The Patient-Centered Medical Home:

Overview, Outlook & Trends

FEBRUARY 20, 2009

Elizabeth E. Stewart, PhD

Center for Research in Primary Care & Family Medicine

TransforMED

What a Medical Home is NOT Meet Rebecca…

Working Mother.

Today she woke up with a fever and UTI symptoms.

She needs to juggle work coverage, child care and household responsibilities along with her immediate healthcare problem.

What a Medical Home is NOT

Difficulty in scheduling appt for that day.

Staff sounded harried; had trouble locating her records

No alternative way to seek treatment from practice.

Hours at practice were limited so Rebecca had to arrange to leave work.

What a Medical Home is NOT

Waited for almost an hour; staff still had not found her records.

Did not see her own physician and repeated the same information to multiple people.

Physician was rushed; Rebecca was too timid to ask about strange pain in her breast.

When Rebecca tried to make a follow-up appointment for full physical, the wait time would be 4 months.

Slide courtesy ofwww.pcpcc.net

Primary Care Crisis Good evidence that primary care that countries with strong primary care infrastructures have lower costs and better outcomes.1

In the US, fewer and fewer graduates are choosing primary care:* Shrinking reimbursements* Increasing demands* Overall lack of respect.

A recent study revealed 49% of PCP’s said they plan to cut back or retire in 3 years.2

Enter: The Medical Home• In 1967, The American Academy of Pediatrics introduced the term to describe a single source of medical information and coordination for sick children.3

• Over the next 40 years, many other organizations endorsed the concept and the term.4

Medical Home Core Features

• In 2007, four major medical organizations (AAFP, AAP, ACP, AOA) reached agreement on “Joint Features of the Patient-Centered Medical Home.” 5

• In 2008, the AMA gave their endorsement.6

Medical Home 7 Core Features

1. Person Physician

Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care.

Medical Home Core Features2. 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

Medical Home Core Features3. Whole person orientation The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.

Medical Home Core Features

4. Care is coordinated and/or integrated across all elements of the complex health care system, making sure patients get the indicated care when and where they need and want it.

Medical Home Core Features

5. Quality & Safety are Hallmarks:• Decisions are made by EBM and appropriate

decision support tools

• Information Technology is used appopriately

• Patients participate in decision making

• Patient feedback is actively sought to ensure expectations are met.

Medical Home Core Features

6. Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication.

Medical Home Core Features

7. Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home.

• Reflect the value of physician and non-physician staff patient-centered care management

• Should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.

The Future of Family Medicine: “Ultimately, system wide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home…” 7

Testing the Feasibilityof the Medical Home

2006

www.transformed.com

Access to Care & Information

• Health care for all

• Same-day appointments

• After-hours access coverage

• Lab results highly accessible

• Online patient services

• e-Visits

• Group visits

Practice Management• Disciplined financial management• Cost-Benefit decision-making• Revenue enhancement• Optimized coding & billing• Personnel/HR management• Facilities management• Optimized office design/redesign• Change management

Practice Services

• Comprehensive care

for both acute and chronic conditions

• Prevention screening and services

• Surgical procedures

• Ancillary therapeutic & support services

• Ancillary diagnostic services

Care Management

• Population management

• Wellness promotion

• Disease prevention

• Chronic disease management

• Care coordination

• Patient engagement and education

• Leverages automated technologies

Continuity of Care Services

• Community-based services• Collaborative relationships

Hospital care

Behavioral health care

Maternity care

Specialist care

Pharmacy

Physical Therapy

Case Management

Practice-Based Care Team

• Provider leadership

• Shared mission and vision

• Effective communication

• Task designation by skill set

• Nurse Practitioner / Physician Assistant

• Patient participation

• Family involvement options

Quality and Safety

• Evidence-based best practices

• Medication management

• Patient satisfaction feedback

• Clinical outcomes analysis

• Quality improvement

• Risk management

• Regulatory compliance

Health Information Technology

• Electronic medical record

• Electronic orders and reporting

• Electronic prescribing

• Evidence-based decision support

• Population management registry

• Practice Web site

• Patient portal

Medical Home: Is it possible?

Early data point to a cautiously optimistic “YES” but…

- Two years is not enough.

- Transformation process is far greater challenge than previously anticipated.

- Many lessons to be learned from real life application.8

Will it save money & improve outcomes?

• Getting the attention of payers & politicians

• > 25 multi-stakeholder projects are underway in 22 states, most with formal evaluations.

• Growing interest in the formation of state MH demonstration projects; use of term in crafting legislation.9

•Since 1999, the state has invested in many MH components through disease management payments to practices with Medicaid pts.

• Emphasis on physician led team approach, disease tracking & care managers within practices.

•Significant improvements in cost, utilization, and quality measures. Two major evaluations estimate it CNCC saved the state between $230 and $260 million in 2004.12

Community Care of North Carolina

MH Outlook: Pilots & Payers

• PCPCC is a coalition of >300 organizations: employers, consumer groups, patient advocates, etc

• Collaboration of like-minded stakeholders actively working toward medical home vision.

• Comprehensive list of pilot projects: www.pcpcc.net

MH Outlook: Accreditation

• National Committee for Quality Assurance offers 3 tiers of “medical home recognition”

• Practices are hopeful that such recognition will lead to higher reimbursement by public and private payers… such recognition is a required part of many ongoing and future pilots.

PCMH Outlook: CMS Demonstration

CMS preparing to launch 2-year Medicare Medical Home Demonstration (MMHD). Looking at impact of medical home on:

- Medicare cost - Utilization - Health outcomes - Patients

- Physicians & Practices

PCMH Outlook: CMS Demonstration

•Practices must meet criteria of NCQA to qualify(Tier 2 and Tier 3 only)

•Qualified practices receive additional care management fees based on RUC work RVUs, practice expenses, and insurance.

• MMHD link on CMS website: http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp

PCMH Outlook: Gaining Political Traction

New economic stimulus bill earmarks ≈ $19 billion to implement electronic

medical records and other health information

technology.13

PCMH Outlook: Gaining Political Traction

Senator Baucus (D-Montana) white paper on health care reform endorsed medical home concept, even suggesting that specialists may see a small cut in reimbursements in order to pay primary care physicians for currently non-reimbursable coordination services.14

PCMH Outlook: Gaining Public Traction

Medical Home: Challenges

• Transformative change doesn’t happen overnight… pilots under pressure for quick results may do more harm than good.

• Simply inserting HIT is not the solution.

• Primary care physicians have mixed responses to the concept.

Medical Home: Physician Outlook

• Excited

• Cautiously optimistic

• Skeptical/cynical

• Too exhausted & stressed to care

Medical Home: Physician Outlook

• Financially-strapped FM physicians are fearful of the high cost of MH changes (time, resources, equipment) without a guarantee of increased reimbursement.

• Like many researchers/policy makers, they are concerned about short time frame of current pilot projects given enormity of necessary changes.

“…some health care policy experts "worry that the push for medical homes could be yet another example of the latest health care fad -- quickly embraced by employers desperate to slow their soaring health costs, and just as quickly forgotten when they do not provide immediate results.” 15

Medical Home: Outlook “I no longer practice medicine encounter to encounter, taking care of the problem the patient presents with. I take care of them in between visits online, plus I use each visit as an opportunity to improve their overall health, addressing any overdue health maintenance or disease mgt with the help of my nurses…”

Dr. Susan AndrewsNat’l Demonstration ProjectFamily Practice PartnersMurfreesboro, TN

Medical Home: Outlook “I do take care of my patients how and when they want to be seen as much as I can, whether it is in the office, online, or by phone and letter… I love my job. I look forward to working with my staff each day. It is a real pleasure seeing a nurse or MA, a receptionist, or an office manager stretch herself and grow. I treasure my interactions with each and every patient.” 16

Dr. Susan AndrewsFamily Practice PartnersMurfreesboro, TN

Medical Home: Outlook

• We know that a strong primary care system reduces health care costs and improves quality outcomes. 17

• We know that primary care doctors feel underpaid and demoralized and their labor forces is shrinking. 18

Medical Home: Outlook

• We know that the majority of primary care physicians would like to embrace the medical home concept… and those that have, cite greater satisfaction with their jobs.19

• Finally, we know that the evidence for a medical home is being created right now... but true change takes time, and so do results.

Medical Home: Trends

From the ground level:What seems to be working for physicians, practices and patients?

PCMHTrends:Same Day

Scheduling: Patients can

schedule an appt for the same day OR in advance

PCMH Trends: Same Day Scheduling

• Huge leap of faith for many physicians fearful of an open schedule.

• Once in place, overwhelmingly positive response from physicians and patients.

• Requires an understanding of the supply/demand cycle by day, week, season.20

Trends: Same Day Scheduling

• Requires constant education of patients using multiple channels.

• Some patients prefer the option to schedule ahead.

• $$ saved – drops in no-show rates, less staff time on reminder calls.21

PCMH Trends:

e-Visits: Physicians offer

structured, secure “office visits”

online

PCMH Trends: e-visits

• Only lukewarm response from patients; takes concerted & consistent promotion by practice

• Many e-visit modules do not interface with EMRS requiring extra work for documentation

• Currently, limited reimbursement by payers23

PCMH Trends: e-visits

• Currently, patients seem to prefer non-secure, non-reimbursable email communication with physicians in lieu of phone calls.

• Physicians acknowledge time saving by email vs. multiple phone calls.

• Potential to be popular with certain pt populations.24

PCMH Trends: Group Visits • Typically centered around a chronic disease; goal is for physician to facilitate peer-to-peer learning.

• Evidence that group visits can result in improved health outcomes & increased pt compliance. 25

PCMH Trends: Group Visits

• Require paradigm shift from physicians: solo encounter to group facilitation process.

• Require tremendous planning and preparation work up-front; difficult without extra staff.

• Concerns about reimbursement & coding.

• Patients often reluctant to attend; then report increased satisfaction after visit.26

Population Management

Disease Prevention

Chronic Disease

Management PCMH Trends:

Disease Registries

PCMH Trends: Disease Registries• Practice runs report on all diabetics overdue for a follow-up visit or out of compliance.

•Pts are called or emailed to set up an appt and get lab work.

• During appt, EBM point-of-care reminders guide staff to arrange additional care (e.g., flu shot, mammogram).

PCMH Trends: Disease Registries

• Many EMRs do not yet offer disease registry capabilities OR process is difficult to establish.

• Many stand-alone disease registries do not interface with EMRs, requiring double data entry.

• Requires paradigm shift: from acute, one-on-one episodic care to proactive management of a population of patients. 27

MA/RN does vital signs, medications, history, standing orders, etc

Doctor completes exam & talks with pt; MA in room might document on EMR during exam

PCMH Trends: Care Teams

Care teams usually consist of a physician and 1 or 2 support staff who take on increased responsibility of patient care.

MA/RN does follow-up education wit pt & follow-up coordination of care (scheduling labs, etc)

PCMH Trends: Care Teams

Doctor goes to next pt with no downtime

Care teams require increased staff training and

allocation of resources up

front; willingness of physician to

delegate.28

PCMH Trends: Care Teams

• Evidence of increase in- Pt volume & revenue- Quality of care- Doctor/staff satisfaction29

• Challenges: - Upfront allocation of resources w/out immediatepay-off - Qualified staff cost more

PCMH Trends: Patient Portals

• Interactive patient portals interfaced with practice EMR

• Pts can schedule appts, refill medication, send in BP or blood sugar results, etc

• Pts can view all or parts of their chart, lab work, test results, etc

PCMH Trends: Patient Portals

• Allows patient greater participation in their care

• Physicians note that having charts online can be “humbling” but helpful to increasing pt engagement

• Online services can save practice staff time & calls

PCMH Trends: Patient Portals

CHALLENGES:

• Portals cost money to implement & maintain but most pts are not willing to pay extra for services

• Some pts are not web-enabled

• Takes additional Dr/staff time upfront to train pts to use portal and redesign workflow processes (e.g. how to return lab results). 30

Greatest PCMH Promises:

Quality of care

Overall costs

Satisfaction

* patients * families

* physicians * staff

Greatest PCMH Challenges:

• Transformation of a practice takes incredible time, energy & resources.

• Currently, majority of implementation & refinement of PCMH is non-reimbursable.

• Engagement and education of patients – their role in the PCMH is also different.31

What a Medical Home IS

Meet Rebecca… Working

Mother.

Today she woke up with a fever and UTI symptoms.

She needs to juggle work coverage, child care and household responsibilities along with her immediate healthcare problem.

What a Medical Home IS She was able to make her appt that day before 8am by using online scheduling.

She was in & out of the office in <45 min.

The disease registry reminded the MA of overdue health maintenance services.

Rebecca could later check her lab results online without playing phone tag.

Rebecca felt warm & welcomed at her PCMH.

Thank you.

Elizabeth E. Stewart, PhD

estewart@transformed.com