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Patient-Centered Medical Homes:
Transforming the
U.S. Health System
Marci Nielsen, PhD, MPH Executive Director
The Patient-Centered Medical Home (PCMH)
§ Why?
§ What?
§ When?
§ Where?
§ Who?
2
Why?
3
Health care expenditure per person by source of funding, 2007*
3,3074,005
2,618 2,726 2,844 2,7582,124 2,446
2,056
3,092
449 589 510 360
441
890
720
1,350 580 246 470528
571542
2,716
38
8820479 343
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
US NOR SWITZ CAN FR GER SWE AUS* UK ITA
Out-of-pocket spendingPrivate spending Public spending
* 2006 Source: OECD Health Data 2009 (June 2009), Commonwealth Fund
Dollars *Adjusted for Differences in Cost of Living
4
Source: Congressional Budget Office, “The Long Term Budget Outlook”, August 2010
Cost of health care by government
5 5
Conservatively, 30% of the annual $2.5 trillion U.S. health expenditure is estimated to be waste, equating to approximately $700B each year.
Key sources of waste1
% of total medical cost that is waste
Admin and system
Provider inefficiencies
Lack of care coordination
Unwarranted
Preventable conditions and avoidable care
Fraud and abuse
4 - 6%
3 - 4%
1 – 2%
11 - 21%
1 - 2%
5 - 8%
~30%
1Thomson Reuters, 2011
Cost of health care “waste”
6
Need for Better Value
7
Solutions point to primary care
Significant problems
Rising healthcare costs à $2.4 trillion (17% of
GDP)
Gaps/variations in quality and safety
Poor access to PCPs
Below-average population health
• PPACA and ARRA legislation • Value-based reimbursement • PCMHs • ACOs • EHR/HIE investment • Disease-management pilots • Alternative care settings • Patient engagement • Care coordination pilots • Health insurance exchanges • Top-of-license practice
… Experiments underway
Across 300+ studies, better
primary care has proven to increase quality and curtail
growth of healthcare costs
… Primary care-centric projects
have proven results
↑ Aging population Chronic disease
8
What?
9
Definition of PCMH
10
Comprehensive team-based care
Patient-centered orientation
Care that is coordinated
Superb access to care
Systems approach to quality and
safety
Source: www.ahrq.gov
A Change in Paradigm
Today Future
Treating Sickness / Episodic Managing Population
Fragmented Care Collaborative Care
Specialty Driven Primary Care Driven
Isolated Patient Files Integrated Electronic Record
Utilization Management Evidence-Based Medicine
Fee for Service Shared Risk/Reward
Payment for Volume Payment for Value
Adversarial Payer-Provider Relations
Cooperative Payer-Provider Relations
“Everyone For Themselves” Joint Contracting 11
Standards for PCMH p National Committee on Quality Assurance (2008)
n Practice level recognition; data used by payers
p Joint Commission (2011) n Primary Care Medical Home certification
p URAC (2011) n Patient Centered Health Care Home Practice
Achievement accreditation n Health plan focused
p Accreditation Association for Ambulatory Health Care (2011) n Ambulatory care focused 12
©2012 Foley & Lardner LLP
13
2011 NCQA PCMH Content and Scoring
Standard 1: Enhance Access and Continuity A. Access During Office Hours** B. After-Hours Access C. Electronic Access D. Continuity E. Medical Home Responsibilities F. Culturally and Linguistically Appropriate
Services G. Practice Team
Pts 4 4 2 2 2 2 4
20
Standard 2: Identify and Manage Patient Populations
A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. Use Data for Population Management**
Pts 3 4 4 5
16
Standard 3: Plan and Manage Care A. Implement Evidence-Based Guidelines B. Identify High-Risk Patients C. Care Management** D. Medication Management E. Use Electronic Prescribing
Pts 4 3 4 3 3
17
Standard 4: Provide Self-Care Support and Community Resources
A. Support Self-Care Process** B. Provide Referrals to Community Resources
Pts 6 3
9
Standard 5: Track and Coordinate Care A. Test Tracking and Follow-Up B. Referral Tracking and Follow-Up** C. Coordinate with Facilities/Care Transitions
Pts 6 6 6
18
Standard 6: Measure and Improve Performance A. Measure Performance B. Measure Patient/Family Experience C. Implement Continuously Quality
Improvement** D. Demonstrate Continuous Quality
Improvement E. Report Performance F. Report Data Externally G. Use of Certified EHR Technology
Pts 4 4 4 3 3 2 0
20
**Must Pass Elements
www.ncqa.org
Health IT Infrastructure
PCMH and Accountable Care: Two Sides of the Same Coin
Accountable Care
PCMH
PCMH
PCMH
PCMH
PCMH Hospitals
Public Health
Shared Services Care Coordination
Care Managers Specialists
14
HIT Infrastructure: EHRs and Connectivity
Primary Care Capacity: Patient Centered Medical Home
Operational Care Coordination: Embedded RN Coordinator and Health Plan Care Coordination $
Value/ Outcome Measurement: Reporting of Quality, Utilization and Patient Satisfaction Measures
Value-Based Purchasing: Reimbursement Tied to Performance on Value Supportive Base for ACOs, PCMH Networks, and Bundled Payments
Trajectory to Value-Based Purchasing It is a journey, not a fixed model of care
15 Source: Taconic Health Information Network & Community, 2010
When?
16
Medical Home Term in Standards of Child Health Care by Council on . Ped. Prac5ce
Alma Alta Declara5on
Surgeon General Koop’s Conf. Report: MH for CSHCN
PCPCC Founded
Medical Home and Hawaii Child Health
Plan (Calvin Sia, MD)
Future of Family Medicine
ACP & Advanced
Medical Home
1989 1967
1967-‐2006 Milestones in PCMH Development
1978 1979 2004 2002 2006
AAFP & TransforMED
17
Joint Principles of PCMH
NCQA PCMH Standards
and Recogni5on
2008
2006-‐Present Milestones in PCMH Development
2007 2010. 2012
Commonwealth Fund PCMH Programs
State & Local PCMH
Pilots
Affordable Care Act Wellpoint
PCMH Na5onal Launch
Na5onal Business Group on Health Award
18
Shift to Accountable Care
p Some people are watching and waiting…
p Some people just putting a toe in…
p Some people diving in head-first.
p Some people are taking laps… p Some people have taken the deep
plunge.
19
Where?
20
PCMH Initiative
Health Care Cost & Acute Care Service
Measures
Health Outcomes & Quality of
Care Measures Horizon Blue Cross Blue Shield of New Jersey (2012)
• 25% fewer inpatient hospital admissions
• 26% fewer ED visits
• Improved diabetes control by 8%
• Screenings for breast and cervical cancer also increased by 6%.
Group Health Cooperative in Seattle
• 29% fewer ED visits • 6% fewer inpatient
hospitalizations • Savings of $10.3 per patient
per month after 21 months
• Clinical quality (HEDIS) measure improvements ranged from 30-40%
Geisinger (2012) • 25% fewer hospital readmissions
• 53% fewer readmissions • Estimated return on
investment of 2:1
• Improved quality of preventive care (74%), coronary artery care (22%), and diabetes care (34.5%)
21
PCMH Initiative
Health Care Cost & Acute Care Service
Measures
Health Outcomes & Quality of
Care Measures Vermont Blue Print for Health (2011)
• Lower inpatient admissions (range of 39.7 % to 15.3%)
• Lower ED admissions (range 33.8% to 2.8%)
• Increase in visits for chronic care & behavioral health
CareMore (2011) Medicare Advantage (California)
• 24% lower inpatient admission rates (compared to Medicare average)
• 15% reduction in overall health care costs
• 97% patient satisfaction • Hospital stays 38%
shorter • Amputation rate for
diabetics 60% lower
Pediatric Alliance for Coordinated Care (Boston)
• Reduction of inpatient hospitalization from 57.7% to 43.2% (post implementation)
• Reduction of parents’ missed work(>20 days) from 26% to 14%
• Increased satisfaction with health care delivery (68.4% easier to talk with same nurse, 60.9% easier to talk with doctor, 60.5% easier to get access)
22
Robust State/local PCMH Activity
p 42 Medicaid programs and numerous local/regional activities
p State maps: p NASHP
n http://www.nashp.org/med-home-map
p AAP n http://
www.medicalhomeinfo.org/state_pages/ 23
Commercial Insurance PCMH Buy-In
n Wellpoint p Nationwide roll-out
n BlueCross BlueShield p 39 states participating in PCMH initiative
n Aetna p CT, NJ – plans to go nationwide
n Humana p 10 states
n UnitedHealthcare p Value-based purchasing for 50-70% of their market
24
* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care. Base: Has chronic condition. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Patient Engagement in Care Management for Chronic Condition
25
Percent reporting positive patient Engagement in managing chronic condition*
25
Percent reporting positive doctor–patient relationship and communication*
Doctor–Patient Relationship and Communication
* Regular doctor always/often: spends enough time with you, encourages you to ask questions, and explains things in a way that is easy to understand. Base: Has a regular doctor/place of care. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
26
Who?
27
Patient = Consumer = Voter
28 IOM (2002); modified from Dahlgren and Whitehead (1991)
29 29
The Patient-Centered Primary Care Collaborative
p Mission is to advance effective and efficient health system built on a strong foundation of primary care and patient-centered medical home (PCMH).
p 1,000 members and growing; began with primary care physician associations and large employers, supported by leadership of IBM.
p Joint Principles feature prominently – AAFP, AAP, ACP, and the AOA. 30
Paul Grundy, MD
31
Campaigning for the PCMH
32 32
PCPCC Re-Org Chart
Board of Directors
Patient, Family & Consumer
Center
Care Delivery Reform Center
Employer & Purchaser
Engagement Center
Advocacy & Policy Action
Center
Outcomes & Evaluation
Center
Special Interest Groups
Event Planning (Annual Mtgs) Taskforces Publications
Finance Committee
Operations Committee
Executive Committee
Role of The Collaborative
33
p Lead from the front n Challenge the status
quo n Drive the marketplace n Disseminate timely
information n Provide networking &
educational opportunities
Examples of PCPCC Resources
34
Value-Based Insurance Design
IT Guide Purchaser Guide
Consumer Guide
Source: PCPCC (www.pcpcc.net)
Medication Management Guide
Payment Reform Guide Participatory Engagement Guide
PCMH – Evidence of Quality
Practice Transformation Guide
Care Coordination Guide
Short video to describe PCMH
http://www.pcpcc.net/consumers-and-patients
36