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Good Neighbors: How Will Medical Homes and the Rest of the Delivery

System Relate to One Another?

March 30, 2010

Hoangmai H. PhamCenter for Studying Health System Change

Why look beyond medical homes?

• Fragmented delivery system• Imperfect information systems• Poorly aligned perceptions of patients’

interests and coordination responsibilities• “Medical neighborhoods” as a bridge from

here to accountable care entities

What PCMH, patients, and neighbors need to work on – together

• Achieve clarity on PCMH role in first-contact, longitudinal, comprehensive care

• Elicit, honor patient preferences • Engage in effective, timely communication• Synthesize information• Facilitate and track receipt of needed services• Engage in shared decision-making• Formally assess performance• Engage in systematic quality improvement

Reciprocity of responsibilities

• Symmetric– PCMH and neighbors each inform the other of

changes to ongoing therapy• Asymmetric– PCMH provides first-contact care, ensures access– Patients responsible for seeking first-contact care

with PCMH, not “doctor shopping”– Neighbors re-direct patients seeking first-contact

care to PCMH

Reliability of overlapping responsibilities

• PCMH has primary responsibility for eliciting and documenting patient’s care preferences

• Neighbors also help elicit and document care preferences

Designing Neighborhoods – Context

• Neighborhood emanates from PCMH• No one size fits all• Some PCMH’s could be led by subspecialists• Not all neighbors are equal• Neighborhoods should be compatible with FFS

and bundled payments• Avoid limiting patient choice• Formalize expectations for PCMH and neighbors

Composition of neighborhoods

• Size, geographic reach• Specialty mix among clinicians• Institutional and community providers• Not all neighbors are equal – “Core” neighbors and other neighbors

Entry into Neighborhoods

• Departs from health plan networks PCMH selects neighbors with patient input

• Voluntary or mandatory• Prospective or retrospective• Overlapping or not• Formal “care coordination agreements”

Accountability

• Positive and negative financial incentives• Public reporting• Patient volume• Regulatory requirements for payment• Reflect different contributions from

neighbors

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Neighborhoods and Accountable Care Organizations

• Negotiating “Bottom up” vs. “Top down”• Protecting prominence of primary care• Ensuring equitable governance• Staying patient centered and population based• Leveraging common resources

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What the legislation says…

• About Medicare investments in medical homes and ACOs– Goals– Payment– Participation by primary care providers

But can we accommodate short, tall, fat, thin?