The Patient Center Medical Home: Is it the future?

1. The Patient Center Medical Home: Is it the future? Mark B. Mengel, MD, MPH Vice-Chancellor, Regional Programs June 15th, 2012 (Some of these slides were borrowed from presentations provided by Dr. James McConnell, OHSU, Dr. Joseph Thompson, ACHI, Becky Hall, (Delta-AHEC), Pat Vannatta, (AHEC Central), Dr. Robert Gabbay, Penn State Hershey Diabetes Institute, the Advisory Board, and Dr. James Marsh, (UAMS)

2. Thanks • Bob Price, Ph.D. and his team at the Central Office • AHEC PCMH teams • AHEC Clinical Leadership Council • Sterling Moore, Jessica Ellis, AHEC business managers, and our back office folks who continuously improve our practice management operations

3. AHEC PCMH Goals • By the end of June 2012, be able to achieve level II NCQA accreditation. • By the end of December 2013, be able to achieve level III NCQA accreditation.* *Will be accelerated if we participate in the CPCI CMS innovation grant.

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

6. The time barrier in primary care • 10.6 hours-amount of time it would take the average primary care doctor to provide all evidence-based chronic disease care to an average panel of 2,500 patients, (10 most common chronic diseases) • 7.4 hours-preventive care • 4.6 hours-acute care • 22.6 hours-total, (that does leave 1.4 hours for sleep!) References: 1. Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3(3):209-214. 2. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635–641. 3. Stange KC, Zyzanski SJ, Jaén CR, et al. Illuminating the ‘black box’. A description of 4454 patient visits to 138 family physicians. J FamPract. 1998;46(5):377–389.

8. Today: Providing Care for the Sick

9. Tomorrow: Keeping Patients Healthy Multi-Disciplinary Team

10. TransforMedLearnings • PCMH is a transformation of a practice, (3 to 5 years), not a small incremental change • Requires capability for organizational learning and development, (Leadership is key!) • Change in relationships, (with patients, staff, other providers) • Supportive health care neighborhood • Reimbursement model changes-care management fees and shared savings

12. Strengthening Primary Care and Care Coordination in Medicare: Distribution of 10-Year Impact on Spending Dollars in billions SAVINGS COSTS Source: C. Schoen et al., Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending, The Commonwealth Fund, December 2008.

14. Clinical Process Improvement

15. Clinical Outcomes Improvement

16. AHEC PCMH Costs • Decreased productivity • Additional Team members not currently present • Purchase and on-going operational costs of EMR’s and other IT tools • Time for staff to meet to design and implement new workflows • Education and marketing to patients

17. AHEC PCMH IT Costs • Initial purchase and license fees; lost productivity; training and consultants; server virtualization: $3,487,6000 (can offset with meaningful use money-AHEC estimate: $3,264,750) • Annual maintenance and IT personal costs: $703,316

18. Additional Team Members • Health Psychologist (1) • PCMH Nurse Coordinator (1) • Medical Assistants or Care Coordinators (2 or 3) • Outreach Workers (2 or 3) • Central Office support: IT Project Manager (1), RN Case Manager (3), Nutritionist (1) • (AHEC’s have NP’s, except AHEC-NE, and Pharmacists, already.) • TOTAL AHEC Annual Implementation Costs: $3,164,438. (For the Equivalent of 35.96 FTE Providers in our FMC’s.)

19. Total PCMH annual costs • $703,316 + $3,164,438=$3,867,754. • Per AHEC: $644,625 • Per FTE Provider: $107,437

20. Estimated PCMH incremental costs • $100,000-$115,000 per primary care clinician, • $78,000 per health coach; 56 percent load for coaching tools (data collection, telephones, IT systems, etc.); • 33 percent FTE data manager at $65,000 per data manager; • and $5,000-$20,000 for health IT and Web site technical support annual maintenance. *Deloitte Center for Health Solutions. The Medical Home: Disruptive Innovation for a new Primary Care Model. 2008.

21. Figure 2: Vision for 21st Century Health Care Delivery in Arkansas

22. CMS Innovation Center’s Comprehensive Primary Care Initiative • 7 Markets selected, AR (state-wide) included • Insurance involved: Medicare, Medicaid, QualChoice, and Blue Cross and Blue Shield • 4 year pilot project of 75 adult primary care practices in Arkansas • EMR • 150 eligible Medicare beneficiaries • 60% of revenues generated by payers participating • Level 1 MU perfered; NCQA PCMH level 1, 2, or 3 preferred or document performance of comprehensive primary care functions

23. Comprehensive Primary Care Functions • Risk-stratified case management • Access and continuity • Planned care for chronic conditions and prevention care • Patient and care giver engagement • Coordination of care across the medical neighborhood

24. CPCI Case Management Fees • Medicare: Average $20 per patient per month first two year, risk adjusted. Decrease to $15 on average in year 3 and 4. • Medicaid: preliminary estimate $7 per patient per month, not risk adjusted, includes kids. • QualChoice: $3 per patient per month, not risk adjusted. • Blue Cross and Blue Shield: $5 per patient per month, not risk adjusted. • SHARED SAVINGS: Only in year 3 and 4, no rules, yet. • CONCLUSION: Only Medicare will cover PCMH capacity costs.

25. Are others on the PCMH train? • Recent MGMA survey: 36% of FM practices moving toward PCMH • Recent MGMA survey: 20% of practices, including multispec groups, have achieved PCMH NCQA accrediation • Ark BCBS pilots (7) • UAMS Center for Primary Care: PCMH’s in FM, Gen IM, and Geriatrics (along with Smart Care).

26. It’s already starting NEJM | March 30, 2011 |

27. NEJM | March 30, 2011 |

29. CURRENT AND EXPECTED VACANCIES FOR PRIMARY CARE PHYSICIANS IN ARKANSAS, 2011

31. Closing thought “Making systems work in health care-shifting from corralling cowboys to producing pit crews-is the great task of your and my generation of clinician and scientists.” AtulGawande, M.D. Harvard Medical School Commencement May 26, 2011