The Patient-Centered Medical Home

1. The Patient-Centered Medical Home Public Health Council April 11, 2008 Lowell H. Keppel, MD, CPE, FACPE, FAAFP President, WAFP Andrea Gavin, MD President-elect, WAFP

2. Agenda • Evidence for the value of PC-MH • The history of PC-MH • PCMH differences from a traditional Primary Care office • OB Care in a PCMH

3. Evidence for PC-MH Value • Barbara Starfield (Johns Hopkins) Analyses • PCP supply is consistently associated with improved health outcomes • In England and US, each additional PCP per 10,000 persons is associated with a decrease in mortality (3-10%) • An increase of 1 PCP is associated with 1.44 fewer deaths/000 • African Americans with a PCP are less likely to die prematurely Sources: See next slide

4. Starfield References • Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83(3):457-502. • Starfield B, Shi L, Grover A, Macinko J. The Effects Of Specialist Supply On Populations' Health: Assessing The Evidence. Health Aff (Millwood) 2005. • Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res 2003;38(3):831-65.

5. Evidence for PC-MH Value (cont.) • Those that live in US states that rely more on primary care have • Lower Medicare spending • Lower resource inputs • Lower utilization • Better quality Sources: Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries' quality Health Affairs. April 2004:W184-197.)

6. Evidence for PC-MH Value (cont.) • Those that live in US states that rely more on primary care have • 33% lower annual adjusted cost of care • 19% lower adjusted mortality, controlling for age, gender, income, insurance, smoking, perceived health (SF-36) and 11 major health conditions [Franks and Fiscella. J FAM PRACT 1998;47:103] • Increased primary care to population ratios are associated with reduced hospitalization rates for 6 ambulatory sensitive conditions [Parchman and Culler. J FAMPRACT 1994;39:123] • Health care costs are higher in regions with higher ratios of specialists to generalists [Welch et al. NEJM 1993;328:621]

7. Current Pilots • Community Care of North Carolina (Medicaid) began a PC-MH project in 1998 (~700K enrollees) and independent evaluations of the program indicate it has saved • $200M in 2003 and $250M in 2004 • $231M in 2005 and 2006 • paying $2.50 PMPM to be used for PCP led team care and case/disease management** • UHC has begun pilots in 3 of their markets to pay PCPs a PMPM AND provide additional team services for chronic illness care to those practices who demonstrate that they are PC-MHs (own criteria) **Source: http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine/20071011ccnccutscosts.html and http://www.aafp.org/online/etc/medialib/aafp_org/documents/ policy/state/medicaid/nccostsave.Par.0001.File.tmp/nccostsavingschart.pdf

8. Current Pilots • Coalition of national employers including GE, IBM, and Verizon is launching an initiative to pay hefty bonuses to PCPs for creating “medical homes” • Reported 1/31/08 in WJS • Pays $125 PMPY (~$10.40 PMPM) for each patient • PCPs required to change practices to f/u on referrals, systematically track tests, flag abnormal tests, adhere to widely accepted medical guidelines for chronic conditions • Employers expect to save $250 - $300 per patient in the first year alone **Source: http://online.wsj.com/public/article/SB120175692402331541.html

9. Current Pilots • 2007 Resolution at the Council of State Governments BE IT RESOLVED, that the Council of State Governments support the Joint Principles of the Patient-Centered Medical Home as a guideline for states to improve the health of its citizens, and BE IT FURTHER RESOLVED, that the Council of State Governments encourage states to implement and fund pilot programs to demonstrate the quality, safety, value, and effectiveness of the patient-centered medical home. • Unanimously passed

10. History • 1967 - AAP introduced the term in the Standards of Child Health Care and defined it as a centralized place for medical records. • 1970s and 80s - Primary Care evolution including many aspects of the medical home • 1990s - PCP precepts embraced by IOM, which specifically mentioned “Medical Home” Sources: Sia et al. History of the Medical Home Concept. Pediatrics 2004 AAFP Monograph on The Patient Centered Medical Home, 11/2007

11. History (cont.) • 2002 - AAP expands definition, AAFP begins the Future of Family Medicine study • 2004 - AAFP FFM report states that every American should have a Personal Medical Home as focal point of their health care • 2006 - ACP publishes monograph on the Advanced Medical Home Sources: AAFP Monograph on The Patient Centered Medical Home, 11/2007 available at http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001.File.dat/PCMH.pdf

12. History (cont.) • 2007 - The AAFP, AAP, ACP, and AOA publish the Joint Principles of the Patient-Centered Medical Home with 7 Core Features • Personal Physician • Whole Person Care Orientation • Coordinated/Integrated Care • Quality and Safety • Enhanced Access • Physician Directed Medical Practice • Full Value Payment Reform Sources: “Joint Principles of the Patient-Centered Medical Home” available at http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File.tmp/022107medicalhome.pdf

13. Differences from PCP Office Personal Physician & Whole Person Orientation • Ongoing relationship with a PP trained to provide first contact, continuous and comprehensive care • Having a usual source of care is associated with a greater likelihood that people receive appropriate care, preventive care, better outcomes, lower cost, more EBM • Care in the context of person’s living situation, community, etc. • Mind and body • All stages of life • Acute, chronic, prevention, end-of-life • May or may not be different from a current PCP office

14. Differences from PCP Office Coordinated/Integrated Care • Facilitated by • Registries • Proactive care • Information Technology • Health Information Exchange • Chronic care coordination • Internal or external care coordinating staff • Frequently part of a patient’s health plan • Reduced duplication and improved coordination across the spectrum of care

15. Differences from PCP Office Quality and Safety • Evidence Based Medical care • Optimal chronic care guidelines embedded in practice • Among all teammates in care • QI projects at the practice level • Quality metrics regularly measured and reviewed • Focused on conditions that matter in a practice • EHR systems can greatly enhance - or inhibit quality • Used appropriately • Adoption of e-prescribing an excellent 1st step

16. Differences from PCP Office Enhanced Access • More than Extended Hours • Open/advanced scheduling • Group visits, team visits • New methods of communication • Secure Email, Web, Text • Appt scheduling, question answering, compliance, lab results • Based upon a person’s preference

17. Differences from PCP Office Physician Directed Medical Practice • Team care • Flexes depending on the complexity of needed care • Low complexity tasks handled by members of the team other than Physician • Collaborative relationship between physician and non-physician practitioners

18. Obstetrics and Pediatrics in the Medical Home • Nationwide • 20.6% of FPs deliver babies • 19.3% Urban • 38.0% Rural • In Wisconson • 57% Deliver babies (Almost 3X National Ave) • 96% Care for children

19. Advantages • Continuity of Care with their Family Doctor • Concurrent Care of acute and chronic illness • Care of the newborn within the Family unit throughout childhood, into adulthood. • Care in the context of person’s living situation, community, etc. • Mind and body • All stages of life, pediatric, adult, both genders, end-of-life • Acute, chronic, prevention

20. Q1: How to Define a PC-MH? • NCQA has developed a scored criteria set of standards (PPC-PCMH™) for medical practices to demonstrate that they are functioning as PC-MHs • Includes a tiered recognition system based upon score • This type of standardized certification is preferable to each MCO developing its own home-grown criteria

21. NCQA Criteria

22. NCQA Scoring

23. Summary: PCMH Impact on Public Health • Improved access • Improved patient safety • Improved costs • Improved EBM • Improved focus on population health • Improved preventive care

24. Discussion And Thank You!