The Patient-Centered Medical Home (PCMH)- So What?: The Missing Link

1. The Patient-Centered Medical Home (PCMH)- So What?: The Missing Link Justin Villines, MBA, HCM Center for Rural Health, UAMS

2. Disclosures The following planners, speakers, moderators, and/or panelists of this CME activity have no relevant financial relationships with commercial interests to disclose: • Justin Villines, MBA,HCM

3. Objectives 1.) Communicate goals and expectations for PCMH transformation in Arkansas 2.) Describe how PCMH can improve compensation to providers 3.)Identify what role payers play in developing a PCMH 4.)Help practices understand the costs and benefits of PCMH transformation

4. Ever Get That Sinking Feeling? Patient Portal Many Forms Payment Reform EMR PCMH MU

5. Health Care Reform Priorities for US health care reform include: • Quality • WHO (World Health Organization) identifies the US health care system as the “most individually responsive” • WHO ranks US health care 37th overall (among 191 countries) • Efficiency • People with acute and chronic medical conditions receive only about two-thirds of the health care that they need. • Between 20 and 30% of tests and procedures provided to patients are neither needed nor beneficial.

6. Health Care Reform Priorities for US health care reform include: • Cost • The U.S. spends more on health care per capita than any other nation. • The U.S. spends more on health care as a proportion of GDP (Gross Domestic Product) than any other nation. • Patient-friendly • Public confidence in hospitals and personal doctors remains relatively high. • While individuals report generally positive experience with medical care, public confidence and trust in the system at large is eroding.

7. Health Care Reform Priorities for US health care reform include: • Access • Lack of insurance is a major reason for not obtaining access to needed care. • The 40 million Americans without insurance coverage are less likely to obtain needed medical care and preventive tests • Even with insurance, barriers to care still exist: • Lack of an established relationship with a doctor • Language barriers • Cultural barriers • Transportation issues • Geography • Automation • Infrastructure for health care delivery has not kept pace with the electronic innovations of other industries. • Many institutions still rely on systems that are not automated and allow opportunities for human error, even though technology exists to minimize errors and improve efficiency.

8. Fundamentals for PCMH Transformation Care Mgmt, Coordination & Communication Practice Viability & Efficiency Medical Homes & Medical Neighborhoods Patient Engagement & Access Leadership & Team-Based Care Outcomes Reporting

9. We Need a Better System of Care:The Patient Centered Medical Home

10. Patient-Centered Medical Home “Patient-Centered Medical Home (PCMH) is defined “… as a team of people embedded in the community who seek to improve the health and healing of the people in that community… Unlike more narrowly focused ways of organizing the delivery of commodities of healthcare, the PCMH aims to personalize, prioritize and integrate care to improve the health of whole people, families, communities and populations.” Source: K.C. Stange, P.A. Nutting, W.L. Miller et al., “Defining and Measuring the Patient-Centered Medical Home,” Journal of General Internal Medicine, June 2010 25(6):601-12.

11. Medical Home “Joint Principles” Personal Physician Physician-Directed Practice Whole-Person Orientation Care Coordination/Integration Quality & Safety Enhanced Access Payment Adopted by the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and American Osteopathic Association (AOA) in Febraury, 2007

12. Medical Home “Joint Principles” Personal Physician Each patient has an ongoing relationshipwith a personal physician, who provides comprehensive, continuous primary care.

13. Medical Home “Joint Principles” Physician-Directed Practice The physician is responsible for directing a team that takes collective responsibility for patient care.

14. Medical Home “Joint Principles” Whole-Person Orientation The physician is responsible for providing comprehensive care at all stages of life and for coordinating care as necessary with appropriate specialists.

15. Medical Home “Joint Principles” Care Coordination/Integration A patient’s care is coordinated across all elements of our complex health system (subspecialty care, hospitals, nursing homes, etc) through disease registries, information technology, health information exchange to ensure that the patient is getting needed and desired care in an appropriate manner.

16. Medical Home “Joint Principles” Quality & Safety Quality and safety are hallmarks of a PCMH; evidence-based practices, clinical decision-support tools, regular quality improvement efforts, and information technology all combine to ensure that patient outcomes attain the highest level of excellence.

17. Medical Home “Joint Principles” Enhanced Access Patients have enhanced access to their physicians and their practices as a result of open scheduling, expanded hours, and/or additional options for communication between patients, physicians, and staff.

18. Medical Home “Joint Principles” Payment Reimbursement appropriately reflects the added value patients receive from being part of a PCMH practice.

19. What Is the National Committee for Quality Assurance (NCQA)?

20. NCQA • National Committee on Quality Assurance (NCQA) • 501(c)(3) dedicated to improving health care quality • NCQA offers “recognition” programs for various aspects of clinical care: diabetes, cardiovascular disease, back pain • One of the recognition programs is for PCMH • 3 levels of accreditation: Level 1 (lowest), Level 2, and Level 3 (highest)

21. 6-Part Series of PCMH Model • Enhance Access and Continuity • Access During Office Hours • Access After Hours • Electronic Access • Continuity (with provider) • Medical Home Responsibilities • Culturally/Linguistically Appropriate Services • Practice Organization • Identify/Manage Patient Populations • Patient Information • Clinical Data • Comprehensive Health Assessment • Use Data for Population Management • Plan/Manage Care • Implement Evidence-Based Guidelines • Identify High-Risk Patients • Manage Care • Manage Medications • Electronic Prescribing • Provide Self-Care and Community Resources A. Self-Care Process B. Referrals to Community Resources • Track/Coordinate Care • Test Tracking and Follow-Up • Referral Tracking and Follow-Up • Coordinate with Facilities/Care Transitions • Measure and Improve Performance • Measures of Performance • Patient/Family Feedback • Implements Continuous Quality Improvement • Demonstrates Continuous Quality Improvement • Report Performance • Report Data Externally

22. Patients today are savvy consumers of health care and have higher expectations. • Communication • Access • Convenience • Coordination • Responsiveness • Source: Medfusion, an AAFP affinity partner, 2008

23. Patient Expectations • 75% want the ability to interact with their physician online (appointments, prescriptions, test results). • 77% want to ask questions without a visit. • 75% want email access as part of their overall care. • 62% of patients say access to these services would influence their choice of physicians.

24. Culture of Improvement Reliable Systems Performance Measurement • Starts with a culture of improvement • Ensure quality improvement initiatives are not punitive; should not discourage physicians from caring for patients • Quality measures should be based in strong clinical evidence • You can’t improve what you don’t measure • Develop reliable systems to collect information Quality Measures

25. Convenient Access Personalized Care Care Coordination • Patients want convenient access to information, communication, and care • Patients want to access to care when they are ill • Patients are engaged in their own care and want to share in decision-making • Patients want increased ability to access information • Patients want coordinated care • Patients want new • approaches to care: group • visits and on-line services Patient Experience Quality Measures

26. Financial Management Personnel Management Clinical Systems • Lab testing • Prescriptions • Registries • All staff are aware of the most effective ways to deliver care • National policies support the investment of resources into primary care practices that are effective and efficient • Every team member understands the important role they play in delivering efficient care and is empowered to make suggestions for improvement • Lab testing • Prescriptions • Patient Registries Practice Organization Patient Experience Quality Measures

27. Business & Clinical Process Automation Connectivity & Communication Evidence-Based Medicine Support Clinical Data Analysis & Representation • Patient reminders • Patient notification for new information • Reminders for recommended care or health maintenance • Makes patient registries possible • Enhances care coordination by improving information flow with other physicians, practices, and providers • Improves patient - physician communication • Point-of-care learning (e.g., Up-to-Date) • Clinical decision support (e.g., Epocrates) • Can quickly pull clinical data for quality analysis • Can enhance business processes Health Information Technology Practice Organization Patient Experience Quality Measures Family Medicine Foundation

28. Comprehensive Primary Care Initiative (CPCi) • Practices were selected through a competitive application process based on their use of health information technology, ability to demonstrate recognition of advanced primary care delivery by accreditation bodies, service to patients covered by participating payers, participation in practice transformation and improvement activities, and diversity of geography, practice size and ownership structure. • The Comprehensive Primary Care (CPC) initiative is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. Medicare will work with commercial and State health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients.

29. Comprehensive Primary Care Initiative (CPCi) • What is it? • 4-year pilot program from CMS Innovation Center – CMMI • Authorized under the Accountable Care Act • Funding for 330,750 Medicare and Medicaid beneficiaries

30. Comprehensive Primary Care Initiative (CPCi) • What is it? • 4-year pilot program from CMS Innovation Center – CMMI • Authorized under the Accountable Care Act • Funding for 330,750 Medicare and Medicaid beneficiaries • Designed to accomplish the “triple aim” at the community level • Aligns multiple payers in a community around common goals

31. Comprehensive Primary Care Initiative (CPCi) • What is it? • 4-year pilot program from CMS Innovation Center – CMMI • Authorized under the Accountable Care Act • Funding for 330,750 Medicare and Medicaid beneficiaries • Designed to accomplish the “triple aim” at the community level • Aligns multiple payers in a community around common goals • Aimed at Primary Care Physicians • Builds on the “Medical Home” concept • Holds PCP practices accountable for the total cost of care • Solicitation issued in late September 2011

32. Comprehensive Primary Care Initiative (CPCi) • CMS’ Framework for Comprehensive Primary Care • Risk stratified care management • Access and continuity • Planned care for chronic conditions and preventive care • Patient and caregiver engagement • Coordination of care across the medical neighborhood

33. Four Basic Steps in the Process • Select communities to participate • Number of commercial plans willing to participate • Support of state Medicaid • Community infrastructure and history of collaboration • Seven Communities were selected • Arkansas – Qual-Chioice, Medicaid, BCBS, Humana • (275 Providers, 69 practices, 54,661 Medicare Patients) • Colorado • New Jersey • Oregon • New York Capital District-Hudson Valley Region • Greater Tulsa Region • Cincinnati-Dayton-Northern Kentucky Region • Community selection completed April 2012

34. Four Basic Steps in the Process • Select Communities to participate (April 2012) • Align payers who are willing to commit to: • Payment above normal Fee-for-Service (e.g. pmpm) • CMS pmt will be risk adjusted and will average $20 pmpm • Provide gainsharing opportunities in years 2-3-4 • Common set of metrics for cost, quality, service • Using 18 of the 33 ACO measures as a starting point • Providing aggregate member level cost/utilization data • Signing a Letter of Intent with CMS • Cincinnati had 10 payers commit to participate • Includes Aetna, Anthem, Humana, Medicaid, MMO, United • Payers signed non-binding LOIs in June 2012

35. Four Basic Steps in the Process • Select Communities to participate • Align payers • Select PCP Practice Locations • Practice = physical office location • 75 practices per market to be selected • Screening Criteria: • 150 FFS Medicare patients • Physicians have attested to Meaningful Use • Qualitative Criteria: • >60% of patients are covered by participating payer • Demonstration of readiness to transform • PCMH Recognized • Commitment to transformational activities • Practices to be selected August 2012

36. Year 1 Commitments Required by CMS • Complete an annual budget • Implement risk stratification methodology for all patients • Attest to 24/7 patient access to a nurse or practitioner with access to the patient’s EHR • Establish baseline for patient satisfaction using CG-CAHPs • Demonstrate care coordination for the medical neighborhood and c omply with at least one of the following: • Notification of ED visit in a timely fashion • Med reconciliation completed with 72 hours of hospital discharge • Exchange of clinical information at the time of admission and at discharge • Exchange of clinical information between PCP-specialists • Participate in quarterly market based learning collaborative

37. Four Basic Steps in the Process • Select Communities to participate • Align payers • Select PCP Practice Locations • “Negotiate” with practices and start program • No negotiations with CMS • Expect limited negotiation with plans • Will need to conform with their LOI commitments • Will plans cover TriHealth PCMH sites not selected? • Not clear if “ASO” employers will participate • Go-live November 1, 2012 • 13 months from solicitation to go-live

38. CPCi v. Accountable Care Organization • Focus is on Patient Centered Medical Home (PCMH) as the foundation for managing care • ACO not as prescriptive as to care management strategy • Provides new funding for infrastructure • Focused on adult PCP sites • For systems: only funds part of the PCP base • For independents: provides funding to sustain independence • Requires participating competitors to cooperate in sharing best practices • Goal is to demonstrate impact at the community level • Monthly meetings of practices

39. CPCi v. Accountable Care Organization • Requires commercial plans/Medicaid support • Must provide additional pmpm funding • Patient attribution updated quarterly • Must commit to a common “menu” of cost/quality measures to be used for gainsharing program • Must provide monthly claims/utilization data • Still defining level of detail • Monthly multi-stakeholder meetings • ASO customers must agree to participate • Does not require gainsharing/full risk on day 1 • Year 1 used to build capabilities and establish data baselines • Gainsharing in years 2-3-4 still undefined

40. CPCi Challenges • Attribution requires 24 months of claims experience • What happens when a commercial enrollee switches plans • Many “Key Success Factors” still undefined • Attribution methodology • Cost/utilization data specificity • Gainsharing methodology • Severity adjustment methodology • CMS’ agenda does not always support community existing initiatives • Public Reporting through the Health Collaborative

41. CPCi Challenges • Self Insured Employers must agree to participate • ASO provider cannot commit without their consent • Threats to health system goal of creating a system brand for their PCP network • TH has 34 PCP practice locations • 30 NCQA Recognized Level 3 PCMH sites • 19 Sites have been selected by CMS to participate • Funding only applies to 19 sites • How to fund remaining 15 sites? • Can we get performance data for non CPCi sites even if we are not part of a payer’s P4P program?

42. CPCi Challenges • Common community agenda still a challenge • 19 Common Quality/Measures Selected • CMS priorities • Medicare Advantage “star” program measures • Medicaid plans’ payment incentives • Commercial payers’ national quality/cost agendas

43. Medicaid commits to launch PCMH in 3 waves, leading the way for broader multi-payer participation over time • Wave 1- CPCI-69 Practices- October 2012 • Wave 2 –Early Adopters- Early 2014 • Wave 3 –All Arkansas Primary Care Practices

44. Medicaid enroll in PCMH • Recognizing that changing practice patterns is challenging, the Arkansas Model aims to deliver support tohelp practices – rural and urban, small, and large – meet this challenge • Participation requirements To enroll in PCMH initially, a practice must • ▪Participate in the ConnectCare Primary Care Case Management Program • ▪Maintain at least 300 attributed beneficiaries

45. Shared savings incentives • Shared savings payments are made to shared savings entities that have a minimum of 5,000 Medicaid beneficiaries who have been attributed for at least 6 months of the performance period. Such an entity may be formed in one of three ways: • ▪Standalone practice that meets the minimum independently • ▪Voluntary pool (of up to 2 practices per entity in 2014; greater than 2 per entity starting in 2015) • ▪Statewide default pool (to be launched in 2015) Starting in 2015, practices must be part of a shared savings entity to participate in PCMH

46. Practices will receive monthly payments to support care coordination and practice transformation • Care Coordination- • Average of $4 per member per month1 (PMPM) • ▪Risk-adjusted • ▪Intended to be ongoing for successful practices • Practice Transformation- • $1 per member per month (PMPM) • ▪Fixed amount per patient to support practices choosing pre-qualified transformation vendor • ▪Intended to catalyze transformation for first 24 months A PCP with 2000 Medicaid attributed patients could receive up to $120,000 a year in support

47. Great Outcomes • Good for patients • Patients enjoy better health. • Patients share in health care decisions. • Good for physicians • Physicians focus on delivering excellent medical care. • Good for practices • Team works effectively together. • Resources support the delivery of excellent patient care. • Good for payors and employers • Ensures quality and efficiency. • Avoids unnecessary costs. Great Outcomes Health Information Technology Practice Organization Patient Experience Quality Measures Family Medicine Foundation

48. Rationale The “Triple Aim” • Lower Costs • Improve Quality • Better Health Outcomes

49. PCMH Gets Results Integrated Delivery System: Group Health Cooperative of Puget Sound • $10 PMPM reduction in total costs Private Payer Sponsored: Blue Cross Blue Shield of North Dakota • Hospital admissions decreased by 6% and emergency department visits decreased by 24% in the PCMH group from 2003 to 2005, while increasing by 45% and 3%, respectively, in the control group.

50. PCMH Gets Results continued Medicaid-sponsored: Community Care of North Carolina • Cumulative savings of $974.5 million over 6 years (2003-2008) • 40% decrease in hospitalizations for asthma • 16% lower emergency department visit rate These results, and more, are available in the report “The Outcomes of Implementing Patient-Centered Medical Home Interventions”Prepared by Kevin Grumbach, MD, Thomas Bodenheimer, MD MPH, and Paul Grundy MD, MPHAugust 2009. http://www.pcpcc.net/files/pcmh_evidence_outcomes_2009.pdf