The Medical Home, And Why You Should Care

1
The Medical Home,And Why You Should Care

• March 7, 2009
• George Schoephoerster, MD

2
ObjectivesMedical Home

• Why am I here talking about it?
• What is it all about?
• Why you should care?

3
Disclosures

• Family Doc small groups solo1982-1996
• Residency training faculty director1996-2004
• Vertically integrated network (CentraCare)2004-20
  09
• Geriatrician Geriatric Services of
  Minnesotapresent

4
Disclosures

• Officer, including President, of the Minnesota
  Academy of Family Physicians2001-2007
• MMA Health Care Reform Task Force2004
• Health Care Access Commissions Cost Containment
  Workgroup 2007
• Minnesota Quality Institute Workgroup 2008
• Health Care Reform Review Committee 2008
• A Better Way Minnesota Medicine, May 2008, a
  newsletter of the Minnesota Medical Association

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Why are we here talking about it?
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The Case for Reform

• Costs issues
• Quality issues
• Commonly accepted concerns with current system

7
Cost Issues

• Health Care Costs 17 of GDP
• St. Cloud Times Wednesday, Feb. 25
• Obama Health Care, Schools, Environment
• Pawlenty The State of Minnesotas share of
  spending on health care increasing by 20 annually

8
Quality Issues

• Per cent of time that Americans receive effective
  care 50
• McGlynn et al., New England Journal of Medicine,
  2003)

9
Commonly accepted issues

• Aging population
• Disparities in access and quality
• Fractured health care system
• Chronic disease management 130 million
  Americans with at least one chronic disease

10
Focused EffortsConcentration of Health Care
Costs
11
What are we trying to fix?

• Fragmented care
• Confused, frustrated patients
• Confused, frustrated providers
• Poor coordination of services
• Poor communication at all levels
• Silos of delivery of care
• Poor outcomes in many areas

12
AMA Response 2008 Interim Meeting
Reference Committee J

• Council on Medical Service Report 4 Seek
  comments on alternate Medicare payment
  methodologies
• Adopt Joint Principles of Patient-Centered
  Medical HomeAAFP, ACP, AAP, AOA on February,
  2007
• So why a Medical Home?
• To better support primary care

13
Evidence supporting a more primary care-based
system (Phillips, AFP, Oct. 15, 2003)

• Based on patient satisfaction, expenditures per
  person, 14 different health care indicators, and
  of medications per person.

14
Barbara Starfield, MD,Professor of Health Policy
Management at John Hopkins(Health Affairs,
March 15, 2005)

• In the US, a 20 increase in the number of
  primary care physicians is associated with a 5
  percent decrease in mortality.

15
Evidence for Continuity of Care and the Role of
a Personal Physician

• Effect of Improved Primary Care Access on Quality
  of Depression Care, Solberg, Annals of Family
  Medicine, Jan./Feb., 2006, Vol. 4, 1.
• Advanced access needs to enhance continuity of
  care.

16
2 Decades of evidence for the benefits of a
primary care-based health care system (Phillips,
AFP, Oct. 15, 03)

• Evidence of Effectiveness
• 1) Reduced all-cause morbidity and mortality
  caused by cardiovascular and pulmonary diseases
  (11)
• 2) Less use of emergency departments and
  hospitals (12,13)
• 3) Better preventive care (14,15)
• 4) Better detection of breast cancer, and
  reduced incidence and mortality caused by
  colon and cervical cancer (16-18)
• Evidence of Efficiency
• Fewer tests, higher patient satisfaction, less
  medication use, and lower care-related costs
  (19,20)
• Evidence of Equity
• Reduced health disparities, particularly for
  areas with the highest income inequality,
  including improved vision, more complete
  immunization, better blood pressure control, and
  better oral health (21-23)

17
DHS Minnesota Home Collaborative CentraCare
Pediatrics Overall results for 2004-2005
0
Copy of care plan
Visited hospital emergency room in past 3 months
Unplanned hospital admission in the past 3 months
18
Savings Estimates

• Shift in location of care
• Savings from elimination of unnecessary emergency
  department and hospital care
• Savings in intensity of care
• Reduced use of unnecessary ICU care
• Alteration in use of preference sensitive care
• Reduced use of unnecessary procedures
  technology
• Savings could range from 10-30 of total cost

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The Patient-Centered Medical Home Model...

• to achieve better value in health care in the
  21st century (better quality at less cost) will
  require a transition from episodic,
  illness-oriented, complaint-based care (the
  current system)to patient-centered,
  physician-guided, cost-efficient, longitudinal
  care.

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(No Transcript)
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What is Medical Home all about?
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What is a Patient-Centered Medical Home?

• A Medical Home is not a place or an actual
  concrete structure, like a house or a building
• 1) It is an approach to the care of patients.
• 2) It is the system of support for the
  physician in providing patient-centered
  primary care.

23
Primary Care PhysiciansPer Cassell

• Doctors who are capable of simultaneously
  utilizing both the longitudinal knowledge of the
  patient and their own knowledge of the science of
  medicine to apply it in the care of that patient

24
Fundamental principles of Primary Care

• First contact
• Continuity of carepersonal physician
• Comprehensive
• Coordination of essential care
• Caring in context (of personal, family and
  community valuesthe culture)
• Continuous quality improvement (PFP)

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Comprehensiveness as key element in the value of
Primary Care

• Either provide the entire health care of a
  patient or facilitate the coordination of certain
  portions of that care, which includes effectively
  communicating that patients health care story
• (Personal report Starfield, March 21, 2008)

26
Why Patient-centered?

• Crossing the Quality ChasmIOM, 2001
• Dartmouth Project, John Wennberg, MD
• Preference Sensitive Care

27
Crossing the Quality Chasm (IOM) 6 Aims for
System Performance

• Safety
• Effectiveness
• Timeliness
• Efficiency
• Equity
• Patient-centeredness
• responds to the needs, values, and expressed
  preferences of the patient

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John Wennberg, MDDartmouth Project

• When patients make choices that truly fit their
  own personal values, the choices are more cost
  effective for the system provide greater
  satisfaction and better results for the patient.

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Origins of Medical Home(A House is not a Home,
by Berenson, Health Affairs 27, 5 (2008)
1219-1230)

• Pediatric Medical Homes
• Patient-centered Primary Care
• Information technology
• Wagners Chronic Care Model

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Joint Principlesinter-related

• Personal Physician/care continuity
• Physician-directedteam-based
• Coordinated/integrated care
• Whole person comprehensive/patient-centered
• Special focus on quality/safety
• Enhanced access
• Payment reform

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Joint Principles

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

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Team-based care

• 1) Practice team
• 2) Teams across silos
• Structure and communication are key

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Care Continuitypersonal physician

• Team leader
• Coordination leader
• Communication leader
• Information manager of the patients medical
  story

34
Joint Principles

• Care would be coordinated and/or integrated
  across all domains of the health care system
  (hospitals, home health agencies, nursing homes,
  consultants and other components of the complex
  health care system), facilitated by registries,
  information technology, health information
  exchange, non-face-to-face care, and other means
  to assure that patients get the indicated care
  when and where they need and want it.
• Will soon need to include all forms of 21st
  century technology

35
Care coordination/integration

• Includes dedicated non-physician funding/time
  commitment
• Care plans
• Disease registries
• Information coordination led by personal physician

36
Joint Principles

• Whole person orientation the personal physician
  is responsible for providing for all the
  patients health care needs or taking
  responsibility for appropriately arranging care
  with other qualified professionals. This
  includes care for all stages of life preventive
  services acute care chronic care and end of
  life care that is consistent with the patients
  needs, values, and preferences (patient-centered).
  

37
Joint Principles

• Quality and safety are hallmarks of the medical
  home
• Evidence-based medicine and clinical
  decision-support tools guide decision making
• Physicians in the practice accept accountability
  for continuous quality improvement through
  voluntary engagement in performance measurement
  and improvement.
• Patients actively participate in decision-making
  and feedback is sought to ensure patients
  expectations are being met

38
Joint Principles

• Quality and safety are hallmarks of the medical
  home
• Information technology is utilized appropriately
  to support optimal patient care, performance
  measurement, patient education, and enhanced
  communication
• Practices go through a voluntary recognition
  process by an appropriate non-governmental entity
  to demonstrate that they have the capabilities to
  provide patient centered services consistent with
  the medical home model.
• Patients and families participate in quality
  improvement activities at the practice level
  (transparency in practice).

39
Joint Principles

• Enhanced access to care is available through
  systems such as open scheduling, expanded hours
  and new options for communication between
  patients, their personal physician and practice
  staff.
• Goals is to eliminate all barriers to access to
  essential care

40
Enhanced access

• Group visits
• Tele-visits
• Patient seen when/where they want/need to be seen
• Patients care needs to be directly supervised by
  the practice team wherever it occurs to assure
  that it is patient-centered

41
Joint Principles

• Payment Model Reform

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Payment Mechanism for Medical Home

• A prospective, bundled structural practice
  component covers the practice overhead costs not
  currently paid under the present system.
• A risk/needs-adjusted comprehensive and
  prospective, bundled care coordination component
  recognizes the work value of physician and
  non-physician clinical and administrative care
  activities that take place outside of
  face-to-face visits.
• A visit-based fee-for-service component
  currently paid under the present system.
• A performance-based component that recognizes
  achievement of quality and efficiency goals,
  including patient satisfaction.

43
Health Care Homeswhat they are not!

• Misconceptions
• Primary care gatekeeper model
• Relationship-focused
• Coordination of care for complex/chronic patients
• Thus a care facilitation model
• Primary care capitation
• Payments are for care coordination
• No other services/providers to be paid for with
  fee
• No financial incentive to withhold care/limit
  referrals

44
(No Transcript)
45
Why you should care
46
Cost Issues

• Health Care Costs 17 of GDP
• St. Cloud Times Wednesday, Feb. 25
• Obama Health Care, Schools, Environment
• Pawlenty The State of Minnesotas share of
  spending on health care increasing by 20 annually

47
Quality Issues

• Per cent of time that Americans receive effective
  care 50
• 9McGlynn et al., New England Journal of Medicine,
  2003)

48
AMA Response 2008 Interim Meeting
Reference Committee J

• Council on Medical Service Report 4 Seek
  comments on alternate Medicare payment
  methodologies
• Adopt Joint Principles of Patient-Centered
  Medical HomeAAFP, ACP, AAP, AOA on February,
  2007
• So why a Medical Home?
• To better support primary care

49
Evidence supporting a more primary care-based
system (Phillips, AFP, Oct. 15, 2003)

• Based on patient satisfaction, expenditures per
  person, 14 different health care indicators, and
  of medications per person.

50
2 Decades of evidence for the benefits of a
primary care-based health care system (Phillips,
AFP, Oct. 15, 03)

• Evidence of Effectiveness
• 1) Reduced all-cause morbidity and mortality
  caused by cardiovascular and pulmonary diseases
  (11)
• 2) Less use of emergency departments and
  hospitals (12,13)
• 3) Better preventive care (14,15)
• 4) Better detection of breast cancer, and
  reduced incidence and mortality caused by
  colon and cervical cancer (16-18)
• Evidence of Efficiency
• Fewer tests, higher patient satisfaction, less
  medication use, and lower care-related costs
  (19,20)
• Evidence of Equity
• Reduced health disparities, particularly for
  areas with the highest income inequality,
  including improved vision, more complete
  immunization, better blood pressure control, and
  better oral health (21-23)

51
Joint Principlesinter-related

• Personal Physician/care continuity
• Physician-directedteam-based
• Coordinated/integrated care
• Whole person comprehensive/patient-centered
• Special focus on quality/safety
• Enhanced access
• Payment reform

52
Health Care Homeswhat they are not!

• Misconceptions
• Primary care gatekeeper model
• Relationship-focused
• Coordination of care for complex/chronic patients
• Thus a care facilitation model
• Primary care capitation
• Payments are for care coordination
• No other services/providers to be paid for with
  fee
• No financial incentive to withhold care/limit
  referrals

53
Why you should care

• Primary Care
• this change process is going to be hard work
• Non-primary care
• isnt this just a shift in income from specialty
  to primary care?

54
Savings Estimates

• Shift in location of care
• Savings from elimination of unnecessary emergency
  department and hospital care
• Savings in intensity of care
• Reduced use of unnecessary ICU care
• Alteration in use of preference sensitive care
• Reduced use of unnecessary procedures
  technology
• Savings could range from 10-30 of total cost

55
The House of Medicine

• A house divided against itself cannot
  standLincoln