Post on 20-Jun-2020
Paul Grundy, MD, MPH, FACOEM, FACPM IBM Director Healthcare Transformation
President Patient Centered Primary Care Collaborative
PCMH Level Care 2011
-participant will understand/be able to discuss the important trend
of PCMH in health care
-participant will understand/be able explore the rationale and
supporting evidence for PCMH
- participant will understand/be able understand the impact on
patients, providers and payers
Disclosure:
– I am a full time Emplyee of IBM I WILL NOT discuss any
pharmaceuticals, medical procedures, or devices
I have gratefully had my expenses covered to do some of my talks
about PCMH by Merck, and Pfizer.
Course Objectives
Who was the
Shooter’s Doctor? Away from Episodes of Care - FFS
Population
management !!
Accountability !!
The Cause? Mostly due to unregulated fee-for-service payments and an over reliance on rescue/specialty care. This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the nation's poor performance are not to blame - it is the failure of the deliver system!!”
- Unaccountable Care Organizations
* Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010
Dubuque, Iowa
USA 2011 Pennsylvania
The Quaker State Pennsylvania is above the national average on Health Care on
a per capita basis
Ranks 38 (New York is last 50th) of 50 for all states for avoidable hospital use and costs.
Real Transformation must
be pursued in collaboration
across the buyers and payers
Employers, State, CMS, Medicaid.
Change of convenient between
buyers and providers
Animated Short: The Amazing Health Care Arms
Race
http://www.publicradio.org/columns/marketplace/
business-news-briefs/2011/09/oh-the-jobs-youll-
create.html
$10,743
$28,530
+166%
Why Innovate Affordability
Costs continue their upward climb…
…with employers still picking up much of the tab…
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
a - Employer Cost - Employee Payroll Contributions - Employee Out of Pocket Expenses
2001 2009 2019
$4,918
+118%
The Elephant in the room
Slide From Dr Martin Sepulveda
If we truly want to understand costs and where they can be reduced
without compromising outcomes, we need to aggregate costs around
the patient. (need a place to do that – that is PCMH)
The way care is currently organized leads to redundant administrative
costs, unnecessary and expensive delays in diagnosis and treatment,
and unproductive time for physicians.
A system integrator a place where data is aggregated, understood and
held accountable at the level of the individual patient -- THAT IS
PCMH.
In fact, cost reduction will often be associated with better outcomes.
The Big Idea: How to Solve the Cost Crisis in Health Care
by Robert S. Kaplan and Michael E. Porter
Sept 2011 Harvard review
Health care is a business issue, not a
benefits issue
Slide From Dr Martin Sepulveda
OUR IBM Patient needs A long-term comprehensive relationship with a
Personal Physician empowered with the right tools and linked to their care team.
The Joint Principles: Patient Centered Medical Home
Personal physician - each patient has an ongoing relationship with a personal
physician trained to provide first contact, and continuous and comprehensive care
Physician directed medical practice – the personal physician leads a team of
individuals at the practice level who collectively take responsibility for the ongoing
care of patients
Whole person orientation – the personal physician is responsible for providing for
all the patient’s health care needs or arranging care with other qualified
professionals
Care is coordinated and integrated across all elements of the complex
healthcare community- coordination is enabled by registries, information
technology, and health information exchanges
Quality and safety are hallmarks of the medical home-
Evidence-based medicine and clinical decision-support tools guide decision-making;
Physicians in the practice accept accountability voluntary engagement in
performance measurement and improvement
Enhanced access to care is available - systems such as open scheduling,
expanded hours, and new communication paths between patients, their personal
physician, and practice staff are used
Payment appropriately recognizes the added value provided to patients who
have a patient-centered medical home- providers and employers work together to
achieve payment reform
12
Every country starts at the base of the pyramid with
Wellness Prevention primary care, and they work
their way up until the money runs out.
3° Care
1° Care, Wellness
Prevention
2° Care
3° Care
2° Care
1° Care
… “We start
at the top of
the pyramid,
and we work
our way down
until the
money runs
out…And so
we have to
change the
pyramid. We
have to start at
the base.”
What’s
wrong
with this
picture?
And the PLAN is – CPCi by CMMI
Care management: Primary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care.
Access and continuity: Primary care practices must be accessible to patients on a 24/7 basis and be able to utilize patient data tools to give real-time healthcare information to patients in need.
Planned care for chronic conditions and preventive care: Participating primary care practices will deliver intensive care management for the patients with high needs and create a plan of care that fits a patient’s individual circumstances and values.
Patient and caregiver engagement: Primary care practices will have the ability to actively engage patients and their families to participate in their care.
Coordination of care across the medical neighborhood: WELLBY
36.3% Drop in hospital days
32.2% Drop in ER use
-9.6% Total cost (Mayo Zero cost increase)
10.5% Inpatient specialty care costs are down
18.9% Ancillary costs down
15.0% Outpatient specialty down
Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US, K. Grumbach & P. Grundy, November 16th 2010
Smarter Healthcare
2010 2011
Adults (18-64)
ER visits -6.6% -9.9% Primary care sensitive
ER Visits -7.0% -11.4% Ambulatory care
sensitive
Hospitalizations (per
1,000) -11.1% -22.0%
BCBS MA 6% decrees cost (NEJM)
BCBS MI 2670 physician (BIG study)
HEALTH INDUSTRY -- WSJ WellPoint's New Hire.
What Is Watson?
IBM – WellPoint
Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!
Unaccountable care, lack of organization, DO NOT GO THERE ALONE !!
Be wise when you pay for care, KNOW WHAT YOU BUY!!
Least Expensive Most Expensive
Ogden, UT $2,623
Dubuque, IA $2,719
McAllen TX $2,950
Anderson, IN $7,231
Punta Gorda, FL $7,168
Racine, WI $6,528
Providence $6,367
Naples, FL $6,312
Ocean City, NJ $6,128
Cost of Commercial lives
“ We don't have a health care delivery system in this country. We
have an expensive plethora of uncoordinated, unlinked, micro
systems, each performing in ways that too often create sub-optimal
performance, both for the overall health care infrastructure and for
individual patients." George Halvorson, from “Healthcare Reform Now
Coordination -- we do NOT know how to play
as a team
“We do kidney transplants and dialysis more often than anyone,
but we need to, because patients are not given the kind of
coordinated primary care that would prevent chronic
complications of renal and heart disease from becoming acute.”
George Halvorson (CEO Kaiser)
from “Healthcare Reform Now”
Population Health
System Integrator
Patient Experience
The System Integrator
Creates a partnership across the medical
neighborhood
Drives PCMH primary care redesign
Offers a utility for
population health and financial management
Per Capita Cost
Productivity
The Quadruple Aim Readiness, Experience of Care, Population Health, Cost
So simple! So much!
If you scan the world for value based healthcare, you will find a common element: a relationship-based team with a project manager! A comprehensivist that can command and control in an accountable system.
Superb Access to Care
Patient Engagement in Care
Clinical Information Systems
Care Coordination
Team Care
Patient Feedback
Publicly Available Information
Defining the Care Centered on Patient
OPM $39 Billion Book with Accountable Care
Patient at the Center
24-7 clinician phone response
Provide open scheduling.
Provide care management and coordination by specially-trained team members.
Use an EHR with decision support.
Use CPOE for all orders, test tracking, and follow-up.
Medication reconciliation for every visit.
Prescription drug decision support.
Implement e-prescribing.
Pre-visit planning and after-visit follow-up for care management.
Offer patient self-management support.
Provide a visit summary to the patient following each visit.
Maintain a summary-of-care record for patient transitions.
Email consultations.
Telephone consultations.
The development of care plans.
Performance outcome
measures.
Payment reform requires more than one method, you have dials, adjust them!!!
fee for health”
“fee for outcome”
“fee for process”
“fee for belonging
“fee for service”
“fee for satisfaction”
11% CMS Shift in payment away from FFS to other dials. CMS Bundling!! CMS Advanced Primary Care
Wellpoint PCMH, BCBS Hawaii no new FFS $$
CMS Plus most other buyers
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 (quality, appropriate utilization and patient satisfaction)
Achieve Supportive Base for ACOs and Bundled Payments with Outcome Measurement and Health Plan Involvement
Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement
Public Health
Prevention
Specialists
PCMH in Action Vermont “Blueprint” model
Community Care Team
Nurse Coordinator Social Workers
Dieticians Community Health Workers
Care Coordinators
Public Health Prevention HEALTH WELLNESS
Hospitals
PCMH
PCMH
Health IT
Framework
Global Information
Framework
Evaluation
Framework
Operations
A Coordinated
Health System
Vermont Financial Impact
$300,000,000
$320,000,000
$340,000,000
$360,000,000
$380,000,000
$400,000,000
$420,000,000
1 2 3 4 5
INC
RE
ME
NTA
L C
OS
T
PE
R Y
EA
R
YEARS
IMPACT OF MEDICAL HOME SAVINGS ACROSS TOTAL POPULATION
Vermont Financial Impact
Avoidable emergency room visits continue downward
trend, seven percent better than market.
Following evidence-based medicine continues to
improve, six percentage points better than market.
Medical cost trend is more than seven percentage
points better than market.
$9 PMPM cost savings.
Diabetes is better controlled, will improve long-term
health and lower medical costs.
And Today in NY PCMH practices
The Pennsylvania State Plan So simple so much
We Developed a better healthcare system starting with Public Private payers Private payers Joined
Strong Primary care is foundational to a high performing healthcare system
Additional resources needed to help primary care manage populations
Learned timely data is essential to success
Learned must build better local healthcare systems (public-private partnership)
Physician leadership is critical
Improve the quality of the care provided and cost will come down
Patient is the center
of the Medical Home
Population Health
Patient-Centered Care
Refocused Medical Training
Patient &
Physician Feedback
Advanced IT Systems
Access to Care
Team-Based
Healthcare Delivery
Decision Support Tools
Model adapted from the
NNMC Medical Home
Enhancing Health and the Patient Experience
Medical Home
Model
Care that is
Accountable
PATIENT CENTERED MEDICAL HOME:
VHA Patient Aligned Care Team
Replaces episodic care based on illness and patient complaints with coordinated care and a
long term healing relationship
Reinventing Medicaid findings are Outstanding Oklahoma's patient-centered medical home initiative has reduced
Medicaid costs $29 per patient per year from 2008 to 2010. Moreover, use of evidence-based primary care, including screening for breast and cervical cancer, increased.
The Colorado initiative expanded access to care. Before the initiative, only 20 percent of pediatricians in the state accepted Medicaid; as of 2010, 96 percent and did and at a lower cost to the state.
Vermont, inpatient care use and related per-person per-month costs decreased 21 percent and 22 percent, respectively, from July 2008 to October 2010. ER use and related per-person per-month costs decreased 31 percent and 36 percent, respectively.
Patient Centered Medical Home in Washington in State Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average.
Citation -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes
Show Promising Results," Health Affairs, July 2011 30(7):1325–34.
The Bottom Line in Medicaid
PCMH starting to show an impact in access to care, quality, and cost control.
Patients love to see meaningful information about
themselves and it take IT tools to
If you give patients educational materials with their name on it and with
their data analyzed in it, they will read it, pour over it and discuss it with
you.
If you tear off a generic sheet and give it to them, it often goes in the waste
basket. If you give patients an analysis of their health risk AND if you
include a “what if” scenario, i.e., what will their health risk be if they make a
change; you can prove to them,
“if you the healer make a change, it will make a difference to your patient.”
PCMH is non-political – the right POV
for delivery transformation
“We never abandoned advocating new
Models of care. We’ve long pushed folks
to realize that Delivery reform is the key.”
The patient-centered medical home is
core.
“We included the attached
chapter on PCMH in our book.
and have a new publication on
ACOs coming out in January.”
Physician Practice
Size
(# of patients) Level 1+ Level 2+ Level 3+
< 10,000 $4.68 $5.34 $6.01
10,000 - 20,000 $3.90 $4.45 $5.01
> 20,000 $3.51 $4.01 $4.51
PMPM Payment: Commercial Population
Level of PCMH Recognition
41
Tier Major Condition Groups Minutes of Work PMPM PMPM Payment
0 None N/A N/A
1 3-Jan 15 $10.14
2 6-Apr 30 $20.27
3 9-Jul 60 $40.54
4 10+ 90 $60.81
42
Payment Model Component PMPM Payment
Care management payments Up to $2.50 PMPM
Pay-for-performance payments Up to $2.50 PMPM
Payment Model Component PMPM Payment
Practice transformation cost payments (year 1
only)
$1.67 PMPM
Performance bonus (beginning in year 2) Up to $2.38 PMPM (value based on performance)
Risk-adjustment Up to $1.67 PMPM (only for practices with above average
patient panel risk profiles; amount varies by practice)
Payment Model Component PMPM Payment
Practice support payments $1.50 PMPM
$0.60 PMPM (ages 0-17)
$1.50 PMPM (ages 18-64)
$5.00 PMPM (ages 65-74)
$7.00 PMPM (ages 75+)
Shared savings Value based on performance
Care management payments