Medicaid PCMH

1. Medicaid PCMH Lonnie Robinson, MD, FAAFP Arkansas Academy of Family Physicians Regional Family Medicine Beth Milligan, MD, FAAFP Arkansas Foundation for Medical Care Saline Med-Peds Sheena Olson, JD Assistant Director of Medical Services Arkansas Medicaid

2. Overview • PCMH Background/Context • My PCMH Experience • Medicaid PCMH Requirements • Questions and Answers

3. Alternative Titles • Practical PCMH • DIY PCMH • “PCMH for the workin’ doc” • PCMH: Yeah, right! • PCMH: All theory, no (green) substance? • PCMH: Why are we still talking about this? • PCMH: Why it (still) matters

4. Why before How “He who has a why to live for can bear almost any how.” -Nietzche

5. Why PCMH? • Increasing healthcare costs, percentage of GDP • Poorer health outcomes • Patient lifestyle/low engagement in care • Increasing understanding of the value and ROI from primary care • Failure of FFS model (incentivize disease and intervention over prevention and wellness) • Burden of chronic disease • Momentum from big business…

6. Frustration with poor health -- both employers and employees Personal Health Costs Medical Care Pharmaceutical costs Workers’ Compensation Costs 30% Iceberg of Additional Costs to Employers from Poor Health ProductivityCosts 70% Absenteeism Short-term Disability Long-term Disability Presenteeism Overtime Turnover Temporary Staffing Administrative Costs Replacement Training Off-Site Travel for Care Customer Dissatisfaction Variable Product Quality Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152

7. Why PCMH is important for Family Physicians… • Primary care is receiving a LOT of attention in the health care debate • The era of value-based purchasing means there is a new normal arriving • Fee For Service with no accountability is becoming a thing of the past • Change is coming…change or die! • You don’t want to be the slowest antelope • Most Important: it’s the right thing for our patients!

8. Leadership is needed: The Four Camps of Health Organizations Greater Resiliency Lower Lower Greater Understanding

9. Arkansas is leading! Medicaid PCMH Comprehensive Primary Care Initiative Private Payer Projects (forthcoming)

10. Leadership: “Pissing people off ata rate they can absorb…” Marci Nielsen, PhD, MPH CEO, Patient Centered Primary Care Collaborative

11. “If you always do what you always did, you will always get what you always got.” - Albert Einstein

12. Cowboys vs. Pit Crews AtulGawande, MD, MPH • Harvard Professor, Surgeon, Writer • Public Health Researcher • Speech at Harvard, 2011 • “We train, hire and pay physicians to be cowboys…” • The Lone Ranger • “…Instead, we should be training them to be like Pit Crews.” • Focused on teamwork, disciplined, data-driven, standardized • Also credited with “Triple Aim…Plus One”

13. Quadruple Aim / Triple Aim + One

14. PCMH “Need to Knows” Dr. Jonathan Sugarman, Qualis Health AAFP Annual Leadership Focus May 2, 2014

15. PCMH “Need to Knows…” • Despite the short half-life of many health policy innovations (buzz words), medical homes continue to capture the attention of key stakeholders • PCMH’s are living up to expectations* • The payment landscape is changing in a positive way *Depending on whom you ask!

16. The Hype Cycle: Waves of Irrational Exuberance Medical Homes? Expectations Real Progress Plateau of Productivity Slope of Enlightenment Trough of Disillusionment Peak of Inflated Expectations Trigger Time Adapted from Gartner Research

17. Are PCMH’s living up to expectations?It depends on whom you ask…

18. Feb. 25, 2014 "There are folks who believe the medical home is a proven intervention that doesn't even need to be tested or refined. Our findings will hopefully change those views," said Mark W. Friedberg, a researcher at RAND Corp. and lead author of the study, published Tuesday in the Journal of the American Medical Association. (Friedberg et al. JAMA. 2014;311(8):815-825).

19. Response to JAMA article • “A practice could be a PCMH without achieving certification and achieving certification does not necessarily mean that a practice is functioning as a PCMH” • The study group received financial incentives for NCQA certification but not for controlling costs • No after hours or extended hours • No targeting of high risk populations • Missing key features: patient-centeredness, team-based care, and behavioral health integration • Authors response ignored results from bulk of previous data

20. States with Medicaid/CHIP Medical Home Activity Since 2006

21. States with an Active Role in a Multi-Payer Medical Home Initiative

22. Medicaid PCMH • Minimum 300 ConnectCare Medicaid Patients • Beginners welcome…No certification required • Practice Support: Qualis, AFMC • Must meet milestones, achieve metrics • Reimbursement via Alternative Payment Model: • PMPM payments (average: $4) • Continued FFS for encounters as previously • *Opportunity to participate in “shared savings” *Must meet eligibility requirements

23. Regional Family Medicine • Formerly Kerr Medical Clinic • 8 physicians, 3 APNs, 50+ employees, • 2 locations • Inpatient / Outpatient / Obstetrics • Lab / Radiology • 27,000+ active patient charts • EHR: e-MD’s (April 2012) • MU/PQRS attested

24. RFM PCMH Journey • Launched e-MD’s April 2012 • Applied CPCi June 30, 2012 • Attested Stage I MU mid-July 2012 • Formed PCMH Transformation Team • Enrolled Medicaid PCMH • January: first PMPM payment! • Pooled for shared savings with pediatric practice in Jonesboro

25. RFM: Existing PCMH Characteristics • Physician-based teams with “care coordinator” • 24/7 live voice access • Extended office hours: Saturday • ER, hospitalization avoidance • Dr. Robert Kerr: “The Answer is ‘Yes’…”

26. RFM Changes • Initial: • Identification of High Risk Patients • “Care Coordinator” • Patient notification (text) • Care Plan (“Well-written SOAP Note”) • Documentationof same day apptrequests • Upcoming/Ongoing: • Formal Quality Improvement Process • Patient Portal • SHARE • Formal Policy & Procedures • Optimizing EMR to perform key PCMH functions

27. PCMH Challenges • Organizational structure, inertia, momentum • Culture change (team-based care mind set) • Documentation • Overcoming Lingo/Jargon Gap • Leveraging technology • Doing all of the above in a traditionally high-volume practice (“Just one more thing, Doc…”) • Payer Issues (comprehensive participation, data mistrust)

28. Bottom Line • PCMH ain’t going away • FFS as sole means of compensation is (rapidly?) becoming a thing of the past • Value-Based Purchasing is becoming the new normal • Medicaid PCMH: great way to start process • PMPM’s to assist in beginning processes • Continued FFS for episodic/acute care • Opportunity for shared savings • Practice support from AFMC, Qualis • Prepares your practice for other opportunities, aligns with other incentives (MU, PQRS, etc.)

30. Medicaid PCMH Requirements Dr. Beth Milligan, MD, FAAFP Arkansas Foundation for Medical Care Saline Med-Peds

31. Patient Centered Medical HomeBuilding a healthier future for all Arkansans Health Care Payment Improvement Initiative

32. Reinvigorate Primary Care

33. Purpose Our aim is to create a Sustainable patient-centered health systemthrough an evidence-based approach to care delivery Population-based care delivery system Episode-based care delivery Triple Aim Accountability Improve the health of the population Enhance patient experience of care Reduce or control cost of care

34. Process Commitment to transform the system State launches PCMH Providers enroll Support for providers Framework for change Financial support for care coordination Technical expertise and vendor support Transparency into performance Incentives for quality and cost Quality metrics ensure provision of appropriate care Shared savings incentives encourage management of cost of care

35. Enrollment/Eligibility PCMH Participation & Eligibility PCPs enrolled in ConnectCare Must have at least 300 beneficiaries Meet participating practice definition (Section 200.000 proposed PCMH manual) May not participate in the PCCM Shared Savings Pilot To Enroll: Provider Portal www.paymentinitiative.org Open Enrollment through December 15 January 1 through May 15, 2014 Voluntary Practice Participation Agreement Annual re-enrollment

36. Enrollment/Eligibility Shared Savings: Incentive payments made to a shared savings entity for delivery of economic, efficient and quality care that meets the requirements of Section 232.000 Minimum of 5,000 Medicaid beneficiaries who have been attributed for at least 6 months Single practice or by pooling attributed benes across more than one practice (up to 2 practices per entity 2014) Practice Support: Section 241.000 – 242.000

37. Shared Savings Criteria First Performance Period January 1, 2014 Single practice or by pooling attributed benes across more than one practice (up to 2 practices per entity 2014) If two practices, they must agree to measure performance together No default pool Second Performance Period Two practice limit for pools is removed Default pool Must be part of a shared savings entity to participate in PCMH

38. Benefits Providers will receive practice support Care Coordination Monthly payments Technical expertise Practice Transformation Option to utilize DMS vendor support Quarterly performance reports Shared Savings Reward high quality care and cost efficiency

39. Enrollment Enrollment