Overview of Patient Centered Medical Home and The Role of PCMH in Health Care Reform

1. Overview of Patient Centered Medical Home and The Role of PCMH in Health Care Reform PCMH Symposium Center for Healthcare Research & Transformation Ann Arbor, MI December 2, 2010 Diane R. Rittenhouse, MD, MPH Department of Family and Community Medicine Philip R. Lee Institute for Health Policy Studies University of California, San Francisco

2. The Size of the Problem Access Quality Cost

4. Primary Care: A Solution in Crisis A strong foundation in primary care is needed to simultaneously increase access, improve quality and slow spending Primary care is in crisis Patient Protection and Affordable Care Act of 2010 includes provisions to strengthen primary care

5. Practice Re-design A physician with a typical panel of 2500 patients would spend 7.4 hours per working day to provide all recommended preventive care Plus 10.6 hours per day to provide all recommended chronic care. Yarnell et al. Am J Public Health 2003;93:635. Ostbye et al. Ann Fam Med 2005;3:209.

6. The 15-minute Doctor Visit 76% of patients with type 2 diabetes received limited or no diabetes education in one study Study of 300 medical encounters: doctors spent average 1.3 minutes giving information Study of 264 visits to family physicians: patients making an initial statement of their problem were interrupted after an average of 23 seconds 50% of patients leave office visit not understanding what the doctor said Study of 1000 physician visits, the patient did not participate in decisions 91% of the time. Clement, Diab Care 1995;18:1204. Roter and Hall. Ann Rev Public Health 1989;10:163. Waitzkin. JAMA 1984;252:2441. Braddock et al. JAMA 1999;282;2313. Marvel JAMA 1999;281:283.

8. The Patient-Centered Medical Home

9. 7 Joint Principles Personal Physician Whole Person Orientation Physician Directed Medical Practice Care is Coordinated and/or Integrated Quality and Safety Enhanced Access Payment Reform Joint Principles of the Patient-Centered Medical Home February 2007

10. The Patient-Centered Medical Home:Four Cornerstones Rittenhouse DR, Shortell SM. The Patient Centered Medical Home: Will it Stand the Test ofHealth Reform? 2009;301(19):2038-2040.

11. PCMH – what is the impact? Early evidence supports positive impact on quality and spending

12. PCMH - what about implementation? Multiple demonstration programs ongoing; new Medicare demonstration programs There is variation in PCMH implementation by setting, payer, patient population

13. National Study of Physician Organizations and the Care of Chronic Illness (NSPO) II Co-investigators: Stephen Shortell, PhD Lawrence Casalino, MD, PhD Robin Gillies, PhD James Robinson, PhD Bernard Lau Funders: Robert Wood Johnson Foundation The Commonwealth Fund California HealthCare Foundation Rittenhouse DR, Casalino LP, Gillies RR, Shortell SM, Lau B. Measuring the medical homeinfrastructurein large medical groups. Health Aff (Millwood). 2008 Sep-Oct;27(5):1246-58.

14. Patient-Centered Medical Home Personal Physician Whole Person Orientation Physician Directed Medical Practice Care is Coordinated and/or Integrated Quality and Safety Enhanced Access Payment Reform

15. Patient-Centered Medical Home 20-Point Index

16. Lowest Performers, by Medical Group Size

17. Highest Performers, by Medical Group Size

18. Smaller Practices Most medical care is delivered in small settings 32% of US physicians practice solo or in 2-person partnerships 60% practice in settings of 5 physicians or fewer

19. National Study of Small to Medium Sized Physician Practices (NSSMPP) National sample of physician practices Preliminary findings Funder: Robert Wood Johnson Foundation

20. The Medical Home:A Work in Progress

21. Patient-Centered Medical Home Personal Physician Whole Person Orientation Physician Directed Medical Practice Care is Coordinated and/or Integrated Quality and Safety Enhanced Access Payment Reform

22. The Patient-Centered Medical Home:Four Cornerstones Rittenhouse DR, Shortell SM. The Patient Centered Medical Home: Will it Stand the Test ofHealth Reform? 2009;301(19):2038-2040.

23. The Medical Neighborhood From the PCMH Joint Principles: Whole Person Orientation … taking responsibility for appropriately arranging care with other qualified professionals. … care for all stages of life …. Care is Coordinated and/or Integrated across all elements of the health care systems and the patient’s community. Payment – … care both within a given practice and between consultants, ancillary providers, and community resources; … share in savings from reduced hospitalizations associated … payments for achieving measurable and continuous quality improvements.

24. Beyond the Control of Primary Care Primary care has little control beyond the primary care practice No direct incentives to other providers to collaborate with primary care providers to optimize care coordination and health outcomes Primary care re-design requires increased investment; savings will accrue to the “system”

25. Accountable Care Organizations Organizations that can receive and distribute payments to participating physicians and hospitals to provide care coordination, to invest in infrastructure and redesign care processes, and to reward high-quality and efficient services. Accountability for defined population across the care continuum Payment reforms that reward QI and slow spending increases Performance measurement

26. Important Synergies: PCMH & ACO Complementary models Integration is important for maximum impact of PCMH An ACO will not achieve necessary improvements in quality and costs if not based on a strong foundation of high-performing primary care Rittenhouse DR, Shortell SM, Fisher ES, Primary Care and Accountable Care: Two Essential Elements of Delivery System Reform. N Engl J Med. 2009;361:2301-2303.

30. Where is the Value? Value Driving Elements in ACO and PCMH: Access Care Coordination Essential Tools for Successful Implementation: Health Information Technology Payment Reform Patient-Centered Primary Care Collaborative (PCPCC), The Dartmouth Institute, The Commonwealth Fund

31. Patient-Centered Care

32. The loftier the building, the deeper must the foundation be laid. Thomas Kempis

33. Institute for Healthcare ImprovementTriple Aim Improve the health of the population  Enhance the patient experience of care (including quality, access, and reliability) Reduce, or at least control, the per capita cost of care

34. Thank you