Nancy L. Swigonski, MD, MPH Department of Public Health and Children’s Health Services Research...

Nancy L. Swigonski, MD, MPH

Department of Public Health and

Children’s Health Services Research

nswigons@iupui.edu

Medical Home– Premise, Promise, Pitfalls and

Possibilities

COI, Acknowledgements• No conflict of interest• Acknowledgements Indiana’s Community Integrated

Systems of Services (CISS) Project Team• Dr. Judy Ganser• Kim Minniear• Mary Jo Paladino• Angela Paxton• Dr. Mary Ciccarelli• Rylin Rodgers• Rebecca Kirby• Meredith Edwards• Dr. Deborah Allen• Dr. Sarah Stelzner

Overview: Medical Home – Premise, Pitfalls, Promise and Possibilities

• Premise that health care in crisis• Pitfalls in primary care• Promise of health care reform• Possibilities of Medical Home• Indiana Medical Home Learning Collaborative

Rising and High Costs

Quality Markers and Outcomes

Premise Our Health Care in Crisis

N.L. Swigonski, MD, MPH

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Average spending on healthper capita ($US PPP*)

Total expenditures on healthas percent of GDP

Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

88 8489 89

99 9788

109 106116 115 113

130134

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

150 1997/98 2002/03

Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.See report Appendix B for list of all conditions considered amenable to health care in the analysis.Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008).

Mortality Amenable to Health Care

Ambulatory Care–Sensitive (Potentially Preventable) Hospital Admissions for Select Conditions

U.S.Average

Top 10%states

Bottom 10%states

U.S.Average

Top 10%states

Bottom 10%states

2002/2003^ 2004

Adjusted rate per 100,000 population

U.S.Average

Top 10%states

Bottom10% states

Diabetes*Heart failure Pediatric asthma

Why Primary Care?• Adults with PCP rather than specialists as their personal physician

– 33% lower annual adjusted cost of care– 19% lower adjusted mortality

Adjusted for age, gender, income, insurance, smoking, perceived health (SF-36) and 11 major health conditions Franks, 1998

• Increased primary care to population ratios are associated with reduced hospitalization rates for 6 ambulatory care sensitive conditions Parchman, 1994

• Health care costs are higher in regions with higher ratios of specialists to generalists Welch, 1998

• Primary care physician supply associated with improved health outcomes, including all-cause, cancer, heart disease, stroke, infant mortality; low birth weight; life expectancy; and self-rated health

Macinko, 2007

Distribution of 10-Year Impact on Spending from Strengthening Primary Care & Care Coordination

-$193.5

-$156.9

-$4.1-$23.4

Systemwide Federal

State and

Local Gov't

Private

Households

Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.

Dollars in billions

"Primary care is the canary in the mine of the broken US health care system"

Kurt Stange, M.D., Ph.D., Professor of family medicine, epidemiology and biostatistics, sociology and

oncology Case Western Reserve University

Pitfalls in Primary Care

Active Primary Care Physicians / 100,000 Population, 2008

AAMC 2009 State Physician Workforce Data Bookhttps://www.aamc.org/download/47340/data/statedata2009.pdf

Primary Care in Crisis

Percentage of Positions Filled With US Seniors vs Mean Overall Income By Specialty

Ebell, M. H. JAMA 2008;300:1131-1132

Graduating medical students faced with repaying loans of averaging over $100,000 are be more inclined to enter a higher-paying specialty.

Shortage of Primary Care Physicians Fostered by Current Payment System

• Fee-for-service – pays based on volume of care – provides financial incentives to perform more

procedures • Rather than “cognitive” services such as providing

counseling, diagnosis and chronic condition management

• Results in a wide income disparity between primary care and specialty care

Shortage of Primary Care Physicians Fostered by Current Payment System

• Primary care doctors increase volume to make ends meet – medical students perceive the lifestyle associated with primary care

physicians as unfavorable – requires more hours and less predictability than specialties

• Low job satisfaction– enter the field with the goal of forming long-term relationships and

coordinating care for patients – instead find back-to-back appointments, long hours, burdensome

paperwork – frustration and stress on the part of patient and doctor

Halsey, A. June 20, 2009. Primary Care Shortage May Undermine Reform Efforts. Washington Post.

Hauer, K. et al. September 2008. Factors Associated With Medical Students' Career Choices Regarding Internal Medicine. JAMA,

300:1154-1164.

Immunizations for Young Children

Vaccines: 4 doses of diphtheria-tetanus-pertussis (DTP), 3+ doses of polio, 1+ dose of measles-mumps-rubella, 3+doses of Haemophilus influenzae type B, and 3+ doses of hepatitis B. National Immunization Survey (NCHS National Immunization Program, Allred 2007).

Percent of children (ages 19–35 months) who received all recommended doses of five key vaccines*

73 74 7579 81 81 8182 80

8489 88 88 86

66 66 6571 72 71 72

2000 2001 2002 2003^ 2004 2005 2006

U.S. average Top 10% states Bottom 10% states

By Family Income, Insurance Status**, and Race/Ethnicity, 2006

0 25 50 75 100

Uninsured all year

Insured part year

Insured all year

100%+ of poverty

<100% of poverty

Hispanic

National Average and State Distribution

3–5 physicians32%

2 physicians14%

Solo practice32%

11 or more physicians

6–10 physicians15%

Distribution of Primary Care Physicians, by Practice Size (number of physicians)

T. Bodenheimer and H. H. Pham, “Primary Care: Current Problems and Proposed Solutions,” Health Affairs, May 2010 29(5):799–805.

Effectiveness of Knowledge Translation / Implementation Interventions

Little or no effect• Educational materials• Didactic educational meetings

Sometimes effective• Audit and feedback• Local opinion leaders• Local consensus processes• Patient mediated interventions

Heath I, Rubinstein A, Kurt C Stange KC, vanDriel ML Quality in primary health care: a multidimensional approach to complexity. BMJ 2009; 338:b1242

Promise of Health Care Reform

What does Health Care Reform do?Primary Care Training and Incentives

• Establishes a workforce commission to study additional training for primary care

• Provides loan forgiveness for primary care providers who work in underserved areas

• Provides a new graduate medical education funding stream for teaching health centers

• Reauthorizes Title VII Health Professions Programs

• Redistributes residency slots with priority for primary care and general surgery, states with low physician-to-resident ratios, and rural areas

• Increases funding for the National Health Service Corps

• Primary care physicians will get a 10% bonus for Medicare services (2011 -2016)

• Medicaid payments for primary care services increase to be at least equal to Medicare payments (2013-2014)

• An Independent Payment Advisory Board starting will recommend Medicare spending reductions to Congress (2014)

• Pilot programs with emphasis on quality measurement and paying for value instead of volume i.e., Medicare and Medicaid patient-centered medical home pilots

• Grants/contracts to support medical homes through:– Community Health Teams increasing access to coordinated care– Community-based collaborative care networks for low-income

populations– Primary Care Extension Center program providing technical assistance

to primary care providers

What does Health Care Reform do?Payment and Practice Reform

Possibilities of Implementation

“The Medical Home is the model for 21st century primary care,

with the goal of addressing and integrating high quality

health promotion, acute care and chronic condition management in a planned, coordinated and

family-centered manner.”

American Academy of Pediatric www.pediatricmedhome.org/

Medical Home as an AAP Priority

[Medical Home]…among the most promising delivery system reforms

• Bending cost curve• Improving patient outcomes

Congressional Budget Officewww.cbo.gov/doc.cfm?index=9925

“I support the concept of a patient-centered medical home, and as part of my health care plan, I will encourage and provide appropriate payment for providers who implement the medical home model, including physician-directed, interdisciplinary teams, care management and care coordination programs, quality assurance mechanisms, and health IT systems which collectively will help to improve care.”

President Barack Obama

AAP, AAFP, ACP, AOA2007 Joint Principles of the Patient-Centered Medical Home (PCMH)

• Personal physician• Physician directed medical practice• Whole person orientation• Care is coordinated and/or integrated• Quality and safety are hallmarks of a medical home• Enhanced access to care• Payment appropriately recognizes the added value

Is This Really Going to Work?

Knowing is not enough we must apply;Willing is not enough, we must do.

Goethe

Building Quality Into RIte CareHigher Quality and Improved Cost Trends

• Quality targets and $ incentives• Improved access, medical home

– Tripled primary care doctors– Doubled clinic visits– One third reduction in hospital

and ER• Significant improvements in prenatal

care, birth spacing, infant mortality, preventive care

Silow-Carroll, Building Quality into RIte Care, Commonwealth Fund, 2003. Leddy T, Outcome Update, Presentation at Princeton Conference, May 20, 2005.

RI Commercial TrendRIte Care Trend

Cumulative Health Insurance Cost Trend

Comparison

Percent

Group Health PCMH Design Principles

1. The relationship between the primary care physician and patient is at the core. The organization will align to promote and sustain this relationship.

2. The primary care physician will be the leader of the clinical team, be responsible for coordination of services, and will collaborate with patients in care planning.

3. Continuous healing relationships will be proactive and encompass all aspects of health and illness. Patients will be actively informed and encouraged to participate.

4. Access will be centered on patients’ needs, be available by various modes 24/7, and maximize the use of technology.

5. Clinical and business systems will align to achieve the most efficient, satisfying, and effective patient experiences.

Reid RJ, et al. Patient-Centered Medical Home Demonstration: A Prospective, Quasi-Experimental, Before and After Evaluation. American Journal of Managed Care; Sept 2009

• Structural and Team Changes– Smaller physician rosters – Longer standard visits time– Physician/medical assistant pairing – Automated phone call routing system– Team member colocation – Dedicated “desktop medicine” time

• Point-of-Care Changes– Communication of team roles to patients – Motivational interviewing techniques– Previsit chart review and visit planning – Promotion of e-mail and phone visits – EMR “best practice alerts” and “health maintenance reminders”– Real-time specialist consulting via EMR – Promotion of patient Web portal functions– Collaborative care planning

Group Health PCMH Changes

• Patient Outreach Changes– New patient outreach – Mailed “birthday reminder” care letters– Emergency visit and inpatient follow-up – Abnormal test outreach– Chronic disease medication outreach – Promotion of e-HRA– Outreach using care deficiency reports – Promotion of self-management workshops– Group visit outreach

• Management Changes– Daily care team huddles – Rapid process improvement cycles– Visual reporting system to track changes – Salary-only physician compensation

Group Health PCMH Changes

• Improved patients’ experiences, quality, and clinician burnout through two years

• Compared to other Group Health clinics, patients in the medical home experienced– 29 percent fewer emergency visits and – 6 percent fewer hospitalizations

• Total savings of $10.3 per patient / month after 21 months into the pilot

The Group Health Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers

Reid, et al. HEALTH AFFAIRS 29,5 (2010): 835–843

Nancy Swigonski, MD, MPH

Review of Successful PCMH Demonstrations - Four Factors Essential • “Significant value” i.e., 10% improvement in quality or cost

Hospitalization reduction (%)

ER visit reduction (%)

Total savings per patient ($)

Colorado 18 -- 169–530Geisinger 15 -- --Group Health 11 29 71Intermountain 4.8–19.2 0–7.3 640North Carolina 40 16 516North Dakota 6 24 530Vermont 11 12 215

Fields D, Leshen E, Patel K. Driving Quality Gains and Costs Savings Through Adoption of Medical Homes. Health Affairs. 2010;29(5):819-826

Review of Successful PCMH Demonstrations - Four Factors Essential

• Primary Care• Dedicated care managers• Expanded access• Performance management tools• Effective incentive payments

Fields D, Leshen E, Patel K. Driving Quality Gains and Costs Savings Through Adoption of Medical Homes. Health Affairs. 2010;29(5):819-826

Two Major Practice Demonstrations

TransForMed

Academy of Family Physicians

Medical Home Learning Collaborative

Results from the AAFP National Demonstration Project - TransForMed

• 36 family practices - facilitated or self-directed• PCMH was measured

– Number of NDP model components practices adopted – Repeated cross-sectional surveys and medical record

audits at baseline, 9 months, and 26 months: • Patient-rated outcomes -core primary care attributes, patient

empowerment, general health status, and satisfaction• Condition-specific outcomes were measures of the quality from

Ambulatory Care Quality Alliance • Receipt of clinical preventive services and chronic disease care

"Evaluation of the American Academy of Family Physicians' Patient-Centered Medical Home National Demonstration Project," Annals of Family Medicine

• Practices adopted ~10 (primarily technologic) components

over 26 months • Facilitated practices adopted more new components on

average than self-directed practices (10.7 vs 7.7, P=.005). • ACQA scores improved in both groups (~8.5%)• Chronic care scores improved in both groups (~5%) • No improvements in patient-rated outcomes or primary care

attributes

CONCLUSIONS

“After slightly more than 2 years, implementation of PCMH components, whether by facilitation or practice self-direction, was associated with small improvements in condition-specific quality of care but not patient experience. PCMH models that call for practice change without altering the broader delivery system may not achieve their intended results, at least in the short term.”

Medical Home Learning Collaboratives

Average Medical Home Index Scores

12345678

Pre-Collaborative

Post-Collaborative

Parents in MHLC Reported Fewer ER Visits and Fewer Unplanned Hospitalizations

Measure 1: ED Visits

Apr May Jun Jul Aug Sep Oct

average

median Measure 2: Unplanned Hospitalizations

Apr May Jun Jul Aug Sep Oct

average

median

Improved Outcomes Associated With Medical Home Implementation in Pediatric Primary Care

Cooley, et al. Pediatrics 2009;124;358-364

• Higher MHI scores and higher subdomain scores for organizational capacity, care coordination, and chronic-condition management were associated with significantly fewer hospitalizations

• Higher chronic-condition management scores were associated with lower emergency department use

Supported by HRSA/MCHB and ISDH

Community Integrated Systems of Service Grant

Indiana’s Medical Home Learning Collaborative

Dr. Judy GanserKim Minniear

Mary Jo PaladinoAngela Paxton

Dr. Mary Ciccarelli

Rylin RodgersRebecca KirbyMeredith EdwardsDr. Deborah AllenDr. Sarah Stelzner

PEDIATRIC PRACTICESBlackburn Health Center Clarian Arnett Healthnet Pediatric Adol. Center Linwood Health Center Pecar Health Center Meridian Pediatrics Riley Hospital MSA 1 St. Vincent Pediatric Primary Care Wishard Primary Care

FAMILY MEDICINE Ball Memorial Hospital Foundations Family MedicineRidge Medical CenterSt. Vincent Faculty PracticeSt. FrancisSt. V’S Family Medicine Residency St. Vincent Physician NetworkBohon/Craton, MDLira, MDShipshewana Family Medicine

Medical Home Learning Collaborative

• Three year Indiana Community Integrated Systems of Services (IN CISS) grant – Begun in October 2009 kick off meeting including

pediatric and family medicine– Nine in first year 2009– Nine more joined in October 2010

• Diverse in size, demographics, location and culture • All using the same method of implementing Medical

Home in their practices, AAP’s Medical Home Tool Kit http://www.pediatricmedhome.org/

Family Medicine and Pediatric practices learning from each other

Rural vs. Urban location

Medical Home Toolkit – What does it take to build a medical home?

1. Commit to being a medical home

2. Assess your current performance

3. Engage parent and family partners

4. Assign a care coordinator

5. Establish a registry

6. Begin pre planned visits and

care planning

The MHLC structure

• Bi-weekly Conference Calls• Face to face site visits every 8-12 weeks• Annual Spring and Fall Meetings

Conference Call Topics• Updates• Huddles • Quality Improvement Team Meetings• Pre-planned Visits• Improved Access• Buy-In to Medical Home• National Committee for Quality Assurance (NACQ)

Standards• Electronic Health Records – Meaningful Use• Registries• Family / Parent Partner Recruitment and Involvement• Medical Home Billing Codes

Number of Family / Parent Partners

July August September October November December0

AAP National Center for Medical Home Implementationand Center for Medical Home Improvement-

Building Your Medical Home ~ Toolkit ~

Supports your development and/or improvement of a pediatric Medical Home.

Prepares you to apply for and potentially meet the National Committee for Quality Assurance (NCQA) Physician Practice Connections® Patient Centered Medical Home (PPC-PCMHTM) Recognition program requirements.

Offers capacity to chart progress

Web site: http://www.pediatricmedhome.org

l Start Building Your Medical Home

1. Care Partnership Support

2. Clinical Care Information

3. Care Delivery Management

4. Resources & Linkages

5. Practice Performance Measurement

6. Payment & Finance

l Medical Home Standards - What is NCQA and How Does it Impact Your Practice?

l Quality Improvement Basics - Your Medical Home: Well Designed Using a Quality Improvement Process

l Progress Summary

Toolkit Building Blocks

Tracking Your Progress

Reviewing your Notes and Action Steps

• Review triage and scheduling processes for relevancy to needs of CSHCN.

• Research development of a practice website

• Identify language support services and informational materials for Spanish-speaking families

4376 clinicians*892 practices*

Indiana 32 clinicianshttp://recognition.ncqa.org/PSearchResults.aspx?state=IN&rp=5

Comparison of PPC-PCMH & PCMH 2011 PPC-PCMH (9 standards/30 elements)

1. Access and Communication– Processes – Results

2. Patient Tracking and Registry Function

3. Care Management– Continuity Between Settings

4. Self-Management Support

5. Electronic Prescribing

6. Test Tracking

7. Referral Tracking

8. Performance Reporting and Improvement– Measures of Performance– Patient Experience

9. Advance Electronic Communication

PCMH 2011 (6 standards/25 elements)

1. Access and Continuity – Access– Electronic Access– Continuity– Medical Home Responsibilities– Practice Organization

2. Identify/Manage Patient Populations

3. Plan/Manage Care– Care Management – Medication Management

4. Self-Management Support

5. Track and Coordinate Care– Test/Referral Tracking– Facilities– Community

6. Performance Measurement and Quality Improvement– Measures of Performance– Patient Experience– Quality Improvement

PCMH 2011 Overview (6 standards/24 elements)

1. Access and Continuity A. Access During Office Hours

B. Access After Hours

C. Electronic Access

D. Continuity (with provider)

E. Patient/Family Partnership

F. Culturally/Linguistically Appropriate Services

G. Practice Organization

2. Identify/Manage Patient PopulationsA. Basic Data

B. Searchable Clinical Data

C. Comprehensive Health Assessment

D. Using Data for Population Management

3. Plan/Manage CareA. Guidelines for Important Conditions

B. Care Management

C. Medication Management

D. Electronic Prescribing

4. Self-Management Support A. Self-Care Process

5. Track/Coordinate CareA. Test Tracking and Follow-Up

B. Referral Tracking and Follow-Up

C. Coordination with Facilities/Care Transitions

D. Referrals to Community Resources

6. Performance Measurement /Quality ImprovementA. Measures of Performance

B. Patient/Family Experience

C. Reporting Performance

D. Quality Improvement

E. Electronic Reporting

Optional Patient Experiences

Recognition Programs for PCMH Developed or Under Development

Quality Organizations PCMH Standards Activity

Resources

Patient Centered Primary Care Collaborative (PCPCC)• Organizations representing over 350,000 physicians

—including ACP and other primary care societies, American College of Cardiology, American Academy of Neurology

• Organizations representing over 50 million employees, including large employer umbrella groups, and individual companies such as IBM, General Motors

• All major health plans• CVS Caremark, including MinuteClinic• Consumer organizations including AARP• Bridges to Excellence• National Association of Community Health Centers

The Patient Centered Primary Care Collaborative

(PCPCC), which formed in 2007, has

over 700 member organizations

PCPCC organizations attest to their support of the PCMH

Joint Principles, including the belief that the PCMH will

“improve health of patients and the viability of the health

delivery system,” and support a better payment model to facilitate implementation

www.pcpcc.net

Provides consultation for primary care medical home development and transformation.

TAPPP (Team, Access, Population, Planned and Patient/family centered) measures practice capacity and offers individualized support (arranged and delivered via phone, web, on-site/face to face, e-mail) to improve "medical homeness”

http://www.medicalhomeimprovement.org

Center for National Medical Home Improvement

American Academy of Family Physicians

Conclusions

Medical Home = 21st Century Primary Care

• Premise that change is necessary

“The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”

Crossing the Quality Chasm, IOM

Medical Home = 21st century primary care

• Pitfalls of primary care = pitfalls of Medical Home

– Workforce – shortages and mal-distribution– Inequities in payment– Focus on volume not quality– Cottage industries– Limited bandwidth & proven methods for change

• Promise of support through health care reform– Primary care training– Workforce distribution and incentives– Payment for primary care– Test models– Technical assistance

• Possibilities– Business model to bend cost curve down and

quality curve up• Integrated delivery system with medical home as foundation to

DECREASE hospitalizations, decrease emergency room visits • Co-management with subspecialist

– Change in culture• Practice level with true system change• Hospitals, payors• Consumers - public health perspective -- more is not better,

prevention not treatment

Nancy L. Swigonski, MD, MPH

Department of Public Health and

Children’s Health Services Research

nswigons@iupui.edu

Medical Home– Premise, Promise, Pitfalls and

Possibilities

Payment and ACOs

Figure 6. Support for Primary Care Foundation for ACOs

“Some experts have advocated requiring a strong primary care foundation for Accountable Care Organizations (ACOs). Please indicate the degree to which you support or oppose establishing

standards for primary care capacity as a condition for qualifying for ACO payment.”

Strongly support

Strongly oppose

Support31%

Neither support nor oppose

Oppose7%

Not sure1%

* Percentages may not be equal to 100 percent because of rounding.Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, July 2010.

UK NZ AUS NET GER CAN US

Percent reporting any financial incentive*

Primary Care Doctors’ Reports of Any Financial Incentives Targeted on Quality of Care

* Receive or have potential to receive payment for: clinical care targets, high patient ratings, managing chronic disease/complex needs, preventive care, or QI activities

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Timeline for Implementation of Primary Care Provisions in the Affordable Care Act

2010 2011 2012 2013 2014–2017

• Student loan support to strengthen the health care workforce:

- primary care student loans - nursing student loans - pediatric health care workforce student loans

• Additional funding for Community Health Centers and the National Health Service Corps begins

• Preventive services coverage without cost-sharing

Source: Commonwealth Fund Analysis of the Affordable Care Act (Public Law 111-148 and 111-152).

• Increased Medicare reimbursement (10%) for primary care services

• State option to allow Medicaid beneficiaries with chronic conditions to designate a health home

• Grants to develop community-based collaborative care networks

• Medicare demonstration program to test payment incentives and delivery system models that utilize home-based primary care teams

• Medicaid primary care provider payment rates set no lower than Medicare rates

• Preventive service coverage for adult Medicaid beneficiaries without cost-sharing increases federal Medicaid assistance percentages

• Grants for states to establish primary care extension centers

• Qualified health plans offering in the exchanges must include federally qualified health centers in covered networks and reimburse at minimum of Medicaid rates

• HHS grants or contracts to establish community health teams to support patient-centered medical homes

PCPCC Payment ModelMay 2007

Coordination

Office Visits

Performance

Blended Hybrid

Payment Model

(expanding upon the existing fee-for-service paradigm)

Key physician and practice accountabilities/ value added

services and toolsProactively work to keep patients healthy and manage existing illness or conditions

Coordinate patient care among an organized team of health care professionals

Utilize systems at the practice level to achieve higher quality of care and better outcomes

Focus on whole person care for their patients

Incentiv

Incentives

Nancy L. Swigonski, MD, MPH Department of Public Health and Children’s Health Services Research...

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