Supports PHM 1: PHM Strategy PHM 3A: Practitioner or Provider Support Requires organizations to support their practitioners or providers through a choice of methods including: Data sharing and PCMH transformation support. PHM 2: Population Identification PHM 3: Delivery System Supports PHM 3B: Value-Based Payment Arrangements Requires organizations to describe their VBP arrangements including provider types in VBP arrangements. PHM 4: Wellness and Prevention PHM 5: Complex Case Management PHM 6: PHM Impact

9. Patient-Centered Care Overview

10. Recognition programs Identifies providers and practices delivering superior care >83,000 clinicians at >14,000 practice sites

11. Presence in Texas Most widely-used measure of advanced primary care • 3,787 clinicians • 892 practices • 85 FQHCs • 18.8% of all PCPs

12. Patient-Centered Care Lowering cost of care in Medicare $265 62% Lower average annual total Medicare spend per beneficiary for patients in NCQA recognized practices of total lower spending per NCQA PCMH Medicare beneficiary was attributable to reductions in payments to acute care hospitals Van Hasselt, M., McCall, N., Keyes, V., Wensky, S. G., & Smith, K. W. (2014). Total Cost of Care Lower among Medicare Fee-for-Service Beneficiaries Receiving Care from Patient-Centered Medical Homes. Health Services Research.

13. Patient-Centered Care Lowering total cost of care NCQA PCMHs lower costs through better chronic care management, preventive medicine, and coordination across care settings and transitions. $482.40 $5m Lower per capita spending for patients in NCQA PCMH1 Annual savings for 100,000 patients in NCQA PCMH pilot2 1 -Department of Vermont Health Access / Vermont Blueprint for Health 2 - Rosenthal MB, et al. (2016). A Difference-in-Difference Analysis of Changes in Quality, Utilization and Cost Following the Colorado Multi-Payer Patient-Centered Medical Home Pilot. Journal of General Internal Medicine.

14. Patient-Centered Care Improving quality, reducing costly utilization NCQA PCMH patients have high-quality disease management, better medication adherence, an emphasis on self-care and community support, and thus experience fewer acute incidents. 39% 5% Higher rate of self-care planning & community support3 Better performance on a 5-measure diabetes care bundle3 22% 6.3% Lower risk-adjusted use of ED services5 Higher rate of optimal medication adherence4 • 3 - Reiss-Brennan B, Brunisholz KD, Dredge C, et al. (2016). Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost. JAMA. • 4 - Lauffenburger JC, et al. (2017). Association Between Patient-Centered Medical Homes and Adherence to Chronic Disease Medications. Annals of Internal Medicine.. • 5 - DeVries, A, Chia-Hsuan W, Sridhar G, Hummel J, Breidbart S., Barron J. (2012) Impact of Medical Homes on Quality Healthcare Utilization and Costs. AJMC.

15. Population Health Management Transformed in the PCMH Current View 30 Patients Per Day 14 have Chronic Conditions Unknown Health Risks Visits Too Short for Coaching New Population View 2500 Patient Population 900 have Chronic Conditions 1100-1250 have Mod-High Health Risk Care Teams Leveraged by HIT Value-Based/Continuous Volume-Based/Episodic

16. PCMH Standards Concepts Team-Based Care and Practice Organization (TC) Knowing and Managing Your Patients (KM) Patient-Centered Access and Continuity (AC) Care Management and Support (CM) Care Coordination and Care Transitions (CC) Performance Measurement & Quality Improvement (QI)

17. PCMH Concepts Supporting provider risk & accountability Team-Based Care & Practice Organization Knowing & Managing Patients Patient-Centered Access & Continuity • Care teams ensure patients get the care & support they need • Prevent costly avoidable complications • Collect data to identify patient risks, care needs • Leverage social & community resources to improve outcomes • Evidence-based care to reduce overuse • Promote continuity of care to manage chronic conditions • Ensure access to practice & clinical advice • Prevent costly specialist, ED visits

18. PCMH Concepts Supporting provider risk & accountability Care Management & Support Care Coordination & Care Transitions Performance Measurement & Quality Improvement • Track referrals, lab results to reduce duplication • Coordinate with specialists to identify gaps in care • Obtain summaries & manage acute care transitions, follow ups • Manage high risk patients to reduce costly acute incidents • Person-centered care planning to support self-care Collect & analyze performance data to drive improvement Increase prevention & care management through measurement Actively track results to identify & improve on gaps in quality

19. PCMH enables structure to support PHM …and vice versa

20. Direction is clear USA’s Largest Payer, Like Most Others, Now Committed to Paying for Value • Incentives for value • Discourages inefficientfee-for-service • Promote move to value- & population-based payment • Puts more teeth into quality, cost and utilization measurement • Patient-centered care, PCMHs & PCSPs, are the key to success!

21. NEXT STEPS IN POPULATION HEALTH Continued Focus in the Medical Neighborhood in PCMH and PCSP program requirements Population Health Management Accreditation for PHM Organizations and Provider Organizations Encourages alignment Between the health plan and the delivery system

22. Tricia Barrett • barrett@ncqa.org • For more information on PCMH: http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh • To access the PCMH Evidence Report: http://www.ncqa.org/programs/recognition/practices/pcmh-evidence • For any other questions: https://my.ncqa.org/