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Patient-Centered Medical Homes: Transforming the U.S. Health System Marci Nielsen, PhD, MPH Executive Director

Marcia Nielsen

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Page 1: Marcia Nielsen

Patient-Centered Medical Homes:

Transforming the

U.S. Health System

Marci Nielsen, PhD, MPH Executive Director

Page 2: Marcia Nielsen

The Patient-Centered Medical Home (PCMH)

§  Why?

§  What?

§  When?

§  Where?

§  Who?

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Page 3: Marcia Nielsen

Why?

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Page 4: Marcia Nielsen

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

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Page 5: Marcia Nielsen

Source: Congressional Budget Office, “The Long Term Budget Outlook”, August 2010

Cost of health care by government

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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”

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Need for Better Value

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Page 8: Marcia Nielsen

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

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What?

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Definition of PCMH

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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

Page 11: Marcia Nielsen

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

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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

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©2012 Foley & Lardner LLP

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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

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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

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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

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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

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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

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**Must Pass Elements

www.ncqa.org

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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

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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

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When?

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Page 17: Marcia Nielsen

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  

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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  

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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.

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Where?

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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%)

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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)

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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

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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

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* 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

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Percent reporting positive patient Engagement in managing chronic condition*

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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.

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Who?

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Patient = Consumer = Voter

28 IOM (2002); modified from Dahlgren and Whitehead (1991)

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29 29

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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

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Campaigning for the PCMH

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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

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Role of The Collaborative

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p  Lead from the front n Challenge the status

quo n Drive the marketplace n Disseminate timely

information n Provide networking &

educational opportunities

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Examples of PCPCC Resources

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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

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Contact Information

www.pcpcc.net Marci Nielsen, PhD, MPH

Executive Director [email protected]

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Short video to describe PCMH

http://www.pcpcc.net/consumers-and-patients

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