Patient Centered Medical Home

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Patient Centered Medical Home

• Utah Academy of Family PhysiciansSilver
  SummitAugust 7, 2008
• Michael K. Magill, MD
• Professor and ChairmanDepartment of Family and
  Preventive MedicineExecutive Medical
  DirectorCommunity Clinics
• University of Utah

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• Of all the forms of inequality, injustice in
  health care is the most shocking and inhumane
• Martin Luther King, Jr.

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Patient Centered Medical Home Outline

• Background Why change?
• Definition Patient Centered Medical Home (PCMH)
• National Committee for Quality Assurance (NCQA)
  PCMH Recognition Program
• Examples of implementation

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What Is a Patient-Centered Medical Home?

• A Patient-Centered Medical Home (PCMH) is an
  approach that provides comprehensive primary care
  across the lifecycle for children, youth, and
  adults.
• The PCMH team coordinates partnerships between
  individual patients and their physicians to meet
  all of the patients healthcare needs.

Adapted from Joint Principles of the
Patient-Centered Medical Home, March 2007.
Available at http//www.aafp.org/online/etc/media
lib/aafp_org/documents/policy/fed/jointprinciplesp
cmh0207.Par.0001.File.dat/022107medicalhome.pdf.
- Merck
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Whats driving the change?

• Health needs
• Americans living longer
• Average lifespan 77 years1
• Chronic disease more prevalent
• gt 40 with chronic conditions have gt 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
  conditions3

• US Department of Health and Human Services.
  Healthy People 2010. Washington DC. US Government
  Printing Office November 2000.
• Institute of Medicine Crossing the Quality
  Chasm A New Health System for the 21st Century.
  Washington, DC National Academy Press 2000.
• McGlynn EA, et al. N Engl J Med. 2003
  348(26)2635-45.
• .

- Merck
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Whats driving the change?
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Scoring

• 37 indicators, 5 dimensions
• Healthy lives
• Quality
• Access
• Efficiency
• Equity
• Benchmark top 10 in US and countries
• Maximum score 100 for each dimension

Commonwealth Fund 2008
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National Scorecard on U.S. HealthSystem
Performance 2008

• Preventable mortality The U.S. fell to last
  place among 19 industrialized nations on
  mortality amenable to health caredeaths that
  might have been prevented with timely and
  effective care.

Commonwealth Fund 2008
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National Scorecard on U.S.HealthSystem
Performance 2008

• Delivery rates for basic preventive care failed
  to improve as of 2005, only half of adults
  received all recommended preventive care.

Commonwealth Fund 2008
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National Scorecard on U.S.HealthSystem
Performance 2008

• The U.S. ranks 37th in the world in overall
  quality
• The U.S. is last in infant mortality
• U.S. life expectancy is lower than the life span
  in more than three dozen countries

Commonwealth Fund 2008
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National Scorecard on U.S.HealthSystem
Performance 2008

• The U.S. spends 16 GDP
• 2.2 trillion
• 82 more than other OECD nations

Commonwealth Fund 2008
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Interventions/Errors

• An estimated 1/3 of interventions (surgical and
  medical) are unnecessary.
• The third leading cause of death in the United
  States , after heart disease and cancer, is
  medical intervention.

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Do we get what we pay for?

• US Ranks for
• Health System Performance 37
• Health 24
• Financial Fairness 54
• Cost 1

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UTAHS State ScorecardIf Utah

• Improved its performance to the level of the best
  performing state
• 124,199 more adults would be covered by health
  insurance
• 49,108 more children would be covered by health
  insurance

Commonwealth Fund 2008
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UTAHS State ScorecardIf Utah

• Improved its performance to the level of the best
  performing state
• 67,910 more adults would receive recommended
  preventive care such as colon cancer screening,
  mammograms, flu shots
• 21,611 more adults with diabetes would receive 3
  recommended services (eye exam, foot exam, and
  hemoglobin A1c test)

Commonwealth Fund 2008
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UTAHS State ScorecardIf Utah

• Improved its performance to the level of the best
  performing state
• 13,379 more children would be up to date on 5
  recommended vaccines

Commonwealth Fund 2008
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UTAHS State ScorecardIf Utah

• Improved its performance to the level of the best
  performing state
• 255,943 more adults would have a usual source of
  care
• 128,336 more children would have a medical home

Commonwealth Fund 2008
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UTAHS State ScorecardIf Utah

• Improved its performance to the level of the best
  performing state
• 625 fewer hospitalizations for ambulatory care
  sensitive conditions would occur for Medicare
  beneficiaries
• 2,897,000 dollars would be saved

Commonwealth Fund 2008
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UTAHS State ScorecardIf Utah

• Improved its performance to the level of the best
  performing state
• 407 fewer hospital readmissions would occur among
  Medicare beneficiaries
• 5,014,000 dollars would be saved from the
  reduction in readmissions

Commonwealth Fund 2008
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Utah Ranking against other states

• Overall 24
• Access 38
• Quality 48

Commonwealth Fund 2008
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Benefits of improvement(50 on many indicators
to reach benchmark)

• Lives saved from causes amenable to health care
  101,000/yr
• Access to primary care 37 million
• All recommended preventive care 70 million
• Medicare savings (reduced readmissions, fewer
  preventable conditions) 12 billion
• Reduced insurance administrative cost 51 billion

Commonwealth Fund 2008
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There is one thing that we know works

• PRIMARY CARE

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Primary Care Definition

• Primary care is the provision of integrated,
  accessible health care services by clinicians who
  are accountable for addressing a large majority
  of personal health care needs, developing a
  sustained partnership with patients, and
  practicing in the context of family and community

Institute of Medicine1996
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BARBARA STARFIELD

• In England, each additional primary care
  physician per 1000 (about a 20 increase) is
  associated with a decrease in mortality of about
  5, adjusting for limiting long-term illness and
  for various demographic and socioeconomic
  characteristics.

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BARBARA STARFIELD

• Adults (age 25 and older) with a primary care
  physician rather than a specialist as their
  personal physician
• had 33 lower cost of care
• were 19 less likely to die (after controlling
  for age, gender, income, insurance, smoking,
  perceived health (SF-36) and 11 major health
  conditions)

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BARBARA STARFIELD

• A greater supply of primary care physicians was
  associated with lower infant mortality

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BARBARA STARFIELD

• All-cause mortality, heart disease mortality, and
  cancer mortality were lower where the supply of
  primary care physicians was greater.

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BARBARA STARFIELD

• Many other studies done WITHIN countries, both
  industrial and developing, show that areas with
  better primary care have better health outcomes,
  including total mortality rates, heart disease
  mortality rates, and infant mortality, and
  earlier detection of cancers such as colorectal
  cancer, breast cancer, uterine/cervical cancer,
  and melanoma. The opposite is the case for higher
  specialist supply, which is associated with worse
  outcomes.?

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Primary Care Higher Quality
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Primary Care Lower Cost
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SUMMARY BENEFITS FROM PRIMARY CARE

• Better Health Outcomes
• Lower Costs
• Greater Equity in health

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Primary Care is critical, but it is dying

• Primary care, the backbone of the nations
  health care system, is at grave risk of collapse
  due to a dysfunctional financing and delivery
  system.
• Immediate and comprehensive reforms are required
  .
• If these reforms do not take place, within a few
  years there will not be enough primary care
  physicians .
• The consequences of failing to act will be
  higher costs, greater inefficiency, lower
  quality, more uninsured persons, and growing
  patient and physician dissatisfaction.

ACP 2006
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Medicare Payment Advisory Committee

• In consideration of the devaluation of primary
  care services, the commission is concerned that
  these services risk being underprovided, as
  physicians view them as less valued and less
  profitable. Yet, primary care services and
  --perhaps more importantly--primary care
  clinicians , are critical to delivering more
  coordinated, high quality care to the Medicare
  population.

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Proportions of Third-Year Internal Medical
Residents Choosing Careers as Generalists,
Subspecialists, and Hospitalists
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Average Medical Specialty Salaries
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The Primary Care- Specialty Income Gap Is
Widening Median pretax compensation of
physicians, 19952004
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Who is driving the change?Payers
When one compares the U.S. health care system
with those of other industrialized countries, one
is led to the conclusion that the two major
problems in U.S. health care are the way we
deliver primary care and the way primary care is
financed primary care is the only natural locus
of control of health care quality and costs. -
Paul Grundy, M.D., M.P.H., Director of Health
Care Technology and Strategic Initiatives,
IBM,and Chair of the Patient-Centered Primary
Care Collaborative (PCPCC)
http//www.aafp.org/online/en/home/publications/ne
ws/news-now/opinion/20080207bren-grundy.mem.html
accessed 5/15/08
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Who is driving the change?Payers

• If primary care is not successful in its core
  tasks of prevention, wellness and the care of
  common conditions, including many chronic
  conditions, it will not be possible to control
  either quality or cost of care in the United
  States hospital care and specialty care are
  crucial to health care, but their use is
  all-too-often the failure of upstream care.
• - Paul Grundy, M.D., M.P.H., Director of Health
  Care Technology and Strategic Initiatives,
  IBM,and Chair of the Patient-Centered Primary
  Care Collaborative (PCPCC)

http//www.aafp.org/online/en/home/publications/ne
ws/news-now/opinion/20080207bren-grundy.mem.html
accessed 5/15/08
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Medical HomeHistory of the Term
2008
1990s
2007
1960s
- Merck
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Chronic Care Model
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Patient Centered Medical HomeUnprecedented
Collaborative Effort

• Joint Principles of PCMH Issued February 2007
• American Academy of Family Physicians
• American Academy of Pediatrics
• American College of Physicians
• American Osteopathic Association
• Patient-Centered Primary Care Collaborative
• Professional organizations and health care
  providers
• Consumer groups
• Employers
• Insurers

- Merck
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Joint Principles
- Merck
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Evidence for Care Principles

• Personal physician
• Patients value continuous healing relationships
  with their physicians
• Continuity of care contributes to quality of
  care1,2
• Physician-directed practice
• Degree to which care delivered in a primary care
  setting conformed to chronic care model was an
  important predictor of glucose control and
  10-year risk of CHD in patients with type 2
  diabetes3,4

1. Forrest CB, et al, JAMA. 2001285(17)2223-31.
2. Flocke SA, et al. J Fam Pract.
199725(2)129-35 3(2)159-66. 3. Parchman ML,
et al. Diabetes Care. 200730(11)2849-54. 4.
Parchman ML, et al. Med Care. 2007
45(12)1129-1134.
- Merck
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Evidence for Infrastructure Principles

• Coordinated carepart 2
• Led to fewer hospitalizations, fewer ICU days,
  shorter lengths of hospital stays in elderly male
  veterans1
• Enhanced access
• Increase of 1 PCP per 10,000 population was
  associated with reduction of 14.4 deaths/100,0002
• Minority patients were just as likely as whites
  to get care when needed, receive preventive
  screenings, and have chronic conditions managed
  appropriately3

• Saultz JW and Lochner JL. Ann Fam Med.
  20053(2)159-166.
• Shi L, et al. Soc Sci Med. 200561(1)65-75.
• Beal AC, et al. Closing the Divide How Medical
  Homes Promote Equity in Health Care. Results From
  the Commonwealth Fund 2006 Health Care Quality
  Survey. June 2007. http//www.commonwealthfund.org
  /publications/publications_show.htm?doc_id506814

- Merck
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Core components of a Medical Home

• ACCESS
• -Written standards
• 24/7 coverage
• Electronic visits
• Group visits
• Satisfaction with access tracked and reported

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Core Components of a Medical Home

• Information Systems
• Repository of personal health information
• Evidence-based protocols built into system to
  facilitate best care being provided through the
  use of reminders
• Registries created to track recommended tests and
  to provide vehicle for outreach calls
• Personal Health Record of patient portal
  encouraged

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Core Components of aMedical Home

• Coordination of Care
• Utilizes TEAM to deliver care
• Provides all preventive care
• Provides Chronic Disease Management
• Uses point of service reminders and registries to
  improve care
• Makes timely and appropriate referrals
• Self efficacy training
• Can demonstrate collaboration with mental health
  providers
• Utilizes health risk appraisals and goal directed
  care
• Engages with community resources

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Core Components of aMedical Home

• Performance Reporting
• Measures and reports clinical and service
  performance to the practice
• Sets goals and takes action to improve
  performance
• Has reporting capability to outside entities

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NCQA PPC-PCMH Recognition Program

• Physician Practice Connections Patient-Centered
  Medical Home Recognition Program
• Activated in January 2008
• Modifies the 2006 Physician Practice Connections
  program
• A recognition program designed to recognize
  physician practices for excellent care management
  and follow-up
• NCQA Recognition has been used by many
  pay-for-performance efforts sponsored by
  employers and health plans in determining
  eligibility for awards
• Reflects the 2007 Joint Principles of the PCMH
• Recognizes physician practices functioning as
  medical homes by using systematic,
  patient-centered and coordinated care management
  processes.

NCQA Physician Practice Connections. Available
at http//web.ncqa.org/Default.aspx?tabid141
and http//web.ncqa.org/tabid/74/Default.aspx
- Merck
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NCQA PPC-PCMH Recognition Program

• Program Elements
• There are nine standards
• Each standard is comprised of 2 to 6 related
  elements, with a total of 10 must pass elements.
• Three levels of recognition have been designed
  around completion of must-pass elements
• Independent self-scoring and assessment tools are
  included in the recognition process

NCQA Physician Practice Connections. Available
at http//web.ncqa.org/Default.aspx?tabid141
and http//web.ncqa.org/tabid/74/Default.aspx
- Merck
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Key to implementation Payment reform to
incentivize investment in PCMH
Pay for PerformanceClinical and Patient
Experience
Fee Schedule for Visits/Procedures

• Payment per patient for
• qualified Patient-Centered Medical Homes

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Implementing Medical Homes

• Community Care of North Carolina
• Focusing on disease management
• Others
• University of Utah Community Clinics
• Care by Design

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Community Care of North Carolina

• Goal Reduce Medicaid costs and improve the
  health of the patient population
• Setting Local partnerships of physicians,
  hospitals, health departments, and departments of
  social services
• Changes
• After-hours pediatric clinic (6 PM to 10 PM)/365
  nights/year
• Nurse advice phone line
• 1 Case Manager per 3,300/pts, averaging 100 to
  200 patients at any giventime
• Developed disease management tools
• Case management fee

• Wilson CF. Community care of North Carolina
  Saving state money and improving patient care. NC
  Med J. 2005 66(3)229-33.

- Merck
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Community Care of North Carolina

• Practices 2.50 per member/per month (pm/pm)
• Networks 3 pm/pm to support local case and
  disease management

http//www.communitycarenc.com/PDFDocs/Entire_2007
Update.pdf, Accessed March 27, 2008
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Community Care of North Carolina

• Outcomes Asthma (first 3 years)
• Hospital admissions ?34
• Emergency Room visits ? 8
• Episode cost ? 24 (687 vs. 853)

• Wilson CF. Community care of North Carolina
  Saving state money and improving patient care. NC
  Med J. 2005 66(3)229-33.
• 2. Asthma Disease Management Program Summary.
  Community Care of North Carolina, 2007. Available
  at http//www.communitycarenc.com/

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North Carolina

• ?14 networks, 3,200 MDs, gt800,000 patients
• ?3 PMPMto each network
• ?Hire care managers/medical management staff
• ?2.50 PMPMto each PCP to serve as medical home
  and participate in disease management
• ?Care improvement asthma, diabetes,
  screening/referral of young children for
  developmental problems, and more!
• ?Case management identify and facilitate
  management of costly patients
• ?Cost (FY2004) -10.2 Million investment
  Savings 124M compared to FY2003 and 225M
  compared to Medicaid FFS(Mercer Consulting)

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Geisinger Health System

• Medical home project
• 20 reduction in hospital admissions
• 12 decrease in hospital readmissions

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Iowa Medicaid

• Saved 66 million over 8 years

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PCMH Other Initiatives

• Medicare
• 3 year, 8 state demonstration begins 2009
• Congress
• Healthy Americans Act (S.334)
• Introduced 1/18/07 by Sen. Wyden (D OR),
  co-sponsored by Sen Bennett (R UT), others.
• MedPAC recommendations 4/9/08
• Primary care
• Larger Medical Home demonstration - 400m
• State demonstration projects
• Washington, New York, Minnesota, Massechussetts,
  Illinois, Kansas, Iowa

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The Tax Relief and Health Care Act 2006

• Provides for Medicare and Medicaid to develop an
  eight state demonstration project on Medical Home
• The Medicare Improvements for Patients and
  Providers Act of 2008 provides an additional 100
  million to augment that demonstration

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Medical Home National Endorsements

• The four primary care specialty societies
• IBM
• Walmart
• Labor and consumer organizations like AFL-CIO
  and AARP

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Private Payors Testing the Model

• Blue Cross Blue Shield
• Aetna

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States

• Pennsylvania beginning state-wide rollout of
  patient-centered medical home model
• 23 states have efforts to test the medical home
  model in state medicaid programs

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New York Times July 21, 2008
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Medical Home

• Is NOT.
• Gatekeeper
• Carveout Chronic Disease Management
• Case Management
• Mandate

• IS
• Relationship
• Access
• Prevention
• Health Risk Appraisal
• Screening
• Comprehensive
• Acute care
• Prospective Care
• Prevention
• Planned Care
• Self care
• Voluntary

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UTAH COLLABORATION

• EMPLOYERS
• University of Utah
• Firmco
• Artic Circle
• Associated Foods
• Steel Encounters
• Cadurx
• Utah Transit Authority
• Deseret Mutual Benefit Association
• ARUP
• O.C. Tanner

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UTAH COLLABORATION

• PROVIDERS
• HealthInsight
• St. Marks Family Practice
• University of Utah Community Clinics
• Utah Academy of Family Physicians
• Chair Family Practice University of Utah
• Salt Lake Community Health Centers

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UTAH COLLABORATION

• PAYORS
• Blue Cross Blue Shield
• Altius
• DMBA
• Select Health
• University Health Plan
• Medicaid

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All this begs the question

• Will we have the collective will to create a high
  functioning health care system?

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The Fix

• It is a shared responsibility between everyone
  with a stake in health care
• Government
• Business
• The Health Care Profession
• Individuals

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PROPOSAL

• Establish a Public/Private coalition between the
  state,payors, and employers to fund a medical
  home demonstration project.
• Medical Groups meeting criteria may apply for
  funding
• Partial capitated payment made in the range of 5
  to 10 pmpm for patients participating in medical
  home practice.

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Prerequisite for Successful PCMH

• Primary Care Practice Redesign

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University of Utah Community ClinicsRe-engineered
Practices
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• Care when and how you want it
• Visit today
• Shared Medical Appointments
• Soon
• Web access
• eVisits

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• Visit provided by a coordinated team
• Expanded MA role deliver the visit from
  start to finish
• Physician does what only a physician can do

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• Evidence-based decision support
• Pre-visit planning
• Soon
• Written plan for every patient

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• Electronic Medical Record

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Clinical Quality Chronic Care
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Clinical Quality - Prevention
91
Colonoscopy Referral Rates
92
Patient Satisfaction
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Conclusions

• Patient Centered Medical Home
• Evidence elements of PCMH reduce cost, improve
  quality
• Growing national consensus payers, employers,
  physician groups
• Multiple demonstration projects
• Is it time for a Utah demonstration project?