Panel DiscussionThe Medical Home Project

High Peaks Resort,Lake Placid

Saturday, January 31, 2009

Panel

Jeff Stone, MD- Latham Medical Group, a division of Community Care Physicians

Diane Cardwell,MPA, ARNP - TransforMed Brian Morrissey - Capital District Physician’s

Health Plan (CDPHP) Martin Kohn, MD,MS,FACEP,CEP

Introduction - Dr.Jeff Stone TransforMed and the “Patient Centered

Medical Home” - Ms. Diane Cardwell Insurer’s Perspective - Mr. Brian Morrissey Employer’s Perspective - Dr.Martin Kohn Physician’s Perspective - Dr. Jeff Stone

Diane Cardwell, MPA, ARNPPractice FacilitatorJanuary 31, 2009

Patient-Centered Medical HomePatient-Centered Medical Home

Our mission is the transformation of healthcare delivery to achieve optimal patient care, professional satisfaction and success of primary care practices.

How is a PCMH different from what we are already doing?

Patient Centered vs. Provider or Practice Centered

Forms the foundation for a healthcare partnership with patient and care network

Involves proactive care vs. reactive care

Practice culture that advocates for and demands what is needed to provided patient-centered, integrated, coordinated care

Creating a Patient Centered Medical Home

Requires attention to relationships

– Between the practice and the patient

– Among members of the practice

– Between the practice & the community

What we know about Practice Transformation…

Requires a team effort Cannot be achieved merely through new technology Takes time Can take unexpected turns

Critical Success Factors in Transformation

Leadership

Teamwork

Communication

When the leadership “system” is in place the practice’s ability to adopt

change accelerates significantly. Leadership

drives the culture.

Teamwork

Transformation is a

team effort!

CommunicationAs the numbers of people involved in a communication increases, so does the complexity of the communications & the potential for misunderstanding!

Questions?

Brian MorrisseyCDPHP VP, Strategy &

DevelopmentJanuary 31, 2009

Why are Most Health Plans Interested in the Medical

Home?Care delivered by primary care

physicians in a patient-centered medical home is consistently associated with better outcomes, reduced mortality, fewer preventable hospital admissions for patients with chronic diseases, lower utilization, improved patient compliance with recommended care, and lower Medicare spending.

PCMH Evidence Document: PCPCC Call-to-Action Summit 11/7/07

CDPHP’s Interest

SAVING PRIMARY CARE!

Mission & Vision

Vision:– Create an innovative and sustainable model for the

reimbursement of primary care physicians leading to a resurgence in the interest in primary care medicine as a career for medical students. Accomplish this while demonstrating better health outcomes and market-leading satisfaction scores for patients, employers, and physicians.

Mission:– The transformation of primary care practice and payment

mechanisms to enhance the value of health care delivery and primary care physician satisfaction.

“Virtual” All Payer Pilot

Can’t practice two different ways Autonomy Speed Unique commitment of CDPHP

CDPHP Pilot

Practice Reform

Payment Reform

Pilot Hypothesis

Are the aggregate savings associated with better health

outcomes and lower utilization sufficient to fund the enhanced

compensation to a primary care physician?

Payment Reform

Comprehensive payment for comprehensive care

Align financial incentives Create an opportunity to significantly

increase primary care physician income (35 – 50%)

Payment Reform –Compensation Today

90-94% FFS

$1pmpm Care mgmt

Fee

6% Quality Payment

80-90% FFS

10% Quality Payment

$5pmpm Care mgmt

Fee

CDPHP Today Typical MH Pilot

The “Evils” of RBRVS Reimbursement (aka FFS)

Incents more care, not better care Limits innovation in care delivery Unintentionally designed to frustrate providers

and patients by driving down length of visit No incentive for care coordination No incentive for better outcomes Significant driver for the primary care crisis

Payment Reform –CDPHP Pilot

70% Risk Adjusted Comprehensive

Payment *

3%FFS - RBRVS

27% Bonus Payment

* Targeted at improving base reimbursement approximately $35,000 to reflect increased costs of implementing and operating a medical home.

Risks

Both practice and payment reform are really, really hard

ROI may not be demonstrated, or if it exists, may be transient

May end up deploying a model that cannot handle the pressures of the real world

Bigger risk is the Bigger risk is the disappearance ofdisappearance of

primary careprimary care

Questions

IBM in Healthcare and Life Sciences

IBM Healthcare

Martin S. Kohn, MD, MS, FACEP, CEP

November 11, 2008

Our VisionHealthy People for a Productive World

Our Client CommitmentInnovations that improve quality and value,

leading to consumer-centric and personalized healthcare

How do you start to fix the foundational issue around why our healthcare system is so expensive and yet so broken??

0

1000

2000

3000

4000

5000

6000

7000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Average spending on healthper capita ($US PPP)

Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the

Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data

Primary care - focus on comprehensive care Many studies show that when our primary care

providers focus on the comprehensive needs of our

employees they end up in the hospital less, the

emergency room less and their overall care costs

less.

Many studies also show that the practice of episodic

care by a partialist (specialist) without someone in

charge of overall care is dangerous, wasteful and

frankly unacceptable.

Starfield B,Shi L. Policy relevant determinants of health: an international perspective. Health Policy 60 (2002) 201–218.. Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA 2002;288:889-893.. Future of Family Medicine Project Leadership Committee. The future of family medicine: A collaborative project of the family medicine community. Ann Fam Med. 2004;2(Suppl 1):S3–32. 5. The Advanced Medical Home. The American College of Physicians, 2006. 6. Grumbach K, Selby JV, Damberg C, et al: Resolving the gatekeeper conundrum. JAMA. 1999;282:261-266.

IBM envisions a new Healthcare System …

Healthcare system that is built around patientspatients and focused on WellnessWellness – Patient-Centered Medical Home model – providing better

outcomes for patients– Wellness Focus – where physician are paid for effective wellness

management A transformed healthcare system transformed healthcare system where all stakeholders

participate in the transformation ……..– Consumers will assume much greater financial oversight and

responsibility for their healthcare, – Payers will take a more holistic view of value– Societies will understand that healthcare funds are not limitless and

will demand that payment for and quality of healthcare services be aligned with the value

Hospital Systems /

Practice Mgt.Systems

IBM’s Strategy is to Transform Healthcare -- with effective information

exchange

Health Record(EHR)

Payer

Clinical InformationExchange

Employer

Health CardPatientEmployeeMember

Subscriber Services

Capital

Authenticated Access

PHR

Eligibility, Plan DataPlan Pay Advice

Consumer PaymentConsumer AdvicePlan Settlement

Sources of Payment

Membership Stake

Adjudication SettlementMedicare Medicaid

FSAHSA

MasterCardVisa

Amer ExpDiscoverFidelityTricare

Determine

Liability

Updated Accumulators

Request for Payment

Remittance Advice

PatientEmployeeMember

Subscriber

PersonalHealth Record

(PHR)

Manage Care

Access PHR

Use Tools

PHR

Smart Medical Devices

… with ultimate focus on wellness

Comparison of IBM Annual Per Capita Medical Cost

$4,4

01

$4,8

88

$5,5

54 $6,3

58

$7,0

88

$7,7

10

$8,2

35

$4,7

56

$5,2

86

$5,9

82

$6,4

46

$6,8

88

$7,2

31

$7,8

20

$3,000

$6,000

$9,000

2000 2001 2002 2003 2004 2005 2006

AverageIBM

Comparison of Annual Trend in Per Capita Medical Cost (Before EE Contributions)

11.0%

13.6%

11.3%

8.2%

5.6%

6.9%

13.5%

8.6%9.1%

5.0%

13.2%

7.8%

11.1%

8.1%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

2000 2001 2002 2003 2004 2005 2006

Average of Surveys

IBM

IBM has transformed itself and has achieved great results

projected

includes healthy living rebate

Source for benchmarks: Average of survey results from Kaiser Family Foundation, Hewitt Associates, and Towers Perrin

projected

2007 data in currently being finalized

We are the ones we’ve been waiting for

Obama Feb. 5, 2008

The Role of IBM with our Clients and Partners in Patient-Centric

Healthcare Deliver innovative solutions

–Leadership in technology and clinical integration–Improved access to information and optimized workflows–Influential application provider relationships

Drive adoption–Cultivate the global ecosystem–Form relationships with a critical mass of collaborators–Encourage the development of value nets–Lead in open standards

Set an example as a best practices employer–Effectively manage IBM’s Global Health and Wellness

programs–Lead in motivating the use of EHR and PHR–Serve as a Health System advisor

In assuming more responsibility for their care, consumers must

make wiser health and financial decisions as patients and

purchasers

Improve access to information

“Health Coach”• Prediction• Healthy lifestyles• Behavioral Change

Make better health-related

choices

“Wealth Coach”• Financial planning• Financing options• Insurance options

Improve financial planning

for healthcare

“Value Coach”• Health plan benefits• Provider selection• Comparative value

Receive personalized

high-value care

Analysis

Continued shift from employer-based togovernment-based

and individual coverage

Increase in consumer responsibility and

accountability

New healthcare requirements,delivery models, capabilities, and reimbursement models

IBM’S Patient Centered Collaborative Care Process

Care Team Collaboration

Select Care Providers

Select Care Providers

Provide On-going Care

Provide On-going Care

Gather Individual Health InformationGather Individual

Health Information

Measure &Reward

Measure &Reward

Assess HealthAssess Health

Pay for Products& Services

Pay for Products& Services

Enroll Patient inPrograms

Enroll Patient inPrograms

Design Care PlanDesign Care Plan

Improve Process Improve Process

Aggregation of health information Clinical / Biometrics / Claims Comprehensive View Focus on Wellness & Prevention

Enroll in programs Employer Government Self-insured

Risk stratification Determine focus areas Prioritization

Evaluate provideroptions

Consider alter-natives

Fit with needs

Evaluate care options Select treatments,

products, & services Based on clinical

input, quality metrics,personal needs, &health plan options

Execute care plan Acute, chronic, or

wellness plan Collect metrics

to establishefficacy

Payments Health plans Medical home

programs Retail

Monitor performance Clinical procedures &

processes Administrative business

process Program efficacy

Improve outcomes Quality of life Patient Satisfaction ROI

2

3

9

8

7

6

5

4

1

Evidence Generation &

HealthAnalytics

Physicians & Specialists

HealthInformationWarehouse

Patients

Dx, Rx

Pharma, Labs,Diagnostics,

Claims, Other Health

Info

Public Health

Portal Access Layer

Disease Dashboards&

Work Flow

Data Acquisition& Integration

UserPortals & Portlets

HealthInformationOperational

Store

ElectronicMedicalRecords

IBM Pc3 Solution (Conceptual View)

Public DataSources

Patient Portal& Monitoring

QualityMeasures

&PatientSafety

Researchers Case Worker

Clinical Admin

Payer State

PatientIdentityMgmt

Data Integration Layer

ClinicalDecision

Support &Health Analytics

PersonalizedCare

Diagnosis &Treatment

UserInteraction

Process Mgmt

InformationMgmt

En

terprise S

ervice Bu

s

IBM Pc3 will require key questions to be answered

Consumers

Who has the best outcomes?

What preventive tests should I have?

When can I see my doctor?

Do I have immunizations due?

EmployersWhat are my most cost effective care options?How can I measure the wellness of my employees?Who provides the highest quality care?

Physicians and Care Team

What are the outcomes of my patient populations by disease profile?

When are the preventive tests and immunizations due?

How can I better manage my referrals?

How compliant is my practice to key core measures and other metrics?

What are my costs of services?

Health PlansWhat are my member outcomes?Have I reduced the number of unnecessary ER visits?How do I manage and report the progression and impact of chronic diseases such as diabetes or stroke within a system, region or market ?How do I predict high risk populations and begin early interventions?

The Physician’s PerspectiveJeff Stone,MD

Family Physician

Important Philosophy of the PCMH Important Philosophy of the PCMH (AAFP 2008)(AAFP 2008)

Continuing, comprehensive and Continuing, comprehensive and personal care in the context of family personal care in the context of family and community. Taking into account and community. Taking into account the physical, psychological and the physical, psychological and spiritual nature of wellness and disease.spiritual nature of wellness and disease.– Sound familiar? – like maybe the core Sound familiar? – like maybe the core

values of primary carevalues of primary care

48Page 48

How do you start to fix the foundational issue around why our healthcare system is so expensive and yet so broken??

0

1000

2000

3000

4000

5000

6000

7000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Average spending on healthper capita ($US PPP)

Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data

49Page 49

76 81 88 84 89 8999 97

8897

109 106116 115 113

130 134 128115

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

0

50

100

150 1997/98 2002/03

Countries’ age-standardized death rates, list of conditions considered amenable to health care Source: E. Nolte and C. M. McKee, Measuring the Health of Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1):58–71

USA worse/1937th by WHO

50Page 50

“We do heart surgery more often than anyone, but we need to, because patients are not given the kind of coordinated primary care that would prevent chronic heart disease from becoming acute.”George Halverson’s (CEO Kaiser) Healthcare Reform Now

The Case for The Medical HomeThe Case for The Medical Home

Important Philosophy of the PCMH Important Philosophy of the PCMH (AAFP 2008)(AAFP 2008)

Continuing, comprehensive and Continuing, comprehensive and personal care in the context of family personal care in the context of family and community. Taking into account and community. Taking into account the physical, psychological and the physical, psychological and spiritual nature of wellness and disease.spiritual nature of wellness and disease.– Sound familiar? – like maybe the core Sound familiar? – like maybe the core

values of primary carevalues of primary care

Questions?