What is the Patient-Centered Medical Home Model?

How Will it Benefit Employers?

Bruce Sherman, MD, FCCP, FACOEM

NJBGH – October 12, 2010

Do we get what we pay for?

US Ranks for… Cost: 1 Health: 24 Health System

Performance: 37 Financial Fairness: 54

What’s driving the change?Recognition we do not get what we pay for

Health needs Americans living longer

Average lifespan 77+ years1

Chronic disease more prevalent > 40% with chronic conditions have > 12

Quality of care Patients not getting services & not achieving

outcomes More than 50% of patients with diabetes, hypertension,

tobacco use, hyperlipidemia, congestive heart failure, asthma, depression and chronic atrial fibrillation were managed inadequately2

45% of adults did not receive recommended care for prevention, acute illness or chronic conditions31. US Department of Health and Human Services. Healthy People 2010. Washington DC. US

Government Printing Office; November 2000. 2. Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century.

Washington, DC: National Academy Press; 2000.3. McGlynn EA, et al. N Engl J Med. 2003; 348(26):2635-45.

.- Merck

The primary care system must be transformed to address current healthcare issues

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The value of primary care Areas with higher density of PCPs have lower

hospitalization rates States with more PCPs per capita had higher

quality care and lower per capita medical costs

Patients with a PCP had 33% lower annual healthcare costs and 19% lower mortality

Individuals with PCPs are more likely to receive preventive services, and have better management of chronic conditions

Sepulveda M, et al: Health Affairs 2008;27:151-158

Joint Principles of the PCMH (February 2007) The following principles were written and agreed

upon by the four primary care physician organizations – the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. Principles:

• Ongoing relationship with personal physician• Physician directed medical practice• Whole person orientation• Coordinated care across the health system• Quality and safety • Enhanced access to care• Payment recognizes the added value

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Personal Physician

Physician-Directed Medical Practice

Whole Person Orientation

Coordinated/Integrated Care

Quality and Safety

Enhanced Access to

Care

Payment

Patient-Centered Medical Home: Seven key tenets

Patient has ongoing relationship w/ a personal doctor, or other qualified lead practitioner

The doctor leads a team who collectively provide ongoing care.

Team provides all patient care needs or arranges for care with other qualified professionals.

Information technology links all elements of care (e.g. hospital, specialist, home health agency, nursing home) and the patient’s community (e.g. family).

Robust partnership among physicians, patients, and their families; evidence-based medicine and CDS support tools guide decision making; IT supports optimal patient care and enhanced communication.

Expanded hours, open scheduling, better communication.

Creates payment structure recognizing added value provided to patients.

A Patient GatewayNOT a Gatekeeper

A comparison of then and now…Attribute 1990’s – Managed

care2009 and onward -

PCMH

Primary stakeholders involved:

Health plansEmployers

Health plansProviders

PCP role: Gatekeeper Medical home

Need to engage/involve:

Providers Employers

Patients have… Limited choices Informed choices

Good health means:

Lower costs Engaged individual

Employer focus: Cost-reduction through appropriate utilization

Value-generation through appropriate utilization

Benefit design considerations:

In/out of network; co-pay used as financial disincentive

Value-based insurance design as financial incentive

TODAY’S CARE MEDICAL HOME CARE

My patients are those who make appointments to see me

Our patients are those who are registered in our medical home

Patients’ chief complaints or reasons for visit determines care

We systematically assess all our patients’ health needs to plan care

Care is determined by today’s problem and time available today

Care is determined by a proactive plan to meet patient needs without visits

Care varies by scheduled time and memory or skill of the doctor

Care is standardized according to evidence-based guidelines

Patients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ care

I know I deliver high quality care because I’m well trained

We measure our quality and make rapid changes to improve it

It’s up to the patient to tell us what happened to them

We track tests & consultations, and follow-up after ED & hospital

Clinic operations center on meeting the doctor’s needs

A multidisciplinary team works at the top of our licenses to serve patients

Acute care is delivered in the next available appointment and walk-ins

Acute care is delivered by open access and non-visit contacts

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

Why should employers care about PCMH? Improved coordination of healthcare Enhanced quality of care Better clinical outcomes Improved patient satisfaction with healthcare And (hopefully) lower health and lost

productivity costs Healthier workforce Healthier families in workforce Increased efficiency of care (reduces costs) More valuable health benefit Improved workforce productivity

Typical US employer healthcare cost distribution

• By improving care quality with a PCMH, primary care costs will increase

• However, implementation of PCMH has been shown to result in lower hospitalization rates – and lower overall health care costs.

6%

39%

34%

19%

Primary care InpatientOutpatient PharmacyEmergency dept.

15%

31%32%

20%

Current statePCMH implementation

Value of a patient-centered medical home Value to patients

Better access Safer care Coordinated, longitudinal care Expanded use of evidence-based care Improved compliance with treatment Better outcomes

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How connected are you to your primary care physician?

“Not surprisingly, those patients with the strongest relationships to specific primary care physicians were more likely to receive recommended tests, and be adherent with medications and preventive care. In fact, this sense of connection with a single doctor had a greater influence on the kind of preventive care received than the patient’s age, sex, race or ethnicity.”

Patient–Physician Connectedness and Quality of Primary Care Atlas, SJ Grant RW, et al. Ann Int Med 2009 :150 :325-335

Physician-connected patientsPerformance

measurePhysician-connected

patients (%)

Practice-connected

patients (%)

p value

Mammography 78.1 65.9 <.001

Cervical cancer 86.4 80.2 <.001

Colorectal cancer

72.1 58.0 <.001

HbA1c in past year

90.3 74.9 <.001

HbA1c <8% 74.7 70.5 .004

LDL in past year 83.2 61.2 <.001

LDL<100mg/dl 77.0 67.2 .64

Atlas SJ, et al. Ann Intern Med. 2009;150:325-335.

• Study involved 155,590 patients seen in one of 13 primary care practice network sites• Patients attributed to physician, practice, or neither based on validated algorithm

Value of a patient-centered medical home Value to payers

Clear practice performance standards Opportunities for incentivizing quality Increased efficiency of care (reduces costs)

Value to purchasers Healthier workforce Healthier families in workforce Increased efficiency of care (reduces costs) More valuable health benefit

While other approaches have addressed some PCMH factors, none has addressed them all

FACTOR PCMH Managed Care Pay for Performance

Disease Management Wagner Model

Purpose and Focus

Facilitatestrong partnership

between doctor and patient

Ideally: cost, quality

Actually: control utilization

Meet operational goals with financial

incentives

Meet specific mgmt targets for chronic

disease

Org. framework for chronic care mgmt

and practice improvement

Patient-Centric/ Personal Physician

Yes No No

Maybe, but often led by actors

independent of primary care

Yes, for chronic illness

Physician-directed Medical “Team”

Yes No No No Yes

Whole Person Orientation (KIDS)

Yes No No No Yes

Care is Coordinated and/or Integrated

Yes No incentive for coordination

No incentive for coordination Maybe Yes

Emphasis on Quality and Safety

Yes, EBM and best practices; improved outcomes rewarded

No, reduced utilization rewarded

Indirectly; process targets rather than outcome targets

Yes, for particular diseases

Yes, for chronic illnesses

Enhanced Access Yes No, reduced access No Maybe No

Appropriate Reimbursement

Yes Potential conflict in motivation

No, still volume-driven

Partially, if EBM used No

P. Grundy, MD. Midwest Business Group on Health, Sept, 200916

PCMH pilots: BCBS North Dakota, Marillac Clinic

Marillac’s Integrated Care Patients (PCMH)

6% decrease in hospital admissions

24 % decrease emergency room use

$500 per member per year savings

PCMH pilots: Promising early results

PCPCC payment model

Care Coordination

Office Visits

Performance

Blended Hybrid Payment Model (expanding upon the existing fee-for-service

paradigm)

Key physician and practice accountabilities/ value added

services and tools

Proactively work to keep patients healthy and manage existing illness or conditions

Coordinate patient care among an organized team of health care professionals

Utilize systems at the practice level to achieve higher quality of care and better outcomes

Focus on whole person care for their patients

Perfo

rman

ce S

tan

dard

s

Incentiv

es

Incentives

Incentives

Medical home case study: Whirlpool PCMH program started 1/1/10 in Findlay, OH Involves 48 provider practices About 2000 covered lives Comprehensive data collection and analysis Considerable community support Other employers evaluating program

participation

Medical home – potential issues Lack of consistent definition of “medical

home” Lack of best-practice reimbursement approach Cost savings data accumulating – snowball is

rolling Patient uptake may be slow based on

entitlement philosophy – consideration for incentives

Practice reengineering demands may be considerable for small practices, but ample support options available

Summary The PCMH model is rapidly gaining attention

as an effective means of improving healthcare quality and clinical outcomes

Healthcare cost control is emerging as a consistent and potentially substantial outcome

Employers can benefit by participating in local/regional PCMH programs

To learn more, go to www.pcpcc.net: The Patient-Centered Primary Care Collaborative

Patient Centered Primary Care Collaborative“Purchaser Guide” Released July, 2008

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Developed by the PCPCC Center for Benefit Redesign and Implementation in partnership with NBCH and the Center’s multi-stakeholder advisory panel.

Guide offers employers and buyers actionable steps as they work with health plans in local markets - over 6000 copies downloaded and/or distributed.

Includes contract language, RFP language and overview of national pilots.

Includes steps employers can take to involve themselves now in local market efforts.

The PCPCC is holding a series of Webinars, sponsored by Pfizer, on the Purchaser Guide.

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Patient Centered Primary Care Collaborative“Proof in Practice– A Compilation of Patient Centered Medical Home Pilot and

Demonstration Projects” Released October 2009

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Developed by the PCPCC Center for Multi-stakeholder Demonstration through a grant from AAFP offering a state-by-state sample of key pilot initiatives.

Offers key contacts, project status, participating practices and market scan of covered lives; physicians.

Inventory of : recognition program used, practice support (technology), project evaluation, and key resources.

Begins to establish framework for program evaluation/ market tracking.

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Patient Centered Primary Care Collaborative“A Collaborative Partnership – Resources to Help Consumers Thrive in the

Medical Home” Released October 2009

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Included in the Guide:•PCPCC activities and

initiatives supporting consumer engagement;

•Research and examples surrounding consumer engagement in PCMH demonstrations;

•Tools for consumers and other stakeholders to assist with PCMH education, engagement and partnerships; and

•A catalogue of resources that provides descriptions of and the means to obtain potential resources for consumers, providers and purchasers seeking to better engage consumers.

Patient Centered Primary Care Collaborative“Aligning Incentives and Systems: VBID and PCMH” Released March 2010

Collaborative white paper by PCPCC, Center for Value-Based Insurance Design, and National Business Coalition on Health

Discussion of the value of integrating supply and demand-side strategies for employers

Case studies of employers, plans and communities implementing these strategies

Coming soon from PCPCC…

Employer Metrics for Evaluating the Business Value of Patient-Centered Medical Home Programs

Questions?

Contact info:Bruce Sherman, MDbws@case.edu216-337-4457