Patient-Centered Medical Home: The Call to Action

Patient-Centered Medical Patient-Centered Medical Home: The Call to ActionHome: The Call to Action

Adele AllisonAdele Allison

National Director of Government National Director of Government AffairsAffairs

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• Historical PerspectiveHistorical Perspective• U.S. Trends and PCP Shortage• PPACA and PCMH• NCQA – Role and Process• HRSA Opportunity• Call to Action• Questions

Patient-Centered Medical Patient-Centered Medical Home (PCMH)Home (PCMH)

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What is a PCMH?What is a PCMH?1. Integrates patients as active participants in

care2. Physician-led medical team that coordinates

• Preventive• Acute• Chronic Disease

3. Uses evidence-based guidelines and technology

4. Offers patients comfort, convenience, and optimal care

5. Manages the patient throughout their lifetime

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PCMH Evolution TimelinePCMH Evolution Timeline

AAP establishes “Medical Home” Concept

“Medical Home” evolves to provide primary care as a community

HI places the “Medical Home” into its Child Health Plan

Surg. Gen’l holds 1st major conference for Children with Special

Health Care Needs (CSHCN)

AAP holds first “Medical Home” Conference

AAP publishes policy statement defining

“Medical Home”

7 U.S. Family Med. Org. publish “Future of Family Medicine” stating

every American should have a “personal medical home”

ACP develops its “Advanced Medical

Home” model

AAFP, AAP, ACP, and AOA release the “Joint

Principles of the PCMH”

20 Bills promoting the “Medical Home”

introduced in 10 states

PPACA is signed into law incorporating the “Medical

Home” into CMS’ establishing Accountable

Care Org. (ACOs)

1967 1978-79 1987 1989 1992 2002 2005 2007 2009 2010 4

• Historical Perspective• U.S. Trends and PCP ShortageU.S. Trends and PCP Shortage• PPACA and PCMH• NCQA – Role and Process• HRSA Opportunity• Call to Action• Questions


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U.S. Trends – Health CareU.S. Trends – Health Care

• 1934-1939 – Great Depression – 25% unemployment rate – Roosevelt enacts SSA as part of the “New Deal”

• 1939 – AHA creates Blue Cross – embracing concept of “prepaid health”

• 1945 – Blue Cross serves 59% of the health insurance market

• 1946 – Prepaid MD service plans affiliate and form Blue Shield

• 1954 – IRS solidifies idea of “prepaid” insurance with tax deduction

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U.S. Trends – Health CareU.S. Trends – Health Care

• 1965 – Medicare/Medicaid created by Pres. Johnson (Title XIX to SSA)– Health Care Spending as a % of GDP is 5.7%– Life Expectancy for males is 66 and for females

is 71.7– Almost 75% of Americans have private

insurance– In 1966, Medicare serves 19.1M → 47M today– In 1966, Medicaid serves 10M → 49M today

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Funding MedicareFunding Medicare

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Unemployment & StatesUnemployment & States

1%

Increase in National

Unemployment Rate

═Decrease in State

Revenue

3-4%

+1M

Increase in ‘Caid and

CHIP Enrollment

1.1M

Increase in Uninsured

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U.S. Medicaid - PresentU.S. Medicaid - Present

Health Insurance – 58M29M Children, 15M Adults,

14M Elderly & Disabled

Asst. to ‘Care Beneficiaries – 8.8M8.8M Aged and Disabled

(21% of Medicare)Long-Term Care – 3.8M

1M Nursing Home, 2.8M Community-based Residents

Support for Healthcare and Safety Net

16% of nat’l spending; 41% of LTC services

State Capacity for Health Coverage

Federal share 50%-76%;44% of all Federal funds to

states

Source: Kaiser Permanente Commission on Medicaid 2010 10

Health Care Spending & GDPHealth Care Spending & GDP

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Health Care Spending & GDPHealth Care Spending & GDP

Source: OEDC Health Data – Total Expenditures as % of GDP 12

PCP ShortagePCP Shortage• NACHC estimates 60M Americans (1 in 5) lack

adequate access to primary• 56% of OV in the U.S. are Primary Care but:

– Only 37% of physicians practice Primary Care medicine– Only 8% of Med School graduates go into Primary Care

• PPACA will cover 16M more Americans by 2014– “Our first available appointment is in 3 months”– Today there is only time for episodic treatment

• Impact of PPACA (Projection)1

Year(All Specialties)

Supply (All Specialties)

Demand(All Specialties)

Shortage(Primary Care)

Shortage(Non-PCP)

Shortage2008 699,100 706,500 7,400 7,400 0

2010 709,700 723,400 13,700 9,000 4,700

2015 735,600 798,500 62,900 29,800 33,100

2020 759,800 851,300 91,500 45,400 46,100

2025 786,400 916,000 130,600 65,800 64,8001Source: Association of American Medical Colleges, June, 2010

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PCP ShortagePCP Shortage

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Role of Prevention & Chronic Role of Prevention & Chronic Disease ManagementDisease Management

• Ah, America …− Obesity → Type 2 Diabetes → $147B

health care spending− Smoking → Direct medical costs (lung

cancer, et al) → $96B health care costs− Alcohol → Alcohol-related health

problems → $22.5B health care costs− Sedentary lifestyles → Heart Disease →

$143B health care spending

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Role of Prevention & Chronic Role of Prevention & Chronic Disease ManagementDisease Management• “An ounce of prevention is worth a pound

of cure,” Ben Franklin 1735

− Chronic Disease affects 138M Americans− Requires care coordination and patient

engagement/education− SuccessEHS offers:

o Population Managemento Patient Portalo Digital Dashboardo Ad Hoc Reportingo Communication tools (e.g. Flags, T/calls, Audit

Trails, CDS, Alerts)16

• Historical Perspective• U.S. Trends and PCP Shortage• PPACA and PCMHPPACA and PCMH• NCQA – Role and Process• HRSA Opportunity• Call to Action• Questions


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PCMH Pre-PPACAPCMH Pre-PPACA

• PCMH Initiatives– 27 multi-stakeholder projects in 20

states– 21 states with single, commercial payer

project– 38 states with Medicaid/CHIP projects– Only 5 states without PCMH

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PCMH Pre-PPACAPCMH Pre-PPACA

• Agency for Healthcare Research and Quality (AHRQ)– Primary Care with orientation toward whole

person and relationship-based collaboration– Caregiver (“Home”) is accountable for majority

of physical and mental health through a “team”– Home coordinates care needs across the health

continuum– Patient accessibility is increased– Systems-based approach to Quality and Safety

(CDS)

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PCMH – Addressing the Heart PCMH – Addressing the Heart of the PCP Shortageof the PCP Shortage• Payment models devalue time spent with patients• PCPs earn 33-50% of income earned by

specialists• PCPs experienced a 10% reduction in income

between 1995 and 2003• PPACA – Ultimately 32M more patients• PCP burn-out• PCMH provides each patient with a personal MD,

and a physician-directed “team” using technology• Transforms episodic care with coordinated/long-

term healing

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Joint Principles of PCMHJoint Principles of PCMH• Developed by AAP, AAFP, ACP, and AOA• Principles:

– Personal MD for each patient for 1st contact and ongoing care

– MD-directed medical team for collective care management– Whole person oriented coordinating tertiary care needs for

all life stages: acute, chronic, preventive, and end-of-life– Coordination/integration of care across the full continuum

and the patient’s community using registries, IT, HIE, etc.– Quality and safety by providing patient advocates,

evidence-based medicine with CDS, continuous quality improvement, patient active engagement in care, and use of HIT for measurement-education-communication

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Joint Principles of PCMHJoint Principles of PCMH• Enhance access through such systems as open

scheduling, expanded hours, and new communication tools.

• Appropriate payment for value added based on:– Reflection of work outside the face-to-face visit– Both within the practice and coordination between consultants,

ancillary providers, and community resources– Adoption and use of Health IT for quality improvement– Support of enhanced communication access (e.g. email, phone

consult)– Value of MD work with remote monitoring using technology– No reduction in payments for face-to-face visits– Recognition of case mix differences being treated– Shared savings from reduced hospital stays associated with care

management– Additional payments for measurable, continuous quality

improvements 22

PPACA – Accountable Care PPACA – Accountable Care OrganizationsOrganizations• ACOs contract to provide services for a defined

population of Medicare patients • ACOs share savings if quality objectives are

achieved and performance measures met• Model is effective January 1, 2012• ACO models include:

– Integrated Delivery Systems (e.g. Kaiser, Group Health Coop.)

– Multi-specialty Group Practices (e.g. Mayo Clinic)– Physician-Hospital Organizations (PHOs)– Independent Physician Associations (IPAs)– Virtual Physician Organizations

• Must be Physician-led with PCMH at the hub 23

PPACA – Legal & Policy Supporting PPACA – Legal & Policy Supporting PCMHPCMH

PPACA or Reconciliation

Act Section Opportunity Description Effective DatePPACA § 5501 Increased

ReimbursementPCPs receive 10% increase in reimbursement for Medicaid and Medicare primary care services.

FY 2011-2016

Reconciliation § 1202 Increased Reimbursement

Medicaid payment rates to PCPs for primary care services shall be no less than 100% of the Medicare payment rates.

2013 and 2014

Reconciliation § 1202 Increased Reimbursement

100% of federal funding for incremental state costs to meet the above noted Medicaid requirement.

2013 and 2014

PPACA § 4104-6Prevention Support

Improved access for preventive services, including Medicaid and Medicare clinical preventive services recommended with a grade A / B by the USPSTF and adult immunizations recommended by ACIP.

CY 2011

PPACA § 4108Prevention Support

Incentives for prevention of chronic disease for Medicaid patients As early as CY 2011

PPACA § 2001Coverage / Service

Expansion

$11B in new funding over 5 years for health center program expansion ($9.5B for operational capacity and $1.5B for facility improvement, expansion, and construction).

FY 2011

PPACA § 5207Workforce

Development

Expands education/training under Titles VII and VIII of the Public Health Service Act with:$1.5B in new funding for the National Health Service Corps for 15,000 PCPs in HPSAs.National Health Service Corps members may count up to 50% of their time spent teaching towards service obligation.

FY 2010 - 2016

PPACA § 5508 Workforce Development

Authorizes health centers to develop residency programs and pays for CHCs operating teaching programs. FY 2010 - 2012

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Act Section Opportunity Description Effective Date

PPACA § 2706Payment Delivery PPACA establishes Accountable Care Organization (ACO) contracting

with CMS effective January 1, 2012. Included is a 5-year Medicaid pediatric demonstration with shared savings incentives. CY 2012

PPACA § 3022 Payment Delivery Establishment of ACOs for Medicare shared savings incentives with CMS. CY 2012

PPACA § 2703 Health HomeMedicaid State Plan Option with enhanced FMAP for enrollees with 2 chronic conditions (or 1 condition with a risk for a second) can designate qualified provider as their health home for care management, coordination, health promotion, transitional care, and community / social support services.

Beginning CY 2011

PPACA § 3502 Health HomeGrants to create community health teams to support PCMH development for patients with chronic conditions. CY 2013

PPACA § 3503 Care DeliveryGrants available to pharmacists for medication therapy management (MTM) May 1, 2010

PPACA § 10333 Care DeliveryGrants available for creation of Community Based Collaborative Care Networks (hospital + FQHC) for comprehensive care coordination for low-income populations. Grants may be used for:Enrollment assistance and provider assignmentCase management and care managementHealth outreach through neighborhood health workersTransportationExpansion for tele-health, after hours services or urgent careDirect patient care services

FY 2011 - 2015

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Act Section Opportunity DescriptionEffective

Date

PPACA § 1139B ReportingAdult quality health measures for Medicaid-eligible adults through a Medicaid Quality Measurement Program. CY 2013

PPACA § 3015, 10305 Reporting

Grants for data collection and other public reporting requirements FY 2010 - 2014

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• Historical Perspective• U.S. Trends and PCP Shortage• PPACA and PCMH• NCQA – Role and ProcessNCQA – Role and Process• HRSA Opportunity• Call to Action• Questions


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NCA-PPC-PCMH 2011NCA-PPC-PCMH 2011• Program contains 6 standards consisting of 27

elements and 149 factors.• Standards contain “Must Pass” and non-must

pass elements• Elements are associated to points, resulting

recognition Level• 3 Levels – Level 1 (lowest) to Level 3 (highest)

Level 3 85-100 points + all 6 must pass elements



No Recognition

34 points or less and/or less than 6 must pass elements28

NCQA PCMH 2011 ScoringNCQA PCMH 2011 ScoringPoints

NCQA PCMH 2011Standard and Element

Number of Factors

Must Pass?

20 PCMH Standard 1: Enhance Access and Continuity 344 Element A: Access during office hours 4 Yes4 Element B: Access after hours 5 No2 Element C: Electronic Access 6 No2 Element D: Continuity 3 No2 Element E: Medical Home Responsibilities 4 No2 Element F: Culturally & Linguistically Appropriate Services (CLAS) 4 No4 Element G: Practice Organization 8 No

17 PCMH Standard 2: Identify and Manage Patient Populations 353 Element A: Patient Information 12 No4 Element B: Clinical Data 9 No4 Element C: Comprehensive Health Assessment 10 No5 Element D: Using Data for Population Management 4 Yes

17 PCMH Standard 3: Plan and Manage Care 234 Element A: Implement evidence-based guidelines 3 No3 Element B: Identify High-Risk Patients 2 No4 Element C: Manage Care 7 Yes3 Element D: Management Medications 5 No3 Element E: Electronic Prescribing 6 No9 PCMH Standard 4: Provide Self-Care and Community Support 106 Element A: Self-Care Process 6 Yes3 Element B: Referrals to Community Resources 4 No

18 PCMH Standard 5: Track and Coordinate Care 256 Element A: Test Tracking and Follow-up 10 No6 Element B: Referral Tracking and Follow-up 7 Yes6 Element C: Coordinate with Facilities / Care Transitions 8 No

20 PCMH Standard 6: Measure and Improve Performance 224 Element A: Measures of performance 4 No4 Element B: Patient / Family feedback 4 No4 Element C: Implements Continuous Quality Improvement 4 Yes3 Element D: Demonstrates Continuous Quality Improvement 4 No3 Element E: Performance Reporting 3 No2 Element F: Report Data Externally 3 No

100 149 6

10 Commandments of PCMH 10 Commandments of PCMH Health IT SupportHealth IT Support1. Collect standardized, accurate, essential data

→ MEDCIN, Multum, Interfaces2. Incorporate data from outside systems →

Interfaces / HIE3. Support care coordination → Referral

Tracking / HIE4. Facilitate medication reconciliation →

Surescripts, Extended eRx5. Capture/Respond to population health needs

→ Clinical Event Manager

6. Link to community resources → Evidence-based CDS 30

7. Collect, store, measure and report on individual and population process, outcomes and quality → Registry, Business Objects, CEM, Dashboard

8. Engage care team in decision support at the point of care → CDS, CEM

9. Facilitate provider engagement to reduce risk stratification → Referral Management, HIE, CPOE with audit trails and alerts

10. Support patient self-management and enhance patient access/communication → Patient Portal, Surveys, Summaries, ExitCare

10 Commandments of PCMH 10 Commandments of PCMH Health IT SupportHealth IT Support

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• Historical Perspective• U.S. Trends and PCP Shortage• PPACA and PCMH• NCQA – Role and Process• HRSA OpportunityHRSA Opportunity• Call to Action• Questions


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• HRSA Patient-Centered Medical Health Home Initiative (PCMHH Initiative)

• Provides cost coverage for recognition process fees ($580-$4,080+ depending on number of clinicians)

• Coordinating strategy with primary care associations, national cooperative agreements and Health Center Controlled Networks (HCCNs)

• Eligibility based upon section 330 funding

HRSA & PCMHHRSA & PCMH

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• HRSA provides 3 types of:− Technical assistance− Training− Mock Surveys− Consultant advice


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• Health Centers must complete a Notice of Intent to receive HRSA support

• NOI available at http://bphc.hrsa.gov/policiesregulations/policies/pdfs/pal201101noi.pdf

• Completed NOI should be emailed to [email protected]

• Once approved, NCAQ will provide PCMH standards and guidelines, instructions and details regarding application

• Additional Links:− Helpline: 877.974.2742 or

[email protected]− NCQA Project Liaison: 888.375.7585 or PCMH-

[email protected]


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• SuccessEHS offers PCMH Specialized Project Management− Gap Analysis− Workflow redesign− Coordination with development of Policies &

Procedures− Reporting Assistance


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• Historical Perspective• U.S. Trends and PCP Shortage• PPACA and PCMH• NCQA – Role and Process• HRSA Opportunity• Call to ActionCall to Action• Questions


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• Increased Quality of Care • National Recognition• Increased Market Competitiveness• Potential Increased Reimbursement• Aligns with PPACA Legislation• Added Structure for CHC Expansion• Parallels and Compliments Meaningful Use• Aligns with new and existing

pilots/demonstration projects• Positions for ACOs under PPACA

PCMH – Why do it?PCMH – Why do it?

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To learn more about the Patient-Centered Medical Home, visit: http://www.successehs.com/category/patient-centered-medical-home.htm

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http://www.successehs.com/category/patient-centered-medical-home.htm

http://www.successehs.com/category/patient-centered-medical-home.htm

Patient-Centered Medical Home: The Call to Action

Technology

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