The Business Case for Medical Home

1. The Business Case for Medical Home Steven E. Wegner, JD MD President & Medical Director AccessCare President, NCCCN September 19, 2007 Sustaining Progress in Your State and Community

2. The National Center of Medical Home Initiatives for Children with Special Needs • Accessible • Care is provided in community • All insurance, including Medicaid, is accepted • Family can speak directly to provider • Family-Centered • Responsibility and trust exists between patient, family, and medical home • Family is recognized as principal caregiver • Clear, unbiased, and complete information and options are continually shared with family Source: www.medicalhomeinfo.org

3. The National Center of Medical Home Initiatives for Children with Special Needs • Continuous • Same primary provider is available from infancy through young adulthood • Assistance with transitions is provided • Medical home provider participates as much as allowed when care is provided by another facility • Comprehensive • Health care is available 24/7 • Preventive, primary, and tertiary care needs are addressed • Medical home provider advocates for patient in obtaining comprehensive care and shares responsibility for care provided Source: www.medicalhomeinfo.org

4. The National Center of Medical Home Initiatives for Children with Special Needs • Coordinated • A plan of care is developed by physician, patient, and family and is shared with other providers • A central record containing all medical information is maintained at practice • Compassionate • Concern for well-being of child and family is expressed • Efforts are made to understand and empathize with feelings and perspectives of family Source: www.medicalhomeinfo.org

5. Joint Principles of the Patient-Centered Medical Home The Patient-Centered Medical Home (PC-MH) is an approach to providing comprehensive primary care for children, youth and adults. The PC-MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate the patient’s family. • American Academy of Family Physicians (AAFP) • American Academy of Pediatrics (AAP) • American College of Physicians (ACP) • American Osteopathic Association (AOA)

6. Joint Principles of the Patient-Centered Medical Home • Personal physician • Physician directed medical practice • Whole person orientation • Care is coordinated and/or integrated • Quality and safety • Enhanced access • Payment

7. BIPA 2000The New Beginning

8. BIPA 2000 –Medicare, Medicaid, and State Children’s Health Insurance Program Benefits Improvement and Protection Act • To encourage the coordination of health care furnished under Medicare • To encourage investment in care management processes for efficient service delivery • To reward physicians for improving health care processes and outcomes Source: Cathy Schoen, Sabrina K.H. How, IIlana Weinbaum, John E. Craig, Jr., Karen Davis. The Commonwealth Fund – Commission on a High Performance Health System

9. BIPA 2000 –Participating Physician Group Practice (PGP) • Ten diverse, large PGPs (>200 physicians) are participating in the demonstration: • Billings Clinic in Montana • Dartmouth-Hitchcock Clinic in New Hampshire • Everett Clinic in Washington • Forsyth Medical Group in North Carolina • Geisinger Health System in Pennsylvania • Marshfield Clinic in Wisconsin • Middlesex Health System in Connecticut • Park Nicollet Health Services in Minnesota • St. John’s Health System in Missouri • University of Michigan Faculty Group Practice in Michigan Source: Cathy Schoen, Sabrina K.H. How, IIlana Weinbaum, John E. Craig, Jr., Karen Davis. The Commonwealth Fund – Commission on a High Performance Health System

10. BIPA 2000 –RTI (Research Triangle Institute) Evaluation –Cross-site Themes 1. Improving Care Management and Coordination of Care • Chronic disease management • High-cost/high-risk patient management • Transition management 2. Expanding Palliative Hospice Care Source: Cathy Schoen, Sabrina K.H. How, IIlana Weinbaum, John E. Craig, Jr., Karen Davis. The Commonwealth Fund – Commission on a High Performance Health System

11. BIPA 2000 –RTI (Research Triangle Institute) Evaluation –Cross-site Themes 3. Modifying Physician Practice Patterns and Behavior 4. Enhancing Information Technology “Demonstration participants feel that attainment of quality and efficiency goals is a function of the system of care and the efforts of the entire care team, so performance payments should be used to improve systems, not to incentivize individual physicians.” Source: Cathy Schoen, Sabrina K.H. How, IIlana Weinbaum, John E. Craig, Jr., Karen Davis. The Commonwealth Fund – Commission on a High Performance Health System

12. What’s a Pound of Prevention Really Worth?New York TimesJan 24, 2007

13. New York Times (cont.) • With the right preventive care, people can cut their risk of a heart attack by up to 80%, cardiologists estimate. • “We have made major improvements in prevention...but it’s difficult. It takes frequent visits, a close relationship between a physician and a patient and a very committed patient.”1 1 Dr. Gregg W. Stone, Director Cardiovascular Research at Columbia University

14. MMA Section 721 Medicare Health Support Pilot • Background: • Chronic conditions are a leading cause of illness, disability, and death among Medicare beneficiaries and account for a disproportionate share of health care expenditures. • For example, about 14%of Medicare beneficiaries have heart failure, but they account for 43% of Medicare spending. About 18 percent of Medicare beneficiaries have diabetes, yet they account for 32% of Medicare spending. • Goals: • To help increase adherence to evidence-based care, • Reduce unnecessary hospital stays and emergency room visits, and • Help participants avoid costly and debilitating complications.

15. MMA Section 721Medicare Health Support PilotOrganizations and Locations

16. MMA Section 646 Medicare Health Quality Demonstration Program 2006 – 2007 • Goal: to improve the quality of care and services delivered to Medicare beneficiaries through system design; • Best practice guideline usage • Continuous quality and patient safety improvement • Shared decision making between providers and patients • The delivery of culturally and ethnically appropriate care • Encourage coordination of Medicare services and reward eligible health care groups for improving health outcomes • Eligible Organizations: • Physician Groups or regional coalitions of physicians groups or IDS • Integrated Delivery Systems (IDS) – includes hospitals, clinics, home health agencies, ambulatory surgery centers, skilled nursing facilities, and physicians

17. American College of Physicians (ACP) 2006: The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care

18. Primary Care is on the verge of collapse • Very few young physicians are going into primary care • There will not be enough primary care physicians to take care of an aging population with growing incidences of chronic diseases • Without primary care, the health care system will become increasingly fragmented, over-specialized, and inefficient-leading to poorer quality care at higher costs • It is anticipated that the demand for general internists will increase from 106,000 in 2000 to nearly 147,000 in 2020 - an increase of 38% • When compared with other developed countries, the United States ranked lowest in its primary care functions and lowest in health care outcomes, yet highest in health care spending

19. American College of Physicians (ACP) 2007: A System in Need of Change

20. What is patient-centered care? Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions INSTITUTE OF MEDICINE, CROSSING THE QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21ST CENTURY, March 2001 Source: Doherty, Robert. “The Patient Centered Medical Home: A proposal for Redesigning Primary Care.” Combined Conferences At Consumer Health World. <http://www.consumerhealthworld.com/PDFs/may07/2.04.ppt.>.

21. A Patient-Centered Health Care System • Provides continuous access to a personal primary physician who cares for the whole patient • Characteristics of care that the evidence shows result in the best possible outcomes • Importance of implementing systems-based approaches • Transparency and information to choose a practice and physician • Accountability and public information • Financing, reimbursement and delivery models • Clinical information systems

22. “Qualified” practices would have systems to facilitate patient-centered care • Patient registries • Evidence-based clinical decision support • Secure e-mail • Open scheduling and group visits • Remote monitoring • Leading to . . . a fully functional EHR that incorporates registries, decision support, interoperability, and quality measurement and reporting

23. The PCMH is a care facilitator, not a gatekeeper • Personal physician accepts responsibility for patient’s “whole health” and helps patients get the care they need from other health professionals • The PCMH facilitates appropriate referrals and sharing of information among a multidisciplinary team • Patients are not “locked in” and may seeaspecialist at any time

24. The PCMH must be supported by better reimbursement • Traditional FFS pays physicians solely based on volume of visits/procedures • It does not recognize the value of the time that physicians spend in coordinating care with other health professionals and family caregivers or engaging the patient on self-directed care • Nor does it recognize the expenses associated with acquiring the systems needed

25. New payment model for services provided by a PCMH • Bundled, severity-adjusted care coordination fee paid on a monthly basis for the following components: • The physician and non-physician clinical staff work required to manage care outside a face-to-face visit • The health information technology and system redesign incurred by the practice • Combined with per visit FFS payment • Performance based bonus payments based on evidence based measures ofcare

26. National Committee for Quality Assurance (NCQA): Physician Practice Connections Practice Requirements For Certification Source: 2006 National Committee for Quality Assurance

27. NCQA – PPC: Standards & Intent 1. Access and Communication • The practice provides patient access during and after regular business hours, and communicates with patients effectively 2. Patient Tracking and Registry Functions • The practice has readily accessible, clinically useful information on patients that enables it to treat patients comprehensively and systematically 3. Care Management • The practice maintains continuous relationships with patients by implementing evidence-based guidelines and applying them to the identified needs of individual patients over time and with the intensity needed by the patients

28. NCQA – PPC 4. Patient Self-Management Support • The practice collaborates with patients to pursue their goals for optimal achievable health 5. Electronic Prescribing • The practice seeks to reduce medical errors and improve efficiency by eliminating handwritten prescriptions and by using drug safety checks and cost information when prescribing 6. Test Tracking • The practice works to improve effectiveness of care, patient safety and efficiency by using timely information on all tests and results

29. NCQA – PPC 7. Referral Tracking • The practice seeks to improve effectiveness, timeliness and coordination of care by following through on consultations with other practitioners. 8. Performance Reporting and Improvement • The practice seeks to improve effectiveness, efficiency, timeliness and other aspects of quality by measuring and reporting performance, comparing itself to national benchmarks, giving physicians regular feedback and taking actions to improve 9. Interoperability • The practice maximizes use of electronic communication to improve timeliness, effectiveness, efficiency and coordination of care

30. Sec. 204 Medicare Medical Home Demonstration Project (Dec 2006) • The Secretary shall establish a medical home demonstration project to redesign the health care delivery system to provide targeted, accessible, continuous and coordinated, family-centered care to high-need populations and -- • Care management fees are paid to personal physicians • Incentive payments are paid to physicians participating in practices that provide a medical home • “High-need population” means individuals with multiple chronic illnesses

31. Sec. 204 Medical Home • Duration – three years • Scope – • Urban, rural, and underserved areas • Not to exceed eight states • Encouraging participation of small physician practices

32. Sec. 204 Medical Home - Definition • Physician practice that: • Is in charge of targeting beneficiaries for participation in the project • Responsible for: • Providing safe and secure technology to promote patient access to personal health information • Developing a health assessment tool • Providing training programs for coordination of care

33. Sec. 204 Medical Home - Requirements • Board certified physician who provides first contact and continuous care for individuals under the physician’s care • Staff and resources to manage the comprehensive and coordinated health care of each such individual

34. Sec. 204 Medical Home - Services • Provides ongoing support, oversight, and guidance to implement an integrated, coherent, cross-discipline medical care plan • Uses evidence-based medicine and point-of-care clinical decision support tools to guide decision-making • Uses health information technology, including remote monitoring and patient registries • Encourages patients to engage in the management of their own health through education and support systems

35. Sec. 204 Medical Home - Payment • Personal Physician Care Management Fee • Secretary shall provide a care management fee to personal physicians. • Using the relative value scale update committee (RUC) process, the Secretary shall develop a care management fee code for such payments and a value for such code.

36. Sec. 204 Medical Home – Payment • Medical Home Sharing in Savings • 80 % of the reductions in expenditures resulting from participation of individuals that are attributable to the medical home shall be paid to the medical home. • The target will be reductions in the occurrence of health complications, hospitalization rates, medical errors, and adverse drug reactions.

37. American Academy of Family Physicians (AAFP) $8 million practice redesign initiative Started in 2006

38. American Academy of Family Physicians (AAFP) (cont.) • TransforMED is a new model with these core elements: • Patient-centered care • Electronic medical records • Team approach to care • Open access for patients • Focus on quality and safety

40. The Patient Centered Primary Care CollaborativeMajor Employers (50 million employees), Consumers and Physicians (330,000) Unite to Revolutionize the Healthcare System

41. The Problem • Employers want to buy high quality healthcare for their employees • Employers cannot buy the model of care they want for their employees • The reimbursement system is inadequate, the IT is insufficient, the accountability and incentives are not in place • This is why we created the PCPCC and want change

42. So we built a team, got together with the providers, patients and the payers, discussed what we want to buy, and set out forming a collaborative to design and implement a new system – one that focuses on primary care and the medical home.

43. Patient-Centered Primary Care Collaborative (PCPCC) • Discussion focused on the Patient-Centered Medical Home (PC-MH) • Models: Medical home pilot study in North Carolina and IT Denmark • Commonwealth Fund’s patient-centered care initiative • How to qualify physician practices and strategies for redesigning the healthcare payment system • Paul Grundy MD, FACPM, FACOEM

44. The Commonwealth FundCommission on a High Performance Health System Public Views on Shaping the Future of the U.S. Health System

45. Public Views • Many had recent experiences or heard of wasteful, inefficient, or unsafe care • Common belief that expanded use of information technology, care teams, and improved delivery of preventive services could improve the quality of care

46. Medical Home Act of 2007Senators Durbin and Burr • Methods to Increase: • Cost efficiencies of health care delivery • Access to appropriate health care services • Patient satisfaction • School attendance • Quality of health care services provided • Methods to Decrease: • Inappropriate emergency room utilization • Duplication of health care services • Methods to provide appropriate: • Preventive care • Referrals to multidisciplinary services

47. Medical Home Act of 2007Project Design • 3-year duration, beginning by October 1, 2009 • Conducted in 8 states, 4 of which have primary care case management services • Voluntary participation • Each enrollee will have a medical home with access to appropriate medical care, being supervised by their personal physician

48. Medical Home Act of 2007 Care Coordination –The demonstration will follow a physician directed care coordination model similar to the highly successful NC Medical Home model. • Uses health information technology (including patient registry systems, clinical decision support tools, remote monitoring, and electronic medical record systems) • Communicates with physician practices and other health care providers • Establishes networks with community practices, hospitals, community health care providers, and local public health departments • Acts as a facilitator in order to ensure that patients receive high-quality care at the appropriate time and place in cost-effective manner • Hires primary care case managers to assist with care coordination

49. Medical Home Act of 2007Payment • Payment rate higher than the rate the State would otherwise pay for services delivered through the personal primary care provider under Medicaid or SCHIP • Payment for performance-based results to recognize achievement of defined quality and efficiency goals

50. Medical Home Act of 2007Evaluation and Report • The Secretary will evaluate the project in order to determine the effectiveness of patients-centered medical homes in terms of : • Quality improvement • Patient and Provider satisfaction • Improvement of health outcomes • Secretary then submits a report to Congress